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Introduction: Atrial fibrillation ablation has historically been guided by fluoroscopy, with the related enhanced risk deriving from radiation. Fluoroscopy exposure may be confined to guide the transseptal puncture. Small sample size study presented a new methodology to perform a totally fluoroless atrial fibrillation ablation in the case of a patent foramen ovale (PFO). We evaluated this methodology in a large sample size of patients and a multicentre experience., Methods and Results: Two hundred and fifty paroxysmal atrial fibrillation patients referred for first atrial fibrillation ablation with a CARTO3 electroanatomic mapping system were enrolled. In 58 out of 250 patients, a PFO allowed crossing of the interatrial septum, and a completely fluoroless ablation was performed applying the new method (Group A). In the remaining patients, a standard transseptal puncture was performed (Group B). Pulmonary vein isolation was achieved in all patients with comparable procedural and clinical outcomes at short- and long-term follow-up., Conclusion: The presence of a PFO may allow a completely fluoroless well tolerated and effective atrial fibrillation ablation. Probing the fossa ovalis looking for the PFO during the procedure is desirable, as it is not time-consuming and can potentially be done in every patient undergoing atrial fibrillation ablation.

Introduction: Pulmonary vein (PV) isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). Surround flow and contact force (CF) measurement capabilities might enhance procedure efficacy and safety. We report on the safety and midterm efficacy of a novel ablation catheter for PV isolation in patients with AF., Methods and Results: Two hundred thirty-three consecutive patients (57 ± 11 years, 76% males, 51% with structural heart disease), referred for paroxysmal (157) or persistent (76) AF, underwent PV isolation by a surround flow catheter with CF measurement capability in four centers. Ablation was guided by electroanatomic mapping allowing radiofrequency (RF) energy delivery in the antral region aiming at PV isolation. Mean overall procedure time was 100 ± 42 minutes with a mean fluoroscopy time of 6 ± 5 minutes. Mean ablation time was 31±15 minutes; 99% of the targeted veins were isolated. The mean CF value during ablation was 13 ± 4 g. Intraprocedural early (30 minutes) PV reconnection occurred in 12% PVs, and all PVs were effectively reisolated. One pericardial effusion and five groin hematomas were reported. During a mean follow-up of 12 ± 6 months, 30 (12.9%) (10% paroxysmal AF vs. 18% persistent AF, P = 0.07) patients had an atrial arrhythmias recurrence., Conclusions: In this multicenter registry, RF ablation using a new surround flow catheter, with CF sensor, resulted as feasible, achieving a high rate of isolated PVs. Procedural and fluoroscopy times and success rates were comparable with other techniques with a low complication rate., (© 2017 Wiley Periodicals, Inc.)

Background: Simultaneous multipolar ablation catheters have been proposed to simplify pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). Recently, a new multipolar irrigated radiofrequency (RF) ablation catheter (nMARQ™, Biosense Webster Inc., Diamond Bar, CA, USA) combining both 3-dimensional electroanatomic mapping and multipolar open-irrigated ablation capability has been developed. Aim of our study was to assess feasibility, acute and short-term success and safety of PVI by the use of this new technology with particular regard to the incidence of postablation silent cerebral ischemia (SCI)., Methods and Results: Twenty-five patients (76% males; age 57 ± 13 years) with paroxysmal AF underwent PVI using the nMARQ™ catheter. PVI, confirmed by Lasso catheter mapping, was achieved in 100 out of 102 pulmonary veins (98%) identified, and final PVI was obtained in 24 out of 25 (96%) patients. The overall concordance between Lasso and nMARQ™ signals in demonstrating PVI was 78%. No major procedural complications occurred and no patient suffered SCI, on the basis of cerebral magnetic resonance imaging performed before and after the procedure. Following a 6-month follow-up, 17/25 (68%) patients remained free from AF without antiarrhythmic drugs., Conclusions: In our preliminary experience, PVI with nMARQ™ catheter appears to be feasible and safe, without incidence of SCI. Long-term clinical efficacy has to be evaluated in further studies., (© 2014 Wiley Periodicals, Inc.)

Introduction: Silent cerebral lesions (SCL) are a sensitive tool to evaluate thromboembolic risk of catheter ablation. Recent data showed the possibility to reduce thrombus formation when the electrode-tissue interface cooling is optimized by a homogeneous flushing of saline along the entire surface of the distal electrode through a larger number of irrigation holes. The study aim is to compare procedural parameters and safety of pulmonary vein isolation (PVI) performed by using open-irrigated catheters with different irrigation design., Methods and Results: Eighty patients (74% males; age 57 ± 12 years) with paroxysmal AF randomly underwent PVI performed with a new irrigation design catheter (group A, 40 patients) versus a standard irrigated catheter (group B, 40 patients). A cerebral magnetic resonance imaging (MRI) was performed before and after the procedure. Postprocedural brain MRI unveiled SCL in 2 patients in group A and in 3 in group B (5% vs 7.5%, P = 0.500). Intraprocedural ACT was the only independent factor associated with the occurrence of SCL (OR = 0.996; 95% CI 0.994-0.998, P < 0.001). Among procedural parameters, we observed a reduction of irrigation saline volume of 662 mL in group A versus group B (P < 0.001)., Conclusion: PVI performed with a new irrigated catheter did not reduce significantly the SCL risk when compared to a standard irrigated catheter. Intraprocedural ACT reduces the SCL risk of 0.4% for each point of ACT increase. For ACT > 320 seconds no SCL occurred. Finally, compared to a standard irrigated catheter, PVI performed with a new irrigation design catheter reduces significantly saline volume infusion., (© 2012 Wiley Periodicals, Inc.)

Unlabelled: LA and PV Anatomy in Patients With AF., Introduction: Although transcatheter atrial fibrillation (AF) ablation requires accurate anatomic knowledge, pulmonary vein (PV) anatomy has not been fully investigated. Aim of this study is to describe left atrium (LA) and PV anatomy by magnetic resonance angiography (MRA) in a large cohort of patients with AF., Methods: MRA was performed in 473 patients preceding transcatheter AF ablation (paroxysmal 60.9%; persistent 39.1%). The Venice Chart classification was used to classify PV branching patterns., Results: About 40% of the patients presented typical PV branching pattern (2 left and 2 right PVs). A representative number of patients presented a common left trunk (19.9% and 11.0% short and long, respectively). A right middle PV was described in 12.5% and 2 right middle PVs in 1.5% patients. The remaining patients presented other complex, previously unclassified patterns: 6.3% presented an accessory PV originating from LA areas not describable as right or "upper" and 8.7% a common left trunk plus right middle PV. Diameters and circumference of each PV, LA, and LA appendage volumes resulted larger in patients presenting persistent compared to paroxysmal AF (P < 0.001)., Conclusion: This study highlights that "typical" PV branching pattern is not a common finding. That 25.6% of the patients present at least 1 accessory PV needs to be kept in careful consideration when planning and performing transcatheter AF ablation. In addition, not only LA volume, but also each PV ostia and LA appendage are significantly enlarged in patients with persistent compared to paroxysmal AF., (© 2010 Wiley Periodicals, Inc.)

Aim: The aim of the present study is to provide, in a large cohort of patients, a description of the left atrium (LA) and pulmonary veins (PV) anatomy in relation to ablation outcome., Background: The role of LA imaging, assessed before transcatheter ablation of atrial fibrillation (AF), is unknown., Methods: 330 patients referred for transcatheter ablation of AF (paroxysmal 62.7%; persistent 25.5%; long-standing 11.8%) underwent contrast-enhanced magnetic resonance imaging (MRI) before the procedure. Transcatheter ablation was performed aiming to AF interruption and/or absence of inducibility. Patients were followed clinically, by ECG, and 24-hour Holter ECG at 1-3-6-12-18-24 months., Results: The MRI preceding the procedure depicted a typical PV branching pattern, two left and two right, in 130 (39.4%) patients; 117 (35.4%) presented common left trunk (short and long) and 75 (22.7%) at least one accessory PV. Mean atrial volume was 142.0 +/- 48.5 ml. The ablation procedure resulted successful, after 15.6 +/- 7.2 months follow-up, in 174 (52.7%) patients. PV branching pattern did not relate (P = 0.304) to ablation outcome. A multiple Cox proportional hazard model, adjusted for potential confounders, proved that only LA volume was independently related to ablation outcome (HR 1.007, 95% CI 1.003-1.011; P = 0.001). A LA cut-off volume of 135 ml emerged as a significant predictor of ablation failure (ROC curve area 0.651, 95% CI 0.591-0.710; P < 0.001)., Conclusions: Less than half of the patients referred for transcatheter AF ablation present a typical PV branching pattern; the PV branching pattern, however, does not affect ablation outcome. LA volume strongly predicts AF ablation outcome.

Aims: To assess retrospectively clinical and procedural predictors of long-term recurrences after atrial fibrillation ablation., Methods: Two hundred and forty consecutive patients (201 men; mean age 60 +/- 10 years) undergoing pulmonary vein isolation (PVI) plus linear lesion ablation for antiarrhythmic drug-refractory atrial fibrillation between 2005 and 2007 were studied. Magnetic resonance imaging of the left atrium was performed in all the patients. Patients were followed up with clinical examination and ECG Holter at 1, 3, 6 months and every 6 months thereafter. In case of recurrence, a second procedure was offered. Clinical and procedural data were evaluated with univariate and multivariate analysis., Results: At a mean follow-up of 30.3 +/- 9.2 months after one or two procedures, 99 (41.3%) patients were in sinus rhythm without antiarrhythmic drugs and 50 patients (20.8%) had arrhythmia recurrences. These groups were compared in order to identify the clinical predictors of recurrences. Variables directly related to failure at univariate analysis were: history of persistent atrial fibrillation, number of previous electrical cardioversions, left atrial volume (LAV) at MRI, presence of pulmonary vein anatomical variants and BMI. At multivariate analysis, only left atrial volume measured at MRI was an independent predictor of failure., Conclusion: With long-term follow-up, LAV at MRI represents the main determinant of outcome after PVI plus linear lesion for ablation of paroxysmal and persistent atrial fibrillation.

Background: The aim of this study was to clarify the role of pulmonary vein isolation (PVI) alone versus left atrial linear lesions in the treatment of permanent atrial fibrillation (AF) in patients with left atrial dilatation and valvular disease. The primary end point was to assess the persistence of sinus rhythm (SR) off antiarrhythmic drugs (AADs) at 2-year follow-up and to correlate clinical outcome with surgical results validated with electroanatomic mapping (EAM)., Methods and Results: A total of 105 patients with permanent AF undergoing valve surgery were assigned to 3 different groups: in groups "U" and "7," left atrial linear cryoablation was performed, whereas in group "PV" patients, anatomic cryoisolation of pulmonary veins only was performed. In groups U and 7, SR was achieved in 57% of patients, whereas it was achieved in 20% of PV patients during 2-year follow-up. In the first 51 patients, the ablation schemes were validated with EAM. The EAM showed that the U lesion was never obtained: in 59% of these patients, a complete 7 lesion was achieved instead; in the 7 group, a complete 7 lesion was present in 65% of patients, whereas a complete PVI was obtained in 71% of patients. Considering patients in whom a complete 7 lesion was demonstrated with the EAM, SR without AADs was achieved in 86% of patients, whereas only 25% of patients with complete PVI were in SR without AADs., Conclusions: In patients with permanent AF, left atrial dilatation and valvular heart disease linear lesions in the posterior region of the left atrium are more effective than PVI alone. With cryoablation, the surgical intent is fulfilled in only approximately 65% of the cases. Knowing the real anatomic and electrophysiological effects of surgical ablation is necessary to correctly interpret the clinical outcome.