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Complex ablation for persistent atrial fibrillation (AF) aims to modify the arrhythmogenic substrates to become incapable to perpetuate the arrhythmia. Ablation-associated determinants of atrial tachycardia (AT) rather than AF recurrences are unknown. The aim of the study was to evaluate the association between the type of arrhythmia recurrence and electrophysiological findings during redo procedures. A total number of 384 consecutive patients with persistent AF underwent complex ablation consisting of PV isolation (PVI), biatrial electrogram-guided ablation, and linear ablation with the desired procedural endpoint of AF termination. Electrophysiological findings during redo procedures and its relation to AR type are the subject of this study. Overall, 177 (46%) patients underwent a second procedure. Patients with AT recurrences had significantly more often persistent PVI (47 vs. 25%; P = 0.002). Moreover, a higher number of recovered PVs were associated with AF recurrence (3 PVs recovered, AF = 16.1% vs. AT = 5.2%; P = 0.02; 4 PVs recovered, AF = 18.5% vs. AT = 6.3%; P = 0.01), regardless of the extent of substrate ablation during the first procedure. Durable PV isolation but not the extent of atrial substrate ablation determines the type of arrhythmia recurrence. Thus, the PVs may represent dominant perpetuators (and not only triggers) of persistent AF even in the presence of a significantly modified atrial substrate.

Underrecognized consequence of three-dimensional mapping tool selection for atrial fibrillation ablation: when the operators’ decision determines the amount of silent micro-embolic burden Thomas Rostock MD, Torsten Konrad MD, Raphael Spittler MDFrom the University Hospital Mainz, Center for Cardiology,Cardiology II / Electrophysiology, Mainz, GermanyWord count: 1460Funding: (None)Disclosures: (None)

INTRODUCTION Procedural atrial fibrillation (AF) termination is considered as a predictor of long-term success after catheter ablation for persistent AF (persAF). However, some patients remain free of arrhythmia recurrences despite failure to achieve AF termination. The objective of this study was to assess long-term outcome and prognostic factors in patients undergoing complex ablation without procedural AF termination. METHODS AND RESULTS This study comprised 419 patients (63.8 ± 10.2 years, 63.4% male) undergoing complex ablation for persAF. Patients without procedural AF termination (n = 137, 64.2 ± 9.7 years, 63.5% male) were categorized into patients who remained in sinus rhythm (SR) in long-term outcome (SR-group) and patients with recurrence of AF or atrial tachycardia (AT) (AR-group). During a follow-up (FU) of 19.6 ± 14.6 months, the SR-group consisted of 65 (47.5%) and the AR-group of 69 (50.4%) patients. Three patients (2.2%) were lost to FU. Left atrial appendage (LAA) flow velocity and left atrium volume index (LAVI) could be identified as predictors for long-term success. LAA flow velocity and baseline AF cycle length (AFCL) were significantly associated with the type of arrhythmia recurrence (AF vs AT), ie, higher values of both are predictive for AT rather than AF recurrences. Patients with a LAVI

Durch die zunehmende interventionelle Behandlung von linksseitigen atrialen Tachyarrhythmien mittels Katheterablation ist die Differenzialdiagnostik von atrialen Tachykardien durch Interpretation des Oberflachen-EKGs bedeutsamer geworden, insbesondere fur die Planung der Katheterintervention. Rechtsatriales typisches Vorhofflattern uber den Isthmus breitet sich von inferior septal nach kranial aus und zeichnet sich daher durch negative sagezahnartige Flatterwellen aus, die in II, III und aVF zunachst langsam negativ abfallen und dann steil wieder ansteigen. Die Flatterfrequenz betragt dabei meist 240–250/min. Dagegen finden sich bei rechtsatrialem Flattern im Uhrzeigersinn („clockwise“), bei Flattern um die V. cava inferior oder superior sowie um eine Narbe (z. B. nach Anschluss der Herz-Lungen-Maschine) positive oder biphasische Flatterwellenmorphologien (perikavaler Reentry). Linksatriales Vorhofflattern (z. B. um die Mitralklappe oder um die Pulmonalvenen) ist ausgesprochen heterogen, zeigt jedoch typischerweise eine positive Flatterwelle in V1, da der linke Vorhof im hinteren Mediastinum liegt. Spezielle Kenntnisse der Flatterwellenmorphologie im Oberflachen-EKG vereinfachen die Planung und Durchfuhrung der Ablationsstrategie.

Atrial tachycardia in virtually all areas of both atria has become more important in the clinical management of patients with previous complex atrial fibrillation ablation. Accurate interpretation of surface electrocardiogram (ECG) characteristics is of paramount importance to localize the origin of atrial tachycardia, particularly for planning interventional treatment. This article highlights the ECG features of different types of right and left atrial tachycardia.Typical right atrial flutter through the cavotricuspid isthmus conducts septally in a cranial direction and demonstrates sawtooth-like flutter waves which start negative in II, III and aVF and then show a steep slope upwards to the isoelectric line. The flutter rate typically ranges between 240-250 beats/min. In contrast, right atrial flutter in a clockwise rotation, flutter around the vena cava inferior or superior and around a scar (e.g. after cardiac surgery) show positive or biphasic flutter waves (lower or upper loop reentry). Left atrial flutter waves (e.g. around the mitral valve or around the pulmonary veins) are very heterogeneous and are typically positive in V1 as the left atrium is located in the posterior mediastinum.Specific knowledge of flutter wave morphology in surface ECG facilitates planning and performance of the ablation strategy.

We aimed at assessing the safety and efficacy of a systematic transradial approach for left ventricular endomyocardial biopsy using a new hydrophilic sheathless guiding catheter. Forty-two consecutive patients were included. The transradial success rate was 98 % (41 of 42). In one case, cross over to femoral access due to irreversible spasm of the right radial artery was necessary. No radial spasm was observed in the other 41 patients. Depending on the indication, several other procedures, such as coronary angiography or ventricular angiography, were additionally performed through the same transradial access site. Median fluoroscopy time was 7.9 min. The mean dose area product was 1867 cGy × cm2. All biopsy samples were graded as good or excellent quality. No patient had any complications. Immediate post-procedural ambulation could be achieved in all patients. Radial artery patency was confirmed by duplex sonography 24 h after removal of the guide. The present study demonstrates safety and efficacy of a systematic transradial access for left ventricular EMB using a highly hydrophilic sheathless guiding catheter. This is of clinical importance since this new technique may overcome critical limitations of the common approach.