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Background: Cryoballoon ablation for atrial fibrillation (AF) requires adequate contact between the pulmonary vein (PV) antrum and cryoballoon. The surge of intraballoon pressure during the initial phase of ablation may change the balloon's shape and compliance, resulting in balloon dislodgement and loss of PV occlusion. Without continuous monitoring, this phenomenon is often undetected but can be associated with incomplete PV isolation (PVI)., Methods: Primary cryoablation of AF was performed in 15 patients. PV occlusion status pre- and post-freezing were analyzed with intracardiac echocardiography (ICE) and dielectric imaging-based occlusion tool (DIOT) to calculate the incidence of expansion dislodgement of cryoballoon., Results: A total of 105 cryoablation applications were performed on 57 veins, including three common ostiums of left pulmonary veins. In the evaluation of PV occlusion, both modalities reported consistent results in 86.7% of the assessments. Despite complete PV occlusion before ablation, peri-balloon leak after initiation of freezing was detected by ICE in 5/22 (22.7%) applications and by DIOT in 8/25 (32%) applications., Conclusion: Incidence of expansion dislodgement of the cryoballoon was detected in one-fourth to one-third of cryoablation applications depending on the imaging modality used, which was clinically frequent and significant., (© 2023 Wiley Periodicals LLC.)

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., (© 2023 Wiley Periodicals LLC.)

Background: With advancements in technology and ablation techniques, catheter ablation for the treatment of atrial fibrillation (AF) has become safer with time. In the past, standard-of-care recommended overnight stay for outpatient procedures. As safety has improved and procedure times have shortened, some centers have allowed for same-day discharge. We report the results of a multi-center, randomized clinical trial investigating the safety of same-day discharge post-cryoballoon ablation., Methods: Patients with paroxysmal atrial fibrillation underwent pulmonary vein isolation (PVI) with the Medtronic Arctic Advance cryoballoon at 3 US centers. Six hours after the procedure, patients were randomized to either stay overnight or be discharged same day., Results: A total of 49 patients were enrolled. Two patients were withdrawn prior to randomization. One patient chose to withdraw after randomization. Of the 22 patients randomized to same-day discharge and the 23 patients randomized the overnight stay, no significant adverse outcomes were reported in either group. Occurrence of adverse events did not differ significantly between the two groups. Procedure time and fluoroscopy time did not significantly differ between groups., Conclusions: This is the first randomized trial examining the safety of same-day discharge post-cryoballoon ablation. Based on our results, same-day discharge following cryoballoon ablation for paroxysmal AF is a safe option following uncomplicated ablation for PVI. Operators should use their discretion in selecting patients for same-day discharge., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In randomized studies, the strategy of pulmonary vein antral isolation (PVI) plus linear ablation has failed to increase success rates for persistent atrial fibrillation (PeAF) ablation when compared with PVI alone. Peri-mitral reentry related atrial tachycardia due to incomplete linear block is an important cause of clinical failures of a first ablation procedure. Ethanol infusion (EI) into the vein of Marshall (EI-VOM) has been demonstrated to facilitate a durable mitral isthmus linear lesion., Objective: This trial is designed to compare arrhythmia-free survival between PVI and an ablation strategy termed upgraded '2C3L' for the ablation of PeAF., Study Design: The PROMPT-AF study (clinicaltrials.gov 04497376) is a prospective, multicenter, open-label, randomized trial using a 1:1 parallel-control approach. Patients (n = 498) undergoing their first catheter ablation of PeAF will be randomized to either the upgraded '2C3L' arm or PVI arm in a 1:1 fashion. The upgraded '2C3L' technique is a fixed ablation approach consisting of EI-VOM, bilateral circumferential PVI, and 3 linear ablation lesion sets across the mitral isthmus, left atrial roof, and cavotricuspid isthmus. The follow-up duration is 12 months. The primary end point is freedom from atrial arrhythmias of >30 seconds, without antiarrhythmic drugs, in 12 months after the index ablation procedure (excluding a blanking period of 3 months)., Conclusions: The PROMPT-AF study will evaluate the efficacy of the fixed '2C3L' approach in conjunction with EI-VOM, compared with PVI alone, in patients with PeAF undergoing de novo ablation., Competing Interests: Conflict of interest None reported., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate the feasibility of real-time visualization and mapping of the right phrenic nerve (RPN) by using intracardiac echocardiography (ICE) during atrial fibrillation (AF) ablation., Background: RPN injury is a complication associated with the ablation of AF. Multiple approaches are currently being used to prevent and detect RPN injuries. However, none of these approaches can directly visualize the RPN in real-time during the ablation procedure., Methods and Results: The RPN was detected using ICE. The RPN and its adjacent structures were analysed. The relationship between the RPN's distance from the superior vena cava (SVC) and its pacing capture threshold was quantified. The safety of SVC isolation guided by the ICE-visualized RPN was evaluated. Thirty-eight people were enrolled in this study. The RPN was visualized by ICE in 92% of patients. It ran through the space between the SVC and the mediastinal pleura and had a 'straw'-like appearance upon ICE imaging. The course of the RPN was close to the SVC (minimum 1.0 ± 0.4 mm) and the right superior pulmonary vein (minimum 14.1 ± 7.3 mm). There was a positive linear correlation between the RPN's capture threshold and its distance from the SVC (Spearman's correlation coefficient = 0.728, < 0.001). SVC isolation was guided by the RPN; none of the patients developed an RPN injury., Conclusions: RPN can be visualized by ICE in most patients, thus providing a novel approach for the real-time detection of RPN during AF ablation., Competing Interests: Conflict of interest: None declared, (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Purpose of Review: This review aims to summarize the recent development, benefit, and safety of extrapulmonary vein ablation for atrial fibrillation., Recent Finding: Studies have shown that extrapulmonary vein ablation can help maintain normal sinus rhythm for patients with persistent atrial fibrillation. As prior strategies targeting anatomical lines and triggers are well utilized, novel techniques for substrate mapping have been rapidly developing. These strategies are well tolerated and could be chosen based on patients' conditions and physicians' experience., Summary: Extrapulmonary vein ablation could be safely and effectively performed for patients with atrial fibrillation. It provides further consolidation of normal sinus rhythm., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: The cryoballoon catheter has been an option for the treatment of atrial fibrillation for over a decade. The most widely used device is the Medtronic Arctic Advance cryoballoon catheter. Recently, Boston Scientific has released the POLARx cryoballoon catheter. Here we review the major changes in the catheter system's design and its implications for procedural practice., Recent Findings: The POLARx cryoballoon catheter has been approved for use in Europe. Some studies have been published detailing the first clinical experiences in vivo with this newest technology., Summary: The changes to the POLARx cryoballoon catheter, particularly its ability to maintain balloon size and pressure, will improve occlusion and theoretically improve procedural outcomes., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Linear ablation in addition to pulmonary vein antrum isolation (PVAI) has failed to improve the success rate for persistent atrial fibrillation (PeAF), due to incomplete block of ablation lines, especially in the mitral isthmus (MI)., Methods and Results: The study enrolled 191 patients (66 in group 1 and 125 in group 2). In group 1, ethanol infusion into the vein of Marshall was first performed, followed by radiofrequency (RF) applications targeting bilateral PVAI and bidirectional block in the roofline, cavotricuspid isthmus, and MI. In group 2, PVAI and the three linear ablations were completed using only RF energy. MI block was achieved in 63 (95.5%) and 101 (80.8%) patients in groups 1 and 2, respectively (p = .006). Patients in group 1 had shorter ablation time for left pulmonary vein antrum (8.15 vs. 12.59 min, p < .001) and MI (7.0 vs. 11.8 min, p < .001) and required less cardioversion (50 [78.5%] vs. 113 [90.4%], p = .007). During the 12-month follow-up, 58 (87.9%) patients were free from atrial fibrillation/atrial tachycardia in group 1 compared with 81 (64.8%) in group 2 (p < .001). In multivariate cox regression, the "upgraded 2C3L" procedure is associated with a lower recurrence rate (hazard ratio = 0.27, 95% confidence interval = 0.12-0.59)., Conclusion: Compared with the conventional "2C3L" approach, the "upgraded 2C3L" approach has higher effectiveness for ablation of PeAF., (© 2021 Wiley Periodicals LLC.)

Aims: Catheter ablation is underutilized in atrial septal defect (ASD) patients who have undergone implantation of an atrial septal occluder (ASO). This study evaluates the feasibility and safety of catheter ablation of atrial fibrillation (AF) in this subset of patients., Methods and Results: Sixteen patients (age 56 ± 12 years, 10 men) with drug-refractory AF (10 paroxysmal and 6 persistent) and previously implanted ASO were enrolled. Balloon dilatation of the closure device was performed if the native septum passage could not be achieved. For paroxysmal AF, the ablation strategy was circumferential pulmonary vein isolation (CPVI), and for persistent AF, additional linear ablation was performed. Transseptal access was achieved through the native septum in 11 patients (Group A) and through the ASO using balloon dilatation in 5 patients (Group B). Circumferential pulmonary vein isolation was achieved in all 16 patients, and linear block was achieved in all persistent patients except for 1 patient who did not achieve mitral isthmus block. The transseptal, total fluoroscopy, and procedural durations were 5 ± 3 vs. 38 ± 8 min, 31 ± 11 vs. 54 ± 15 min, and 165 ± 35 vs. 224 ± 36 min, respectively, in Group A vs. Group B, respectively (all P < 0.05). No shunt at atrial level was detected by transthoracic echocardiography at 3-month follow-up. During a follow-up of 16 ± 6 months, sinus rhythm was maintained in 12 of 16 patients. No severe complications were observed., Conclusion: In ASD patients with ASO, catheter ablation of AF is feasible, safe, and effective. The balloon dilatation technique can facilitate transseptal access through the ASO.

Aims: Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF (PAF) and severe LA scarring identified by 3D mapping, undergoing pulmonary vein isolation (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI+ ablation of the non-PV triggers., Methods and Results: Totally, 177 consecutive patients with PAF and severe LA scarring were included. Patients underwent PVAI only (n = 45, Group 1), PVAI+ scar homogenization (n = 66, Group 2) or PVAI+ ablation of non-PV triggers (n = 66, Group 3) based on operator's choice. Baseline characteristics were similar across the groups. After first procedure, all patients were followed-up for a minimum of 2 years. The success rate at the end of the follow-up was 18% (8 pts), 21% (14 pts), and 61% (40 pts) in Groups 1, 2, and 3, respectively. Cumulative probability of AF-free survival was significantly higher in Group 3 (overall log-rank P <0.01, pairwise comparison 1 vs. 3 and 2 vs. 3 P < 0.01). During repeat procedures, non-PV triggers were ablated in all. After average 1.5 procedures, the success rates were 28 (62%), 41 (62%), and 56 (85%) in Groups 1, 2, and 3, respectively (log-rank P< 0.001)., Conclusions: In patients with PAF and severe LA scarring, PVAI+ ablation of non-PV triggers is associated with significantly better long-term outcome than PVAI alone or PVAI+ scar homogenization., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For Permissions, please email: journals.permissions@oup.com.)

Purpose: While AF is considered more like a left atrial (LA) disease, to what extent the right atrium contributes to the pathogenesis and ablation outcome of AF remains unclear. This study aimed to identify if right atrial diameter (RAD) could predict arrhythmia recurrence after catheter ablation of atrial fibrillation (AF)., Methods: Four hundred and seventy patients with drug-resistant AF [paroxysmal AF (PAF) 196; non-PAF 274] who underwent primary catheter ablation were enrolled. Ablation strategy included complete bilateral pulmonary vein isolation (PVI) in all patients and additional linear ablation across mitral isthmus, LA roof, and tricuspid isthmus in non-PAF cases. Risk factors associated with recurrence were determined by a Cox regression model, and the predictive power was evaluated by using receiver operating characteristic curve., Results: After 24.3 ± 18.0 months, 284 patients (60.6%) experienced atrial tachyarrhythmia recurrence (111 in PAF, 173 in non-PAF). RAD was moderately associated with LA diameter (r = 0.371, P < 0.001), left ventricular ejection fraction (r = -0.205, P < 0.001), and left ventricular end-diastolic diameter (r = 0.319, P < 0.001). Multivariate Cox regression analysis demonstrated that RAD was an independent predictor for recurrence only in PAF patients with LAD ≥35 mm (HR 1.044, 95% CI 1.007-1.082, P = 0.021). The RAD cutoff value of 35.5 mm predicts atrial tachyarrhythmia recurrence with 85.4% sensitivity and 29.2% specificity. Kaplan-Meier analysis indicated that RAD over 35.5 mm is associated with more recurrence after PAF ablation (log-rank P = 0.034), comparing to those with RAD <35.5 mm., Conclusions: RAD predicts outcome of ablation only in patients with PAF and concurrent LA enlargement. Under this condition, RAD <35.5 mm is associated with a more favorable recurrence-free survival at over 2-year follow-up.

Background: Thyroid hormone (TH) is known to enhance arrhythmogenicity, and high-normal thyroid function is related with an increased recurrence of atrial fibrillation (AF) after catheter ablation. However, the impact of thyroid hormone replacement (THR) on AF ablation is not well known., Methods: This study evaluated 1163 consecutive paroxysmal AF patients [160 (14%) on THR and 1003 (86%) without THR] undergoing their first catheter ablation. A total of 146 patients on THR and 146 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model (age, sex, body mass index, and left atrium size). The presence of non-pulmonary vein (PV) triggers was disclosed by a high-dose isoproterenol challenge (up to 30 μg/min) after PV isolation., Results: Clinical characteristics were not different between the groups. When compared to the control, non-PV triggers were significantly greater in the THR patients [112 (77%) vs. 47 (32%), P < 0.001], and most frequently originated from the right atrium (95 vs. 56%, P < 0.001). Other sources of non-PV triggers were the interatrial septum (25 vs. 11%, P = 0.002), coronary sinus (70 vs. 52%, P = 0.01), left atrial appendage (47 vs. 34%, P = 0.03), crista terminalis/superior vena cava (11 vs. 8%, P = 0.43), and mitral valve annulus (7 vs. 5%, P = 0.45) (THR vs. control), respectively. After mean follow-up of 14.7 ± 5.2 months, success rate was lower in patients on THR therapy [94 (64.4%)] compared to patients not receiving THR therapy [110 (75.3%), log-rank test value = 0.04]., Conclusions: Right atrial non-PV triggers were more prevalent in AF patients treated with THR. Elimination of non-PV triggers provided better arrhythmia-free survival in the non-THR group.

Background: For repeat treatment with paroxysmal atrial fibrillation (PAF) recurrence, gap-closure at pulmonary vein ostia alone is not enough. Many recent studies indicated that ganglionated plexi (GPs) denervation could reduce the recurrence of AF. However, it is unclear whether the clinical outcomes of additional GP ablation plus pulmonary veins (PVs ) reisolation during a repeat procedure were associated with less recurrence in PAF patients. The purpose of this study was to evaluate if a repeat procedure of GP ablation (GPA) combining repeated procedure of pulmonary vein isolation (re-PVI), i.e., gap-closure, can offer additional benefit for patients with PAF recurrence., Method: A total of 123 consecutive patients with PAF recurrence who underwent success repeat procedures were retrospectively analyzed in our center (2014-2015). Note that 64 patients (group 1, GPA group) were performed with GPA plus re-PVI, while 59 patients (group 2, re-PVI group) had re-PVI (gap-closure) alone. Organized atrial tachycardias (OATs) documented or induced at the end of the procedure were all mapped and ablated. Patients were scheduled for a 12-month follow-up. Clinical presentation and outcome data for the two groups were assessed., Result: At the 12-month follow-up 58 of 64 patients (90.6%) in group 1 and 46 of 59 patients (78%) in group 2 remained in sinus rhythm (SR) off antiarrhythmia drugs (AADs) (P = 0.045)., Conclusion: GPA conferred incremental benefit when performed in addition to re-PVI in patients with PAF recurrence; the GPA group yielded higher success rates than the re-PVI group., (© 2017 Wiley Periodicals, Inc.)

Background: Verification of bidirectional block is important for mitral isthmus (MI) ablation. However, recurrent perimitral reentry exists despite apparently MI block., Objective: The purpose of this study was to identify and investigate the characteristics of the ridge breakthrough despite apparent bidirectional MI block and related reentry., Methods: In 60 patients undergoing MI ablation and achieving the criteria of bidirectional block when assessed on the line, the pattern under differential pacing was reassessed at the ridge away from the line to check whether a breakthrough existed. Also, activation and entrainment mapping was performed in 7 patients with ridge-related reentry (RRR) to investigate its possible mechanism., Results: A ridge breakthrough was found in 7 of 60 patients (11.7%) apparently fulfilling the criteria of bidirectional block. The delay from pacing artifact during distal coronary sinus pacing was shorter at the ridge than on the line (95.6 ± 11.7 ms vs 130.9 ± 15.3 ms; P < .001). In 7 patients with RRR, the left atrial endocardial activation time accounted for 58.5% ± 3.2% of the tachycardia cycle length (TCL) and wide double potential could be recorded on the line. The post-pacing interval (PPI) - TCL after entrainment at the ridge was shorter than that on the line (11.4 ± 3.9 ms vs 34.3 ± 6.6 ms; P < .001), and in 2 patients in whom entrainment from the coronary sinus was possible, the PPI - TCL was 15 and 18 ms, respectively., Conclusion: Apparent bidirectional MI block despite a ridge breakthrough is not uncommon and may lead to RRR, while the line is not part of the reentry., (Copyright © 2016. Published by Elsevier Inc.)

Background: We report the outcome of pulmonary vein (PV) antrum isolation in paroxysmal atrial fibrillation (AF) patients over more than a decade of follow-up., Methods and Results: A total of 513 paroxysmal AF patients (age 54±11 years, 73% males) undergoing catheter ablation at our institutions were included in this analysis. PV antrum isolation extended to the posterior wall between PVs plus empirical isolation of the superior vena cava was performed in all. Non-PV triggers were targeted during repeat procedure(s). Follow-up was performed quarterly for the first year and every 6 to 9 months thereafter. The outcome of this study was freedom from recurrent AF/atrial tachycardia. At 12 years, single-procedure arrhythmia-free survival was achieved in 58.7% of patients. Overall, the rate of recurrent arrhythmia (AF/atrial tachycardia) was 21% at 1 year, 11% between 1 and 3 years, 4% between 3 and 6 years, and 5.3% between 6 and 12 years. Repeat procedure was performed in 74% of patients. Reconnection in the PV antrum was found in 31% of patients after a single procedure and in no patients after 2 procedures. Non-PV triggers were found and targeted in all patients presenting with recurrent arrhythmia after ≥2 procedures. At 12 years, after multiple procedures, freedom from recurrent AF/atrial tachycardia was achieved in 87%., Conclusions: In patients with paroxysmal AF undergoing extended PV antrum isolation, the rate of late recurrence is lower than what previously reported with segmental or less extensive antral isolation. However, over more than a decade of follow-up, nearly 14% of patients developed recurrence because of new non-PV triggers., (© 2016 American Heart Association, Inc.)

Background: It is unclear whether isolation of the left atrial posterior wall (LAPW) offers additional benefits over pulmonary vein antrum isolation (PVAI) alone in patients with persistent atrial fibrillation (AF)., Objective: We sought to determine the impact of PVAI and LAPW isolation (PVAI+LAPW) versus PVAI alone on the outcome of ablation of persistent AF., Methods: During the first procedure, PVAI was performed in 20 patients (group 1), whereas in 32 patients (group 2), PVAI was extended to the left atrial (LA) septum and coronary sinus (CS), and isolation of the LAPW was targeted (ePVAI+LAPW). Isolation of the superior vena cava was achieved in both groups. All patients, regardless of arrhythmia recurrence, underwent a second procedure 3 months after the first procedure. In patients with reconnection of pulmonary veins or LAPW, reisolation was performed, and a third procedure was performed 3 months later to verify isolation. Patients entered follow-up only after PVAI (group 1) or PVAI+LAPW (group 2) isolation was proven., Results: At the 1-, 2-, and 3-year follow-up examinations, the rates of freedom from atrial tachyarrhythmia without use of an antiarrhythmic drug were 20%, 15%, and 10% in group 1 and 65%, 50%, and 40% in group 2, respectively (log-rank P < .001). The median recurrence-free survival time was 8.5 months (interquartile range 6.5-11.0) in group 1 and 28.0 months (interquartile range 8.5-32.0) in group 2., Conclusion: Proven isolation of the LAPW provides additional benefits over PVAI alone in the treatment of persistent AF and improves procedural outcome at follow-up. However, the ablation strategy of ePVAI+LAPW is still associated with a significant high incidence of very late recurrence of atrial tachyarrhythmia., Clinical Trial Registration: "Outcome of Atrial Fibrillation Ablation After Permanent Pulmonary Vein Antrum Isolation With or Without Proven Left Atrial Posterior Wall Isolation" (LIBERATION). ClinicalTrials.gov Identifier: NCT01660100., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Whether ablation of non-pulmonary vein (PV) triggers after pulmonary vein antrum isolation (PVAI) improves the long-term procedure outcome in patients with paroxysmal atrial fibrillation (PAF) and left ventricular systolic dysfunction is unknown., Objective: We sought to evaluate whether a more extensive ablation procedure improves outcomes at follow-up., Methods: Consecutive patients with PAF refractory to antiarrhythmic drugs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: patients with left ventricular ejection fraction (LVEF) ≤35% (group I; n = 175) and patients with LVEF ≥50% (group II; n = 545). Patients in group I were further divided according to whether additional ablation of non-PV triggers was performed (group IA; n = 88) or not (group IB; n = 87). Long-term ablation success off antiarrhythmic drugs after a single procedure was analyzed., Results: Patients in group I had more non-PV triggers than did patients in group II (69.1% vs 26.6%; P < .001). During a follow-up of 15.8 ± 4.7 months, fewer patients in group I remained free from recurrences than those in group II (53.7% vs 81.7%; P < .001). Long-term ablation success was higher in group IA than in group IB (75.0% vs 32.2%; P < .001) and similar to that in group II (75.0% vs 81.7%; P = .44). In multivariate analysis, LVEF ≤35% (hazard ratio 1.68; P = .003) and non-PV triggers (hazard ratio 3.12; P < .001) were independent predictors of recurrences., Conclusion: In patients with PAF and left ventricular systolic dysfunction, ablation of non-PV triggers in addition to PVAI significantly improves their long-term procedure outcome., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: This study examined incidence of AF following cavotricuspid isthmus (CTI) ablation alone or CTI plus prophylactic pulmonary vein isolation (PVI) in patients presenting with isolated atrial flutter (AFL) with no history of AF., Methods and Results: We enrolled 216 patients with isolated typical atrial flutter and randomized them to CTI alone (group 1, n = 108, 61.2 ± 9.7 year, 75% male) or CTI+PVI ablation (group 2, n = 108, 62.4 ± 9.3 year, 73% male). Insertible loop recorder (ILR) was implanted in 21 and 19 patients from groups 1 and 2, respectively. Remaining patients were monitored with event recorders, ECG, 7-day Holter. Follow-up period was for 18 ± 6 months. Compared to group 1, group 2 had significantly longer procedural duration (75.9 ± 33 min vs. 161 ± 48 min [P < 0.001]) and fluoroscopy time (15.9 ± 12.3 min vs. 56.4+21 min [P < 0.001]). At the end of follow-up, 65 (60.2%) in group 1 and 77 (71.3%) in group 2 were arrhythmia free off-AAD (log-rank P = 0.044). A subgroup analysis was performed with 55 year age cut-off. In the <55 age group the CTI only population had similar success as in CTI+PVI, (21 of 24 [83.3%] vs. 19 of 22 [86.4%], respectively, log-rank P = 0.74). In the ≥55 group, having CTI+PVI showed significantly higher success compared to CTI only; 45 of 84 (53.6%) were AF/AT free in CTI only group versus 58 of 86 (67.4%) with CTI+PVI (log-rank P = 0.029)., Conclusion: Prophylactic PVI reduced new-onset AF in patients with lone atrial flutter., (© 2015 Wiley Periodicals, Inc.)

Aims: Transient ST-T elevation (STE) is a rare complication that occurs during transseptal catheterization. This study aims to delineate the incidence and characteristics of transient STE during transseptal catheterization for atrial fibrillation (AF) ablation., Methods and Results: Consecutive patients who underwent fluoroscopy-guided transseptal catheterization for circumferential pulmonary vein radiofrequency ablation in Beijing An Zhen Hospital from January 2006 to January 2013 were enrolled in this study. Out of 2965 patients with a total of 3452 transseptal catheterization procedures, 13 patients (0.38%, mean age 57 ± 8, 6 female, 12 paroxysmal AF, mean left atrial diameter 35.4 ± 3.8 mm) had STE. ST-T elevation occurred after transseptal puncture in 10 patients and after pulmonary vein venography in three patients. Systolic blood pressure (129 ± 10 vs. 104 ± 20 mmHg, P < 0.001), diastolic blood pressure (78 ± 6 vs. 64 ± 11 mmHg, P < 0.001), and heart rate (83 ± 19 bpm vs. 64 ± 23 b.p.m., P = 0.022) significantly decreased when STE occurred. Eleven patients complained of chest pain, one patient complained of dizziness, and one patient had no symptoms. Patients recovered in about 4.6 min (2-10 min) with dopamine or fast saline drip. Catheter ablation of AF was completed in all the 13 patients without sequelae or other complications. Four of the 13 patients (30.8%) had recurrence of AF after a mean follow-up of 21.7 months., Conclusion: ST-T elevation is a rare complication associated with transseptal catheterization without sequelae. Catheter ablation of AF could be safely completed in these patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Background: The impact of amiodarone on ablation outcome in longstanding persistent atrial fibrillation (LSPAF) patients is not known yet., Objective: The purpose of this study was to assess the effect of amiodarone on procedural-outcomes in LSPAF patients undergoing catheter ablation., Methods: We enrolled 112 LSPAF patients on amiodarone and scheduled to undergo atrial fibrillation (AF) ablation. Patients were randomized to amiodarone discontinuation 4 months before ablation (group 1, n = 56) and a control group (group 2, n = 56) in which ablation was performed without amiodarone discontinuation. All patients underwent pulmonary vein (PV) antrum and posterior wall isolation, defragmentation and extra PV triggers ablation. Patients were followed up for recurrence for 32 ± 8 months post-ablation. Repeat procedures in all recurrent patients were performed off amiodarone., Results: During ablation, AF termination was more frequent in group 2 compared to group 1 [44 (79%) vs 32 (57%), P = .015]. After high-dosage isoproterenol, more non-PV triggers were disclosed in group 1 compared to group 2 (42 [75%] vs 24 [43%] respectively, P <.001). Group 2 had lower procedure, radiofrequency and fluoroscopy times compared to group 1 (2.7 ± 1 vs 3.1 ± 1 h, 69 ± 13 min vs 87 ± 11 min and 64 ± 14 min vs 85 ± 18 min respectively, p < .05). At 32 ± 8 month follow-up, on or off antiarrhythmic drug success rate was 37 (66%) in group 1 and 27 (48%) in group 2 (P = .04). During redo, new non-PV trigger sites were identified in group 2 patients., Conclusion: Periprocedural continuous amiodarone was associated with higher organization rate and lower radiofrequency ablation rate. However, masking non-PV triggers increased the late recurrence rate., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Aims: This study sought to explore the predictors of recurrence in patients with paroxysmal atrial fibrillation (AF) undergoing repeat catheter ablation, especially the impact of left atrial (LA) remodelling after the original procedure on the outcome of repeat procedure., Methods and Results: Ninety-five patients undergoing repeat ablation were enrolled in this study. Repeat procedure endpoints were pulmonary vein isolation, linear block when linear ablation is performed, and non-inducibility of atrial tachyarrhythmia by burst pacing. Patients with LA enlargement between the pre-original procedure and pre-repeat procedure were categorized as Group 1 (35 patients), while individuals with no change or decrease of LA diameter were categorized as Group 2 (60 patients). The mean duration from the original procedure to the repeat procedure was 12 months (1-40 months). After 29.6 ± 20.5 (3-73) months follow-up from the repeat procedure, 33 patients experienced recurrence (34.7%). The recurrence rate was significantly higher in Group 1 than in Group 2 (51.4 VS. 25.0%, P = 0.017). In univariate analysis, LA remodelling was the only predictor of recurrence. In multivariate analysis, after adjustment for age and LA diameter, Group 1 had a greater risk of recurrence after the repeat procedure (hazard ratio = 2.22, 95% confidence interval: 1.02-4.81, P = 0.043)., Conclusions: Left atrial enlargement after undergoing the original catheter ablation of paroxysmal AF was an independent risk factor of recurrence after repeat ablation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Introduction: It is unclear whether extended pulmonary vein antrum isolation (PVAI) plus nonpulmonary vein (non-PV) trigger elimination prevents more arrhythmia recurrence than PVAI alone in patients with mechanical mitral valve (MMV) undergoing AF ablation. This study compared the efficacy and long-term outcome of 2 ablation strategies--PVAI alone versus extended PVAI plus non-PV trigger elimination--for the treatment of AF in patients with MMV., Methods and Results: One hundred and nine consecutive AF patients with MMV were divided into 2 groups: standard PVAI was performed in group 1 (N = 45); in group 2 (N = 64) PVAI was extended to the LA posterior wall, LA septum, and CS; and all non-PV triggers were eliminated. Patients were followed up for 3 years. At the 12th month, 7 (15.6%) patients in group 1, and 39 (60.9%) patients in group 2 were arrhythmia free (log-rank P < 0.001). Four patients (8.9%; 3 cases of AT and 1 case of AF) from group 1, and 12 patients (18.8%; 9 cases of AT, and 3 cases of AFL) from group 2 experienced very late recurrence. At 36 ± 7 months follow-up, the cumulative recurrence after a single procedure was 42/45 (93.3%) in group 1, and 37/64 (57.8%) in group 2 (log-rank P < 0.001)., Conclusion: Compared with the standard PVAI alone, a strategy including extended PVAI and non-PV trigger elimination is associated with a higher 12-month and long-term arrhythmia-free survival in patients with MMV undergoing AF ablation. Very late recurrence may occur years after the initial procedure with focal AT as the most common type of recurrent arrhythmia., (© 2014 Wiley Periodicals, Inc.)

Background: Pulmonary vein antrum isolation (PVAI) remains associated with atrial fibrillation (AF) recurrence. We administered adenosine and isoproterenol (ISP) after PVAI to uncover non-PV atrial triggers and PV reconnection, potentially increasing ablation success rate., Methods: One hundred and ninety-two consecutive patients with symptomatic AF presenting for PVAI were prospectively studied (group 1). Following PVAI, adenosine (18-24 mg) and ISP (20-30 mcg/min) were administered intravenously. Supplemental ablation was performed in patients with non-PV triggers that induced AF (group 1A). Other subgroups included patients with (group 1B) or without (group 1C) consistent non-PV atrial foci that did not induce AF. A cohort of 196 matched control patients undergoing PVAI without drug challenge was used for comparison (group 2)., Results: A total of 132 atrial non-PV foci were revealed (31 inducing AF). The majority of atrial foci were observed with ISP (113/132, 86%). Less than 5% of patients had persistent PV recovery during the drug challenge. During a mean follow-up of 22 ± 8 months, PVAI was successful in 110/192 (57%, group 1) versus 100/196 (52%, group 2), P = 0.038. Furthermore, the success rate was statistically different between group 1A (25/32, 78%), group 1B (28/83, 34%), and group 1C (57/74, 74%), P < 0.001., Conclusion: After PVAI, ablation guided by the administration of adenosine and ISP to target non-PV triggers inducing AF increased AF ablation outcomes. Patients with non-PV foci that did not induce AF had no further ablation, with the lowest ablation success rate. This group may likely benefit from further ablation after PVAI., (© 2013 Wiley Periodicals, Inc.)

The impact of atrial fibrillation on the healthcare systems of Western countries is overwhelming, due to its independent association with death, systemic thromboembolism, impaired quality of life and hospitalizations. Catheter ablation is the only treatment thus far demonstrated capable of achieving cure in a substantial proportion of patients. Pulmonary vein antrum isolation (PVAI) is the cornerstone of current atrial fibrillation ablation techniques, with the greatest efficacy as a stand-alone procedure in patients with paroxysmal atrial fibrillation. Use of general anesthesia, open-irrigated ablation catheters and maintenance of periprocedural therapeutic warfarin has been demonstrated to increase the safety and effectiveness of PVAI. In patients with paroxysmal atrial fibrillation, the systematic addition of superior vena cava isolation increases the long-term freedom from atrial fibrillation recurrence. A more extensive ablation approach extending to the entire left atrial posterior wall and to complex fractionated electrograms (CFAEs) is warranted in nonparoxysmal atrial fibrillation patients, in whom nonpulmonary vein trigger sites are frequently identified. Up to one-third of these patients experiencing atrial fibrillation recurrence after ablation have evidence of triggers from the left atrial appendage. Isolation of this structure is the best treatment strategy to improve the long-term success rate. In recent years, in addition to the development of ablation techniques to increase the success rate, outcomes of atrial fibrillation treatment trials have been reconsidered. In particular, reduction of hospitalization, stroke and mortality, as well as economic factors, have all been considered relevant to evaluate the effectiveness of atrial fibrillation treatment. Large ongoing trials are specifically evaluating the impact of atrial fibrillation ablation on these outcomes. This article will summarize the state-of-the art techniques for atrial fibrillation ablation, and will discuss the contribution of ongoing studies to the future of atrial fibrillation ablation.

Background: Complex fractionated atrial electrograms (CFAE) ablation has been performed in addition to pulmonary veins (PV) isolation to increase the success rate of atrial fibrillation (AF) ablation in patients with longstanding (LS) persistent AF. The mechanism underlying the clinical benefit of CFAE ablation remains, however, poorly understood., Objective: We compared the impact of CFAE ablation on the prevalence of non-PV atrial triggers inducing AF in 2 groups of patients with LS persistent AF. One group underwent PVAI alone, and the other group underwent PVAI plus CFAE ablation. In addition, we correlated the site of non-PV triggers with the presence of CFAE., Methods: A total of 98 consecutive patients with symptomatic drug refractory LS persistent AF presenting for ablation had a preablation electroanatomic CFAE map. Patients randomized to either isolation of the PVs and posterior wall (PVAI) (group I, n = 48 pts) or PVAI and biatrial ablation of CFAEs (group II, 50 pts). After ablation, infusion of isoproterenol up to 30 mcg/min was given to reveal non PV foci inducing AF. Those foci were mapped and correlated with CFAE regions and ablated., Results: A total of 19 patients (76%) with PV foci inducing AF were associated with either stable or transient CFAE after PVAI, respectively, in 12 patients (48%) and 7 patients (28%). A total of 20 (42%) non-PV triggers were observed in group I versus 5 (10%) in group II (P < 0.001) in 18 and 5 patients, respectively. After a mean f/u of 17.2 ± 5.2 months, 33 (69%) patients in group I and 36 (72%) patients in group II were in SR (P = NS)., Conclusion: Non-PV triggers inducing AF post-PVAI were associated with the presence of stable or transient CFAE in 48% and 28% of cases, respectively, in LS persistent AF. CFAE ablation after PVAI was associated with a significantly higher elimination of those non-PV triggers. This suggests that at least part of the beneficial effect achieved by CFAE ablation reflects elimination of non-PV AF triggers., (© 2011 Wiley Periodicals, Inc.)

Background: Radiofrequency catheter ablation of atrial fibrillation can be performed under general anesthesia or conscious sedation at the physician's preference., Objective: We randomized a series of consecutive patients with paroxysmal atrial fibrillation (AF) undergoing radiofrequency catheter ablation to either general anesthesia or conscious sedation to assess differences in pulmonary vein (PV) reconnection during redo procedures and impact on success rate., Methods: A total of 257 consecutive patients with paroxysmal AF undergoing AF ablation were enrolled and randomized to either conscious sedation with fentanyl or midazolam (128 patients, group 1) and general anesthesia (129 patients, group 2). In all patients, a high dosage of isoproterenol up to 30 μg/min was used to disclose PV reconnection or extra PV firings., Results: Baseline clinical characteristics were not significantly different between the 2 groups. At 17 ± 8 month follow-up after the first ablation, 88 (69%) patients in group 1 were free of atrial arrhythmias off all antiarrhythmic drugs (AAD), as compared with 114 (88%) in group 2 (log-rank P <.001). All patients with recurrence had a second procedure. At the repeat procedure, 42% (66 of 158) of PVs in group 1 had recovered PV conduction, compared with 19% (11 of 57) in group 2 (P = .003). Compared with group 1, group 2 had a significantly shorter fluoroscopy time (53 ± 9 min vs. 84 ± 21 min, P <.001) and procedure time (2.4 ± 1.4 h vs. 3.6 ± 1.1 h, P <.001)., Conclusion: The use of general anesthesia is associated with higher cure rate with a single procedure, and it seems to reduce the prevalence of PV reconnection observed at the time of repeat ablation., (Copyright © 2011 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objectives: We aimed at assessing the feasibility and efficacy of remote magnetic navigation (MN) and ablation in patients with atrial fibrillation (AF)., Background: This novel MN system could facilitate standardization of the procedures, reducing the importance of the operator skill., Methods: After becoming familiar with the system in 48 previous patients, 45 consecutive patients with AF were considered for ablation using the Niobe II remote magnetic system (Stereotaxis, St. Louis, Missouri) in a stepwise approach: circumferential pulmonary vein ablation (CPVA), pulmonary vein antrum isolation (PVAI), and, if failed, PVAI using the conventional approach. Remote navigation was done using the coordinate or the wand approach. Ablation end point was electrical disconnection of the pulmonary veins (PVs)., Results: Using the coordinate approach, the target location was reached in only 60% of the sites, whereas by using the wand approach 100% of the sites could be reached. After step 2 ablation, only 1 PV in 4 patients (8%) could be electrically isolated. Charring on the ablation catheter tip was seen in 15 (33%) of the cases. In 23 patients, all PVs were isolated with the conventional thermocool catheter, and in 22 patients only the right PVs were isolated with the conventional catheter. After a mean follow-up period of 11 +/- 2 months, recurrence was seen in 5 patients (22%) with complete PVAI and in 20 patients (90%) with incomplete PVAI., Conclusions: Remote navigation using a magnetic system is a feasible technique. With the present catheter technology, effective lesions cannot be achieved in most cases. This appears to impact the cure rate of AF patients.

Objectives: We present the clinical course and management outcomes of patients with total pulmonary vein occlusion (PVO)., Background: Pulmonary vein occlusion is a rare complication that can develop after radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The long term follow-up data of patients diagnosed with PVO are minimal., Methods: Data from 18 patients with complete occlusion of at least one pulmonary vein (PV) were prospectively collected. All patients underwent RFA for AF using different strategies between September 1999 and May 2004. Pulmonary vein occlusion was diagnosed using computed tomography (CT) and later confirmed by angiography when intervention was warranted. Lung perfusion scans were performed on all patients before and after intervention. The percent stenoses of the veins draining each independent lung were added together to yield an average cumulative stenosis of the vascular cross-sectional area draining the affected lung (cumulative stenosis index [CSI])., Results: The patients' symptoms had a positive correlation with the CSI (r = 0.843, p < 0.05) and a negative one with the lung perfusion (r = -0.667, p < 0.05). A CSI > or =75% correlated well with low lung perfusion (<25%; r = -0.854, p < 0.01). Patients with a CSI > or =75% appeared to improve mostly when early (r = -0.497) and repeat dilation/stenting (r = 0.0765) were performed., Conclusions: Patients with single PVO are mostly asymptomatic and should undergo routine imaging. On the other hand, patients with concomitant ipsilateral PV stenosis/PVO and a CSI > or =75% require early and, when necessary, repeated pulmonary interventions for restoration of pulmonary flow and prevention of associated lung disease.