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Background The risk of cerebrovascular embolic events with atrial fibrillation (AF) is potentially linked to an increased risk of cognitive decline and dementia. However, epidemiologic studies exploring the association between AF and incident dementia have reported conflicting results. Objective The purpose of this study was to perform a meta-analysis of observational studies specifically designed to evaluate the prospective relationship between AF and incident dementia. Methods We searched PubMed, CENTRAL, BioMedCentral, Embase, Cardiosource, clinicaltrials.gov, and ISI Web of Science (January 1980 to May 2012). No language restriction was applied. Two independent reviewers screened titles and abstracts to identify population-based studies that prospectively evaluated the association between AF and the incidence of dementia in patients not suffering an acute stroke and with normal cognitive function at baseline, providing the hazard ratio (HR) obtained in multiple Cox regression analyses, and adjusted for all confounding variables. Two independent reviewers assessed risk of bias according to the Cochrane Collaboration, and extracted patient and study characteristics and the adjusted HR of incident dementia with its 95% confidence interval (CI) of patients with AF vs those without AF. Results Eight studies with 77,668 patients were included in the analysis. All studies had a prospective observational design and included elderly patients (mean age range 61–84 years) with normal cognitive function at baseline, of whom 11,700 (15%) had AF. After a mean follow-up of 7.7 ± 9.1 years (range 1.8–30 years), 4773 of 73,321 (6.5%) patients developed dementia. Two studies did not report the rates of dementia at follow-up but reported the adjusted HR and were included in the pooled analysis. At pooled analysis adjusted for baseline confounders and covariates, AF was independently associated with increased risk of incident dementia (HR = 1.42 [95% CI 1.17–1.72], P Conclusion AF is independently associated with increased risk of dementia. Patients with AF should be periodically screened for dementia, which should be included among the outcomes assessed in AF treatment trials.

Introduction: Balloon-based catheters are an emerging technology in catheter ablation for atrial fibrillation, which aim to achieve consistent and rapid ablation encirclement of pulmonary veins (PVs). Recent emphasis has been placed on achieving more proximal electrical isolation within the PV–left atrial (LA) junction. We sought to evaluate the precise anatomic level of PV electrical disconnection with current design balloon-based catheters. Methods and Results: Thirteen patients with drug-refractory paroxysmal atrial fibrillation undergoing balloon catheter ablation with the endoscopic laser system (CardioFocus) or the high frequency-focused ultrasound system (ProRhythm) underwent electroanatomic mapping (EAM) of the left atrium. Intracardiac echocardiographic (ICE) imaging was used for visualization of the position of the balloon catheter during energy delivery. Detailed point analysis of the location of electrical disconnection was then documented on EAM and with ICE. Successful electrical isolation was achieved in all 52 PVs. Despite ICE imaging confirming balloon catheter position at the antrum of the PVs, the location of electrical disconnection was demonstrated to be at or near the tubular ostium of the PVs on EAM and on ICE in all patients. Conclusion: Current generation balloon-based catheter ablation achieves electrical isolation distal in the LA–PV junction. This may limit the results of such systems in treating nonparoxysmal forms of atrial fibrillation.

Ablation of atrial fibrillation is generally considered safe and effective. However, atrial-esophageal fistulas have recently been reported as a rare but fatal complication.To describe 9 patients with atrial-esophageal fistulas after ablation for atrial fibrillation.Retrospective case series.Institutions where cardiologists performed atrial fibrillation ablation procedures.9 patients with atrial-esophageal fistulas after atrial fibrillation ablation.Demographic characteristics, mortality, presenting signs and symptoms, and days to presentation.Patients presented a mean of 12.3 days (range, 10 to 16 days) after their procedures. Nonspecific symptoms included fever, leukocytosis, and neurologic abnormalities. All patients died. Only 4 patients received correct diagnoses before death, although all patients presented to a physician. In 3 patients, surgical repair was attempted.Few physicians reported cases, and only approximate numbers of procedures performed by the physicians are known. Thus, the authors could not estimate the incidence of atrial-esophageal fistulas after ablation.Formation of atrial-esophageal fistulas is a rare but potentially devastating complication of atrial fibrillation ablation. This disorder may have an indolent presentation and may mimic other disease states, such as stroke or sepsis.

Background— Left atrioesophageal fistula is a devastating complication of atrial fibrillation ablation. There is no standard approach for avoiding this complication, which is caused by thermal injury during ablation. The objectives of this study were to evaluate the course of the esophagus and the temperature within the esophagus during pulmonary vein antrum isolation (PVAI) and correlate these data with esophagus tissue damage. Methods and Results— Eight-one patients presenting for PVAI underwent esophagus evaluation that included temperature probe placement. Esophagus course was obtained with computed tomography, 3D imaging (NAVX), or intracardiac echocardiography. For each lesion, the power, catheter and esophagus temperature, location, and presence of microbubbles were recorded. Lesion location and esophagus course were defined with 6 predetermined left atrial anatomic segments. Endoscopy evaluated tissue changes during and after PVAI. Of 81 patients, the esophagus coursed near the right pulmonary veins in 23 (28.4%), left pulmonary veins in 31 (38.3%), and mid-posterior wall in 27 (33%). Esophagus temperature was significantly higher during left atrial lesions along its course than with lesions elsewhere (38.9±1.4°C, 36.8±0.5°C, P P Conclusions— Lesions near the course of the esophagus that generated microbubbles significantly increased esophagus temperature compared with lesions that did not. Power did not correlate with esophagus temperatures. Esophagus variability makes the avoidance of lesions along its course difficult. Rather than avoiding posterior lesions, emphasis could be placed on better esophagus monitoring for creation of safer lesions.

ObjectivesWe sought to test how catheter ablation using an open irrigation catheter (OIC) compares with standard catheters for pulmonary vein antrum isolation.BackgroundOpen irrigation catheters have the advantage of delivering greater power without increasing the temperature of the catheter tip, which enables deeper and wider lesions without the formation of coagulum on catheters.MethodsCatheter ablation was performed using an 8-mm catheter (8MC) or an OIC. Patients were randomized to 3 groups: 8MC; OIC-1, OIC with a higher peak power (50 W); and OIC-2, OIC with lower peak power (35 W).ResultsA total of 180 patients were randomized to the 3 treatment strategies. Isolation of pulmonary vein antra was achieved in all patients. The freedom from atrial fibrillation was significantly greater in the 8MC and OIC-1 groups compared with the OIC-2 group (78%, 82%, and 68%, respectively, p = 0.043). Fluoroscopy time was lower in OIC-1 compared with OIC-2 and 8MC (28 ± 1 min, 53 ± 2 min, and 46 ± 2 min, respectively, p = 0.001). The mean left atrium instrumentation time was lower in the OIC-1 compared with the OIC-2 and 8MC groups (59 ± 3 min, 90 ± 5 min, and 88 ± 4 min, respectively, p = 0.001). However, there was a greater incidence of “pops” in the OIC-1 (100%, 0%, 0%, p < 0.001) along with higher incidences of pericardial effusion (20%, 0%, 0%, p < 0.001) and gastrointestinal complaints (17% in OIC-1, 3% in 8MC, and 5% in OIC-2, p = 0.031).ConclusionsAlthough there was a decrease in fluoroscopy and left atrium instrumentation time with the use of OIC at higher power, this setting was associated with increased cardiovascular and gastrointestinal complications.

ObjectivesThe aim of this study was to assess the incidence of atrial flutter (AFL) after pulmonary vein antrum isolation (PVAI) in patients with previous cardiac surgery (PCS) in comparison to patients without PCS and to assess the need for AFL ablation in both groups.BackgroundAtrial fibrillation (AF) and AFL often co-exist. Pulmonary vein antrum isolation may be sufficient to control both arrhythmias. However, in patients with PCS, atrial incisions, cannulations, and scar areas may cause AFL recurrence despite elimination of pulmonary vein triggers.MethodsData from 1,345 patients who had PVAI were analyzed. Patients with a history of AFL ablation and patients who had concomitant AFL ablation during PVAI were excluded from analysis. Sixty-three patients constituted the PCS group (Group 1, age 57 ± 13 years, 12 female) and 1,062 patients constituted the non-PCS group (Group 2, age 55 ± 12 years, 212 female). Patients in Group 1 had larger left atria, higher incidence of AFL pre-PVAI, and lower ejection fraction.ResultsThere was no significant difference in post-PVAI AF recurrence between Groups 1 and 2, but AFL incidence after PVAI was higher in Group 1 (33% vs. 4%, p < 0.0001). Ablation of AFL in Group 1 patients resulted in an 86% acute success rate and 11% recurrence over a mean follow-up of 357 ± 201 days.ConclusionsIn patients with PCS, post-PVAI AF recurrence is similar to patients without PCS. However, history of PCS is associated with a higher recurrence of AFL after PVAI. In a significant number of patients with PCS, AFL ablation is required to achieve a cure.

Background Periprocedural anticoagulation management with uninterrupted warfarin and a "therapeutic" international normalized ratio is the best approach for reducing both thromboembolic and bleeding complications in the setting of catheter ablation for atrial fibrillation (AF). Objective The purpose of this study was to evaluate the safety and feasibility of uninterrupted apixaban in this setting. Methods This was a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation at 4 institutions in United States and Europe with uninterrupted apixaban. These patients were compared with an equal number of patients, matched for age, gender, and type of AF, undergoing AF ablation on uninterrupted warfarin. The apixaban group was comprised of consecutive patients who had taken their last dose of apixaban the morning of the procedure. A subset of 29 patients in the apixaban group underwent diffusion magnetic resonance imaging (dMRI) to detect silent cerebral ischemia. Results A total of 400 patients (200 patients in each group) were included in the study. The average age was 65.9 ± 9.9 years, 286 (71.5%) were male, and 334 (83.5%) had nonparoxysmal AF. There were no statistical differences with regard to major complications (1% vs 0.5%, P = 1), minor complications (3.5% vs 2.5%, P = .56), or total bleeding complications (4.5% vs 3%, P = .43) between the apixaban and warfarin groups. There were no symptomatic thromboembolic complications. All dMRIs were negative for "new" silent cerebral ischemia in the apixaban group. Conclusion Uninterrupted apixaban administration in patients undergoing AF ablation seems to be feasible and effective in preventing clinical and silent thromboembolic events without increasing the risk of major bleeding.

Percutaneous positioning of closure devices is a well-established treatment of atrial septal defects (ASD). Atrial fibrillation (AF) is highly prevalent in these pts, and it is unclear whether ASD closure might affect the progression of AF in pts presenting with concomitant ASD and AF. We report the

ICD with resynchronization therapy can provide information on the intrathoracic fluid status of the pts by measuring transpulmonary electric bioimpedance, Out of 2185 consecutive pts undergoing catheter ablation for AF with an open irrigated catheter, 132 (6p) had heart failure (HF). CRT-D

In pts with atrial fibrillation (AF) and CHADS2 score 0-1 the indication for antithrombotic therapy is controversial. We evaluated different LAA morphologies by computed tomography (CT) and by magnetic resonance imaging (MRI) in pts with CHADS2 score 0-1 and AF to correlate the different