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Arrhythmia Inducibility Post-AF Ablation Introduction Prior reports demonstrate prognostic value in noninducibility of atrial arrhythmias after atrial fibrillation (AF) ablation and suggest their utility in guiding additional ablation lesion sets. The type and mechanism of induced atrial arrhythmias, their relationship to the underlying atrial substrate, and prognostic significance of induced organized atrial arrhythmias are unknown. Methods and Results One hundred forty-four patients (30 women; median age 60 years; 54% with paroxysmal AF) undergoing AF ablation (circumferential pulmonary vein isolation and focal ablation of nonvein triggers on isoproterenol) were evaluated prospectively. All underwent a standardized postablation induction protocol from the coronary sinus and right atrium: 15 beat burst pacing at 250 milliseconds and decrementing to 180 milliseconds. Sustained rhythms were defined as greater than 2 minutes Of 144 patients, 55 patients (38.2%) did not have sustained inducible arrhythmias. Fifty-two (36.1%) had inducible AF and 37 (25.7%) had inducible organized arrhythmias. A logistic regression analysis showed that age (OR 2.10 per decade; P = 0.003) and hypertension (OR 4.15; P = 0.009) were predictive of inducibility. However, inducibility of either AF or organized arrhythmias was not prognostic of clinical recurrence at 1 year postablation (P = 0.65). Furthermore, inducibility of organized arrhythmias did not predict clinical recurrence of an organized arrhythmia. Only LA size (OR 2.18; 95% CI 1.02–4.67; P = 0.04) and persistent AF (OR 2.43; 95% CI 1.09–5.40; P = 0.03) predicted atrial arrhythmia recurrence. Conclusions Multisite atrial burst pacing post-AF ablation induced organized rhythms in 25.7% and AF in 36.1% of patients after AF ablation. Hypertension and age predict inducibility of arrhythmias, but inducibility did not predict clinical recurrence in follow-up. Distinguishing organized atrial arrhythmias from AF did not yield any further prognostic information. The utility of aggressive stimulation protocols after AF ablation for prognosis and to guide therapy appears limited.

Cryo-balloon catheters have attracted an increasing amount of interest in the medical community as they can reduce patient risk during left atrial pulmonary vein ablation procedures. As cryo-balloon catheters are not equipped with electrodes, they cannot be localized automatically by electro-anatomical mapping systems. As a consequence, X-ray fluoroscopy has remained an important means for guidance during the procedure. Most recently, image guidance methods for fluoroscopy-based procedures have been proposed, but they provide only limited support for cryo-balloon catheters and require significant user interaction. To improve this situation, we propose a novel method for automatic cryo-balloon catheter detection in fluoroscopic images by detecting the cryo-balloon catheter's built-in X-ray marker. Our approach is based on a blob detection algorithm to find possible X-ray marker candidates. Several of these candidates are then excluded using prior knowledge. For the remaining candidates, several catheter specific features are introduced. They are processed using a machine learning approach to arrive at the final X-ray marker position. Our method was evaluated on 75 biplane fluoroscopy images from 40 patients, from two sites, acquired with a biplane angiography system. The method yielded a success rate of 99.0% in plane A and 90.6% in plane B, respectively. The detection achieved an accuracy of $1.00~{\rm mm}\pm 0.82~{\rm mm}$ in plane A and $1.13~{\rm mm}\pm 0.24~{\rm mm}$ in plane B. The localization in 3-D was associated with an average error of $0.36~{\rm mm}\pm 0.86~{\rm mm}$ .

During a procedure for pulmonary vein ablation in a male patient, resistance to Brockenbrough needle advancement into dilator was felt. Needle advancement was …

IntroductionPulmonary vein isolation (PVI) is considered to be a cornerstone of invasive therapy of paroxysmal atrial fibrillation (PAF). However, numerous technologies appeared on the market during last 10 years and besides typical “point-by-point” ablation, other “single-burn” technologies or remote navigation emerged.GoalThe aim of this article is to summarize single center experience with PVI using different technologies.Methods and resultsThe study was conducted in partially retrospective and mainly prospective manner. Consecutive cohorts of patients with PAF were followed after their index procedure using four different systems (CARTO XP, pulmonary vein ablation catheter (PVAC), CARTO3 and Sensei robotic system). After 3 month blanking period, repeated 7 day-Holters were carried out every 3 months following the index procedure, which consisted of catheter-based radiofrequency PVI. Documented episodes of AF lasting >60s on any of these 7-day Holters were considered a failure of treatment. Using of the PVAC technology was associated with the shortest procedure duration when compared to any other system (p

Effect of Anxiety and Depression on the Recurrence of Paroxysmal Atrial Fibrillation. Introduction: Whether circumferential pulmonary vein ablation (CPVA) can alleviate anxiety and depression symptoms is unknown and the effect of anxiety and depression on the recurrence of atrial fibrillation (AF) after CPVA is not clear. Methods: Two hundred and ten patients with a diagnosis of paroxysmal AF were admitted in the study. Ninety-eight patients (CPVA group) and 102 patients (medicine group) were treated with CPVA and antiarrhythmic drugs, respectively. All patients were followed up for 1 year. Zung Self-Rating Anxiety Scale (SAS), Zung Self-Rating Depression Scale (SDS), and Short-Form life survey-36 items (SF-36) were assessed before and after follow-up. Results: In CPVA group, the scores of SAS and SDS decreased (41.69 ± 8.32 vs 37.66 ± 4.82, P < 0.001 and 45.01 ± 9.71 vs 40.05 ± 8.56, P < 0.001, respectively) and SF-36 score improved (565.29 ± 143.37 vs 606.84 ± 102.84, P = 0.021) after follow-up. Compared with the data in recurrent patients, the SAS and SDS scores were significantly lower in nonrecurrent patients at baseline (44.68 ± 8.40 vs 38.10 ± 7.55, P < 0.001 and 51.75 ± 9.41 vs 43.96 ± 8.95, P < 0.001, respectively). The results of multivariate logistic regression analysis showed normalized scores of SAS (OR = 3.20, 95% CI [3.05, 3.48], P = 0.023) and SDS (OR = 3.26, 95% CI [3.12, 3.49], P = 0.023) were the independent risk factor of AF recurrence after CPVA. Conclusions: CPVA can ameliorate anxiety and depression, which may contribute to improvement of quality of life in patients with paroxysmal AF. Anxiety and depression increase the recurrence risk of AF after CPVA. (J Cardiovasc Electrophysiol, Vol. 23, pp. S17-S23, November 2012)

Pulmonary vein ablation is increasingly used for patients with difficult to manage atrial fibrillation. Echocardiography plays a central role in the assessment of patients undergoing ablation therapy, not only in the pre-ablation patient selection and post-ablation assessment, but also in the peri-procedural guidance. Newer echocardiographic techniques including atrial mechanics measurements are also reviewed.

real-time 3-dimensioanl transesophageal echocardiography (RT3DTEE) provides high quality images of the posterior structures of the heart ([1][1]) and has been used for guiding several catheter-based procedures ([2][2]). The electrical isolation of pulmonary veins (PVs) has become a highly effective

The purpose of this study was to compare the efficacy of focused ultrasound circumferential pulmonary vein ablation (CPVa) and BOX ablation (BOXa) in an acute atrial fibrillation (AF) model. Twenty mongrel dogs were divided into either CPVa or BOXa groups. CPV or BOX focused ultrasonic ablation was conducted in each group after successful establishment of the AF model. Before-and-after ablation left atrial effective refractory period (LAERP), AF inducibility, and induced AF lasting time were measured in both groups. The LAERP after AF model establishment was significantly shorter than that before establishment (102 ± 10 vs. 140 ± 10 ms, p

In the Era of expanding use of transseptal structural heart disease interventions and catheter ablation techniques for atrial fibrillation, there is increasing interest in the iatrogenic atrial septal defect (iASD) often associated with these procedures. The purpose of this review is to summarize the current evidence on the incidence and clinical impact of iASD, to identify possible predictors of persistent iASD, and to propose a standardized method for the detection, follow up and management of iASD.

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important source for mortality and morbidity on a population level. Despite the clear association between AF and death, stroke, and other cardiovascular events, there is no evidence that rhythm control treatment improves outcome in AF patients. The poor outcome of rhythm control relates to the severity of the atrial substrate for AF not only due to the underlying atrial remodelling process but also due to the poor efficacy and adverse events of the currently available ion-channel antiarrhythmic drugs and ablation techniques. Data suggest, however, an association between sinus rhythm maintenance and improved survival. Hypothetically, sinus rhythm may also lead to a lower risk of stroke and heart failure. The presence of AF, thus, seems one of the modifiable factors associated with death and cardiovascular morbidity in AF patients. Patients with a short history of AF and the underlying heart disease have not been studied before. It is fair to assume that abolishment of AF in these patients is more successful and possibly also safer, which could translate into a prognostic benefit of early rhythm control therapy. Several trials are now investigating whether aggressive early rhythm control therapy can reduce cardiovascular morbidity and mortality and increase maintenance of sinus rhythm. In the present paper we describe the background of these studies and provide some information on their design.

Atrial fibrillation (AF) is the most common sustained arrhythmia and an important source for mortality and morbidity on a population level. Despite the clear association between AF and death, stroke, and other cardiovascular events, there is no evidence that rhythm control treatment improves outcome in AF patients. The poor outcome of rhythm control relates to the severity of the atrial substrate for AF not only due to the underlying atrial remodelling process but also due to the poor efficacy and adverse events of the currently available ion-channel antiarrhythmic drugs and ablation techniques. Data suggest, however, an association between sinus rhythm maintenance and improved survival. Hypothetically, sinus rhythm may also lead to a lower risk of stroke and heart failure. The presence of AF, thus, seems one of the modifiable factors associated with death and cardiovascular morbidity in AF patients. Patients with a short history of AF and the underlying heart disease have not been studied before. It is fair to assume that abolishment of AF in these patients is more successful and possibly also safer, which could translate into a prognostic benefit of early rhythm control therapy. Several trials are now investigating whether aggressive early rhythm control therapy can reduce cardiovascular morbidity and mortality and increase maintenance of sinus rhythm. In the present paper we describe the background of these studies and provide some information on their design.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: is it safe to stop anticoagulants after successful surgery for atrial fibrillation? Altogether, 177 papers were found using the reported search, of which 14 were selected that represented the best evidence to answer the clinical question. Selection criteria included study relevance, primary outcome, size of study population and length of follow-up. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The weight of evidence, including over 10,000 patient-years of follow-up, supports the discontinuation of warfarin following atrial fibrillation correction procedures as being safe, with an associated annual thromboembolic stroke rate of 0-3.8% off warfarin, in studies where warfarin was stopped at a mean of 3.6 months (range 0-8 months) after the procedure. However, the confidence of this conclusion suffers from a paucity of high-quality randomized controlled trials in the field, with the main body of evidence coming instead from observational non-randomized studies. The stroke rate also varies with the exact procedure performed; pulmonary vein isolation procedures are the most extensively evaluated and carry the lowest stroke rate following warfarin discontinuation (0-0.4% per annum when performed as an isolated procedure). By contrast, left atrial appendage occlusion by insertion of a transcatheter device has an associated annual stroke rate of 0-3.8% off warfarin. Thus, discontinuation of warfarin following such transcatheter procedures cannot be recommended at this time. Concomitant heart surgeries, such as mitral valve repair have been shown to increase the thromboembolic rate both unpredictably and dramatically, and this review thus identifies concomitant mitral valve surgery as a potentially substantial risk factor for late thromboembolic stroke in patients undergoing corrective surgeries for atrial fibrillation. This review finds in favour of warfarin discontinuation in selected patients at three months post-procedure, emphasizing consideration of the patient's individual risk-factor profile as paramount. This recommendation is in line with the 2010 guidelines for the management of atrial fibrillation produced by the European Society of Cardiology.

Aims Transoesophageal echocardiography (TEE) is recommended prior to circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) to identify left atrial (LA) or left atrial appendage (LAA) wall thrombi. It is not clear whether all patients undergoing CPVA should receive pre-procedural TEE. We wanted to assess the incidence of LA thrombus in these patients and to identify factors associated with its presence. Methods and results Consecutive patients referred for CPVA from 2004 to 2009 underwent TEE within 48 h prior to the procedure. Of 408 patients included in the study, 6 patients (1.47%) had LA thrombi, persistent AF, and LA dilation. Compared with patients without thrombus, these six patients had larger LA diameter ( P = 0.0001) and more frequently were women ( P = 0.002), had persistent AF ( P = 0.04), and had underlying structural cardiac disease ( P = 0.014). The likelihood of presenting LA thrombus increased with the number of these four risk factors present ( P < 0.001). None of the patients with paroxysmal AF and without LA dilation had LA thrombus. A cut-off value of 48.5 mm LA diameter yielded 83% sensitivity, 92% specificity, and a 10.1 likelihood ratio to predict LA thrombus appearance. Conclusion The incidence of LA thrombus prior to CPVA is low. Persistent AF, female sex, structural cardiopathy, and LA dilation were associated with the presence of LA thrombus. Our data suggest that the use of TEE prior to CPVA to detect LA thrombi might not be needed in patients with paroxysmal AF and no LA dilation or structural cardiopathy.

Despite the primary trigger for atrial fibrillation (AF) being within the pulmonary vein, current treatments avoid direct ablation of this substrate because of the prohibitive incidence of pulmonary vein (PV) stenosis. Given the suboptimal results with contemporary thermal AF ablation, we previously

Atrial fibrillation (AF) significantly impairs patients’ quality of life (QOL) and has a great effect on health care resource utilization (HCU). We performed a study to compare the effect of a multi-electrode Pulmonary Vein Ablation Catheter (PVAC) vs. traditional point-by-point AF ablation

Catheter ablation can restore sinus rhythm in selected patients with atrial fibrillation (AF), but its preventive function for thromboembolic events (TE) is still underdetermined.We retrospectively studied 520 consecutive patients with AF who were referred for circumferential pulmonary vein ablation. The incidence of late TE was investigated, and the predictors of late TE were identified from analysis of the basic clinical variables of patients with late TE.Eight (1.5%) patients experienced late TE during 28+/-8 months follow-up. When TE occurred, most (6/8, 75%) patients were documented with recurrence episode. The recurrence of AF was more frequent in patients with late TE than patients without late TE (75.0% vs 30.5%, P=0.007). Multivariate logistic regression analysis identified that all risk factors, including all clinical variants prior ablation and the CHADS2 score, were not related to late TE but the presence of recurrence was the only predictor of late TE (odds ratio, 5.542; 95% confidence interval [1.416-45.013], P=0.019).Our study demonstrates a strong relationship between the recurrence after ablation and TE post-operation and supports the proposal that free of recurrence is an indication for discontinuation of anticoagulation after ablation.

Aims Long-term endurance sport practice has been increasingly recognized as a risk factor for lone atrial fibrillation (AF). However, data on the outcome of circumferential pulmonary vein ablation (CPVA) in endurance athletes are scarce. The aim of the study was to evaluate the efficacy of CPVA in AF secondary to endurance sport practice. Methods and results Patients submitted to CPVA answered a questionnaire about lifetime history of endurance sport practice. Endurance athletes were defined as those who engaged in >3 h per week of high-intensity exercise for at least the 10 years immediately preceding their AF diagnosis. A series of 182 consecutive patients was included (51 ± 11 years, 65% with paroxysmal AF, 81% men, 42 ± 6 mm mean left atrial diameter); 107 (59%) patients had lone AF, and 42 of them (23% of the study population) were classified as endurance athletes (lone AF sport group). Freedom from arrhythmia after a single CPVA was similar in the lone AF sport group compared with the remaining patients ( P = 0.446). Left atrial size and long-standing AF were the only independent predictors for arrhythmia recurrence after ablation. Conclusion Circumferential pulmonary vein ablation was as effective in AF secondary to endurance sport practice as in other aetiologies of AF.

Die korrekte Diagnosestellung bei komplexen Arrhythmien erfordert die genaue Kenntnis der Arrhythmiemechanismen und deren Anwendung auf den konkreten Fall. So konnte bei einem Patienten mit dilatativer Kardiomyopathie und unklarer „Sinustachykardie“ durch die Interpretation der Koronarvenensinus-Elektrogramme rasch die Moglichkeit einer linksatrialen Tachykardie aufgebracht werden. Bei einem Patienten mit Tachykardien, vorbestehendem Linksschenkelblock und Synkope ergab letztlich der Induktionsmechanismus der Tachykardie in der elektrophysiologischen Untersuchung wie auch die detaillierte Analyse des His-Bundel-Elektrogramms den Nachweis einer sich ungewohnlich prasentierenden AV-Knoten-Reentrytachykardie. Bei dem Patienten mit Breitkomplextachykardie und koronare Herzkrankheit war die erfolgreiche Ablationsbehandlung erst nach der Erkenntnis erfolgreich durchfuhrbar, dass der Zugriff zum Areal der langsamen Leitung nur von epikardial moglich ist. Atriale Makro-Reentrytachykardien nach Vorhofflimmerablation sind eine wachsende Herausforderung in der klinischen Rhythmologie. Eine derartige Konstellation wurde mit der Kasuistik Linksatriales perimitrales Vorhofflattern nach Pulmonalvenenablation analysiert.

The reliability of delayed cure of early recurrence of atrial fibrillation (ERAF) is still undetermined. Furthermore, the predictors of recurrence after delayed cure of ERAF are less investigated in depth.The purpose of this study was to investigate the long-term efficacy of delayed cure of ERAF after catheter ablation of AF and explore the he predictors of recurrence after delayed cure of ERAF.We prospectively studied 300 consecutive patients with atrial fibrillation (AF) who were referred for circumferential pulmonary vein ablation (CPVA). After a follow-up of 19.2 +/- 4.1months, of the 87 patients with early recurrence of AF 41 achieved delayed cure, 11 of them reoccurred AF subsequently. Univariate analysis showed that persistent AF, absence of pulmonary vein (PV) isolation and external cardioversion were related to reoccurrence after delayed cure. Logistic regression analysis identified only absence of PV isolation as a predictor of recurrent AF after delayed cure.Delayed cure after CPVA is relatively common and its efficacy at long-term follow-up is reasonably consistent. However, in patients without PV isolation, delayed cure is unstable and the risk of late recurrence is increased.

We describe a 70-year-old man with persistent atrial fibrillation (AF) lasting for 3 months who underwent radiofrequency catheter ablation (RFCA) during on-going AF under navigation using a noncontact mapping system (NCM). The AF was converted by the RFCA first to a secondary atrial tachycardia (AT) consisting of common atrial flutter during the left atrial (LA) roof line creation, second to a secondary AT consisting of a focal AT originating from the right superior pulmonary vein, third to a secondary AT which rotated around the LA appendage, and finally to an AT consisting of a peri-mitral flutter after the completion of the circumferential pulmonary vein ablation and LA roof line creation. All the ATs were quickly identified by the dynamic activation map constructed with the NCM and subsequent detailed analysis of the virtual unipolar electrograms, and were eliminated by additional RFCA for each AT mechanism identified. The patient has had no recurrence during 10 months of follow-up without taking any antiarrhythmic agents.

Substrate Ablation in Treatment of Atrial Fibrillation. From the time catheter ablation of atrial fibrillation (AF) was first reported, of the two dominant approaches for AF ablation, only pulmonary vein (PV) isolation has been modified, while circumferential pulmonary vein ablation (CPVA) as performed by our group in Milan has remained substantially unmodified. In fact, PV isolation as initially performed by Haissaguerre et al. has undergone rapid evolution toward substrate modification with significantly higher success rates without major complications. Modification of such technique was due to modification of the substrate. It is now evident that substrate modification is indeed crucial for curing AF particularly in patients with long-lasting or permanent AF. Indeed, to achieve good outcomes, any ablation technique should simultaneously include elimination of all triggers associated with modification of both anatomic and autonomic substrate, as we started to do many years ago by performing CPVA.

Aims The purpose of this study was to determine the occurrence of asymptomatic episodes of atrial fibrillation (AF) and wrong AF perception after pulmonary vein isolation (PVI). We evaluated the success of ablation by using the following measurements: (i) clinical symptoms and duration of symptoms noticed by patients and (ii) synchronous event recording (ER). Methods and results Eighty patients with paroxysmal AF underwent PVI and were provided repeatedly with a portable ER upon discharge and every 3 months for a year. The ER automatically detects arrhythmias by a detection algorithm and can also be manually triggered by the patient. In 46/80 patients (57.5%), episodes of AF were documented. Asymptomatic AF was detected in 21.3%. In 9/80 patients (11.3%), who reported clinical AF recurrence, no AF could be shown by ER. We compared patients’ perception to have suffered AF episodes with the ERs and found a sensitivity of 75% and a specificity of 92%. Conclusion Reliance on perception of AF by patients after PVI results in an underestimation of recurrence of the arrhythmia. We observed a maximal occurrence of silent AF or wrong perception of AF in 26/80 (32.6%) patients.

To avoid fatal complications after extensive pulmonary vein (PV) ablation, it has been proved important to comprehend the anatomic relation between the PVs and the esophagus. In 42 consecutive patients with atrial fibrillation, PV ostial isolation was performed using a basket catheter. The shortest distance and anatomic relation between the esophageal lead and PV ostium, determined by successful PV ostial isolation, was analyzed in biplane fluoroscopic views. In 18 left superior PVs (LSPVs) (43%), 13 left inferior PVs (32%) (LIPVs), and all the right PVs (group A), the shortest distance was10 mm inor = 1 of the biplane fluoroscopic views. In 4 LSPVs (10%) and 2 LIPVs (5%) (group B), the shortest distance wasor = 5 mm in the fluoroscopic views. In the remaining PVs (group C), the esophagus was situated directly behind 10 LSPVs (24%) and 12 LIPVs (29%) (group C1), posteromedial to 1 LSPV (2%) and 9 LIPVs (22%) (group C2), and medial to 9 LSPVs (21%) and 5 LIPVs (12%) (group C3). The risk of esophagus-associated complications with ablation around the left PV ostia was suggested to be high in group B, very low in group A, and relatively low in group C. In group C3, extensive PV ablation might increase the risk of that complication. In conclusion, esophageal leads are useful for determining strategies for PV ablation to avoid esophagus-associated complications, because they enable comprehension of the anatomic relation between the PVs and the esophagus.

Atrial fibrillation is often highly symptomatic in patients with hypertrophic cardiomyopathy. In the present paper we describe the results of circumferential pulmonary vein ablation in two such patients. Although multiple antiarrhythmic drugs failed to prevent recurrences of AF in each patient, catheter ablation resulted in long-term maintenance of sinus rhythm and stabilization of heart failure.

Atrial premature depolarizations (APDs) triggering atrial fibrillation (AF) originate from mainly the pulmonary veins (PVs), but, in some cases, atrial ectopic beats (AEBs) triggering AF originate from the right atrium (RA) or the superior vena cava. Accurate identification of the origin of APDs in the PVs by means of RA and coronary sinus mapping is difficult. Purpose: The aim of this study was to identify the origin of AEBs triggering AF before transseptal catheterization. Electrode catheters were placed in the posteroseptal RA (PSRA), right pulmonary artery (RPA), left pulmonary artery (LPA), and esophagus in 10 patients with paroxysmal AF. We analyzed endocardial electrograms from the PSRA, RPA and LPA, and epicardial electrograms from the esophagus. The origin of the AEBs in the PVs was determined before PV ablation by mapping 4 PVs simultaneously. Four AEBs originated from the left superior PV (LSPV), 2 from the left inferior PV (LIPV), 4 from the right superior PV (RSPV), 2 from the RA or superior vena cava. In AEBs originating from the RA, the PSRA activation was the earliest and it proceeded in a cranial to caudal direction. In AEBs originating from the RUPV, RPA was the earliest. The esophageal activation sequence was in a cranial to caudal direction. In AEBs from the LSPV, LPA was the earliest and the esophageal activation sequence proceeded in a cranial to caudal direction. In AEDs from LIPV, LPA was the earliest, and the esophageal activation sequence was nearly simultaneous. Atrial activation sequences from the PSRA, RPA, LPA, and esophageal catheters can accurately identify the location of the initiating foci of AF before a transseptal procedure.

Introduction: Segmental ostial pulmonary vein isolation (PVI) is considered a potentially curative therapeutic approach in the treatment of paroxysmal atrial fibrillation (PAF). There is only limited data available on the long-term effect of this procedure. Methods: Patients (Pts) underwent a regular clinical follow up visit at 3, 6 and 24 months after PVI. Clinical success was classified as complete (i.e. no arrhythmia recurrences, no antiarrhythmic drug), partial (i.e. no/only few recurrences, on drug) or as a failure (no benefit). The clinical responder rate (CRR) was determined by combining complete and partial success. Results: 117 patients (96 male, 21 female), aged 51±11 years (range 25 to 73) underwent a total of 166 procedures (1.4/patient) in 2-4 pulmonary veins (PV). 115 patients (98%) had AF, 2 patients presented with regular PV atrial tachycardia. ,109/115 patients. exhibited PAF as the primary arrhythmia (versus persistent AF). A total of 113 patients with PVI in the years 2001 to 2003 were evaluated for their CRR after 6 (3) months. A single intervention was carried out in 63 patients (55.8%), two interventions were performed in 45 patients (39.8%) and three interventions in 5 patients (4.4%). The clinical response demonstrated a complete success of 52% (59 patients), a partial success of 26% (29 patients) and a failure rate of 22% (25 patients), leading to a CRR of 78% (88 patients). Ostial PVI in all 4 PVs exhibited a tendency towards higher curative success rates (54% versus 44% in patients with 3 PVs ablated for the 6 month follow up). Long-term clinical outcome was evaluated in 39 patients with an ablation attempt at 3 PVs only (excluding the right inferior PV in our early experience) and a mean clinical follow up of 21±6 months. At this point in time the success rate was 41% (complete, 16 patients) and 21% (partial, 8 patients), respectively, adding up to a CRR of 62% (24 patients). In total, 20 patients (17.1%) had either a single or 2 (3 patients, 2.6%) complications independent of the number of procedures performed with PV stenosis as the leading cause (7.7%). Conclusion: The CRR of patients with medical refractory PAF in our patient cohort is 78% at the 6 month follow up. PV stenosis is the main cause for procedure-related complications. Ablation of all 4 PV exhibits a tendency towards higher complete success rates despite equal CRR. Calculation of the clinical response after a mid- to long-term follow of 21±6 months in those patients with an ostial PVI in only 3 pulmonary veins (sparing the right inferior PV) shows a further reduction to 62%, exclusively caused by a drop in patients with a former partial success. To evaluate the long-term clinical benefit of segmental ostial PVI in comparison with other ablation techniques, more extended follow up periods are mandatory, including a larger study cohort and a detailed description of procedural parameters.

Background The future of medicine is tied-up in robotics and lasers. We've heard the hype for years, but only in the last 10 years has it actually started to come to fruition that robotic systems are beginning to play a role in surgery. Methods Multiple groups have reported over the past 10 years on increasingly complex cardiac surgical procedures being performed with the aid of robotic systems. With an increasing percentage of atrial fibrillation and with insight that atrial fibrillation results in poor long-term survival, attempts have been made to create a surgical cure. Results Much work has been done in the past several years to develop a less-invasive surgical option than the standard cut-and-sew Maze to achieve pulmonary vein ablation. Laser is a unique energy source for tissue ablation because it is a form of light. Conclusion While traditional energy sources focus on applying heat-based elements to the tissue's surface allowing temperature to propagate across the thickness of the tissue laser is an innovative, tissue-specific energy for creating tissue ablation. Copyright © 2006 John Wiley & Sons, Ltd.