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ObjectivePulmonary vein isolation (PVI) guided by a standardised CLOSE (contiguous optimised lesions) protocol has been shown to increase clinical success after catheter ablation for paroxysmal atrial fibrillation (PAF). This study analysed healthcare utilisation and quality of life (QOL) outcomes from a large multicentre prospective study, measured association between QOL and atrial fibrillation (AF) burden and identified factors associated with lack of QOL improvement.MethodsCLOSE-guided ablation was performed in 329 consecutive patients (age 61.4 years, 60.8% male) with drug-refractory PAF in 17 European centres. QOL was measured at baseline and 12 months post-ablation via Atrial Fibrillation Effect on QualiTy of Life Survey (AFEQT) and EuroQoL EQ-5D-5L questionnaires. All-cause and cardiovascular hospitalisations and cardioversions over 12 months pre-ablation and post-ablation were recorded. Rhythm monitoring included weekly and symptom-driven trans-telephonic monitoring, plus ECG and Holter monitoring at 3, 6 and 12 months. AF burden was defined as the percentage of postblanking tracings with an atrial tachyarrhythmia ≥30 s. Continuous measures across multiple time points were analysed using paired t-tests, and associations between various continuous measures were analysed using independent sample t-tests. Each statistical test used two-sided p values with a significance level of 0.05.ResultsBoth QOL instruments showed significant 12-month improvements across all domains: AFEQT score increased 25.1–37.5 points and 33.3%–50.8% fewer patients reporting any problem across EuroQoL EQ-5D-5L domains. Overall, AFEQT improvement was highly associated with AF burden (p=0.009 for 2DS2-VASc scores at baseline, and higher AF burden following PVI.ConclusionsQOL improved and healthcare utilisation decreased significantly after ablation with a standardised CLOSE protocol. QOL improvement was significantly associated with impairment at baseline and AF burden after ablation.Trial registration numberNCT03062046.

DIAMOND-AF (DiamondTemp™ Ablation System for the Treatment of Paroxysmal Atrial Fibrillation) was a prospective, multicenter, noninferiority, randomized trial that compared the safety and effectiveness of the DTA system versus those of a force-sensing RF ablation system (control) for the treatment of patients with drug-refractory, recurrent, symptomatic paroxysmal atrial fibrillation (AF).Irrigated radiofrequency (RF) ablation catheters lose tissue temperature acuity, which is vital in assessing lesion formation. DiamondTemp Ablation (DTA) was designed to re-establish accurate tissue temperature measurements during ablation.A total of 482 patients with paroxysmal AF were randomized (239 DTA, 243 control) to undergo pulmonary vein isolation and were followed up at 23 sites. Patients were screened for disease progression, cardiac characteristics, and prior interventions. Primary endpoints were effectiveness (freedom from atrial arrhythmia recurrence) and safety (composite of procedure- and device-related serious adverse events).The primary safety event rate was 3.3% in the DTA group versus 6.6% in the control group (p 0.001 vs. 6.5% noninferiority margin). Primary effectiveness was met in 79.1% of DTA subjects and 75.7% of control subjects (p 0.001 vs. -12.5% noninferiority margin). Secondary endpoint analysis found that off-drug effectiveness favored DTA compared with the control (142 [59.4%] vs. 120 [49.4%], respectively; p = 0.03). Total RF time and individual RF ablation duration were significantly shorter with less saline infused through the DTA catheter (p 0.001). Both arms saw clinically meaningful improvements in quality of life at 12 months.Safety and efficacy of the DTA system proved noninferior to force-sensing RF ablation in a paroxysmal AF population. Efficiencies were observed using DTA with shorter total RF times, individual RF ablation durations, and less saline infusion. (DiamondTemp™ Ablation System for the Treatment of Paroxysmal Atrial Fibrillation; NCT03334630).

Background: Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease, and sudden cardiac death represents an important mode of death in these patients. Data evaluating the implantable cardioverter defibrillator (ICD) in this patient population remain scarce. Methods: A Nationwide French Registry including all patients with tetralogy of Fallot with an ICD was initiated in 2010 by the French Institute of Health and Medical Research. The primary time to event end point was the time from ICD implantation to first appropriate ICD therapy. Secondary outcomes included ICD-related complications, heart transplantation, and death. Clinical events were centrally adjudicated by a blinded committee. Results: A total of 165 patients (mean age, 42.2±13.3 years, 70.1% males) were included from 40 centers, including 104 (63.0%) in secondary prevention. During a median (interquartile range) follow-up of 6.8 (2.5–11.4) years, 78 (47.3%) patients received at least 1 appropriate ICD therapy. The annual incidence of the primary outcome was 10.5% (7.1% and 12.5% in primary and secondary prevention, respectively; P =0.03). Overall, 71 (43.0%) patients presented with at least 1 ICD complication, including inappropriate shocks in 42 (25.5%) patients and lead dysfunction in 36 (21.8%) patients. Among 61 (37.0%) patients in primary prevention, the annual rate of appropriate ICD therapies was 4.1%, 5.3%, 9.5%, and 13.3% in patients with, respectively, 0, 1, 2, or ≥3 guidelines-recommended risk factors. QRS fragmentation was the only independent predictor of appropriate ICD therapies (hazard ratio, 3.47 [95% CI, 1.19–10.11]), and its integration in a model with current criteria increased the 5-year time-dependent area under the curve from 0.68 to 0.81 ( P =0.006). Patients with congestive heart failure or reduced left ventricular ejection fraction had a higher risk of nonarrhythmic death or heart transplantation (hazard ratio, 11.01 [95% CI, 2.96–40.95]). Conclusions: Patients with tetralogy of Fallot and an ICD experience high rates of appropriate therapies, including those implanted in primary prevention. The considerable long-term burden of ICD-related complications, however, underlines the need for careful candidate selection. A combination of easy-to-use criteria including QRS fragmentation might improve risk stratification. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03837574.

Background Electroanatomic mapping is usually required in order to obtain a precise diagnosis and guide the ablation of atrial tachycardias (ATs) after ablation for atrial fibrillation (AF). However, epicardial connections may limit the interpretation of the endocardial activation sequence as well as the efficacy of endocardial radiofrequency ablation. Case summary A 53-year-old man with history of AF ablation 2 years ago was admitted for ablation of a recurrent AT (cycle length 275 ms). Ultra-high-density mapping with the Rhythmia™ system revealed a challenging activation map with two focal points of early activation in the left atrium. The use of an advanced mapping software allowed the rapid reanalysis and reannotation of the activation map and suggested epicardial involvement of the Marshall bundle (MB). Subsequent ethanol infusion in the vein of Marshall (VOM) immediately terminated the tachycardia. Six months post-ablation, the patient had no recurrence of arrhythmias. Discussion This case highlights the role of novel diagnostic and treatment methods in the management of a post-AF ablation AT. By developments in cardiac mapping systems, the rapid editing of a high-density activation map and clarification of the arrhythmia origin can be facilitated overcoming the limitations of conventional techniques. Moreover, ethanol infusion in the VOM was shown to be an effective alternative method in the management of MB-related tachycardias.

Type-2 diabetes mellitus (DM) is associated with an increased risk of atrial fibrillation (AF). It is unclear whether DM is a risk factor for arrhythmia recurrence following catheter ablation of AF. We performed a nonrandomised, observational study in 7 high-volume European centres. A total of 2,504 patients who underwent catheter ablation of AF were included, and procedural outcomes were compared among patients with or without DM. Patients with DM (234) accounted for 9.3% of the sample, and were significantly older, had a higher BMI and suffered more frequently from persistent AF. Arrhythmia relapses at 12 months after AF ablation occurred more frequently in the DM group (32.0% vs 25.3%, p = 0.031). After adjusting for type of AF (i.e., paroxysmal vs persistent), during a median follow-up of 17 ± 16 months, atrial arrhythmia free-survival was lower in the diabetics with persistent AF (log-rank p = 0.003), and comparable for paroxysmal AF (log-rank p = 0.554). These results were confirmed in a propensity-matched analysis, and DM was also an independent predictor of AF recurrence on the multivariate analysis (hazard ratio 1.39; 95% confidence interval 95%1.07 to 1.88; p = 0.016). There was no significant difference in the rate of periprocedural complications among DM and non-DM patients (3.8% vs 6.3%, p = 0.128). Efficacy and safety of cryoballoon ablation were comparable to radiofrequency ablation in both DM and no-DM groups. In conclusion, catheter ablation of AF appears to be safe in patients with DM. However, DM is associated with higher rate of atrial arrhythmia relapse, particularly for patients with persistent AF.

Background The assessment of noninvasive markers of left atrial (LA) low-voltage substrate (LVS) enables the identification of atrial fibrillation (AF) patients at risk for arrhythmia recurrence after pulmonary vein isolation (PVI). Methods In this prospective multicenter study, 292 consecutive AF patients (72% male, 62 +/- 11 years, 65% persistent AF) underwent high-density LA voltage mapping in sinus rhythm. LA-LVS (

INTRODUCTION: Catheter ablation of atrial fibrillation (AF) has been recently shown to have an impact on the outcome of patients with heart failure and reduced LV ejection fraction (LVEF). We aimed to assess patients with reduced LVEF referred to catheter ablation of AF, and the efficacy and safety of this procedure compared with healthier patients. METHODS: 2083 consecutive procedures of catheter ablation of AF in six centers were divided into two groups on the basis of LVEF (≤ vs >35%) and comparisons were performed regarding procedural safety and efficacy. RESULTS: Only 51 (2.4%) of patients had low LVEF. Complication rate was comparable: 8.0% vs 6.9% (P = .760). Low LVEF patients are more frequently in persistent AF at the time of the procedure, have a higher degree of left atrial dilation, and higher CHA2 DS2 VASc score. The rate of atrial arrhythmia relapse post-blanking period in the first 12 months was higher in the low LVEF group: 58.0% vs 37.6% (P

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

Aims Despite advances in interventional treatment strategies, atrial fibrillation (AF) remains associated with significant morbidity and mortality. Fibrotic atrial myopathy (FAM) is a main factor for adverse outcomes of AF-ablation, but complex to diagnose using current methods. We aimed to derive a scoring system based entirely on easily available clinical parameters to predict FAM and ablation-success in everyday care. Methods In this multicenter, prospective study, a new risk stratification model termed AF-SCORE was derived in 220 patients undergoing high-density left-atrial(LA) voltage-mapping to quantify FAM. AF-SCORE was validated for FAM in an external mapping-validation cohort (n = 220) and for success following pulmonary vein isolation (PVI)-only (without adjunctive left- or right atrial ablations) in an external outcome-validation cohort (n = 518). Results FAM was rare in patients p p p p Conclusions Age, sex and AF-phenotype are the main determinants for the development of FAM. A low AF-SCORE ≤ 2 is found in paroxysmal AF-patients of any age and younger patients with persistent AF irrespective of sex, and associated with favorable outcomes of PVI-only. Freedom from arrhythmia remains unsatisfactory with AF-SCORE ≥ 3 as found in older patients, particularly females, with persistent AF, and future studies investigating adjunctive atrial ablations to PVI-only should focus on these groups of patients. Graphical abstract

BACKGROUND The STAR AF II (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation 2) was a multicenter, randomized trial which randomized patients to pulmonary vein isolation (PVI) alone, PVI plus complex fractionated electrograms (CFE), or PVI plus linear ablation (roof line and mitral line). The study failed to show any additional benefit of additional substrate ablation (CFE or lines) in addition to PVI. However, complete block of linear ablations or total elimination of CFE was not achieved in all patients in the adjuvant ablation arms and this could explain why these additive ablation strategies did not improve outcome. We sought to determine whether completeness of adjuvant linear or CFE ablation affected the outcome of these additive ablation strategies when combined with PVI. METHODS AND RESULTS In STAR AF II, 549 patients were randomized 1:4:4 to PVI alone, PVI plus lines, and PVI plus CFE. In this substudy, outcomes of patients with complete linear block and without complete linear block in the PVI + lines group and outcomes for patients with all CFE regions successfully ablated and without all of them ablated in the PVI + CFE are analysed. Of the 243 patients in the PVI plus lines group who received both mitral and roof lines, bidirectional block across both lines was achieved in 179 (74%) but was not achieved in 65 (26%). At 18 months follow-up, AF recurrence occurred in 107 of 179 patients (59.8%) with complete block conduction block across lines and in 40 of 64 patients (62.5%) without complete block (p=0.89) (Figure 1). Even after 2 procedures, AF recurred in 51.9% of patients with complete linear block and 46% of patients without complete block (p=0.09). Of the 207 patients in the PVI plus CFE group who actually underwent CFE ablation, 188 (91%) had elimination of all CFE sites while all CFE were not eliminated in 19 (9%). At 18 months follow-up, AF recurrence occurred in 117 of 188 patients (62.2%) with all the CFE ablated and in 11 of 19 patients (57.9%) without all CFE ablated (p=0.47) (Figure 1). After 2 procedures, AF recurrence occurred in 56.7% of patients with all CFE ablated and 68.0% of patients without all CFE ablated (p=0.29). CONCLUSION PVI combined with both linear and CFE ablation did not result in less AF recurrence compared to PVI alone even after more than one procedure regardless of how well empiric linear or CFE ablation is performed.

Aims To evaluate the safety and effectiveness of pulmonary vein isolation in paroxysmal atrial fibrillation (PAF) using a standardized workflow aiming to enclose the veins with contiguous and optimized radiofrequency lesions. Methods and results This multicentre, prospective, non-randomized study was conducted at 17 European sites. Pulmonary vein isolation was guided by VISITAG SURPOINT (VS target ≥550 on the anterior wall; ≥400 on the posterior wall) and intertag distance (≤6 mm). Atrial arrhythmia recurrence was stringently monitored with weekly and symptom-driven transtelephonic monitoring on top of standard-of-care monitoring (24-h Holter and 12-lead electrocardiogram at 3, 6, and 12 months follow-up). Three hundred and forty participants with drug refractory PAF were enrolled. Acute effectiveness (first-pass isolation proof to a 30-min wait period and adenosine challenge) was 82.4% [95% confidence interval (CI) 77.4–86.7%]. At 12-month follow-up, the rate of freedom from any documented atrial arrhythmia was 78.3% (95% CI 73.8–82.8%), while freedom from atrial arrhythmia by standard-of-care monitoring was 89.4% (95% CI 78.8–87.0%). Freedom fromrepeat ablations by the Kaplan–Meier analysis was 90.4% during 12 months of follow-up. Of the 34 patients with repeat ablations, 14 (41.2%) demonstrated full isolation of all pulmonary vein circles. Primary adverse event (PAE) rate was 3.6% (95% CI 1.9–6.3%). Conclusions The VISTAX trial demonstrated that a standardized PAF ablation workflow aiming for contiguous lesions leads to low rates of PAEs, high acute first-pass isolation rates, and 12-month freedom from arrhythmias approaching 80%. Further research is needed to improve the reproducibility of the outcomes across a wider range of centres. Clinical trial registration: ClinicalTrials.gov, number NCT03062046, https://clinicaltrials.gov/ct2/show/NCT03062046.

Sergio Conti, Chen-yang Jiang, Timothy R. Betts, Jian Chen, Isabel Deisenhofer, Roberto Mantovan ... et al.

BACKGROUND AND PURPOSE: Saline-irrigated radiofrequency ablation (RFA) for atrial fibrillation (AF) is limited by the absence of reliable thermal feedback limiting the utility of temperature monitoring for power titration. The DiamondTemp (DT) ablation catheter was designed to allow efficient temperature-controlled irrigated ablation. We sought to assess the 1-year clinical safety and efficacy of the DT catheter in treating drug-refractory paroxysmal AF. METHODS: The TRAC-AF trial (NCT02821351) is a prospective, multi-center (n = 4), single-arm study which enrolled patients with symptomatic, drug-refractory, paroxysmal AF. Using the DT catheter, point-by-point ablation was performed around all pulmonary veins (PVs) to achieve PV isolation (PVI). Ablation was performed in a temperature-controlled mode (60 °C, max 50 W). Acute and chronic efficacy and safety was evaluated. RESULTS: Seventy-one patients (age 69.9 ± 11.0 years; 60.6% male) were ablated using the DT catheter. The mean fluoroscopy and RF ablationtimes were 9.3 ± 6.1 min and 20.6 ± 8.9 min, respectively. Acute isolation of all PVs was achieved in 100% of patients, and freedom from AF after 1 year was 70.6%. There were no steam pops, char, or coagulum on the catheter tip after ablation. There were few serious procedure/device-related adverse events including a single case of cardiac tamponade (1.4%) and transient ischemic attack (1.4). CONCLUSION: This first in man series demonstrates that temperature-controlled irrigated RFA with the DT catheter is efficient, safe, and effective in the treatment of paroxysmal AF. Randomized controlled trials are ongoing and will evaluate better the role of this catheter in relation to standard RFA. TRIAL REGISTRATION: Registered on the site ClinicalTrials.gov January 2016 with identifier: NCT02821351.

Aims: Saline-irrigated radiofrequency ablation (RFA) for atrial fibrillation (AF) is limited by the absence of reliable thermal feedback limiting the utility of temperature monitoring for power titration. The DiamondTemp (DT) ablation catheter allow efficient temperature-controlled irrigated ablation. We sought to assess the 1-year clinical safety and efficacy of the DT catheter in treating drug-refractory paroxysmal AF. Methods and results: The TRAC-AF trial (NCT02821351) is a prospective, multi-center (n=4), single-arm study that enrolled patients with symptomatic, drug-refractory paroxysmal AF. Using the DT catheter, point-by-point ablation was performed around all pulmonary veins (PVs) to achieve PV isolation (PVI). Ablation was performed in a temperature-control mode (60oC, max 50 W) until the split-tip EGM amplitude decreased by ≤75%. The primary efficacy endpoints included acute procedural success and freedom from AF at 12 months. A total of 62 patients (age 60.3 ± 11.4 years; 60% male) were evaluated after AF ablation using the DT catheter. The mean fluoroscopy and RF ablation times were 9.4±6.4 min and 19.8±8.6 min, respectively. Acute isolation of all PVs was achieved in 100% of patients. There were no steam pops and there were not seen any char or caugulum on the catheter tip after ablation. There were very few serious procedure/device-related adverse events including a single case of cardiac tamponade (1.6%). At 1 year, the freedom from AF was 74.2%. Conclusion: This first in man series demonstrates that temperature-controlled irrigated RFA with the DT catheter is efficient, safe, and effective in the treatment of paroxysmal AF.

Background/Introduction The use of a standardized ‘CLOSE’ ablation workflow for pulmonary vein isolation (PVI), with defined inter-tag distance (ITD) with targeted ablation index (AI) values, has been shown in single centre reports to result in good outcomes. The effect of this approach on patients’ quality of life (QoL) has not been studied. Purpose To evaluate the effects of paroxysmal atrial fibrillation (PAF) ablation by the CLOSE workflow on QoL and symptomatic AF reduction in the multicenter VISTAX study. Methods 329 patients with PAF (61.5% male, 61.3 ± 10.1 year) were treated at 17 European centres by point-by-point radiofrequency ablation using the CLOSE protocol to achieve PVI. An ITD ≤6mm and AI values of ≥400 on the posterior wall and ≥550 on the anterior wall were targeted. The AI value on the posterior wall was lowered as per investigator discretion in case of safety concerns. Patients were monitored for atrial arrhythmia recurrences via weekly and symptom-activated transtelephonic monitoring (TTM), for 12 months post procedure. Patients completed an Atrial Fibrillation Effect on Quality-of-life (AFEQT) questionnaire at their baseline and 12-month follow up visits. Results Majority (83.3% [274/329]) of patients experienced freedom from symptomatic atrial recurrence through 12 months. Of the 70 documented recurrences, 34 (49%) were documented by trans-telephonic monitoring only. All domains captured on the AFEQT questionnaire showed improvement with the overall score improving by 25.7, which exceeded the threshold of clinically meaningful improvement (±5) (Table). Patient reported most improvements in PAF control and symptoms relieved. The overall AFEQT score improvement was seen both in patients with or without documented atrial arrhythmia recurrence, with improvement by 21.5 and 26.8, respectively. Conclusion PAF ablation using a standardized CLOSE workflow resulted in consistent improvements in QoL. The improved QoL was observed regardless of atrial arrhythmia recurrence likely reflecting the low residual arrhythmia burden in patients with documented recurrence identified only on TTM. AFEQT Scores Through 12 Months AFEQT Domain Baseline 12 Months Change from Baseline* Daily Activities 59.2 85.3 26.0 Treatment Concerns 62.2 88.1 26.0 Controlling PAF 50.2 87.8 37.5 Symptoms 63.7 89.0 25.1 Symptoms Relieved 52.0 88.4 36.3 Overall AFEQT Score 61.3 87.2 25.7 *only includes patients who completed both baseline and 12 month AFEQT questionnaire

Background Advancements in electrophysiology 3-D mapping systems facilitate the broadening scope of electrophysiology study and catheter ablation to treat complex arrhythmias. While electroanatomical mapping systems have default settings available for a variety of mapping parameters, significant operator customization driven by arrhythmia type and experience can occur. However, multicenter comprehensive reporting of customized mapping settings is lacking. Methods In this prospective, multicenter observational registry, subjects with cardiac arrhythmias underwent electrophysiology study and ablation procedure using the EnSite Precision™ electroanatomical mapping system per standard of care, and associated automated mapping thresholds and procedural characteristics were observed. Results Cardiac mapping and ablation was performed in 503 patients (64.4% male, 59.6 ± 13.2 years) for a variety of indications including atrial fibrillation (N = 277), atrial flutter (N = 67), other supraventricular tachycardias (N = 96), and ventricular tachycardia (N = 56). Automated electroanatomical mapping was used to generate 88.2% of all maps, and arrhythmia-specific adjustments of mapping thresholds were utilized to collect electrophysiologically relevant data. The most commonly used thresholds for mapping in AF were Distance (average 2.7 ± 3.5 mm) and Signal-to-Noise Ratio (5.2 ± 1.1), while mapping in VT commonly used Score (88.5 ± 6.5%) and Distance (0.6 ± 0.5 mm). Automated mapping collected and utilized 8.8 times more data than manual mapping without increasing mapping time. Conclusions This registry revealed arrhythmia-specific automated mapping settings used to generate electroanatomical maps of multiple cardiac rhythms with higher point density than manual mapping without increasing mapping time. Commonly used mapping threshold settings could serve as an important reference for new automated electroanatomical mapping users or those expanding their usage to new indications and arrhythmias.

Controversy exists about the impact of acute atrial fibrillation (AF) termination and prolongation of atrial fibrillation cycle length (AFCL) during ablation on long-term procedural outcome.The purpose of this study was to analyze the influence of AF termination and AFCL prolongation on freedom from AF in patients from the STAR AF II (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial-Part II) trial.Acute changes in AFCL and AF termination were collected during the index procedure of the STAR AF II trial and compared to recurrence of AF at 18 months. Recurrence was assessed by ECG, Holter (3, 6, 9, 12, 18 months), and weekly transtelephonic ECG monitoring for 18 months.AF terminated in 8% of the pulmonary vein isolation (PVI) arm, 45% in the PVI+complex electrogram arm, and 22% of the PVI+linear ablation arm (P.001), but freedom from AF did not differ among the 3 groups (P = .15). Freedom from AF was significantly higher in patients who presented to the laboratory in sinus rhythm (SR) compared to those without AF termination (63% vs 44%, P = .007). Patients with AF termination had an intermediate outcome (53%) that was not significantly different from those in SR (P = .84) or those who did not terminate (P = .08). AF termination was a univariable predictor of success (P = .007), but by multivariable analysis, presence of early SR was the strongest predictor of success (hazard ratio 0.67, P = .004). Prolongation of AFCL was not predictive of 18-month freedom from AF.Acute AF termination and prolongation in AFCL did not consistently predict 18-month freedom from AF. Presence of SR before or early during the ablation was the strongest predictor of better outcome.

Background For conventional ablation of paroxysmal atrial fibrillation (AF), an ablation catheter in conjunction with a circular mapping catheter (CMC) is typically used for pulmonary vein isolation (PVI). Objective The purpose of this study was to evaluate an approach for PVI with a single contact-force (CF) ablation catheter in terms of procedural reliability, outcomes, and cost-effectiveness. Methods One hundred consecutive patients with paroxysmal AF were included in the study. Fifty patients (study group) underwent a CF-guided single-catheter approach, whereby PVI was demonstrated when sequential pacing at 9 equidistant points within the lesion set (carina included) failed to capture the left atrium. For confirmation, PVI was verified with a CMC. In comparison, 50 patients (control group) underwent a conventional PVI ablation guided by a CMC. Results Procedure time (101 ± 17 minutes vs 107 ± 15 minutes, P = .11), ablation time (24.2 ± 7.1 minutes vs 22.6 ± 8.8 minutes, P = .37), fluoroscopy time (5.6 ± 2.2 minutes vs 8.3 ± 3.4 minutes, P = .09), and applied CF (17.8 ± 2.6 g vs 18 ± 2.8 g, P = .72) did not reach statistical difference between the study and control groups. CF-guided single-catheter ablation achieved successful PVI in 98% of the study group and a 31% reduction in cost. At 1-year follow-up, sinus rhythm maintenance rate was similar in both groups (86% vs 84%, P = .78). Conclusion In paroxysmal AF, a CF-guided single-catheter technique is an effective method for PVI, yielding substantial cost savings and clinical results similar to a conventional approach.

Aims Non-invasive electrocardiogram (ECG) mapping allows the activation of the entire atrial epicardium to be recorded simultaneously, potentially identifying mechanisms critical for atrial fibrillation (AF) persistence. We sought to evaluate the utility of ECG mapping as a practical tool prior to ablation of persistent AF (PsAF) in centres with no practical experience of the system. Methods and results A total of 118 patients with continuous AF duration

Background Outcomes of catheter ablation of atrial fibrillation ( AF ) are variable and the predictors of success require further elucidation since the identification of correctable risk factors could help to optimize therapy. We aimed to assess the impact of body mass index ( BMI ) in the overall safety and efficacy of catheter ablation of AF , with emphasis on the use of cryoballoon ablation and novel oral anticoagulants. Methods and Results There were 2497 consecutive patients undergoing catheter ablation of AF in 7 European high volume centers were stratified according to BMI (normal weight 2 , pre‐obese 25–30 kg/m 2 , obesity 30–35 kg/m 2 , and morbid obesity ≥35 kg/m 2 ) and comparisons of procedural outcomes evaluated. Pre‐obese and obese patients presented more comorbidities (hypertension, diabetes mellitus, and sleep apnea), and had higher rates of non‐paroxysmal AF ablation procedures. The rate of atrial 12‐month arrhythmia relapse increased alongside with BMI (35.2%, 35.7%, 43.6%, and 48.0% P BMI was an independent predictor of relapse (hazard ratio=1.01 per kg/m 2 ; 95% CI 1.01–1.02; P =0.002), adding incremental predictive value to obstructive sleep apnea. BMI was not a predictor for any of the reported complications. Using novel oral anticoagulants and cryoballoon ablation was safe and efficacy was comparable with vitamin‐K antagonists and radiofrequency ablation. Conclusions Obese patients present with a more adverse comorbidity profile, more advanced forms of AF , and have lower chances of being free from AF relapse after ablation. Use of novel oral anticoagulants and cryoballoon ablation may be an option in this patient group.

Background: The FIRE AND ICE trial assessed efficacy and safety of pulmonary vein (PV) isolation using cryoballoon versus radiofrequency current (RFC) ablation in patients with drug refractory, symptomatic, paroxysmal atrial fibrillation (AF). The purpose of the current study was to assess index lesion durability as well as reablation strategy and outcomes in trial patients undergoing a reablation procedure. Methods: Patients with reablation procedures during FIRE AND ICE were retrospectively consented and enrolled at 13 trial centers. The first reablation for each patient was included in the analysis. Documented arrhythmias before reablation, number and location of reconnected PVs, lesions created during reablations, procedural characteristics, and acute as well as long-term outcomes were assessed. Results: Eighty-nine (36 cryoballoon and 53 RFC) patients were included in this study. Paroxysmal atrial fibrillation was the predominant recurrent arrhythmia (69%) before reablation. Reablations occurred at a median of 173 and 182 days ( P =0.54) in the cryoballoon and RFC cohorts, respectively. The number of reconnected PVs was significantly higher in the RFC than the cryoballoon group (2.1±1.4 versus 1.4±1.1; P =0.010), which was driven by significantly more reconnected left superior PVs and markedly more reconnected right superior PVs. The number of (predominantly RFC) lesions applied during reablation was significantly greater in patients originally treated with RFC (3.3±1.3 versus 2.5±1.5; P =0.015) with no difference in overall acute success ( P =0.70). After reablation, no differences in procedure-related rehospitalization or antiarrhythmic drug utilization were observed between cohorts. Conclusions: At reablation, patients originally treated with the cryoballoon had significantly fewer reconnected PVs, which may reflect RFC catheter instability in certain left atrial regions, and thus required fewer lesions for reablation success. Repeat ablations were predominantly performed with RFC and resulted in similar acute success, duration of hospitalization, and antiarrhythmic drug prescription between the study cohorts. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03314753.

In 2012, the year the FIRE AND ICE Trial was initiated, the European Society of Cardiology and the Heart Rhythm Society consensus statements recognized RFC as the dominant energy source for AF catheter ablation and discussed PVI as a promising treatment approach.14, 15 In response to the FIRE AND ICE Trial and many other trials, the consensus documents were updated to recognize PVI as a safe and effective strategy for the treatment of AF with either of the 2 leading catheter ablation modalities, cryoballoon or RFC ablation.16, 17 Evaluation of the comprehensive end points, in addition to the primary end point that demonstrated noninferiority between the treatment modalities, may have contributed to the acceptance and adoption of cryoballoon ablation. Indeed, secondary end points of the trial were critical in identifying clinically important differences between the 2 treatment cohorts. Thoughtful design and rigorous assessment of secondary outcomes of future clinical trials may be essential to defining the patient‐specific impact of new catheter ablation technologies for the treatment of AF.

IMPORTANCE: Catheter ablation is effective in reducing atrial fibrillation (AF), but the association of ablation for AF with quality of life is unclear. OBJECTIVE: To evaluate whether the procedural outcome of ablation for AF is associated with quality of life (QOL) measures. DESIGN, SETTING, AND PARTICIPANTS: This was a prespecified secondary analysis of the Substrate and Trigger Ablation for Reduction of Atrial Fibrillation–Part II (STAR AF II) prospective randomized clinical trial, which compared 3 strategies for ablation of persistent AF. This analysis included 549 of the 589 patients enrolled in the trial who underwent ablation. Enrollment occurred at 35 centers in Europe, Canada, Australia, China, and Korea from November 2010 to July 2012. Data for the current study were analyzed on December 11, 2019. INTERVENTIONS: Patients underwent AF ablation with 1 of 3 ablation strategies: (1) pulmonary vein isolation (PVI), (2) PVI plus complex fractionated electrograms, or (3) PVI plus linear lesions. MAIN OUTCOMES AND MEASURES: Quality of life was assessed at baseline and at 6, 12, and 18 months after ablation for AF using the 36-Item Short Form Health Survey and the EuroQol Health-Related Quality of Life 5-Dimension 3-Level questionnaire. Scores were also converted to a physical health component score (PCS) and a mental health component score (MCS). Individual AF burden was calculated by the total time with AF from Holter monitors and the percentage of transtelephonic monitor recordings showing AF. RESULTS: Among the 549 patients included in this secondary analysis, QOL was assessed in 466 (85%) at baseline and at 6, 12, and 18 months after ablation for AF. The mean (SD) age of the study population was 60 (9) years; 434 (79%) individuals were men, and 417 (76%) had continuous AF for 6 months or more before ablation. The AF burden significantly decreased from a mean (SD) of 82% (36%) before ablation to 6.6% (23%) after ablation (P

International audience; PURPOSE:Recent data show no benefit of additional ablation beyond pulmonary vein isolation (PVI) in persistent atrial fibrillation (AF). Evidence suggests that radiofrequency energy (RF) and cryoballoon (CRYO) have comparable efficacy for PVI. We aimed to assess the outcomes after a single catheter ablation procedure, comparing PVI using CRYO vs. RF ablation for PVI plus additional ablation in a cohort of patients with persistent AF.METHODS:In this prospective multicenter propensity score-matched comparison, 59 consecutive patients undergoing CRYO ablation of persistent AF were matched to 59 patients treated with RF from November 2010 to June 2012.RESULTS:During a mean follow-up of 15.6 ± 11.5 months, 43.2 % of patients presented atrial arrhythmia relapse after a blanking period of 3 months, which was comparable between the two groups (40.7 % in CRYO vs. 45.8 % in RF, Log rank P = 0.14; HR = 0.67, 95 %CI 0.38-1.16, P = 0.15), despite the fact that 52.5 % of RF patients add additional complex fractionated atrial electrogram ablation, as well as left atrial linear ablation in over two-thirds (roof line in 67.8 % and mitral isthmus in 32.2 %). On multivariate Cox regression, only AF duration in years (HR = 1.10, 95 %CI 1.01-1.10, P = 0.04) was a predictor of relapse. Patients undergoing RF ablation presented a numerically, but non-significantly, lower complication rate (6.8 vs 10.2 %, P = 0.51).CONCLUSION:In our multicenter experience, freedom from atrial arrhythmias was comparable among matched patients treated with CRYO and RF, despite non-significant trends in favor of RF in terms of complications, at the cost of longer procedure times.

International audience; The prevalence of atrial fibrillation (AF) is increased in hyperthyroidism. The degree to which thyroid hormones affect the outcomes of left atrial (LA) ablation is still unclear. From September 2010 to September 2013, 1,095 patients who underwent LA ablation (59.7% paroxysmal AF, 32.3% persistent AF, and 8.0% LA tachycardia) had their serum thyroid-stimulating hormone (TSH) and free thyroxine (FT4) levels measured in the 48 hours before the procedure. Patients were followed until they presented the first AF relapse after a blanking period of 3 months. TSH and FT4 were assessed as predictors of arrhythmia relapse and were adjusted for possible confounders. During a mean follow-up of 12.5 ± 7.9 months, 28.9% of patients presented an atrial arrhythmia relapse. TSH was not a predictor of relapse. In contrast, after adjustment, FT4 (median = 11.8 ng/L and interquartile range 10.6 to 14.6 ng/L) remained a predictor of relapse with 15% increase per quartile (hazard ratio 1.15, 95% confidence interval 1.03 to 1.29, p = 0.014). In conclusion, FT4 levels influence the success rate of LA ablation procedures, even when in the normal range.

Background: Data on predictors of long-term clinical outcomes after catheter ablation of atrial fibrillation (AF) are limited. We sought to assess the association of baseline covariates with clinical outcomes in the 750 patients with drug-refractory paroxysmal AF enrolled in FIRE AND ICE. Methods: In a 2-part analysis, univariate and multivariable Cox regression models were first used to identify baseline patient characteristics predictive of catheter ablation efficacy determined by the clinical end points of (1) atrial arrhythmia recurrence (primary efficacy failure), (2) cardiovascular rehospitalization, and (3) repeat ablation. Propensity score stratification methods were then used to account for differences in baseline characteristics between sexes. RESULTS: Female sex (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.08–1.73; P =0.010) and prior direct current cardioversion (HR, 1.40; 95% CI, 1.07–1.82; P =0.013) were independently associated with atrial arrhythmia recurrence. Female sex (HR, 1.36; 95% CI, 1.02–1.80; P =0.035) and hypertension (HR, 1.48; 95% CI, 1.09–2.00; P =0.013) independently predicted cardiovascular rehospitalization. A longer history of AF (HR, 1.03; 95% CI, 1.00–1.06; P =0.039) increased the rate of repeat ablation. Women continued to have higher rates of primary efficacy failure and cardiovascular rehospitalization after propensity score adjustment, with adjusted HRs of 1.51 (95% CI, 1.16–2.18; P P Conclusions: After catheter ablation of paroxysmal AF, female sex was associated with an almost 40% increase in the risks of primary efficacy failure and cardiovascular rehospitalization. Primary efficacy failure was also adversely impacted by a history of direct current cardioversion, whereas hypertension had a negative impact on cardiovascular rehospitalization. History of AF was the only predictor of repeat ablation. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01490814.

Introduction The aim of this study was to evaluate a spatial correlation between active atrial fibrillation (AF) drivers measured by electrocardiographic imaging and complex fractionated atrial electrograms (CFAEs) in patients with persistent AF. Methods Sixteen patients with persistent AF were included. A biatrial geometry relative to an array of 252-body-surface-electrodes was obtained from a noncontrast computed tomography scan. The reconstructed unipolar AF electrograms were signal-processed (ECVUE™, CardioInsight Technologies Inc., Cleveland, OH, USA) to identify AF drivers. Before driver ablation, a biatrial mapping using the NavX system (St. Jude Medical, St. Paul, MN, USA) was performed to identify CFAEs. CFAE and driver regions were then quantified and compared. Results AF was terminated by driver ablation in 11/16 (70%) patients. The mean number of ablated driver regions was 4 ± 1 per patient. The most frequent driver locations were the inferior left atrium and coronary sinus, the right pulmonary veins, and the right atrium. In 49/63 (78%) of the driver locations, more than 75% of the driver site showed CFAEs. The mean ablated driver area was 58 ± 24 cm2 (19 ± 11% of total surface area). The mean CFAE area was 178 ± 59 cm2 (49 ± 16%). The percentage of non-ablated CFAE area was 76 ± 13% of total CFAEs. In 9/11 patients with AF termination, the termination site showed CFAEs. Conclusions There is a significant overlap between AF driver regions identified by the ECVUE™ system and CFAE areas identified by the NavX system. AF driver regions are smaller and mostly embedded in larger CFAE areas. Selective ablation of drivers in CFAE areas seems sufficient to terminate persistent AF in the majority of patients.

Pulmonary vein isolation is the cornerstone of paroxysmal atrial fibrillation ablation. Radiofrequency (RF) ablation is currently the most widespread technique. Recently, cryoballoon ablation has emerged as an alternative to RF ablation for paroxysmal atrial fibrillation. Until now there are no data from randomized trial comparing these two techniques. The purpose of this report was to review the pulmonary vein isolation acute success, the efficiency at follow-up and the safety of these two ablation strategies. Additionally, some considerations are made concerning the contact-force sensing RF catheters and the second-generation cryoballoon.

BackgroundCatheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation. MethodsWe randomly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure. ResultsProcedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P

Background Atrial fibrillation (AF) progressively leads to electrical remodeling (ER) and anatomical-mechanical remodeling (AR), whose relationships in humans remain poorly known. Methods ER and AR were compared in patients undergoing percutaneous radiofrequency (RF) ablation for AF. ER was defined by right and left appendage activation rates as a surrogate for atrial refractory periods. AR was approached by left atrial (LA) diameters and area and left atrial appendage (LAA) area and contractile function (mean emptying flow velocity) (LAAFV) before RF ablation. Mean duration between successive LAA contractions was considered as LAA mechanical rate. Results Forty-one patients (31 men, age: 64 ± 9 years) with paroxysmal (27%), persistent (61%), or long-persistent AF (12%) were prospectively included (ejection fraction: 44 ± 16%). Parameters exploring AR were highly correlated to each other: LA area (28 ± 7 cm2), LAA area (5.7 ± 2.25 cm2), LA transverse (49 ± 7 mm), and anteroposterior diameter (59 ± 13 mm) or LAAFV (29 ± 13 cm/s; P < 0.05 for each comparison). Parameters exploring ER were also highly correlated: right atrial appendage (RAA; 181 ± 39 ms) and LAA (176 ± 33 ms) activation rates (P < 0.0001). There was no significant correlation between any ER and AR parameter. Only LAA mechanical rate (174 ± 36 ms) was correlated to LAA or RAA activations rates (P ≤ 0.01). Conclusion ER and AR are not mutually related, atrial activation rate being not correlated to LA or LAA size or function. Thus, the mechanisms leading to AF-induced atrial remodeling may differ for anatomical and electrophysiological aspects.

Rationale and Design of Fire and IceBackground Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia imposing substantial morbidity and mortality. Catheter-based pulmonary vein isolation (PVI) using radiofrequency current (RFC) has become a standard treatment for drug-resistant and symptomatic paroxysmal AF (PAF). In recent years, the cryoballoon-based technique is increasingly used as a promising alternative with a short learning curve. Methods The FIRE AND ICE trial is a prospective, randomized, controlled, open, blinded outcome assessment, noninferiority trial comparing cryoballoon-, and RFC-based PVI. Patients with drug-resistant PAF will be randomized in a 1:1 matrix in multiple European centers. The primary hypothesis is that cryoballoon ablation is not inferior to RFC ablation using 3-dimensional mapping with respect to clinical efficacy. The primary endpoint is defined as the time to first documented clinical failure, including: (1) recurrence of AF; (2) atrial flutter or atrial tachycardia; (3) prescription of class I or III antiarrhythmic drugs; or (4) re-ablation, whichever comes first, following a blanking period of 3 months after the index ablation procedure. The primary safety endpoint is a composite of death, stroke/transient ischemic attack, cardiac arrhythmias (apart from AF recurrence) causally related to the therapeutic intervention, and procedure-related serious adverse events. Conclusion The FIRE AND ICE trial compares 2 different technologies to perform catheter ablation of PAF with respect to efficacy and safety. It aims at providing objective data to guide selection and usage of ablation catheters in the treatment of AF.

Aim Real-time assessment of pulmonary vein (PV) disconnection is possible using an inner circular mapping catheter during cryoablation of atrial fibrillation (AF). However, it has been recently demonstrated that such continuous monitoring may only be possible in

Real-Time Contact Force Sensing for Pulmonary Vein IsolationIntroduction The additional benefit of contact force (CF) technology during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) to improve mid-term clinical outcome is unclear. Methods and Results Eligible patients with symptomatic paroxysmal AF were enrolled in this prospective trial, comparing circular antral catheter ablation (guided by Carto 3 System, Biosense Webster) using either a new open-irrigated CF catheter (SmartTouch Thermocool, Biosense Webster) (CF group) or a non-CF open-irrigated catheter (EZ Steer Thermocool, Biosense Webster) (control group). Overall, 30 patients were enrolled in each group, with a standardized 12-month follow-up, free of antiarrhythmic therapy. Demographic, cardiovascular and anatomic characteristics were similar in both groups. Though complete PVI was eventually achieved in all cases in both groups, success using an exclusive anatomic approach was 80.0% in CF group versus 36.7% in control group (P < 0.0001). CF use was associated with significant reductions in fluoroscopy exposure (P < 0.01) and radiofrequency time (P = 0.01). The incidence rates of AF recurrence were 10.5% (95% CI, 1.38–22.4) in the CF group, and 35.9% (95% CI, 12.4–59.4) in the control group (log rank test, P = 0.04). After adjustment on potential confounders, the use of CF catheter was found to be associated with a lower AF recurrence (OR 0.18, 95% CI 0.04–0.94, P = 0.04). Conclusion Our findings suggest a potential benefit of real-time CF sensing technology, in reducing AF recurrence during the first year after PVI.

Background Dabigatran etexilate, a new thrombin inhibitor, has been shown to be comparable to warfarin in patients with atrial fibrillation (AF). However, there is a limited body of evidence on the efficacy and safety of using dabigatran among patients undergoing AF catheter ablation. Objective A random effects meta-analysis was performed of controlled trials comparing dabigatran and warfarin in paroxysmal/persistent AF patients undergoing catheter ablation. Methods Data sources included Medline, Embase, and Cochrane (from inception to April 2013). Three independent reviewers selected studies comparing warfarin to dabigatran. Descriptive and quantitative information was extracted from each selected study, regarding periprocedural all cause mortality, thromboembolic events and major bleeding, as well as modalities of periprocedural anticoagulation bridging. Results After a detailed screening of 228 search results, 14 studies were identified enrolling a total of 4782 patients (1823 treated with dabigatran and 2959 with warfarin). No deaths were reported. No significant differences were found between patients treated with dabigatran and warfarin as regards thromboembolic events (0.55% dabigatran vs 0.17% warfarin; risk ratios (RR)=1.78, 95% CI 0.66 to 4.80; p=0.26) and major bleeding (1.48% dabigatran vs 1.35% warfarin; RR=1.07, 95% CI 0.51 to 2.26; p=0.86). No difference was found between the 110 mg twice daily and 150 mg twice daily dabigatran dosages concerning major bleeding (0% vs 1.62%, respectively; RR=0.19, 95% CI 0.01 to 3.18; p=0.25) and thromboembolism (0% vs 0.40%, respectively; RR=0.72, 95% CI 0.04 to 12.98; p=0.82). Conclusions In the specific setting of AF catheter ablation, this first pooled analysis suggests that patients treated with dabigatran have a similar incidence of thromboembolic events and major bleeding compared to warfarin, with low event rates overall.

We have read with interest the letter by Canpolat and would like to thank him to his important remarks.1 We suggested in our study that cryoballoon ablation displayed comparable results to radiofrequency, irrespectively of pulmonary vein anatomy, assessed as number of veins on each side.2 Indeed, some previous studies have shown some discrepant results according with the pulmonary veins anatomy and the energy source. Such data with detailed anatomical evaluation like PV orientation, PV ostium …

Aims The primary safety and efficacy endpoints of the randomized FIRE AND ICE trial have recently demonstrated non-inferiority of cryoballoon vs. radiofrequency current (RFC) catheter ablation in patients with drug-refractory symptomatic paroxysmal atrial fibrillation (AF). The aim of the current study was to assess outcome parameters that are important for the daily clinical management of patients using key secondary analyses. Specifically, reinterventions, rehospitalizations, and quality-of-life were examined in this randomized trial of cryoballoon vs. RFC catheter ablation. Methods and results Patients (374 subjects in the cryoballoon group and 376 subjects in the RFC group) were evaluated in the modified intention-to-treat cohort. After the index ablation, log-rank testing over 1000 days of follow-up demonstrated that there were statistically significant differences in favour of cryoballoon ablation with respect to repeat ablations (11.8% cryoballoon vs. 17.6% RFC; P = 0.03), direct-current cardioversions (3.2% cryoballoon vs. 6.4% RFC; P = 0.04), all-cause rehospitalizations (32.6% cryoballoon vs. 41.5% RFC; P = 0.01), and cardiovascular rehospitalizations (23.8% cryoballoon vs. 35.9% RFC; P < 0.01). There were no statistical differences between groups in the quality-of-life surveys (both mental and physical) as measured by the Short Form-12 health survey and the EuroQol five-dimension questionnaire. There was an improvement in both mental and physical quality-of-life in all patients that began at 6 months after the index ablation and was maintained throughout the 30 months of follow-up. Conclusion Patients treated with cryoballoon as opposed to RFC ablation had significantly fewer repeat ablations, direct-current cardioversions, all-cause rehospitalizations, and cardiovascular rehospitalizations during follow-up. Both patient groups improved in quality-of-life scores after AF ablation. Clinical trial registration ClinicalTrials.gov identifier: [NCT01490814][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01490814&atom=%2Fehj%2Fearly%2F2016%2F07%2F04%2Feurheartj.ehw285.atom

Although pulmonary vein isolation (PVI) is the cornerstone for catheter ablation of atrial fibrillation (AF), it is not known if additional ablation would improve outcomes, particularly for persistent AF [(1,2)][1]. Recently, the multicenter randomized STAR AF II (The Substrate and Trigger Ablation

Ablation of paroxysmal AF in symptomatic patients is a clear indication after failure of anti-arrhythmic therapy (class IIa according to the recommendations). Ablation of persistent AF is feasible, as second line after failure of medical treatment, although there is no real consensus on ablative techniques : this procedure is long and complex, exposure to ionizing radiation is important. Regarding ablation of persistent AF, a careful selection of patients and multiple interventions are often necessary to increase the success rate. Standardization of the procedure and better reproducibility of results are essential to increase the indications for ablation in patients with persistent AF. Improvements are expected concerning the operative strategy, the targets of ablation and available tools.

Introduction: Recent expert consensus guidelines mention that one of the principles for infected device replacement following removal is to “reevaluate carefully if there is a continued need for a new cardiac device replacement.” This is a Class I recommendation, which nevertheless suffers from a very low level of evidence (level of evidence C), since no study has revisited the systematic practice of reimplanting the same device based on a meticulous clinical reassessment. In the present paper, we examined the safety of withholding the implantation of pacing systems in selected patients. Methods and Results: Between January 2005 and December 2007, 188 consecutive patients underwent extractions of infected pacing systems at 2 medical centers. “Low-risk” patients were identified by (1) a spontaneous heart rate >45 bpm, (2) no symptomatic asystole during monitoring, (3) QRS duration

International audience; AIMS: The aim of this study was to investigate the 12-month incidence, predictive factors, and prognosis of sustained ventricular tachycardia (VT) in chronic heart failure patients implanted with biventricular pacemakers without a back-up defibrillator (CRT-P), assessed by continuous intracardiac ventricular electrograms. METHODS AND RESULTS: The Mona Lisa study, a prospective, multicentre, cohort study, designed to determine the incidence of sustained VT and its prognostic impact in CRT-P recipients within the year after implant enrolled 198 patients with moderate or severe chronic heart failure, despite optimal pharmacological therapy. An independent committee reviewed the data from all arrhythmic episodes as well as causes of death according to predefined criteria. During a mean follow-up of 9.8 +/- 3.1 months after implantation, 8 patients experienced at least one episode of sustained VT [4.3%; 95% confidence interval (CI), 1.1-7.5] and 21 deaths occurred, giving a 12-month mortality rate of 11.7% (95% CI, 6.4-16.9). The presence of sustained VT was associated with a high risk of sudden cardiac death (SCD) and the lowest 12-month overall survival (P < 0.0001). CONCLUSION: The incidence of sustained VT remains relatively low in the first year after CRT-P implantation, but when present appears closely associated with short-term adverse outcomes, especially SCD. This emphasizes the possible value of remote monitoring to detect high-risk patients for urgent upgrading.

The authors underline the importance of carrying out a simple clinical examination to assess the level of two-to-one auriculoventricular block before any invasive electrophysiological procedures are performed. Clinical examination can indeed easily distinguish between the two different prognostic entities, represented by nodal and infra-nodal atrioventricular block. This initial evaluation of the severity of conduction disorders, as soon as the patient arrives at the emergency department or attends a consultation, may be greatly helpful in selecting the most appropriate management of those patients.

Aims In the setting of atrioventricular nodal re-entrant tachycardia (AVNRT), radiofrequency (RF) catheter ablation of the slow-pathway (SP) ensures excellent outcome. However, the risk of complete heart block (CHB) remains real (≈1%) and detrimental. This study reports on a gradual power titration approach using RF energy, which allows a significant decrease in CHB occurrence. Methods and results Slow-pathway ablation was performed in 468 patients (mean age 43.8 ± 17.2 years, 311 women). Initial settings were 5 W, 60°C, 120 s (temperature-controlled mode). The power was increased by steps of 5 W for every 5 s until slow-accelerated junctional rhythm was obtained, and then further increased to 10 W maximum above this value. The acute success rate, the mean RF pulses applied per patient, and the average power delivered per successful RF applications were 99%, 3.2 ± 1.1, and 31.7 ± 3.0 W, respectively. There were nine (1.9%) transient and reversible AV blocks, and one (0.2%) permanent CHB only necessitating pacemaker insertion. The recurrence rate was 3.6% and the follow-up period was 28.1 ± 14.1 months. Conclusion Atrioventricular nodal re-entrant tachycardia RF ablation using gradual power titration is an efficient technique, capable of improving safety since it can decrease CHB occurrence.

In the context of chronic atrial fibrillation (AF) ablation, substrate modulation has demonstrated its efficacy and its positive impact both into conversion of the AF either directly to sinus rhythm (SR) or to atrial tachycardia (AT) and into SR maintenance. However, substrate modulation, which can be performed either by linear lesions deployment or/and by targeting complex and fractionated atrial electrograms (CFAEs), can be a difficult task. We present a safe and non time-consuming technique conceived in our center which we think is of interest for substrate modulation purpose in the AF ablation framework. This technique named the "clockwise loop approach" may permit both extensive and accurate mapping of a great amount of the LA and facilitation of LA linear lesions deployment.

Arrhythmic cardiomyopathies are due to ventricular dysfunction following prolonged or chronic tachycardia; the clinical pictures one of congestive heart failure, which is totally reversible after the treatment of tachycardia and the restoration of sinus rhythm. Since Whipple's first description of this model of heart failure, several teams have shown that ventricular or atrial pacing at rates exceeding 220 beats per minute produces a profound and largely reversible depression of ventricular function, and a constellation of neuroendocrine abnormalities and metabolic, electrophysiological and anatomic alterations of the myocardium. The associated heart failure generally starts to improve within days of achieving ventricular rhythm control, but clinical recovery may take several weeks or months. All forms of chronic tachycardia may induce heart failure, but the onset of cardiomyopathy depends more on the heart rate and the duration of the arrhythmia than on its type. The pathophysiological mechanisms are multiple and complex, and include abnormalities in the structure and function of cardiomyocytes and disturbances in excitation-contraction coupling. Treatment consists of restoring and maintaining sinus rhythm, or at least of controlling the ventricular rate. Because of its curative effect, selective radiofrequency ablation is the treatment of choice when the arrhythmogenic substrate is localized. Control of the ventricular rate by radiofrequency modification of atrioventricular conduction is the treatment of choice for chronic atrial fibrillation.

AIMS: Whether pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using contact force (CF)-guided radiofrequency (RF) or second-generation cryoballoon (CB) present similar efficacy and safety remains uncertain. METHODS AND RESULTS: We performed a multicentre study comparing procedural safety and arrhythmia recurrence after standardized PVI catheter ablation for PAF using CF-guided RF ablation (Thermocool(®) SmartTouch™, Biosense Webster; or Tacticath™, St Jude Medical) (CF group) with second-generation CB ablation (Arctic Front Advance™, Medtronic) (CB group). Overall, 376 patients (mean age 59.8 ± 10.4 years, 280 males) were enrolled in 4 centres: 198 in CF group and 178 in CB group. Procedure was shorter for CB group than for CF group (109.6 ± 40 vs. 122.5 ± 40.7 min, P = 0.003), but fluoroscopy duration and X-ray exposure were not statistically different (P = 0.1 and P = 0.22, respectively). Overall complication rate was similar in both groups: 14 (7.1%) in the CF group vs. 13 (7.3%) in the CB group (P = 0.93). However, transient right phrenic nerve palsy occurred only in CB group (10 patients, 5.6%; P = 0.001 vs. CF group) and severe non-lethal complications (embolic event, tamponade, or oesophageal injury) occurred only in CF group (5 patients, 2.5%; P = 0.03 vs. CB group). No periprocedural death occurred in either group. Single-procedure freedom from any atrial arrhythmias at 18 months post-ablation was comparable in CF group and CB group (76 vs. 73.3%, respectively, log rank P = 0.63). CONCLUSION: Pulmonary vein isolation using CF-guided RF and second-generation CB leads to comparable single-procedure arrhythmia-free survival at up to 18 months with similar overall complication rate.