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Background: Atrial fibrillation (AF) is an uncommon arrhythmia in young adults without structural heart disease, and cryoballoon pulmonary vein isolation (CB-PVI) is an important therapeutic strategy for rhythm control in patients with drug-refractory AF. The aim of this analysis was to evaluate efficacy and safety of CB-PVI in a large cohort of young patients in comparison with middle-aged adults in a real-world setting., Methods: From 2012 to 2020, a total of 3033 patients with AF underwent CB-PVI and were followed prospectively in the framework of the 1STOP Clinical Service project, involving 34 Italian centers. Out of 3033 total 1STOP project subjects, a subgroup of 1318 patients were defined which included a YOUNG group (age ≤ 45 years; n = 368) and a MIDDLE-AGED group (age 60-65 years; n = 950)., Results: The acute success rate of PVI did not differ between the two cohorts (99.9 ± 1.3% vs. 99.8 ± 3.2%, p = 0.415). There was no difference in procedural characteristics, and periprocedural complication rates were similar among the two cohort (1.9% vs. 2.3%, p = 0.646). The 12-month freedom from AF recurrence was 88.9% (95% confidence interval [CI]: 84.7-92.0) in the YOUNG cohort and 85.6% (95% CI: 82.9-88.0) in the MIDDLE-AGED group. At 36-month follow-up, freedom from AF recurrence was 72.4% (65.5%-78.2%) and 71.8% (67.7%-75.6%), respectively with no significant difference among groups (p = 0.550)., Conclusion: CB-PVI had similar efficacy and safety in YOUNG and MIDDLE-AGED patients. Younger age did not affect acute procedural results, complication rate, or AF recurrence after a single procedure., (© 2022 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Purpose: Ablation index (AI) is a radiofrequency lesion quality marker. The AI value that allows effective and safe pulmonary vein isolation (PVI) is still debated. We evaluated the incidence of acute and late PV reconnection (PVR) with different AI settings and its predictors., Methods: The Ablation Index Registry is a multicenter study that included patients with paroxysmal/persistent atrial fibrillation (AF) who underwent first-time ablation. Each operator performed the ablation using his preferred ablation catheter (ThermoCool® SmartTouch or Surround Flow) and AI setting (380 posterior-500 anterior and 330 posterior-450 anterior). We divided the study population into two groups according to the AI setting used: group 1 (330-450) and group 2 (380-500). Incidence of acute PVR was validated within 30 min after PVI, whereas the incidence of late PVR was evaluated at repeat procedure., Results: Overall, 490 patients were divided into groups 1 (258) and 2 (232). There was no significant difference in the procedural time, fluoroscopy time, and rate of the first-pass PVI between the two study groups. Acute PVR was observed in 5.6% PVs. The rate of acute PVR was slightly higher in group 2 (64/943, 6.8%, PVs) than in group 1 (48/1045, 4.6% PVs, p = 0.04). Thirty patients (6%) underwent a repeat procedure and late PVR was observed in 57/116 (49%) PVs (number of reconnected PV per patient of 1.9 ± 1.6). A similar rate of late PVR was found in the two study groups. No predictors of acute and late PVR were found., Conclusion: Ablation with a lower range of AI is highly effective and is not associated with a higher rate of acute and late PVR. No predictors of PV reconnection were found., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: The aims of this study were to determine the rate and the predictors of early recurrences of atrial fibrillation (ERAF) after cryoballoon (CB) ablation and to evaluate whether ERAF correlate with the long-term outcome., Methods and Results: Three thousand, six hundred, and eighty-one consecutive patients (59.9 ± 10.5 years, female 26.5%, and 74.3% paroxysmal AF) were included in the analysis. Atrial fibrillation recurrence, lasting at least 30 s, was collected during and after the 3-month blanking period. Three-hundred and sixteen patients (8.6%) (Group A) had ERAF during the blanking period, and 3365 patients (Group B) had no ERAF. Persistent AF and number of tested anti-arrhythmic drugs ≥2 resulted as significant predictors of ERAF. After a mean follow-up of 16.8 ± 16.4 months, 923/3681 (25%) patients had at least one AF recurrence. The observed freedom from AF recurrence, at 24-month follow-up from procedure, was 25.7% and 64.8% in Groups A and B, respectively (P < 0.001). ERAF, persistent AF, and number of tested anti-arrhythmic drugs ≥2 resulted as significant predictors of AF. In a propensity score matching, the logistic model showed that ERAF 1 month after ablation are the best predictor of long-term AF recurrence (P = 0.042)., Conclusion: In patients undergoing CB ablation for AF, ERAF are rare and are a strong predictor of AF recurrence in the follow-up, above all when occur >30 days after the ablation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: Ablation index (AI) is a new lesion quality marker that has been demonstrated to allow a high single-procedure arrhythmia-free survival in single-center studies. This prospective, multi-center study was designed to evaluate the reproducibility of pulmonary vein (PV) isolation guided by the AI., Methods: A total of 490 consecutive patients with paroxysmal (80.4%) and persistent AF underwent first time PV isolation and were divided in four study groups according to operator's preference in choosing the ablation catheter (a contact force (ST) or contact force surround flow (STSF) catheter) and the AI setting (330-450 or 380-500 at anterior wall or posterior wall, respectively)., Results: At 12 months a high rate of freedom from AF recurrences was observed in patients with both paroxysmal and persistent AF (91% vs 83.3%; P = .039). There was no difference in the rate of AF recurrence among the four study groups (4.5% in group ST330-450, 12.2% in group ST 380-500, 14.9% in group STSF330-450, 9.4% in group STSF380-500; P = .083). Recurrence was also similar between patients treated with a ST (8%) or STSF catheter (12.1%; P = .2), and within patients targeting an AI settings of 330 to 450 (10.9%) or 380 to 500 (10.3%; P = .64). In patients with paroxysmal AF, there was no difference (P = .12) in the 1-year freedom from AF recurrence among 14 operators that performed ≥10 ablation procedure., Conclusions: An ablation protocol respecting strict criteria for contiguity and quality lesion resulted in high rate of 1-year freedom from AF recurrence, irrespective of the ablation catheters, AI settings, and operator., (© 2020 Wiley Periodicals LLC.)

Background: Atrial fibrillation (AF) ablation outcome is still operator dependent. Ablation Index (AI) is a new lesion quality marker that has been demonstrated to allow acute durable pulmonary vein (PV) isolation followed by a high single-procedure arrhythmia-free survival. This prospective, multicenter study was designed to evaluate the reproducibility of acute PV isolation guided by the AI., Methods: A total of 490 consecutive patients with paroxysmal (80.4%) and persistent AF underwent first time PV encircling and were divided in four study groups according to operator preference in choosing the ablation catheter (a contact force [ST] or contact force surround flow [STSF] catheter) and the AI setting (330 at posterior and 450 at anterior wall or 380 at posterior and 500 at anterior wall). Radiofrequency was delivered targeting interlesion distance ≤6 mm., Results: The rate of first-pass PV isolation (ST330 90 ± 16%, ST380 87 ± 19%, STSF330 90 ± 17%, STSF380 91 ± 15%, P = .585) was similar among the four study groups, whereas procedure (ST330 129 ± 44 minutes, ST380 144 ± 44 minutes, STSF330 120 ± 72 minutes, STSF380 125 ± 73 minutes, P < .001) and fluoroscopy time (ST330 542 ± 285 seconds, ST380 540 ± 416 seconds, STSF330 257 ± 356 seconds, STSF380 379 ± 454 seconds, P < 0.001) significantly differed. The difference in the rate of first-pass isolation was not statistical different (P = .06) among the 12 operators that performed at least 15 procedures., Conclusions: An ablation protocol respecting strict criteria for contiguity and quality lesion results in high and comparable rate of acute PV isolation among operator performing ablation with different catheters, AI settings, procedure, and fluoroscopy times., (© 2019 Wiley Periodicals, Inc.)

Purpose: Catheter-tissue contact is critical for effective lesion creation in radiofrequency catheter ablation (RFCA). In a multicenter prospective study, we assessed the relationship between catheter contact force (CF) during RFCA for paroxysmal atrial fibrillation (AF) and clinical recurrences over a mid-term follow-up., Methods: All patients underwent RFCA for paroxysmal AF by antral pulmonary vein (PV) isolation, aiming at entry and exit conduction block in all PVs. A new open-irrigated tip catheter with CF sensing (SmartTouch(TM), Biosense Webster Inc. CA) was used. All patients were followed for at least 12 months and the relationship between CF and clinical outcomes assessed., Results: One year follow-up was available in 92/95 of the patients enrolled. Acute PV isolation was achieved in 100 % of the veins. Mean CF during RFCA was 12.2 ± 3.9 g. Mean force-time integral (FTI) was 733 ± 505 gs. Following the 3-month blanking period, 17 (18 %) patients experienced at least 1 atrial tachyarrhythmia relapse. There was no statistical difference in mean CF (13 ± 3.4 g vs 12 ± 4 g, p = 0.32) and mean FTI (713 ± 487 gs vs 822 ± 590 gs, p = 0.42) between patients with and without arrhythmia recurrences. Recurrences were recorded in 22 % of patients achieving a mean FTI value below the median of 544 gs and in 15 % of patients with a mean FTI value above the median (p = 0.64)., Conclusions: RFCA with CF data during PV isolation for paroxysmal AF improves physician's knowledge on catheter-tissue contact. In the present dataset, however, higher CF values did not impact mid-term clinical RFCA outcome.

Aims: Catheter-tissue contact is critical for effective lesion creation in radiofrequency catheter ablation (RFCA). In a multicentre prospective study, we assessed the effect of direct contact force (CF) measurement on acute procedural parameters during RFCA of atrial fibrillation (AF)., Methods and Results: A new open-irrigated tip catheter with CF sensing (SmartTouch™, Biosense Webster Inc.) was used. All the patients underwent the first ablation procedure for paroxysmal AF with antral pulmonary vein (PV) isolation, aiming at entry and exit conduction block in all PVs. Ninety-five patients were enroled in nine centres and successfully underwent ablation. Overall procedure time, fluoroscopy time, and ablation time were 138.0 ± 67.0, 14.3 ± 11.2, and 33.8 ± 19.4 min, respectively. The mean CF value during ablation was 12.2 ± 3.9 g. Force time integral (FTI) analysis showed that patients achieving a value below the median of 543.0gs required longer procedural (158.0 ± 74.0 vs. 117.0 ± 52.0 min, P = 0.004) and fluoroscopy (17.5 ± 13.0 vs. 11.0 ± 7.7 min, P = 0.007) times as compared with those in whom FTI was above this value. Patients in whom the mean CF during ablation was >20 g required shorter procedural time (92.0 ± 23.0 vs. 160.0 ± 67.0 min, P = 0.01) as compared with patients in whom this value was <10 g. Four groin haematomas were the only complications observed., Conclusion: Contact force during RFCA for PV isolation affects procedural parameters, in particular procedural and fluoroscopy times, without increasing complications.

Background: The aim of this study was to investigate the efficacy of catheter ablation in the treatment of persistent atrial fibrillation (AF) and the predictors of arrhythmia recurrence., Methods: Absence of atrial tachyarrhythmia (AT) recurrence during a mid-term follow-up was correlated with several clinical and procedural characteristics in a population of 82 patients aged 20-70 years who had experienced at least one documented relapse of persistent AF during a single trial of antiarrhythmic drug therapy. Electrophysiological success of ablation was declared when all identified PVs were isolated (confirmation of entry and exit block). Patients were followed for a maximum of 24 months after the blanking period with outpatient visits, ECG recordings, 24-hour Holter monitoring, and weekly transtelephonic monitoring for 30s., Results: Electrophysiological success was documented in 38/82 (46.3%) patients. During a mean follow-up of 24.7 ± 4.2 months, 69/82 (84.1%) patients presented at least one episode of AT after the 2 month blanking period. According to univariate and multivariate logistic regression analyses, only an electrophysiologically successful ablation significantly correlated with the absence of documented AT relapse (OR 5.32, 95% CL 1.02-27.72; p=.0472)., Conclusions: Mid-term outcome of a single procedure of catheter ablation without the adjunction of antiarrhythmic drug therapy is poor in patients with persistent AF. Documented PV isolation is useful to increase the success rate of circumferential PV ablation even in persistent AF patients., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

Introduction: Aim of this study was to compare efficacy and safety of the new ThermoCool Surround Flow® catheter (SFc) versus the ThermoCool® (TCc) in achieving persistent circumferential electrical isolation of the pulmonary veins (PVs) in patients with paroxysmal atrial fibrillation (AF)., Methods and Results: This multicenter, randomized, controlled study enrolled patients suffering from paroxysmal AF. Randomization was run in a one-to-one fashion between radiofrequency ablation by TCc or SFc. Aim of PVs ablation was documentation of electrical isolation with exit/entrance block recorded on a circular catheter. Among the 106 enrolled patients, 52 (49.0%) were randomized to TCc and 54 (51.0%) to SFc. Total volume of infused saline solution during the procedure was lower in the SFc than in TCc group (752.7 ± 268.6 mL vs 1,165.9 ± 436.2 mL, P < 0.0001). Number of identified and isolated PVs was similar in the 2 groups. Number of PVs remaining isolated 30 minutes after ablation was higher in the SFc than in TCc group (95.2% vs 90.5%, P < 0.03), mainly driven by acute ablation result in the left PVs (96.1% vs 89.7%, P < 0.04). Complications were seldom and observed only in the TCc group (0% vs 3.84%, P < 0.03). At 6-month follow-up SFc patients reported a trend toward less AF recurrences compared to those in the TCc group (22.9% vs 27.0%, P = 0.69)., Conclusion: PV isolation by SFc lowered the rate of left PV early reconnections and reduced the volume of infused saline solution while maintaining the safety profile of AF ablation., (© 2012 Wiley Periodicals, Inc.)

Background: The role of additional left atrial linear lesions performed during pulmonary vein isolation (PVI) to prevent atrial tachycardias (ATs) is not yet clear., Objective: To analyse successful ablation sites of late-onset post-PVI AT, and to understand whether additional ablation lines at mitral isthmus and left atrium (LA) roof could have been useful in preventing these jatrogenic ATs., Methods: From March, 2002 to August, 2008, 366 patients underwent PVI alone for drug-refractory atrial fibrillation (AF). Twenty-six (7.1%) of these patients developed late AT during follow-up, and were referred for ablation. Successful discrete ablation sites were analysed. In no patient the index AT was terminated by a linear lesion in mitral isthmus or LA roof., Results: Twenty-seven ATs were mapped; mean CL was 261 ± 71.6 ms. In 3/26 patients (11.5%), mapping was unsuccessful, while 23/26 (88.5%) patients underwent a successful procedure (24 AT morphologies in 23 patients - 3/24 were mapped as mitral isthmus, and 1/24, as LA roof-dependent AT). Among the 24 successfully mapped ATs, 17/24 (70.8%) displayed a macroreentrant activation and the remaining 7/24 (29.1%), a focal pattern. Finally, in 22/26 (84.6%) patients, ATs were no more inducible. At a mean f/u of 22.4 ± 12.2 months, 23/26 (88.4%) patients remained AT-free (antiarrhythmic drugs prescribed in 5/26, 19.2% patients for AF prevention)., Conclusions: In our case series, less than one-fifth of late-onset post-PVI ATs were mapped as mitral isthmus- or LA roof-dependent circuits., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: The role of pulmonary veins (PV) isolation in patients with persistent atrial fibrillation (AF) is still debated. The aim of this study was to evaluate the adjunctive role of PV isolation in patients with persistent AF who underwent circumferential PV ablation (anatomical approach)., Methods: We treated 97 consecutive patients presenting with drug-refractory persistent AF by an anatomical approach (group A, n = 36, mean age = 60 +/- 8 years, 29 males) or an integrated approach (group B, n = 61, mean age 59 +/- 10 years, 48 males). In all patients, radiofrequency (RF) ablation was performed by means of a nonfluoroscopic navigation system, in order to anatomically create circumferential lines around the PV. In group B, the persistence of PV potentials was ascertained with a multipolar circular catheter. If PV potentials persisted, RF energy targeting the electrophysiological breakthroughs was delivered to disconnect the PV. Past a 2-month period of observation, success was defined as absence of any atrial tachyarrhythmia recurrence lasting >30 seconds., Results: Total procedure duration (220 +/- 62 minutes vs 140 +/- 43 minutes, P < 0.001), fluoroscopy time (35 +/- 15 minutes vs 17 +/- 9 minutes, P < 0.001), and RF delivery time (48 +/- 22 minutes vs 27 +/- 9 minutes, P < 0.001) were significantly longer in group B than in group A. One cardiac perforation occurred in group A. After 15 +/- 9.1 months, 21 patients in group A (58%) and 34 patients in group B (56%) were free of atrial tachyarrhythmia recurrence (P = 0.9)., Conclusions: In patients with persistent AF, who underwent an anatomical approach, electrophysiological confirmation of PV disconnection significantly increased the fluoroscopy and procedural times, without effect on the long-term outcomes.

Objectives: The aims of this observational study were to evaluate (i) the feasibility of obtaining bidirectional pulmonary vein (PV) isolation by means of circumferential radiofrequency ablation of the antral aspect of the PV ostium; (ii) whether the electrophysiological demonstration of bidirectional PV isolation predicts freedom from atrial tachyarrhythmia recurrence after ablation in patients with paroxysmal atrial fibrillation., Methods: The study group comprised 28 patients affected by frequent recurrences of paroxysmal atrial fibrillation refractory to antiarrhythmic drugs, who underwent transcatheter ablation of the PVs by means of a non-fluoroscopic navigation system. Radiofrequency pulses were delivered in a point-by-point fashion at the antral aspect of the ostium of each vein presenting distal PV potentials. After ablation of each PV, bidirectional isolation was tested by means of a basket catheter. No antiarrhythmic drugs were prescribed on discharge. Outpatient visits, 24-h electrocardiographic Holter monitoring, and continuous 7-day digital electrocardiogram were scheduled at 3, 6, and 12 months., Results: A distal potential was detected in 101/123 (82%) mapped PVs. Bidirectional isolation was obtained in 81/101 (80%) PVs; bidirectional isolation of all targeted PVs was obtained in 17 (61%) patients. After a mean follow-up of 12.2 +/- 4.2 months, clinical success was observed in 15 (53%) patients. On multivariate analysis, only bidirectional isolation of all targeted PVs predicted the clinical success of ablation (P < 0.003; hazard ratio 7.504; confidence interval 1.943-28.990)., Conclusions: Circumferential antral ablation achieves bidirectional isolation in 80% of PVs. Bidirectional isolation of all PVs is essential to curing patients with paroxysmal atrial fibrillation.

Background: Data on the procedural safety of pulmonary vein radiofrequency catheter ablation for atrial fibrillation (AF) are as yet scant., Objective: The aims of the present study were to prospectively evaluate the incidence of early complications of pulmonary vein ablation for AF in an unselected population of consecutive patients, and to identify possible predictors., Methods: From April 2005 to October 2006, data from 1,011 consecutive patients who were undergoing radiofrequency catheter ablation for every type of AF in 10 Italian centers were collected. All complications occurring from the admission of the patient up to the 30th day were considered., Results: No procedure-related death was observed. Complications occurred in 40 patients (3.9%): 12 (1.2%) had peripheral vascular complications, 8 (0.8%) had conservatively treated pericardial effusion, 6 (0.6%) had cardiac tamponade (successfully drained), 5 (0.5%) had cerebral embolisms, 4 (0.4%) presented pulmonary vein stenosis >50%, and 5 (0.5%) presented other isolated adverse events. History of coronary artery disease (odds ratio 5,603, 95% confidence interval 1,559 to 20,139, P < .008) characterized patients who presented with hemorrhagic complications., Conclusion: Early complications of pulmonary vein catheter ablation seem to be fewer than in the early years of AF ablation, but still occur in 3.9% of procedures.

Background: Circumferential anatomical isolation of the pulmonary veins by radiofrequency transcatheter ablation is a new technique for the treatment of atrial fibrillation (AF). The aim of our study was to evaluate the efficacy and the safety of circumferential radiofrequency ablation of the pulmonary veins and to analyze clinical, echocardiographic and procedural parameters as possible predictors of clinical success., Methods: We performed circumferential isolation of the pulmonary veins in 33 patients with paroxysmal (15 patients) or persistent AF (18 patients) refractory to at least two antiarrhythmic drugs. All patients continued antiarrhythmic therapy after the procedure for at least 12 months., Results: At the end of the follow-up (mean 13.7 +/- 5.1 months) 70% of the patients resulted responders to the ablation, with no differences between patients with paroxysmal and persistent AF. Complications were observed in 3% of patients. Among clinical, echocardiographic and procedural parameters analyzed none turned out to be predictor of clinical success., Conclusions: Circumferential isolation of the pulmonary veins by radiofrequency transcatheter ablation associated with antiarrhythmic drugs was efficacious in 70% of patients with either paroxysmal or persistent AF. None of the analyzed variables predicted clinical success.

A 57-year-old woman with frequent isolated and repetitive premature atrial contractions initiating paroxysmal atrial fibrillation, underwent electrophysiological study and catheter ablation. A real-time three-dimensional map of the left atrium was reconstructed using a nonfluoroscopic navigation system. By means of a deflectable decapolar catheter, the left superior pulmonary vein (PV) was identified as the arrhythmogenic vein, and PV potentials were found in the left inferior and right superior veins. Ablation was performed under electroanatomic guidance. After circumferential ablation outside the PV ostia, dissociation of PV potentials was obtained in the left superior vein, and PV potentials were eliminated in the other two veins.

Radiofrequency (RF) catheter ablation has been proposed as a treatment of atrial fibrillation (AF). Several approaches have been reported and success rates have been dependent on procedural volume and operator's experience. This is the first report of a multicenter study of RF ablation of AF. We treated 44 men and 25 women with paroxysmal (n = 40) or persistent (n = 29), drug refractory AF. Circular pulmonary vein (PV) ostial lesions were deployed transseptally, during sinus rhythm (n = 42) or AF (n = 26), under three-dimensional electroanatomic guidance. Cavo-tricuspid isthmus ablation was performed in 27 (40%) patients. The mean procedure time was 215 +/- 76 minutes (93-530), mean fluoroscopic exposure 32 +/- 14 minutes (12-79), and mean number of RF pulses per patient 56 +/- 29 (18-166). The mean numbers of separate PV ostia mapped and isolated per patient were 3.9 +/- 0.5, and 3.8 +/- 0.7, respectively. Major complications were observed in 3 (4%) patients, including pericardial effusion, transient ischemic attack, and tamponade. At 1-month follow-up, 21 of 68 (31%) patients had had AF recurrences, of whom 8 required electrical cardioversion. After the first month, over a mean period of 9 +/- 3 (5-14) months, 57 (84%) patients remained free of atrial arrhythmias. RF ablation of AF by circumferential PV ostial ablation is feasible with a high short-term success rate. While the procedure and fluoroscopic exposure duration were short, the incidence of major cardiac complications was not negligible.