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Objective: Inflammation is thought to play a role in the pathogenesis of atrial fibrillation. The relationship between CD40 ligand (CD40L), a prothrombotic and proinflammatory molecule, and lone atrial fibrillation was presently investigated for the first time. Levels of serum CD40L were also tested, regarding potential to distinguish patients with lone atrial fibrillation from healthy individuals. Methods: Presently included were 35 patients with lone persistent atrial fibrillation and a control group of 30 healthy individuals. Serum levels of CD40L and high-sensitive C-reactive protein (hs-CRP) were measured, and transthoracic echocardiography was performed. Results: Mean serum CD40L, hs-CRP, left ventricular end-diastolic diameter, and left atrial diameter values were significantly higher in the group with lone persistent atrial fibrillation than in the control group (7.4+-3.5 ng/mL vs 4.3+-1.2 ng/mL, p4.5 ng/mL successfully discriminated patients with lone atrial fibrillation from controls (area under the curve: 0.847; 95% confidence interval: 0.759–0.934; p

Aims The ESC-EHRA Atrial Fibrillation Ablation Long-Term registry is a prospective, multinational study that aims at providing an accurate picture of contemporary real-world ablation for atrial fibrillation (AFib) and its outcome. Methods and results A total of 104 centres in 27 European countries participated and were asked to enrol 20–50 consecutive patients scheduled for first and re-do AFib ablation. Pre-procedural, procedural and 1-year follow-up data were captured on a web-based electronic case record form. Overall, 3630 patients were included, of which 3593 underwent an AFib ablation (98.9%). Median age was 59 years and 32.4% patients had lone atrial fibrillation. Pulmonary vein isolation was attempted in 98.8% of patients and achieved in 95–97%. AFib-related symptoms were present in 97%. In-hospital complications occurred in 7.8% and one patient died due to an atrioesophageal fistula. One-year follow-up was performed in 3180 (88.6%) at a median of 12.4 months (11.9–13.4) after ablation: 52.8% by clinical visit, 44.2% by telephone contact and 3.0% by contact with the general practitioner. At 12-months, the success rate with or without antiarrhythmic drugs (AADs) was 73.6%. A significant portion (46%) was still on AADs. Late complications included 14 additional deaths (4 cardiac, 4 vascular, 6 other causes) and 333 (10.7%) other complications. Conclusion AFib ablation in clinical practice is mostly performed in symptomatic, relatively young and otherwise healthy patients. Overall success rate is satisfactory, but complication rate remains considerable and a significant portion of patients remain on AADs. Monitoring after ablation shows wide variations. Antithrombotic treatment after ablation shows insufficient guideline-adherence.

Background Minimally invasive surgical treatment of lone atrial fibrillation (AF) is an alternative for AF that is refractory to medical treatment. We present long-term results of standalone surgical ablation of AF using a bipolar ablation device in 91 consecutive patients. Methods This was an observational, retrospective study of 91 patients (77 % males; mean age, 53 ± 10 years [range, 23–75 years]) who underwent minimally invasive standalone surgical ablation of persistent and longstanding persistent AF using a bipolar ablation device from 2008 to 2014. Mean follow-up was 60 ± 21 months. The absence of arrhythmia was confirmed at 3, 6, and 12 months, and annually thereafter, with 24-hour Holter monitoring. Results The mean duration of preoperative AF was 6.5 ± 5.4 years. Persistent AF was present in 86 % of patients and longstanding persistent AF in 14 %. Mean left atrial diameter was 4.3 ± 0.8 cm. There were two postoperative strokes (2 %) and three conversions to median sternotomy (3 %). Permanent pacemakers were implanted in six (7 %) patients. There were no intra- or postoperative deaths. At 1, 2, 3, 4, and 5 years postoperatively, freedom from AF was 59, 45, 41, 38, and 38 % of patients, respectively. The failure to achieve pulmonary vein isolation was the only independent predictor of long-term recurrence of AF (HR −3 [95 % CI 1,858 to 8,586], p = 0,001). There was a tendency towards higher rates of SR at long term follow up in patients with pulmonary vein isolation if division of ligament of Marshall was performed (HR - 2 [95 % CI 0.987 to 4,202], p = 0,067). Conclusions In the present series, the efficacy of epicardial surgical ablation was similar to that reported previously. The rate of arrhythmia recurrence increased over time. Achieving pulmonary vein isolation is essential to AF elimination. The division of ligament of Marshall could contribute to improved rates of SR restoration in patients with persistent or long-standing persistent AF if PVI is achieved.

Atrial fibrillation (AF) is the most commonly occurring arrhythmia, with a characterised pattern of progression. The many different presentations of AF and approaches to its management refect the complex nature of this condition. This article describes the overall management of a patient with lone paroxysmal AF, with a focus on pharmacological therapy and catheter ablation. In order to understand the therapeutic strategies employed, an appreciation of the pathophysiological processes involved in the development and perpetuation of AF is required. Ultimately, the driving force for any management strategy adopted should be determined by the symptoms experienced by the patient, and the effect that the arrhythmia has on their quality of life.

ObjectivesThis study investigated whether an individual's risk of developing lone atrial fibrillation (AF) before age 60 years is associated with lone AF in relatives.BackgroundGenetic factors may play a role in the development of lone AF.MethodsUsing Danish national registers, a cohort was established of ∼4 million persons born between 1950 and 2008, and those with a family history of lone AF (AF without preceding cardiovascular/endocrine diagnoses) were identified. Individuals were followed up until the first diagnosis of lone AF. Poisson regression was used to estimate incidence rate ratios (IRRs).ResultsIn ∼92 million person-years of follow-up, 9,507 persons were identified as having lone AF. The IRRs for lone AF given an affected first- or second-degree relative were 3.48 (95% confidence interval [CI]: 3.08 to 3.93) and 1.64 (95% CI: 1.04 to 2.59), respectively. IRRs were higher for men than for women but were not associated with the affected relative's sex. IRR for lone AF was 6.24 (95% CI: 2.59 to 15.0), given at least 2 first-degree relatives affected with lone AF. The IRR for lone AF in persons aged

The renin-angiotensin-aldosterone system (RAAS) plays a key role in atrial structural and electrical remodeling. The aim of this study was to investigate the potential associations of angiotensin-converting enzyme (ACE) gene insertion/ deletion (I/D) and aldosterone synthase (CYP11B2) gene −344T/C polymorphisms with the risk and recurrence of lone atrial fibrillation (AF). One hundred and ninety-three patients who underwent successful catheter ablation for lone AF were recruited. Two hundred and ninety-seven sinus rhythm subjects without a history of arrhythmia served as controls. The subjects were genotyped for ACE gene I/D and CYP11B2 gene −344T/C polymorphisms. Results showed that the ACE gene DD genotype and D allele were associated with a greater prevalence of lone AF (both P

The Cox-Maze procedure has been performed successfully since 1987. The original surgery was performed by using the "cut and sew" technique and is considered quite complex and technically demanding; therefore, it never gained popularity among cardiac surgeons and referring cardiologists. As surgical ablation technology improved, the Cox-Maze procedure can now be performed by using new ablation devices that deliver different energy sources (radiofrequency, cryothermia, and others). The use of ablation technology simplified the technical aspects of the procedure and has led to decreased time on cardiopulmonary bypass, easier placement of ablation lines, and the development of various minimally invasive approaches to include off-pump techniques. The Heart Rhythm Society recommends surgical ablation for symptomatic patients, patients who are unable to take anticoagulation therapy, who have failed other therapies to include percutaneous catheter ablation, or by personal request. Therefore, with guidelines in place as to patient selection and newer, easier-to-use technology, more surgeons are tackling surgical ablation of atrial fibrillation, offering another treatment option for patients with lone atrial fibrillation. This article will review the current state of surgery for the ablation of lone atrial fibrillation.

Objective Surgical ablation with radiofrequency is a safe and effective treatment for atrial fibrillation. Recent advances in instrumentation have allowed for the application of bipolar radiofrequency through a minimally invasive approach using small bilateral thoracotomies for pulmonary vein isolation, destruction of autonomic ganglia, and excision of the left atrial appendage (GALAXY procedure). Methods Thirty-two patients underwent surgical ablation of atrial fibrillation with the GALAXY procedure over a 43-month period. Data were collected in a prospective manner during hospitalization and at 1-, 3-, 6-, and 12-month intervals for rhythm, medications, and subsequent interventions. Results There were no operative mortality, no myocardial infarction, and no stroke. One patient required reexploration for bleeding. Mean follow-up was 28 months (range, 4–43 months). Freedom from atrial fibrillation at 12 and 24 months, respectively, was 90% and 67% for patients with paroxysmal fibrillation and 80% and 63% for patients with persistent atrial fibrillation. Of the patients who were not in sinus rhythm, four reverted to atrial fibrillation and two reverted to atrial flutter. Conclusions The GALAXY procedure is a safe and effective, minimally invasive method for treatment of isolated (lone) atrial fibrillation. The operation provides excellent short-term freedom from atrial fibrillation and should be considered in patients with isolated paroxysmal atrial fibrillation.

Background and Aim of the Study: We present our results with minimally invasive surgical treatment of lone atrial fibrillation (LAF) employing a radiofrequency (RF) source through a bilateral thoracoscopy. Methods: Between January 2007 and January 2011, 28 consecutive patients (85.7% male, mean age 67.1 +/- 9.1 years) with LAF underwent video-assisted bilateral RF ablation. Fourteen patients (50%) had paroxysmal, five (17.8%) persistent, and nine (32.2%) long-persistent LAF. All patients were followed-up according to the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) and success/failure was reported as suggested by Society of Thoracic Surgeon (STS) guidelines. Mean follow-up was 27.8 +/- 8.6 months. Results: Time-related prevalence of postoperative AF was 4.5% at 36 months. Success was much more likely in subjects with paroxysmal (3-year prevalence, 0%) or persistent (3-year prevalence, 0%) than long-standing persistent LAF (3-year prevalence, 8.3%). At 36 months the estimated prevalence of antiarrhythmic drugs was 11.3% (8.8 to 13.7). No major thromboembolic events were detected during the follow-up period and 36-month prevalence of Warfarin use was 15.2% (11.5 to 18.1). Finally, no patient underwent electrical cardioversion. Conclusions: This approach yielded satisfactory results with a high degree of safety. Further larger studies are necessary to confirm our findings. doi: 10.1111/j.1540-8191.2011.01272.x (J Card Surg 2011;26:453-459)

The Cox-maze III procedure (CMP) has achieved high success rates for the surgical treatment of atrial fibrillation (AF). In 2002, our group introduced a simplified CMP, in which most incisions were replaced with linear lines of ablation using bipolar radiofrequency and cryoenergy. This operation, termed the CMP-IV, has significantly shortened operative times and allowed for a minimally invasive approach. This report evaluates our results in 100 consecutive patients undergoing a stand-alone CMP-IV.Data were collected prospectively on 100 patients (mean age, 56 ± 10 years) who underwent a CMP-IV from January 2002 through May 2010. All patients were available for follow-up with a mean follow-up of 17 ± 10 months. Electrocardiograms or 24-h Holter monitorings were obtained at 6, 12, and 24 months. Data were analyzed using a longitudinal database containing over 380 variables.Thirty-one percent of patients had paroxysmal AF, with the remainder having persistent (6%) or longstanding persistent AF (63%). The mean preoperative duration of AF was 7.4 ± 6.7 years. The mean left atrial diameter was 4.7 ± 1.1 cm. In this group, 40 patients had failed with a mean of 2.6 ± 1.3 catheter ablations. Mean aortic cross-clamp time was 41 ± 13 min. There was one postoperative mortality. Postoperative freedom from AF was 93%, 90%, and 90% at 6, 12, and 24 months, respectively. Freedom from AF off antiarrhythmic medication was 82%, 82%, and 84% at 6, 12, and 24 months, respectively.The less invasive CMP-IV has a high single procedure success rate, even with improved follow-up and stricter definitions of failure.

Objectives: The aim of this study was to screen lone atrial fibrillation (AF) patients for mutations in the genes KCNJ2, KCNJ3 and KCNJ5, all encoding potassium channels. Furthermore, we wanted to replicate the prior association of two single-nucleotide polymorphisms (SNPs) in KCNJ5, C171T (rs6590357) and G810T (rs7118824), with lone AF in Han Chinese. Methods: We sequenced the coding region and splice site of KCNJ2, KCNJ3 and KCNJ5 in 187 early-onset lone-AF patients screening for mutations and counting SNP frequencies for the two noted SNPs in KCNJ5. Results: No mutations were found in KCNJ2, KCNJ3 or KCNJ5. Both genotype distribution and allele frequencies of the SNPs rs6590357 and rs7118824 significantly differed between the AF and control group (pgenotype = 0.0067, pallele = 0.0021 and pgenotype = 0.014, pallele = 0.0101, respectively). On allele level, the OR for lone AF for rs6590357 was 1.77 (95% CI 1.16–2.73, p = 0.009) and for rs7118824 it was 1.71 (95% CI 1.13–2.57, p = 0.01) in a model adjusted for age and gender. Conclusions: Our findings indicate that rs6590357 and rs7118824 in KCNJ5 are associated with early-onset lone AF in Caucasians. No mutations were found in the exon or splice site of KCNJ2, KCNJ3 or KCNJ5.

The aim of article is to give a brief description to the surgical strategies for patients with lone atrial fibrillation without associated cardiac operations, and present the possible indications of on-pump Maze procedures through a mid-sternotomy approach.

associated with incidence of atrial fibrillation. J Intern Med 2014;275:84–92. [17] Eryd SA, Borne Y, Melander O, et al. Red blood cell distribution width is associated with incidence of atrial fibrillation. J Intern Med 2014;275:84–92. [18] Patel KV, Semba RD, Ferrucci L, et al. Red cell distribution width and mortality in older adults: a meta-analysis. J Gerontol A Biol Sci Med Sci 2010;65(3):258–65. [19] Leftheriotis DI, Fountoulaki KT, Flevari PG, et al. The predictive value of inflammatory and oxidative markers following the successful cardioversion of persistent lone atrial fibrillation. Int J Cardiol 2009;135:361–9. [20] Toyama K, Yamabe H, Uemura T, et al. Analysis of oxidative stress expressed by urinary level of 8-hydroxy-2'-deoxyguanosine and biopyrrin in atrial fibrillation: effect of sinus rhythm restoration. Int J Cardiol 2013;168:80–5. [21] Wu Y, Zhang K, Zhao L, et al. Increased serum HMGB1 is related to oxidative stress in patients with atrial fibrillation. J Int Med Res 2013;41:1796–802. [22] Katoh S, Honda S, Watanabe T, et al. Atrial endothelial impairment through Tolllike receptor 4 signaling causes atrial thrombogenesis. Heart Vessels 2014;29(2):263–72. [23] Gracie JA, Robertson SE, McInnes IB. Interleukin-18. J Leukoc Biol 2003;73:213–24. [24] Luan Y, Guo Y, Li S, et al. Interleukin-18 among atrial fibrillation patients in the absence of structural heart disease. Europace 2010;12:1713–8.

BACKGROUND Lone atrial fibrillation (AF) is thought to be a benign type or an early stage of the disease. OBJECTIVE This study sought to compare the left atrium (LA) substrate using delayed-enhanced magnetic resonance imaging (DE-MRI) in patients with lone AF versus those with comorbidities. METHODS Forty of 333 included patients met criteria for lone AF. All patients underwent DE-MRI to quantify atrial fibrosis as a marker for structural remodeling (SRM) and underwent catheter ablation. Based on the degree of SRM, patients were staged into 4 groups: Utah I (5% LA wall enhancement), Utah II (5% to 20%), Utah III (20% to 35%), or Utah IV (35%). RESULTS Distribution in Utah I to IV was comparable in patients with lone AF and non‐lone AF. In both groups, a number of patients showed extensive SRM. Mean enhancement (14.08 8.94 vs. 16.94 11.37) was not significantly different between the 2 groups (P .0721). In the lone AF group, catheter ablation was successful in suppressing AF in all of Utah I, 81.82% of Utah II, 62.5% of Utah III, and none of Utah IV patients. Similar results were achieved in the non‐lone AF group. Outcome after ablation was significantly dependent on the SRM of the LA (P .001). CONCLUSION The degree of LA structural remodeling as detected using DE-MRI is independent of AF type and associated comorbidities. Selecting appropriate treatment candidates based on the quality and quantity of atrial fibrosis using DE-MRI would improve procedural outcome and avoid unnecessary intervention.

Patients with lone atrial fibrillation (AF) have an abnormal atrial substrate.The purpose of this study was to determine the role of direction-dependent conduction in patients with lone AF.Twenty-four patients with paroxysmal lone AF and 24 reference patients with left-sided accessory pathways were studied. Multipolar catheters placed at the lateral right atrium, crista terminalis, coronary sinus (CS), and left atrial roof were used to determine direction-dependent conduction characteristics. Biatrial electroanatomic maps were created during sinus rhythm and with distal CS pacing to characterize direction-dependent differences in conduction velocities, electrogram complexity, and voltage.Differing wavefront directions caused changes in conduction velocity (P.001), biatrial activation times (P.001), electrogram fragmentation (P.001), site-specific conduction delays (P.001), and voltage (P.001) in both lone AF and reference patients. These direction-dependent abnormalities were amplified in lone AF patients compared to reference patients, who exhibited greater slowing in conduction velocities (P = .02), prolongation of biatrial activation time (P = .04), increase in number (P.001) and length (P.001) of lines of conduction block, increase in proportion of fractionated electrograms (P.001), and decrease in voltage (P = .03) during distal CS pacing compared to sinus rhythm.This study demonstrates the marked direction-dependent conduction abnormalities present in patients with lone AF. These results provide further insights into the critical interplay between the underlying abnormal substrate and differing wavefront directions. The study suggests that direction-dependent conduction abnormalities may explain in part the greater arrhythmogenicity of ectopic triggers from the left atrium rather than the right atrium.

Aim. Endoscopic surgery demonstrates promising results of treatment in patients with non-paroxysmal atrial fibrillation. Minimally invasive thoracoscopic ablation contributes to the growing interest in such operations all over the world. Nowadays totally thoracoscopic ablations are available for patients in Russian Federation. Emphasis in our study was placed on the collection and analysis of data on thoracoscopic ablation procedures used for treating patients with lone atrial fibrillation.Methods. The study covered the operations performed by Russian cardiac surgeons over a period up until January 1, 2018. Data collection was based on emailed registration forms containing information about the date of procedures, type of ablation pattern, previous catheter procedures, used devices, methods of left atrial appendage closure and safety profile information. 30-day mortality, conversion to sternotomy/thoracotomy, stroke/ transient ischemic attack, reexplorations, cardiac tamponade and phrenic nerve damage were considered as major complications.Results. The study encompassed 10 cardiosurgical centers in Russian Federation where totally thoracoscopic ablations had been carried out between 2011– 2018. Six hundred fifty-two procedures were registered. Most patients were ablated in Dallas and Box Lesion patterns. Left atrial appendage exclusion was performed in 90,4% patients. Major complications were observed in 27 (4%) patients, mostly during the “learning curve” period.Conclusion. The given study is the first attempt to collect and systematize the data on a new surgical procedure for treatment of patients with atrial fibrillation. The data obtained allow for making a conclusion that thoracoscopic ablation is becoming a wide-spread surgical technique to treat patients with lone atrial fibrillation in Russia. The quantity of procedure increases annually. Introducing thoracoscopic procedures in clinical practice may be accompanied by complications at any center. Nevertheless, according to our investigation the rate of complications is low, which enables us to recommend thoracoscopic ablation to treat a numerous cohort of atrial fibrillation patients in Russia.Received 13 June 2018. Revised 22 July 2018. Accepted 23 July 2018.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

We examined 43 pregnant women with paroxysms of asymptomatic lone atrial fibrillation. It was revealed that the increasing of the gestational age leads to increase of number of single, paired and group supraventricular extrasystoles; single and paired ventricular extrasystoles; number and duration of paroxysms of atrial fibrillation. However, the number of extrasystoles and paroxysms of arrhythmia decreased to baseline values after delivery. Thus, it was proved that pregnancy contributes to the increase of paroxysms of lone atrial fibrillation due to the increased influence of modulating components on the triggering extrasystoles. The importance of the method of 24-hour ECG monitoring in the detection of arrhythmia in pregnant women is emphasized. Keywords: lone atrial fibrillation, extrasystole, pregnancy.

We present the case of a 50-year old female with a history of paroxysmal atrial fibrillation and without any antithrombotic therapy, who was admitted to the neurologic department of our hospital with symptoms of cerebral ischemia. Two hours after the release of the neurological syndrome, she experienced an acute ST-segment elevation myocardial infarction (STEMI) of the inferior wall, which was not thrombolysed due to active menstruation. The coronary angiography was performed nine days later and it showed normal coronary arteries. This is the first case report of a TIA and an acute myocardial infarction due to atrial emboli, in a middle aged woman without any coronary lesions. In our opinion it points out the strength and the effectiveness of the internal fibrinolytic mechanisms.

Aims Transvenous pulmonary vein isolation (PVI) is the cornerstone of non-pharmacological rhythm control therapy in symptomatic atrial fibrillation (AF). Success and complications rates are, however, still not optimal. New techniques and energy sources are therefore being developed. Methods and results Fifteen patients with lone AF refractory for antiarrhythmic drugs (AADs) underwent PVI by minimal invasive epicardial off-pump monolateral right-sided video-assisted thoracic surgery (VATS) using the UltraCinch with high-intensity focused ultrasound (HIFU). Primary endpoint was successful ablation defined as absence of AF or atrial flutter/tachycardia after 6 months assessed by complaints, 12 lead electrocardiogram, and 96 h Holter monitoring. Secondary endpoints were ablation success at the end of follow-up irrespective of AADs use or re-ablation and complications related to the procedure. Mean age was 47 ± 10 years and 14 (93%) were male. Eleven (73%) had paroxysmal, and 4 (27%) patients had persistent AF. Median AF history was 5 (1–12) years. At 6 months, six (40%) patients had sinus rhythm after one epicardial PVI (four on AADs). After 1.3 ± 0.6 years, four (27%) patients had sinus rhythm after one epicardial PVI (two on AADs) and in six (40%) patients endocardial radiofrequency re-ablation was performed, which was successful in three patients (20%). Two patients (13%) were planned for re-ablation. Three others (20%) refused re-ablation. Two major complications occurred (one late tamponade and one bleeding during surgery, necessitating sternotomy). Conclusion Epicardial PVI using monolateral right-sided VATS with the UltraCinch delivering HIFU is feasible, but is associated with substantial complications. Furthermore, the success rate was low. More research is therefore warranted to assess optimal ablation techniques and energy sources to perform PVI. Trial Registration clinicaltrials.gov Identifier: NCT00448656.

Studies have shown that continuous rhythm monitoring enables the detection of significantly more atrial fibrillation (AF) episodes than routine follow-up of patients, i.e. based on perception of symptoms or on 24-48 h Holter monitoring. The positive outcome of radiofrequency ablation (RFA) may be easily overestimated, especially in patients with paroxysmal AF. Thirty-three consecutive patients, aged 59.4+/-8.9 years (range 38-75 years) participated in this study. All patients had documented AF episodes with an AF duration of 9.4+/-7.1 years (range 1.5-25 years). A new monitoring device, the AF-Alarm was used to more accurately assess the outcome after surgical isolation of pulmonary veins. The AF-Alarm was applied for a duration of 128+/-42.5 h (range 49-191 h) during a period of 8-15 days. The success rate was 87% based on serial electrocardiograms (ECGs) and 24-48 h Holter monitoring during regular outpatient visits. Combination of ECG, Holter and AF-Alarm data yielded a significantly lower success rate, i.e. at the latest follow-up 69% of the patients were free from AF after surgical ablation (P

Human urotensin II (U-II) is an 11-amino acid peptide that plays an important role in hypertension and coronary artery disease. However, because there is no information on the role of U-II in the development of lone atrial fibrillation (AF), the goal of this study was to clarify the role of U-II in the development of lone AF. The study enrolled 42 patients (42.1 +/- 4.0 years old) with paroxysmal lone AF and 30 healthy gender- and age-matched control subjects. The following factors were measured in blood collected after an overnight fast: glucose, total cholesterol, low-density lipoprotein cholesterol, triglycerides, high-sensitivity C-reactive protein (hs-CRP), U-II, and vascular cell adhesion molecule 1 (VCAM-1). U-II levels were significantly higher in the lone AF than in the control group (4.09 +/- 1.28 vs 2.85 +/- 0.63 ng/ml, p0.001). VCAM-1 levels were also higher in the lone AF than in the control group (337 +/- 250 vs 218 +/- 117 ng/ml, p = 0.018). In addition, hs-CRP levels were higher in the lone AF than in the control group (0.88 +/- 0.29 mg/dl vs 0.67 +/- 0.31 mg/dl, p = 0.004). Multivariate logistic regression analysis that included U-II, VCAM-1, hs-CP, and conventional AF risk factors showed that only U-II and hs-CRP were independently associated with lone AF. In conclusion, the results indicate that increased levels of U-II are associated with the development of lone AF. Additional studies will be necessary to determine whether the elevation of U-II is the cause or the result of AF.

Atrial fibrillation is the most common sustained arrhythmia and represents a considerable health burden. In recent years there has been an increased interest in ablation treatment of atrial fibrillation. The Cardioblate surgical ablation system offers a complete system for surgical ablation as a concomitant or lone atrial fibrillation procedure. Saline-irrigated radiofrequency energy is used to produce electrically isolating lines in the atrial tissue. A range of disposable devices can be connected to the generator. A comprehensive review of the devices and the results achieved with the system is given. The system is compared with other alternative energy sources and to the Cox-Maze procedure.

Four recent major studies concerning the prognosis in atrial fibrillation (AF) are reviewed. The one-year mortality ranged from 16.0 to 0.2%, highest in elderly, hospitalized patients with chronic AF and lowest in young individuals with paroxysmal AF without other heart disease. The recognized clinical impression that the prognosis in AF is determined by age, type of AF and clinical status is thus confirmed. In three studies, however, the prognosis in lone atrial fibrillation seemed to be poorer than previously thought. The overall rate of thromboembolic complications in AF was about 25% in several studies. The effectiveness of coumarin drugs in the prophylaxis of these complications is not proved, and the time has come to subject them to more careful clinical investigation.

Twenty-six patients with lone atrial fibrillation were studied prospectively by M-mode echocardiography less than two months before and one month after cardioversion (CV). Seven patients had reverted to atrial fibrillation (AF) one month after CV. These patients (AF group) differed significantly with regard to mean left atrial dimension (LA) from the 19 patients (73%) who maintained sinus rhythm (S group) (p less than 0.001). Initial LA was 38.6 +/- 4.9 mm in the S group and 47.6 +/- 2.3 mm in the AF group. These values had not changed significantly in either group when measured one month after CV. The radiological heart size index showed a closely corresponding pattern. On the other hand, the mean heart size in both groups (441 +/- 100 and 544 +/- 98 ml/m2 BSA, respectively) was well below the upper normal limit (700 ml/m2) that is conventionally used as exclusion criterion from CV. In conclusion, in patients with AF and only moderate cardiac enlargement on chest X-ray, the echocardiographic LA can be used as predictor of maintaining sinus rhythm for at least one month following CV.

Objectives This study was designed to evaluate the correlation between lone atrial fibrillation and inflammation. Methods A total of 411 subjects were enrolled in this study, including 333 patients with lone atrial fibrillation, and 78 controls. C-reactive protein (CRP) and echocardiography were evaluated, and the electrocardiograph was monitored to identify cardiac rhythm at the time of blood sampling. According to the rhythm, paroxysmal atrial fibrillation was divided into presence and absence of atrial fibrillation. Results Subjects with lone atrial fibrillation had higher CRP levels than controls (media, 1.00 mg/L; IQR, 1.00–2.54 versus media, 1.00 mg/L; IQR, 1.00–1.55; p = 0.016) and subjects with persistent atrial fibrillation had higher CRP levels than those with paroxysmal atrial fibrillation (media, 1.62 mg/L; IQR, 1.00–3.98 versus media, 1.00 mg/L, IQR, 1.00–2.10; p = 0.022), and so did presence of atrial fibrillation rather than absence of atrial fibrillation (media, 2.11 mg/L; IQR, 1.00–3.60 versus media, 1.00 mg/L; IQR, 1.00–1.76; p = 0.000) in paroxysmal atrial fibrillation. However, there was no significant difference in CRP levels between persistent atrial fibrillation and presence of atrial fibrillation in paroxysmal atrial fibrillation (p = 0.992). Neither was there any difference between absence of atrial fibrillation in paroxysmal atrial fibrillation and controls (p = 0.483). In patients with lone atrial fibrillation, atrial fibrillation rhythm (B = 4.85, 95%CI: 2.61–8.99) was the only independent predictor of elevated CRP levels after adjusted covariants. Conclusions Patients with lone atrial fibrillation had elevated CRP levels only when they were in atrial fibrillation rhythm and an elevated CRP level was not related to duration of time or history of atrial fibrillation. Copyright © 2009 Wiley Periodicals, Inc.

We studied 21 consecutive patients from the Lausanne Stroke Registry, who had first-ever ischemic stroke and lone atrial fibrillation, with a standard protocol of investigations including brain CT, and non-invasive cardiac and arterial tests. Rarity of associated risk factors and extracranial; arterial disease, presence of distal intracerebral occlusions on early angiography, and topography of cerebral infarct suggested that cardioembolism was the cause of stroke, though echocardiographic evidence for an atrial thrombus was uncommon. There was no recurrence during a post-stroke 14-day phase, during which anticoagulant and antiaggregant therapies were systematically avoided. Though low, the main risk of stroke recurrence was 0.99 per 100 patient-years during a mean follow-up period of 4.8 years, including a mean duration of anticoagulant therapy of 2.3 years in 18 patients. On the other hand, no death, severe cardiac events, or disabling anticoagulation-related hemorrhages occurred.

ObjectivesThe aim of the present study was to verify whether angiotensin-II converting enzyme (ACE) inhibition is also effective in preventing relapses of lone atrial fibrillation (LAF), that is, in the absence of hypertension and/or heart disease.BackgroundSeveral studies have shown that ACE inhibitors are effective in preventing atrial fibrillation (AF) relapses in patients with arterial hypertension or several forms of heart disease, that is, in the presence of clinical conditions that are recognized as causing a higher risk of atrial arrhythmias.MethodsSixty-two patients admitted to the emergency department of our institution for a first-ever episode of LAF were enrolled in the study after excluding the presence of cardiac or extracardiac conditions known to be associated with an increased risk of AF, by medical history, physical examination, complete echocardiographic study, and the evaluation of blood pressure, thyroid function, urinary catecholamines, serum electrolytes, blood glucose, red blood cell count, and arterial blood gases. After cardioversion to sinus rhythm by intravenous propafenone, patients were randomized to either ramipril 5 mg/day (n = 31) or placebo (n = 31). Holter monitoring and clinical examination were performed every 3 months.ResultsAfter a 3-year follow-up, AF relapses were observed in 3 patients treated with ramipril and in 10 patients allocated to placebo (p < 0.03, Kaplan-Meier, log-rank test). During follow-up, none of the patients developed arterial hypertension or other cardiac or extracardiac condition known to be associated with increased risk of AF, that is, in all patients the diagnosis of LAF was confirmed.ConclusionsRamipril is effective in preventing relapses of LAF.

Background Minimally invasive surgical pulmonary vein isolation has become an alterative therapy for lone atrial fibrillation. This study evaluated the effect of the procedure on persistent atrial fibrillation by epicardial atrial electrography. Methods Five consecutive patients with lone persistent atrial fibrillation were enrolled. Intraoperative electrophysiology tests were performed before and after minimally invasive surgical pulmonary vein isolation. Morphology of the recordings and atrial fibrillation cycle length were analyzed. Results Sixty sites were recorded in 5 patients. Three types of bipolar electrogram were recorded at these sites. After ablation, all electrograms changed into type I in pulmonary veins and proximal antra, and remained unchanged in all proximal left atria. Atrial fibrillation cycle length at the proximal left atrium was shorter than that at the pulmonary veins. Atrial fibrillation cycle length recorded at proximal left atrium sites correlated with atrial diameter. The atrial fibrillation cycle length of the left atrium increased from 143 ± 11 to 170 ± 12 ms after pulmonary vein isolation. All 5 patients had atrial fibrillation immediately after the procedure and were treated with direct-current cardioversion and received amiodarone postoperatively. Freedom from atrial fibrillation was 100% at discharge and 60% at 6 months' follow-up. Conclusions Ectopic foci outside the pulmonary veins play an important role in persistent atrial fibrillation. Minimally invasive surgical pulmonary vein isolation might not be sufficient for persistent atrial fibrillation termination. The pulmonary vein isolation procedure, however, slows atrial fibrillation and makes supplemental pharmacologic cardioversion effective.

Introduction: Epidemiological studies report a male predominance in lone atrial fibrillation (LAF). Phenotypic differences between sporadic and familial LAF could aid in deciding which cases should undergo family screening. We sought to determine gender distribution in sporadic and familial LAF, gender-based differences, and phenotypic differences between sporadic and familial LAF. Methods: Since November 2000, 192 unrelated LAF probands were recruited. Sporadic LAF was defined as the absence of a family history of LAF. Familial LAF was classified as possible if one first- or second-degree relative had LAF, or confirmed if ≥ 2 relatives had LAF. Affected relatives (n = 87) of 34 confirmed familial probands were also evaluated. For unrelated LAF probands, differences in proportions and means were tested using χ2 and ANOVA, respectively. Difference in gender ratio among the family history groups was tested using mixed models. Results: Male proportion was greater among sporadic (82%) and possible familial probands (84%) than confirmed familial probands (62%), and affected relatives (54%), P < 0.001. Sporadic LAF was more common in men (62%) than women (51%), P = 0.03. More women were affected by palpitation and nocturnal symptoms than men. More patients had permanent AF in the confirmed familial group (27%), compared with the possible familial (7%) and the sporadic LAF group (8%), P = 0.05, but no other phenotypic discriminators were identified. Conclusions: Male predilection for LAF is attenuated as the likelihood of dominant Mendelian inheritance increases. Increased frequency of “sporadic” LAF among men could be partially due to X-linked recessive inheritance. Finally, sporadic and familial LAF are clinically indistinguishable.

Background: The success rate and prognosis of cardioversion of atrial fibrillation (AF) in patients with organic heart disease is well known. In contrast, little data exist about cardioversion success and maintenance of sinus rhythm (SR) in patients with lone AF and in patients with hypertension as the only underlying cardiovascular disease. Methods: In a prospective cardioversion registry 148 of 181 patients (81.8%) with lone AF (age 58 ± 13 years, duration of AF 7.6 ± 19 weeks) and 120 of 148 patients (81.1%) with hypertension (age 62 ± 10 years, duration of AF 6.6 ± 21 weeks) had successful cardioversion and were followed for 7.7 ± 1.9 months. Results: At follow-up, 120 patients (81.1%) with lone AF were in SR, and 18 of these patients had had repeated cardioversion during follow-up (AF total recurrence rate 31.1%). In stepwise regression analysis, the number of previous cardioversions was predictive of rhythm at follow-up (P = 0.0453). Rhythm at follow-up did not differ between patients who were or were not on antiarrhythmic drugs. At follow-up 96 patients (80%) with hypertension were in SR, and 9 of these had had repeated cardioversion during follow-up (AF total recurrence rate 27.5%). As in lone AF, the recurrence rate of AF did not differ between patients with or without antiarrhythmic drug treatment, and in multivariate regression analysis, the number of previous cardioversions was the only clinical predictor of rhythm at follow-up (P = 0.0284). Conclusions: Even in patients with such benign conditions as lone AF or hypertension as the only underlying disease, the prognosis of cardioversion in terms of maintenance of SR is poor. Future studies of rhythm control versus rate control need to include not only patients with organic heart disease but also patients with lone AF and patients with hypertension, since the long-term benefits of these two strategies remain unclear even in these subsets of patients.

Background Cigarette smoking is a risk factor for atrial fibrillation (AF), but whether secondhand smoke (SHS) impacts the risk of AF remains unknown. Objective To determine if SHS exposure is associated with an increased risk of AF. Methods We performed a cross-sectional analysis of data from participants enrolled in the Health eHeart Study, an internet-based, longitudinal cardiovascular cohort study, who completed baseline SHS exposure and medical conditions questionnaires. SHS was assessed through a validated 22-question survey, and prevalent AF was assessed by self-report, with validation of a subset (n = 42) by review of electronic medical records. Results Of 4976 participants, 593 (11.9%) reported having AF. In unadjusted analyses, patients with AF were more likely to have been exposed to SHS in utero, as a child, as an adult, at home, and at work. After multivariable adjustment for potential confounders, having had a smoking parent during gestational development (OR 1.37, 95% CI 1.08–1.73, P = .009) and residing with a smoker during childhood (OR 1.40, 95% CI 1.10–1.79, P = .007) were each significantly associated with AF. Both positive associations were more pronounced among patients without risk factors for AF ( P values for interaction Conclusions SHS exposure during gestational development and during childhood was associated with having AF later in life. This association was even stronger in the absence of established risk factors for AF. Our findings indicate that SHS in early life may be an important, potentially modifiable risk factor for the development of AF.

A fibrillation (AF) is the most prevalent sustained cardiac arrhythmia in adult population. Aim of the present study is to evaluate the association of paroxysmal lone AF with endothelial dysfunction in young patients. Two groups of participants were prospectively enrolled. The first group comprised of 70 patients with recurrent paroxysmal lone AF. The second group comprised of 20 healthy controls in sinus rhythm matched by age and gender. All the participants underwent physical examination, laboratory analysis (including determination of C-reactive protein (CRP)), standard echocardiography, exercise-stress testing, brachial artery Flow Mediated Dilatation (FMD) percent and Circulating Endothelial cells (CECs) by flow cytometry were assessed. There were no differences between the 2 groups regarding age, gender and most clinical, laboratory and echocardiographic characteristics (all p>0.05 except CRP level). FMD% of lone AF patients was significantly lower 6.4±1.6 versus 6.4±1.6 (p

BACKGROUND: Lone atrial fibrillation (LAF) develops in younger individuals without cardiovascular or pulmonary disease. As pulmonary vein isolation has been recognized as an optimal treatment for drug-resistant atrial fibrillation, cryoballoon ablation with second-generation balloon (CB-A) may be an ideal solution for LAF patients. OBJECTIVE: The aim of this study was to investigate acute success, periprocedural complications and outcome over a 12-month follow-up period in a cohort of patients having undergone PV isolation (PVI) for LAF using CB-A technology. METHODS: 75 consecutive patients (50 male, mean age 47±12 years) with a diagnosis of lone paroxysmal atrial fibrillation who underwent Pulmonary Vein Isolation (PVI) by CB-A from June 2012 were included. All patients underwent this procedure with the 28 mm CB-A. A total of 299 PVs (100%) could be isolated with CB-A alone. RESULTS: The freedom from AF recurrence after a single procedure was 92% of patients during the entire 13-month follow-up. When considering a blanking period (BP) of 3 months, success rate was 93,3%. Transient phrenic nerve palsy (PNP) was the most frequent complication occurring in 5.3% of individuals (4 patients); complete recovery was documented for all of these patients prior to hospital discharge. CONCLUSIONS: CB-A is extremely effective in achieving PVI and affords freedom from AF at 13-month follow-up in 93% of young patients affected by drug-resistant LPAF following a 3-month BP. The most frequent complication observed was PNP, which reverted prior to discharge in all patients. This article is protected by copyright. All rights reserved.

Electrophysiological (EP) studies have shown differences in inter-atrial conduction. Conduction pathways may have relevance for atrial fibrillation (AF). We investigated if patients with lone paroxysmal AF presenting diverse inter-atrial conduction pathways in EPS also differ in non-invasive magnetocardiographic (MCG) mappings. Measurements were carried out during sinus rhythm. Atrial activation maps acquired in EPS were used to identify conduction pathways. For MCG, we used pseudocurrent parameterization and created a new method to characterize the orientation of a magnetic field map (MFM). The results suggest that MFM orientation is sensitive to differences in inter-atrial conduction.

Background This paper aims to evaluate the feasibility and the efficacy of a new off-pump, bilateral thoracoscopic pulmonary vein isolation technique in patients with lone atrial fibrillation. Methods Between April 2004 and February 2006, 26 drug-resistant and symptomatic lone atrial fibrillation patients (18 permanent, 8 paroxysmal) underwent an irrigated radiofrequency ablation procedure using the Cardioblate ablation system (Medtronic, Minnesota). There were 16 men and 10 women with a mean age of 55 ± 11 years. Mean duration of atrial fibrillation was 34.2 ± 18.9 months. All patients underwent a bilateral thoracoscopic procedure in which both pulmonary veins were ablated with an atrial cuff using an off-pump epicardial approach. The conduction block was assessed by pacing the pulmonary veins after each ablation. Sixteen patients underwent endoscopic stapling of the left atrial appendage. Results There were no hospital deaths. All procedures were completed as planned without any conversions to sternotomy. There were no major complications. Follow-up was complete at 6 months, and 80% of the patients were in sinus rhythm (paroxysmal: 100%, permanent: 72%). Of the patients with permanent atrial fibrillation, 85% had regained their atrial transport function. No major thromboembolic event was observed during the follow-up period. Conclusions The video-assisted bilateral pulmonary vein isolation technique was safe and effective. It was curative for paroxysmal atrial fibrillation patients and effective for permanent atrial fibrillation cases. This technique may find wider application if accumulating data further support these findings.

We recently identified a large family with a high prevalence of lone atrial fibrillation (AF) and saddleback-type ST-segment elevation in leads V(1-3), without a history of ventricular arrhythmias or syncope. On the basis of this finding, we studied whether there is a relationship between saddleback ST-elevation and lone AF.We examined 168 (mean age 50+/-8 years, 130 males) lone AF patients and 541 (mean age 50+/-6 years, 274 males) healthy subjects. The prevalence of saddleback ST-elevation was higher in the lone AF group than the control group (10 vs. 0.4%, P0.001). None had a coved-type ST-elevation in baseline ECG or during drug challenge with ajmaline or flecainide (n=13), a family history of sudden cardiac death, ventricular tachyarrhythmias, syncope, or any other features diagnostic to the Brugada syndrome. Familial clustering of lone AF (i.e. AF in30% of first-degree relatives) was more common among the subjects with saddleback ST-elevation (24 vs. 7%, P=0.03).Saddleback-type ST-segment elevation is a relatively common finding among patients with lone AF. The familial clustering of the disorder indicates that genetic factors may be involved in the pathogenesis of the ECG abnormality and lone AF in these patients.

To investigate left atrium (LA) strain properties of patients with lone atrial fibrillation (LAF) and to assess relationships between LA strain parameters and total atrial conduction time measured with tissue Doppler imaging (PA-TDI). The study population consisted of 53 patients with LAF. The control group was comprised of 50 normal volunteers. Conventional echocardiography indices were measured. Mitral annular velocities and PA-TDI were assessed with TDI. Two-dimensional speckle-tracking echocardiography (2D-STE) was used to assess LA segmental strain and strain rate. Compared with the control group, PA-TDI was significantly prolonged and LA myocardial Ss, SRs, Sa, and SRa were significantly decreased in the LAF group (all P

Introduction: Hypertension and structural heart disease (SHD) are the most frequent causes of Atrial Fibrillation (AF). Hemodynamic overload and inflammation are key mediators of the arrhythmogenic substrate, at least partly by triggering accelerated senescence. Remarkably, up to one third of AF patients have no associated SHD (lone AF), and their arrhythmogenic substrate is largely unknown. We sought to compare structural and senescence changes in AF patients with or without SHD. Methods: Atrial appendage samples from four groups of patients were analyzed; patients with no SHD (AF_lone, n=10), AF patients with SHD (AF_Card, n=14), controls with no AF but with other cardiovascular diseases (CVD) (C_CVD, n=18) and controls with no CVD (C_Healthy, n=5). The percentage of intramyocardial collagen deposition was quantified by sirius red staining and morphometric analysis, and connexin-43 was analyzed by immunohistochemistry. Tissue senescence was evaluated with telomere length quantification and mRNA levels of a family of proteins involved in cellular senescence (Sirtuin-1, -2, -3 and -6). Results: There were no differences in age (overall mean 60 ± 2 years) and the percentage of male gender (overall 67%) between groups of patients. AF patients had a marked increase in atrial fibrosis, with no differences between AF_lone and AF_Card (Figure A). Connexin-43 quantification and distribution was similar in AF patients with or without SHD. Nevertheless, telomeres were longer in AF_lone than in AF_Card patients (Figure B). Also, AF_lone samples had higher mRNA levels of sirtuin-2 and -3 compared to AF_Card samples with no changes in sirtuin-1 and -6. Conclusions: Even though a similar degree of structural remodelling was found, AF_Card patients presented an accelerated atrial senescence when compared to AF_lone patients. These results could have important implications in the prognosis and therapeutic options of AF_lone patients.

Background: Current evidence links atrial fibrillation (AF) to the inflammation. Inflammatory indexes such as high-sensitive C-reactive protein (hs-CRP) have been related to the development and persistence of AF. However, the role of inflammation in the atrial electrophysiological remodeling indexed by P-wave dispersion (P d ) remains unclear. Methods: The study consisted of 71 patients with lone paroxysmal AF (AF group) and 71 age- and gender-matched controls of paroxysmal supraventricular tachycardia without history of AF (control group). Electrocardiography, P d , hs-CRP, and other clinical characteristics were compared between the two groups. Results: There was no significant difference between the two groups regarding age, gender, hyperlipidemia, etc. Compared to controls, left atrial diameter (44 ± 7 vs 39 ± 7 mm), P d (49 ± 13 vs 26 ± 8 ms), and hs-CRP (2.17 [1.46-2.89] vs 1.12 [0.74-1.41] mg/L) were increased (P < 0.05), respectively. Linear regression identified hs-CRP as an independent correlation of P d level both in the total population and the AF group (r = 0.464 and 0.313; P < 0.001, respectively). Multiple logistic regression revealed hs-CRP as an independent determinant of AF (odds ratio [OR] =15.430, 95% confidence interval: 6.031-39.476: P

Aims: In the face of increasing evidence of underlying genetic heterogeneity for lone atrial fibrillation (LAF), we undertook a clinical analysis of subjects to identify the phenotypic subsets of this arrhythmia. Methods and Results: We evaluated serial patients who presented with LAF between July 5, 2001 and December 19, 2003. Subjects underwent a standardized interview to elicit a detailed medical history, prior therapies, and precipitants of atrial fibrillation. The results of a physical exam, electrocardiogram and echocardiogram were reviewed. One hundred and eighty subjects with a mean age of 45 years (15–67 years) at the time of diagnosis were enrolled. The majority of patients originally presented with paroxysmal fibrillation (94%), and 7.8% progressed to permanent AF. Reported triggers for AF included sleeping (44%), exercise (36%), alcohol use (36%), and eating (34%). Women with LAF had distinct symptoms, triggers for episodic AF, and over one-fourth had an underlying rheumatologic condition. Several subsets of AF including familial AF (39%), exercise-induced AF (32%), and conduction system disease requiring pacemaker implantation (7%), were identified. Conclusions: Family history, exercise as a trigger of AF, and a history of a pacemaker identified subtypes of LAF.

Vorhofflimmern ist die häufigste anhaltende Herzrhythmusstörung, wobei die Prävalenz mit zunehmendem Alter ansteigt. Obwohl Vorhofflimmern häufig mit einer strukturellen Herzerkrankung vergesellschaftet ist, tritt es bei vielen Patienten auch ohne erkennbare zugrunde liegende Herzerkrankung auf. Hämodynamische Beeinträchtigung und thromboembolische Ereignisse führen zu einer bedeutenden Morbidität, Mortalität und auch zu relevanten Gesundheitskosten. In dieser Übersichtsarbeit wird das zeitgemäße Management von Vorhofflimmern besprochen.

Surgical treatment is effective and less invasive for lone atrial fibrillation because of the emergence of the endoscopic technology and the adoption of new type of energy. On the basis of these improvements, we developed a new surgical ablation procedure by endoscopy for lone atrial fibrillation. The procedure enrolls only three ports on the left chest wall, which can provide pulmonary vein isolation, resection of the left atrial appendage, ganglionic plexus ablation, and make ablation of left atrium with direct vision. A total of 45 procedures were successfully performed. We reported the technique and result of the procedure.

Background Thoracoscopic ablation for lone atrial fibrillation (AF) has evolved rapidly in the past decade. We investigated the electrophysiologic results and midterm durability of totally thoracoscopic ablation in patients with lone persistent AF. Methods Seventy-nine consecutive patients with paroxysmal AF (8 patients, 10.1%), persistent AF (17 patients, 21.5%), and long-standing persistent AF (54 patients, 68.3%) were prospectively enrolled. Thoracoscopic ablation consisted of a bilateral closed-chest approach to performing pulmonary isolation (a box lesion), ganglionated plexus ablation, division of the Marshall ligament, and left atrial auricle resection. An electrophysiologic study was performed 5 days after the surgical procedure in 61 patients (77%). Freedom from AF was assessed with electrocardiograms or Holter monitoring every 3 months, with a mean follow-up of 12.1 (maximum, 28) months. Results No deaths or conversion to cardiopulmonary bypass occurred. During electrophysiologic study, 28 residual pulmonary vein potentials were observed in 15 patients (19%). Out of a total of 28 gaps, 20 (71%) were located in the superior and inferior ridges of pulmonary veins. Six gaps (21%) were detected in the carina of pulmonary veins. The mitral isthmus was ablated in 2 patients (7%). Freedom from AF at 2 years was 92.6 ± 3.3%. Freedom from cardiac-related events at 2 years was 74.7 ± 6.0%. Cox regression analysis demonstrated that the predictors of atrial arrhythmias were old age, hypertension, and left atrial volume index. Conclusions Thoracoscopic ablation followed by electrophysiologic confirmation was safe and provided excellent midterm durability in patients with AF. However, the incidence of residual potentials around the pulmonary veins was not negligible.

Predictors of recurrence in lone atrial fibrillation have not been clearly identified. Acoustic quantification (AQ) is a promising method in the assessment of left atrial (LA) volumes. The purpose of the present study was to investigate the potential of LA volumes obtained by standard manual tracing and AQ methods in predicting AF-recurrence after restoring the sinus rhythm in patients with lone AF, and to test the agreement between the two approaches. Standard echocardiography combined with AQ was performed in 28 patients with lone AF one hour after the sinus rhythm was regained, and in 10 controls. LA volumes were determined by conventional manual tracing and AQ methods. AQ waveforms of LA were obtained by drawing a region of interest around the LA border. The agreement of the two methods was tested by Bland-Altman analysis. Patients were followed up for 6 months for the occurrence of AF recurrence. A good correlation was observed between AQ and manual tracing methods in determining both minimal (r=0.59) and maximal (r=0.88) LA volumes. Patients with AF recurrence had a significantly larger maximum LA volume as assessed with both methods (P