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PurposePulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in persistent AF (persAF), and cryoballoon PVI emerged as an initial ablation strategy. Symptomatic atrial arrhythmia recurrence following successful PVI in persAF is observed more frequently than in paroxysmal AF. Predictors for arrhythmia recurrence following cryoballoon PVI for persAF are not well described, and the role of left atrial appendage (LAA) anatomy is uncertain.MethodsPatients with symptomatic persAF and pre-procedural cardiac computed tomography angiography (CCTA) images undergoing initial second-generation cryoballoon (CBG2) were enrolled. Left atrial (LA), pulmonary vein (PV) and LAA anatomical data were assessed. Clinical outcome and predictors for atrial arrhythmia recurrence were evaluated by univariate and multivariate regression analysis.ResultsFrom May 2012 to September 2016, 488 consecutive persAF patients underwent CBG2-PVI. CCTA with sufficient quality for measurements was available in 196 (60.4%) patients. Mean age was 65.7 ± 9.5 years. Freedom from arrhythmia was 58.2% after a median follow-up of 19 (13; 29) months. No major complications occurred. Independent predictors for arrhythmia recurrence were LAA volume (HR 1.082; 95% CI, 1.032 to 1.134; p = 0.001) and mitral regurgitation ≥ grade 2 (HR, 2.49; 95% CI 1.207 to 5.126; p = 0.013). LA volumes ≥110.35 ml [sensitivity: 0.81, specificity: 0.40, area under the curve (AUC) = 0.62] and LAA volumes ≥9.75 ml (sensitivity: 0.56, specificity 0.70, AUC = 0.64) were associated with recurrence. LAA-morphology, classified as chicken-wing (21.9%), windsock (52.6%), cactus (10.2%) and cauliflower (15.3%), did not predict outcome (log-rank, p = 0.832).ConclusionLAA volume and mitral regurgitation were independent predictors for arrhythmia recurrence following cryoballoon ablation in persAF. LA volume was less predictive and correlated with LAA volume. LAA morphology did not predict the clinical outcome. To improve outcomes in persAF ablation, further studies should focus on treatment strategies for persAF patients with large LAA and mitral regurgitation.

Summary Even though data on gender-specific differences of arrhythmias is currently limited, there is growing awareness that arrhythmia occurrence and clinical manifestation may differ between women and men. This may influence both the acute and longterm management of arrhythmia patients. Apart from electrocardiographic differences such as a higher resting heart rate and longer QTc intervals that have been known for a long time, there are significant differences in the epidemiology and clinical manifestation of common arrhythmias such as some types of paroxysmal supraventricular tachycardias (i. e., AV nodal reentrant tachycardia), atrial fibrillation and even ventricular tachycardia or fibrillation. In particular, women have a much higher prevalence of both congenital or acquired forms of long QT syndrome than men. [ABSTRACT FROM AUTHOR]

Introduction: Cryoballoon ablation (CBA) aiming at pulmonary vein isolation (PVI) became a standardized atrial fibrillation (AF) ablation procedure. Life-threatening complications like cardiac tamponade exist. Intracardiac echocardiography (ICE) usage is associated with superior safety in radiofrequency ablation. It is unclear if ICE has an impact on safety of CBA., Methods: The FREEZE Cohort (NCT01360008) subanalysis included patients undergoing "PVI only" CBA. Patients with intraprocedural transesophageal echocardiography were excluded. Group A comprises conventional, group B ICE-guided CBA. Periprocedural results were compared., Results: From 2011 to 2016, a total of 4189 patients were enrolled, and 1906 (45.5%) were included in this subanalysis, split up in two groups (A: 1066 [55.9%], B: 840 [44.1%]). Group A was younger (60.6 ± 10.8 vs. 62.4 ± 10.5 years, p < .001), with smaller left atria (41 vs. 43 mm, p < .001), and less persistent AF (23.1 vs. 38.1%, p < .001). Procedure, left atrial, and fluoroscopy times were shorter in group A as compared to group B. Dose area product was significantly higher in group A (2911 vs. 2072 cGyxcm 2 , p < .001). In-hospital major adverse cerebrovascular and cardiac event rates including two deaths in group A were not different between groups (0.5% vs. 0.1%, p = .18). The rate of total procedural (10.4% vs. 5.1%, p < .001) and major complications (3.2% vs. 1.3%, p < .001) was significantly higher in group A. Cardiac tamponade occurred significantly more frequently in group A (8 [0.8%] vs. 1 [0.1%], p = .046). Independent predictors for major complications were female sex (odds ratio [OR] 2.03, p = .03) and non-ICE usage (OR 2.38, p = .02). No differences were observed for persistent phrenic nerve palsy, nor for groin complications., Conclusion: CBA was significantly safer and required less radiation if ICE was used, although the procedures were more complex. The risk of groin complications was not increased with ICE usage. Non-ICE usage was the only modifiable independent predictor of major complications., (© 2023 Wiley Periodicals LLC.)

Purpose: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in persistent AF (persAF), and cryoballoon PVI emerged as an initial ablation strategy. Symptomatic atrial arrhythmia recurrence following successful PVI in persAF is observed more frequently than in paroxysmal AF. Predictors for arrhythmia recurrence following cryoballoon PVI for persAF are not well described, and the role of left atrial appendage (LAA) anatomy is uncertain., Methods: Patients with symptomatic persAF and pre-procedural cardiac computed tomography angiography (CCTA) images undergoing initial second-generation cryoballoon (CBG2) were enrolled. Left atrial (LA), pulmonary vein (PV) and LAA anatomical data were assessed. Clinical outcome and predictors for atrial arrhythmia recurrence were evaluated by univariate and multivariate regression analysis., Results: From May 2012 to September 2016, 488 consecutive persAF patients underwent CBG2-PVI. CCTA with sufficient quality for measurements was available in 196 (60.4%) patients. Mean age was 65.7 ± 9.5 years. Freedom from arrhythmia was 58.2% after a median follow-up of 19 (13; 29) months. No major complications occurred. Independent predictors for arrhythmia recurrence were LAA volume (HR 1.082; 95% CI, 1.032 to 1.134; p  = 0.001) and mitral regurgitation ≥ grade 2 (HR, 2.49; 95% CI 1.207 to 5.126; p  = 0.013). LA volumes ≥110.35 ml [sensitivity: 0.81, specificity: 0.40, area under the curve (AUC) = 0.62] and LAA volumes ≥9.75 ml (sensitivity: 0.56, specificity 0.70, AUC = 0.64) were associated with recurrence. LAA-morphology, classified as chicken-wing (21.9%), windsock (52.6%), cactus (10.2%) and cauliflower (15.3%), did not predict outcome (log-rank, p  = 0.832)., Conclusion: LAA volume and mitral regurgitation were independent predictors for arrhythmia recurrence following cryoballoon ablation in persAF. LA volume was less predictive and correlated with LAA volume. LAA morphology did not predict the clinical outcome. To improve outcomes in persAF ablation, further studies should focus on treatment strategies for persAF patients with large LAA and mitral regurgitation., Competing Interests: Straube received honoraria for lectures from Medtronic, Boston Scientific, Philips, Bristol Myers-Squibb, and Astra Zeneca outside the submitted work. Dorwarth reports honoraria for lectures from Medtronic Inc., Bristol-Myers-Squibb, and Astra Zeneca, outside the submitted work. Hoffmann is head of the department; the department received compensation for participation in clinical research trials outside the submitted work from Abbott, Bayer, Biotronik, Boehringer Ingelheim, Edwards, Elixier, Medtronic, and Stentys. Hartl participates in the EP fellowship from Boston Scientific, received educational support from Biotronik, Daiichi Sankyo and honoraria for lectures from Bristol Myers Squibb outside the submitted word. Dres. Brueck, Crispin, Ebersberger, Helmberger, Pongratz, Tesche, and Wankerl have nothing declared., (© 2023 Pongratz, Riess, Hartl, Brück, Tesche, Ebersberger, Helmberger, Crispin, Wankerl, Dorwarth, Hoffmann and Straube.)

Background: Pulmonary vein isolation (PVI) is recommended to treat paroxysmal and persistent atrial fibrillation (AF). This analysis aimed to assess the hospital efficiency of single-shot cryoballoon ablation (CBA) and point-by-point radiofrequency ablation (RFA)., Methods: The discrete event simulation used PVI procedure times from the FREEZE Cohort study to establish the electrophysiology (EP) lab occupancy time. 1000 EP lab days were simulated according to an illustrative German hospital, including 3 PVI cases per day using CBA at one site and RFA at the other., Results: The analysis included 1560 CBA patients and 1344 RFA patients from the FREEZE Cohort. Some baseline patients' characteristics were different between groups (age, AF type, and some concomitant diseases), without being statistically associated to ablation procedure time. Mean procedure time was 122.2 ± 39.4 min for CBA and 160.3 ± 53.5 min for RFA (p < 0.0001). RFA was associated with a more than five-fold increase of cumulative overtime compared to CBA over the simulated period (1285 h with RFA and 253 h with CBA). 70.7% of RFA lab days included overtime versus 25.7% for CBA. CBA was associated with more days with an additional hour at the end of the EP lab shift compared to RFA (47.8% vs 11.5% days with one hour left, respectively)., Conclusion: CBA is faster and more predictable than point-by-point RFA, and enables improvements in EP lab efficiency, including: fewer cumulative overtime hours, more days where overtime is avoided and more days with remaining time for the staff or for any EP lab usage. Clinical trial registration NCT01360008 (first registration 25/05/2011)., (© 2023. The Author(s).)

Background: Cryoballoon ablation (CBA) for pulmonary vein isolation (PVI) is a standard in atrial fibrillation (AF) ablation but might not be enough in complex atrial arrhythmias (AA). An open three-dimensional wide-band dielectric imaging system (3D-WBDIS) has been introduced to guide CBA., Material and Methods: Pilot study evaluating feasibility and safety of 3D-WBDIS in combination with CBA and optional radiofrequency ablation (RFA) in patients with complex AA defined as (1) history of persistent AF, (2) additional atrial tachycardia/flutter, or (3) previous left atrial ablation., Results: Prospectively, seventeen patients, 68.9 ± 12.2 years of age, with complex AA were enrolled. In 70 pulmonary veins (PV), balloon positioning maneuvers ( n = 129) were guided additionally by the occlusion tool (1.84/PV). Compared to angiography, its sensitivity and specificity was 94.5, and 85%, respectively. CBA-PVI was achieved in 100% of PVs including variants. In 68 maps, the median number of mapping points was 251.0 (interquartile range (IQR) 298.0) with a median map volume of 52.8 (IQR 83.9) mL. Following CBA, six additional arrhythmias (two right and two left atrial flutter, one left atrial appendage tachycardia, and one atrioventricular nodal reentry tachycardia) were identified and successfully ablated by means of RFA in five patients (29.4%). Left atrial and fluoroscopy times were 88 (IQR 40) and 20 (IQR 10) minutes, respectively. Dose area product was 1,100 (IQR 1252) cGyxcm 2 . Freedom from AA after 6 months follow-up time and 90 days blanking period was documented in 10/17 (59%) patients, and 8/17 (47%) without a blanking period. No major complication was observed., Conclusion: The combined use of CBA with optional RFA guided by a novel 3D-WBDIS is feasible and safe in patients suffering from complex AA. The occlusion tool shows high sensitivity and specificity for assessment of the balloon occlusion. Additional arrhythmias were successfully mapped and ablated. Short-term outcome is promising, and subsequent prospective, larger outcome studies are necessary to confirm our observations., Competing Interests: FS received honoraria for lectures from Philips GmbH, Medtronic GmbH, and Bristol-Myers-Squibb, outside the submitted work; educational support from Pfizer. UD reports honoraria for lectures from Medtronic Inc., outside the submitted work. EH is head of the department; the department received compensation for participation in clinical research trials outside the submitted work from Abbott, Bayer, Biotronik, Boehringer Ingelheim, Edwards, Elixier, Medtronic, and Stentys. YS is employed by EPD Solutions (a Philips Company). The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Pongratz, Dorwarth, Riess, Schwartz, Wankerl, Hoffmann and Straube.)

Background: Cryoballoon ablation is established for pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). The objective was to evaluate CBA strategy in consecutive patients with persistent AF in the initial AF ablation procedure. Material and Methods: Prospectively, patients with symptomatic persistent AF scheduled for AF ablation all underwent cryoballoon PVI. Technical enhancements, laboratory management, safety, single-procedure outcome, predictors of recurrence, and durability of PVI were evaluated. Results: From 2007 to 2020, a total of 1,140 patients with persistent AF, median age 68 years, underwent cryoballoon ablation (CBA). Median left atrial (LA) diameter was 45 mm (interquantile range, IQR, 8), and Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category (CHA 2 DS 2 -VASc) score was 3. Acute isolation was achieved in 99.6% of the pulmonary veins by CBA. Median LA time and median dose area product decreased significantly over time ( p < 0.001). Major complications occurred in 17 (1.5%) patients including 2 (0.2%) stroke/transitory ischemic attack (TIA), 1 (0.1%) tamponade, relevant groin complications, 1 (0.1%) significant ASD, and 4 (0.4%) persistent phrenic nerve palsy (PNP). Transient PNP occurred in 66 (5.5%) patients. No atrio-esophageal fistula was documented. Five deaths (0.4%), unrelated to the procedure, occurred very late during follow-up. After initial CBA, arrhythmia recurrences occurred in 46.6% of the patients. Freedom from atrial arrhythmias at 1-, and 2-year was 81.8 and 61.7%, respectively. Independent predictors of recurrence were LA diameter, female sex, and use of the first cryoballoon generation. Repeat ablations due to recurrences were performed in 268 (23.5%) of the 1,140 patients. No pulmonary vein (PV) reconduction was found in 49.6% of the patients and 73.5% of PVs. This rate increased to 66.4% of the patients and 88% of PVs if an advanced cryoballoon was used in the first AF ablation procedure. Conclusion: Cryoballoon ablation for symptomatic persistent AF is a reasonable strategy in the initial AF ablation procedure., Competing Interests: FS received honoraria for lectures from Medtronic and Bristol-Myers-Squibb outside the submitted study and educational support from Pfizer. UD reports honoraria for lectures from Medtronic Inc., outside the submitted study. SH participates in the EP fellowship from Boston Scientific, received educational support from Biotronik, Daiichi Sankyo, and honoraria for lectures from Bristol Myers Squibb outside the submitted study. EH was head of the department; the department received compensation for participation in clinical research trials outside the submitted study from Abbott, Bayer, Biotronik, Boehringer Ingelheim, Edwards, Elixier, Medtronic, and Stentys. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Straube, Pongratz, Kosmalla, Brueck, Riess, Hartl, Tesche, Ebersberger, Wankerl, Dorwarth and Hoffmann.)

Background: Left atrial appendage (LAA) is a potential source of atrial fibrillation (AF) triggers., Hypothesis: LAA morphology and dimensions are associated with AF recurrence after pulmonary vein isolation (PVI)., Methods: From cardiac computed tomography angiography (CCTA), left atrial (LA), pulmonary vein (PV), and LAA anatomy were assessed in cryoballoon ablation (CBA) patients., Results: Among 1103 patients undergoing second-generation CBA, 725 (65.7%) received CCTA with 473 (42.9%) qualifying for detailed LAA analysis (66.3 ± 9.5 years). Symptomatic AF reoccurred in 166 (35.1%) patients during a median follow-up of 19 months. Independent predictors of recurrence were LA volume, female sex, and mitral regurgitation ≥°II. LAA volume and AF-type were dependent predictors of recurrence due to their strong correlations with LA volume. LA volumes ≥122.7 ml (sensitivity 0.53, specificity 0.69, area under the curve [AUC] 0.63) and LAA volumes ≥11.25 ml (sensitivity 0.39, specificity 0.79, AUC 0.59) were associated with recurrence. LA volume was significantly smaller in females. LAA volumes showed no sex-specific difference. LAA morphology, classified as windsock (51.4%), chicken-wing (20.7%), cactus (12.5%), and cauliflower-type (15.2%), did not predict successful PVI (log-rank; p = 0.596)., Conclusions: LAA volume was strongly correlated to LA volume and was a dependent predictor of recurrence after CBA. Main independent predictors were LA volume, female sex, and mitral regurgitation ≥°II. Gender differences in LA volumes were observed. Individual LAA morphology was not associated with AF recurrence after cryo-PVI. Our results indicate that preprocedural CCTA might be a useful imaging modality to evaluate ablation strategies for patients with recurrences despite successful PVI., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Introduction: The objective was to analyze the impact of patient age on clinical characteristics, procedural results, safety, and outcome of cryoballoon ablation (CBA) as the primary approach in the interventional treatment of symptomatic atrial fibrillation (AF)., Methods and Results: The single-center prospective observational study investigated consecutive patients who underwent initial left atrial ablation for symptomatic paroxysmal (PAF) or persistent AF (persAF). Age groups (A-F) of less than 40, 40-49, 50-59, 60-69, 70-79 and more than or equal to 80 years were evaluated. Follow-up (FU) included ECG, Holter monitoring and assessment of AF-symptoms. From 2012 to 2016, a total of 786 patients (64 ± 11 years, range 21-85) underwent CBA. With advancing age, more cardiovascular comorbidities and larger LA diameter were observed, more females were included (each p < .001). PAF (57%) and persAF (43%, p = .320) were equally distributed over all age groups. Age was neither related to procedural parameters, nor to the complication rate (3.9%, p = .233). Median FU was 38 months. Two non-procedure related noncardiac deaths occurred late during FU. Freedom from arrhythmia was independent of age at 18 months (p = .210) but decreased for patients more than or equal to 70 years at 24 months (p = .02). At 36 months, freedom from arrhythmia was 66%-74% (groups A-D), 54% (E) and 49% (F), respectively (p = .002). LA diameter and persAF were independent predictors, whereas age was a dependent predictor of recurrence., Conclusion: CBA as the primary approach in the initial ablation procedure is safe and highly effective in the young, middle aged, and elderly population. LA diameter and persAF, but not ageing, were independent predictors for arrhythmia recurrence., (© 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Aims: Symptomatic atrial arrhythmias despite complete pulmonary vein isolation (PVI) are common. The purpose was to evaluate ultra-high-density multi-electrode electroanatomical mapping-guided radiofrequency ablation (RFA) in PVI non-responders., Methods and Results: Ultra-high-density multi-electrode electroanatomical mapping-guided RFA in consecutive symptomatic atrial fibrillation (AF) patients after initial cryoballoon PVI was performed. Patients were included if all pulmonary veins (PVs) were still isolated. Radiofrequency targets were atrial tachycardia (AT), extra-PV trigger, and/or substrate. Procedural results and outcome were evaluated. Of 95 patients, 67 (70.5%) with complete PVI were included (70 years, CHA2DS2Vasc 2.9, left atrium 45 mm, persistent AF 45%, AT 45%). The median time to reablation was 26 months. One hundred and seven maps (1.6/patient) and 11.890 ± 9.018 electrograms were acquired in 33 ± 12 min. Twenty-eight percent of the left atrial (LA) wall showed pathological voltage signals, predominantly at the anterior (37%) and septal wall (26%). Atrial tachycardia (49 left, 4 right) were ablated in 35 patients (52%), extra-PV trigger in two patients (3%). One atrioventricular nodal re-entry tachycardia and seven right atrial isthmus ablation (10%) were performed. In 32 patients (48%), no AT was present and substrate-based ablation was performed. Mean LA area ablated was 7 ± 6 cm2 (7%). No major complication occurred. The mean follow-up time was 772 ± 317 days. Freedom from atrial arrhythmia recurrence off antiarrhythmic drugs was 49% at 12 months., Conclusion: Pulmonary vein isolation non-responders are older, mainly suffering from complex atrial arrhythmias. Left atrial substrate is predominantly located at the anterior and septal wall. Ultra-high-density multi-electrode electroanatomical mapping-guided RFA is safe and effective. At 1 year, 5 out of 10 patients were in stable sinus rhythm off antiarrhythmic drugs., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: To evaluate the effectiveness and safety of cryoballoon ablation (CBA) compared with radiofrequency ablation (RFA) for symptomatic paroxysmal or drug-refractory persistent atrial fibrillation (AF)., Methods and Results: Prospective cluster cohort study in experienced CBA and RFA centres. Primary endpoint was 'atrial arrhythmia recurrence', secondary endpoints were as follows: procedural results, safety, and clinical course. A total of 4189 patients were included: CBA 2329 (55.6%) and RFA 1860 (44.4%). Cryoballoon ablation population was younger, with fewer comorbidities. Procedure time was longer in the RFA group (P = 0.01). Radiation exposure was 2487 (CBA) and 1792 cGycm2 (RFA) (P < 0.001). Follow-up duration was 441 (CBA) and 511 days (RFA) (P < 0.0001). Primary endpoint occurred in 30.7% (CBA) and 39.4% patients (RFA) [adjusted hazard ratio (adjHR) 0.85, 95% confidence interval (CI) 0.70-1.04; P = 0.12). In paroxysmal AF, CBA resulted in a lower risk of recurrence (adjHR 0.80, 95% CI 0.64-0.99; P = 0.047). In persistent AF, the primary outcome was not different between groups. Major adverse cardiovascular and cerebrovascular event rates were 1.0% (CBA) and 2.8% (RFA) (adjHR 0.53, 95% CI 0.26-1.10; P = 0.088). Re-ablations (adjHR 0.46, 95% CI 0.34-0.61; P < 0.0001) and adverse events during follow-up (adjHR 0.64, 95% CI 0.48-0.88; P = 0.005) were less common after CBA. Higher rehospitalization rates with RFA were caused by re-ablations., Conclusions: The primary endpoint did not differ between CBA and RFA. Cryoballoon ablation was completed rapidly; the radiation exposure was greater. Rehospitalization due to re-ablations and adverse events during follow-up were observed significantly less frequently after CBA than after RFA. Subgroup analysis suggested a lower risk of recurrence after CBA in paroxysmal AF., Trial Registration: ClinicalTrials.gov (NCT01360008), https://clinicaltrials.gov/ct2/show/NCT01360008., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: Time-to-isolation (TTI) guided ablation protocols have been developed to ensure durable pulmonary vein isolation (PVI) in cryoballoon ablation (CBA). The aim was to determine the feasibility and safety of the fourth generation cryoballoon (CBG4) with a shortened tip., Methods and Results: Consecutive patients scheduled for initial atrial fibrillation (AF) ablation were prospectively included. PVI with the 28 mm CBG4 and the latest 20 mm spiral-mapping catheter (SMC) was performed. A total of 302 pulmonary veins (PVs) in 76 patients (64.8 ± 10.4 years, paroxysmal AF 49%) were treated with 617 applications. Left atrium (LA) time, fluoroscopy time, and dose-area product were 65.5 ± 19.2 minutes, 14.6 ± 5.6 minutes, and 1094 (738; 2097) cGy·cm 2 , respectively. PVI in cryoballoon technique was achieved in 302 of 302 (100%) PVs. TTI was determined in 256 (84.8%) of PVs. The mean TTI was 45.3 ± 26.4 seconds. Single-shot isolation was achieved in 247 (82%) PVs. In 6 of 302 (2.0%) PV the SMC was changed to a stiff wire to isolate the PV because of instability, and in 17 of 302 (5.6%) of PVs, the 23 mm CB was used to isolate. No radiofrequency touch-up applications were applied. The mean nadir balloon temperature was -44.8°C ± 6.6°C. Balloon dislodgement during positioning occurred in 3 of 617 (0.5%) applications without complications. One PN palsy occurred which resolved until discharge. One patient suffered from the inflammatory syndrome., Conclusion: The CBG4 with a shorter distal tip seems to be safe and effective, and allows determining the TTI in 84.8% of PVs. In case of balloon instability, the exchange of the SMC to a stiff wire or, in small PV, the 23 mm cryoballoon facilitate PVI., (© 2019 Wiley Periodicals, Inc.)

Background: Cryoablation for paroxysmal atrial fibrillation (PAF) is well established. The single-big-balloon strategy has been preferred for pulmonary vein isolation (PVI) using the second generation cryoballoon (CBG2). Individual PV-morphologies raise the question if an individualized anatomic approach using the 23-mm or 28-mm CB is reasonable., Methods: Consecutive patients were prospectively enrolled in the non-randomized single-center study. Patients were treated with the 28-mm CB, if any PV was >21mm, the 23-mm CB, if all PV were ≤21mm, or both sizes, if PVI was difficult. The primary endpoint was arrhythmia-free survival. The secondary endpoint considered procedural results and complications., Results: Overall, 197 patients with symptomatic PAF (64±11 years, 36% female) were included. Acute PVI was achieved in 99.9% of PV. Based on preprocedural imaging, the 28-mm CB was applied as the primary catheter in 47% (92/197 patients), the 23-mm CB in 53% (105/197, p=0.23). The 23-mm CB group included more females, patients with short left atrial (LA)-diameters (each p<0.01), and smaller patients (p=0.04). Both CB-sizes were used in 24% (47/197). Additional 23-mm CB usage was necessary in 23% (21/92) of patients, mainly because of insufficient PV-occlusion with the 28-mm CB. Additional 28-mm CB usage was necessary in 25% (26/105, p=0.82), mainly because PV diameters were larger than initially measured. Both CB-sizes were equally safe and effective with a low complication rate and an overall success rate of 86% at 12 and 71% at 18 months (6% on antiarrhythmic drugs). No predictors for AF-recurrence were identified., Conclusion: CB ablation can sometimes be challenging. The 28-mm CB is the preferred catheter in all patients. If balloon positioning is difficult, the 23-mm CB is an option to achieve PVI in small veins. Further studies need to investigate if the 23-mm CB could be beneficial as the primary CB in females with small body height and short LA diameter., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Patients with frequent premature ventricular contractions (PVCs) are often highly symptomatic with significantly reduced quality-of-life. We evaluated the outcome and success of PVC ablation in patients in the German Ablation Registry., Methods: The German Ablation Registry is a nationwide prospective multicenter database of patients who underwent an ablation procedure, initiated by the "Stiftung Institut für Herzinfarktforschung" (IHF), Ludwigshafen, Germany. Data were acquired from March 2007 to May 2011. Patients underwent PVC ablation in the enrolling ablation centers., Results: A total of 408 patients (age 53.5 ± 15 years, 55 % female) undergoing ablation for PVCs were included. 32 % of patients showed a co-existing structural heart disease. Acute ablation success of the procedure was 82 % in the overall patient group. In patients without structural heart disease, acute success was significantly higher compared with patients with structural heart disease (86 vs. 74 %, p = 0.002). All patients were discharged alive after a median of 3 days. No patient suffered an acute myocardial infarction, stroke, or major bleeding. After 12 months' follow-up, 99 % of patients were still alive showing a significant different mortality between patients with structural heart disease compared with those without (2.3 vs. 0 %, p = 0.012). In addition, 76 % of patients showed significantly improved symptoms after 12 months of follow-up., Conclusion: Based on the data from this registry, ablation of PVCs is a safe and efficient procedure with an excellent outcome and improved symptoms after 12 months.

Background: Different catheter ablation (CA) strategies have been established in the treatment of persistent atrial fibrillation (persAF). Pulmonary vein isolation (PVI) only might be an option for the initial ablation procedure. There is a paucity of outcome data on second-generation cryoballoon (CBG2) PVI in persAF., Methods: Patients with symptomatic drug-refractory persAF who underwent initial CA of AF were prospectively enrolled and PVI was performed with CBG2. The primary composite endpoint was freedom from AF, atrial tachycardia, or related symptoms after a 3-month blanking period. The secondary endpoint referred to periprocedural complications., Results: One hundred seventy-three consecutive patients (64±10 years, 29% female) with symptomatic drug-refractory persAF were identified. Acute PVI was achieved in 100% of pulmonary veins with the CB technique. The left atrial procedure time was 112±30min. Major complications occurred in 1.7% (3 of 173 patients) including two phrenic nerve palsies (1%), which resolved until discharge, and one pericardial effusion (0.6%). Follow-up ≥12 months was completed for 157 of 173 patients (91%). Median follow-up was 14 months. At 12 months, the primary composite endpoint was achieved in 129 of 157 patients (82%). However, 22 of 129 patients at risk (17%) were still on antiarrhythmic drugs. A relapse during the blanking period was identified as the only independent predictor for AF recurrence., Conclusion: PVI using the second-generation cryoballoon is a reasonable treatment option for patients with symptomatic drug-refractory persAF with a favorable rate of freedom from AF and a low complication rate., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Although radiofrequency (RF) ablation has long been the standard of care for atrial fibrillation (AF) ablation, cryoballoon technology has emerged as a feasible approach with promising results. Prospective multicenter registry data referring to both ablation technologies in AF ablation are lacking so far., Objective: The purpose of this study was to report data from the German ablation registry with respect to efficacy and safety in pulmonary vein ablation with different energy sources for paroxysmal AF after 1-year follow-up., Methods: A total of 2306 patients with symptomatic paroxysmal AF from the German ablation registry were included in this analysis. The cohort was divided into two groups according to the ablation energy source used: cryoballoon and RF ablation. MACCE was defined as a combination of death, myocardial infarction, or stroke., Results: AF recurrence rate after a single ablation procedure at 1 year follow-up was not significantly different between the two groups (45.8% after cryoablation and 45.4% after RF ablation, P = .87). Also, the rate of patients without AF recurrence and free of antiarrhythmic drug at 12-month follow-up was similar (cryoablation 44.2% and RF 41.4%, P = .25). MACCE occurred with an incidence of 0.7% within 500 days after cryoablation and 1.4% after RF ablation (P = .30). Persistent phrenic nerve palsy was more common after cryoablation compared to RF ablation (1.1% vs. 0.3%, P <.05)., Conclusion: AF recurrence rate at 1-year follow-up was similar in RF ablation compared to cryoablation, whereas the spectrum and relevance of complications were significantly different between the two ablation methods. This finding might influence the choice of ablation method offered to the individual paroxysmal AF patient., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Aims: First-line ablation prior to antiarrhythmic drug (AAD) therapy is an option for symptomatic paroxysmal atrial fibrillation (PAF); however, the optimal ablation technique, radiofrequency (RF), or cryoballoon (CB) has to be determined., Methods and Results: The FREEZE Cohort Study compares RF and CB ablation. Treatment-naïve patients were documented in the FREEZEplus Registry. Periprocedural data and outcome were analysed. From 2011 to 2014, a total of 373/4184 (8.9%) patients with PAF naïve to AAD were identified. Pulmonary vein isolation (PVI) was performed with RF (n = 180) or CB (n = 193). In the RF group, patients were older (65 vs. 61 years, P < 0.01) compared with the CB group. The procedure time was significantly shorter and radiation exposure higher in the CB group. Major adverse events occurred in 1.6% (CB) and 3.7% (RF) of patients (P = 0.22). AF/atrial tachycardia (AT) recurrence until discharge was 4.5% (RF) and 8.5% (CB, P = 0.2). Follow-up (FU) ≥12 months was available in 99 (RF) and 107 (CB) patients. After 1.4 years of FU, freedom from AF/atrial tachycardia (AT) was 61% (RF) and 71% (CB, P = 0.11). In the RF group, more patients underwent cardioversion, and a trend for more repeat ablations was observed. Persistent phrenic nerve palsy was observed in one patient treated by CB., Conclusion: First-line ablation for PAF is safe and effective with either RF or CB. The procedure was faster with the CB, but the radiation exposure was higher. Although there was a trend for more recurrences and complications in the RF group, a more favourable risk profile in patients undergoing CB ablation might have biased the results., Clinicaltrialsgov Identifier: NCT01360008., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Purpose: The second-generation cryoballoon (CBG2) is highly effective for pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF). One-year outcome data are consistent among different research groups. First results suggest that a shortened application time might be equally effective. The objective of the study was to compare procedural and outcome data for a 240 and 180-s protocol., Methods: Prospectively, consecutive patients with symptomatic PAF underwent initial PVI with CBG2. In succession, two groups were created: the application time was 240 s in group 1 and 180 s in group 2. In both groups, a bonus application was applied. Periprocedural data, complications, and freedom from atrial fibrillation (AF)/AT/symptoms were compared between the groups., Results: From May 2012 to June 2013, 114 patients (57 per group, 38% female) were included. The mean left atrial dwelling time decreased by 19 min (-16%) in group 2 compared to group 1 (p = 0.005). Intraprocedural pulmonary vein (PV) reconduction occurred infrequently (0.4% in both groups, p = 1.0). One persistent PNP occurred and resolved during the follow-up. Complications were without significant differences. One patient was lost to follow-up. The cumulative rates of freedom from recurrence at 12 months are 76.8% in group 1 and 83.6% in group 2. After a mean follow-up of 491 ± 208 days, the rates of freedom from AF/AT/symptoms at last visit were 38/57 (67%) and 44/56 (78.6%) in groups 1 and 2 (p = 0.14), respectively. Female sex was identified as a predictor for recurrence., Conclusions: Compared to a protocol with cryoballoon applications of 240 s, a shortened application time to 180 s results in a faster procedure with comparable high rates of freedom from AF at 16 months. Female sex seems to be predictive for recurrences; this finding has to be reconfirmed in a larger population.

Background: Cryoballoon ablation is nowadays a standard approach for pulmonary vein isolation in symptomatic atrial fibrillation. The second generation cryoballoon was introduced in 2012 and modifications and enhancement to the system promised a higher efficiency., Objectives, Materials and Methods: A comprehensive overview of advances in cryoballoon ablation is provided and the consequences for daily practice are described based on a PubMed literature search, taking into account own experiences., Results and Conclusion: Advances in cryoballoon ablation result in a significantly higher efficiency. To maintain the overall safety of the procedure and to avoid phrenic nerve palsy and esophageal lesions, special care needs to be taken by following some safety aspects and cut-off criteria. More data are necessary to clarify if recommendations for cryoenergy titration with the new balloon are reasonable. Ongoing prospective studies comparing cryoballoon and radiofrequency (RF) ablation will give answers to the question which energy source is more favorable, and upcoming studies will evaluate the impact of cryoballoon ablation as a first line treatment option.

Aims: Cryoballoon (CB) ablation with the second-generation cryoballoon (CBG2) seems to be more effective than its predecessor [first-generation cryoballoon (CBG1)], but phrenic nerve palsies were observed more frequently. The aim of this study was to compare the safety and efficacy of CBG1 and CBG2 in a substudy of the prospective multicentre, multinational FREEZE Cohort Study., Methods and Results: Periprocedural data were analysed, and a total of 532 patients with paroxysmal atrial fibrillation (AF) were examined (n = 224 for CBG1 and n = 308 for CBG2). Procedure time decreased significantly from 149 to 130 min when comparing CBG1 with CBG2 (P < 0.0001), and pulmonary vein isolation (PVI) was achieved in 97.8 and 97.6% of PVs with CBG1 and CBG2 (P = 0.77), respectively. The need for dual-balloon usage within a procedure dropped (20.1 vs. 9.0%, P < 0.001), and the fluoroscopy time was reduced when operating the CBG2. Atrial fibrillation recurrence rates until discharge were similar (5.0 vs. 5.8%, P = 0.69). Comparable low rates of major complications were observed with both CBs, and there was a non-significant trend for more phrenic nerve palsies., Conclusion: Second-generation cryoballoon demonstrated a high rate of acute PVI in a significant faster procedure, which also utilized less radiation exposure and less dual-balloon usage during an average procedure. The safety profile remains favourable with a non-significant trend for more phrenic nerve palsies. If the enhancements lead to a higher clinical benefit has to be determined. The 1-year outcome data from the ongoing FREEZE Cohort Study comparing radiofrequency and CB ablation will shed some light on that issue., Clinical Trials Gov Identifier: NCT01360008., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Background: Cryoballoon (CB) ablation results in >70% freedom from atrial fibrillation at 1 year. Single-center data of the first (CBG1) and second (CBG2) cryoballoon, recently introduced, were analyzed to compare safety and efficacy., Methods and Results: From March 2011 to December 2012, CB ablation with spiral mapping was performed consecutively in 484 patients with symptomatic atrial fibrillation. CBG1 was used in 364 of 484 (75%) and CBG2 in 120 of 484 (25%) patients. Periprocedural data were analyzed. Acute pulmonary vein (PV) isolation with CB only was achieved in 99.86% and 100% of veins with CBG1 and CBG2, respectively (P=0.43). Number of applications until PV isolation decreased significantly with CBG2 (1.45±0.81 versus 1.28±0.64; P=0.001). Procedural, left atrial, and fluoroscopy time were reduced by -5%, -11%, and -15% (P<0.05), respectively. Two balloons were used less frequently. Time to isolation decreased significantly with 23-mm (48 versus 33 seconds; P<0.0001) and 28-mm CBG2 (76 versus 52 seconds; P<0.0001). Early PV reconduction rarely occurred with CBG2 (2.6% versus 0.42%; P=0.0023). In-hospital atrial fibrillation recurrence rates were similar. Balloon temperatures were significantly warmer with 23-mm CBG2 and a trend for colder balloon temperature with 28-mm CBG2 were observed compared with their predecessors. Comparable low rates of phrenic nerve palsy were recorded (1.1% versus 1.7%; P=0.64). Esophageal temperatures were similar. Major complication rates were low (3.3% versus 3.33%; P=1.0)., Conclusions: CBG2 attains high rates of acute PV isolation within a significant faster and less complex procedure. Time to isolation is shorter, and PV isolation is achieved with fewer applications using CBG2. These enhancements were not at the cost of complications. Long-term success rates remain to be demonstrated.

Background: Catheter ablation is used extensively with curative intention in atrial fibrillation. Radiofrequency ablation has long been a standard of care, while cryoballoon technology has emerged as a feasible approach with promising results. Prospective multicenter registry data referring to both ablation technologies in AF ablation therapy are lacking., Methods: Between January 2007 and August 2011, a total of 3,775 consecutive patients with symptomatic paroxysmal AF who underwent PV ablation in their respective centers were enrolled. The cohort was divided into 2 groups according to the ablation energy source used: cryoballoon ablation (group 1, n = 905 [24.0%], median age 63 years, 64.3% men) and RF ablation (group 2, n = 2870 [76.0%], median age 63 years, 62.7% men). Comorbidities and baseline clinical characteristics were similar in both groups., Results: Acute success rate was similar in both groups (97.5% in cryo vs 97.6% in RF; P = 0.81). Procedure times were similar, ablation and fluoroscopy times were higher in cryoballoon when compared to RF ablation. Overall complication rate was similar in cryo- (4.6%) and RF-ablation (4.6%; P = 1.0). Phrenic nerve palsy was more often in cryo versus RF ablation (2.1% in cryo vs 0.0% in RF; P < 0.001). Other complications were more common in RF compared to cryoablation (4.6% in RF vs 2.7% in cryo; P < 0.05)., Conclusion: RF ablation is the most widespread ablation method in Germany, but use of cryoballoon increased significantly. Procedure times were similar, but ablation and fluoroscopy times were longer in cryoballoon ablation. No significant differences were found in terms of acute success and overall complication rate., (© 2014 Wiley Periodicals, Inc.)

Introduction: Complete occlusion of the pulmonary veins (PV) is crucial for successful PV isolation. While two different sizes of cryoballoons (23 and 28 mm) are available, complete occlusion is not always achieved in any given PV. We investigated the role of PV ostial anatomy during cryoballoon PV occlusion grading and atrial fibrillation (AF) recurrence rate., Methods: PV ostial diameter was analyzed in 168 consecutive patients (111 men, 61 ± 10 years, 124 paroxysmal (px) and 44 persistent AF) using cardiac computed tomography (CT) prior to procedure. The ovality index at the PV ostial level was calculated in any given PV. During follow-up, 7-day holter monitors were performed at 1, 3, 6, 9, 12, 18 and 24 months post-ablation., Results: The success rate at 12 ± 6 months follow-up was 69% including a 3-month blanking period (px AF: 66%; persistent AF 77%). The ovality index of the left-sided PVs was significantly larger ("more oval") than that of the right-sided PVs (p<0.001). An optimized PV occlusion in all individual PVs (complete occlusion, grading 4/4) was achieved during ablation in 49% of patients with AF recurrence and in 73% of patients without AF recurrence (p=0.004). Patients with AF recurrence had "more oval" left-sided PVs compared to patients free from AF recurrence (LSPV 0.40 ± 0.2 vs. 0.33 ± 0.2; p=0.04 and LIPV 0.41 ± 0.3 vs. 0.32 ± 0.2; p=0.03), whereas no significant association was found for right sided PVs., Conclusion: The ostial PV anatomy seems to have an important impact on clinical outcome and should be considered when planning and performing cryoballoon AF ablation procedures., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Both cardiac computed tomography (CT) and interventional electrophysiology (EP) have evolved considerably in recent years. Technical improvements in CT have significantly reduced the radiation dose in cardiac applications. This imaging technology plays an important role in preprocedural planning and guidance of the procedures in many EP centers worldwide. Furthermore, CT is the imaging modality of choice to diagnose relevant complications in ablation of atrial fibrillation, e.g. pulmonary vein stenosis or atrioesophageal fistula. In anatomically driven ablation procedures, such as balloon-based procedures in atrial fibrillation, detailed analysis of the relevant cardiac structures is absolutely crucial not only to reduce radiation exposure and procedure times but also to improve ablation success and to reduce the occurrence of complications. Current software applications enable 3-dimensional reconstruction of cardiac images and the integration into electroanatomical navigation systems. This article reviews the available evidence in this field and highlights recent developments in image guidance for ablation of atrial fibrillation.

Aims: Cryoballoon technology is a promising technique in paroxysmal atrial fibrillation (AF) ablation. However, success rates in patients with persistent AF have not been convincing. There is a trend toward performing more extensive procedures that are referred to as 'pulmonary vein isolation plus.' To combine pulmonary vein isolation (PVI) and antral substrate modification, we used both the 23-mm and 28-mm cryoballoon in a single approach in patients with persistent AF., Methods and Results: 33 consecutive patients (26 men, age 60 ± 10 years, LA size 44 ± 5 mm) with persistent AF were prospectively included. All patients underwent the "double balloon strategy:" at least two applications at each pulmonary vein (PV) using the smaller 23-mm balloon to isolate the PV at the ostial level plus at least one additional freeze by the 28-mm balloon at the wide PV antral level. 7-day Holter monitors were performed during follow-up at 1, 3, 6, 9, 12, 18 and 24 months post-ablation. 131 of 133 PVs were targeted and isolated (98.4 %). A mean of 14 ± 2 cryoballoon applications per patient or 3.5 ± 1.5 applications per vein were performed. After a single procedure and mean follow-up of 15 ± 3 months, 69.7 % of patients remained in sinus rhythm (3-month blanking period). There were no major complications., Conclusions: In persistent AF, the "double balloon strategy;" combining the small and large cryoballoon allowed ostial PV isolation followed by antral cryoablation is feasible, safe and associated with a favorable outcome.

Introduction: The recently proposed "maximum voltage-guided" (MVG) technique for radiofrequency catheter ablation of atrial flutter targets high-voltage electrograms along cavotricuspid isthmus (CTI) to ablate the functionally important anatomic muscle bundles alone, without drawing a complete anatomic line across the CTI. This innovative approach may shorten ablation time and procedure duration., Methods and Results: Within the multicenter AURUM 8 study, which compared 8-mm gold- and Pt-Ir-tip catheters in atrial flutter ablation, we made a post hoc comparison of procedural data from 72 patients treated with MVG technique with data from 281 patients undergoing anatomic CTI ablation (unmatched) and with data from 72 patients selected from among those 281 patients such that they were matched with the MVG group with respect to selected baseline parameters and catheter type (matched). The MVG technique markedly reduced (P < 0.001) ablation time (mean 6.9 minutes vs 10.9/9.7 minutes [unmatched/matched]), number of lesions (8.3 vs 13.7/12.9), fluoroscopy time (9.5 minutes vs 20.6/17.9 minutes), procedure duration (59 minutes vs 93/86 minutes), and energy delivered (19 kJ vs 34/30 kJ) compared with anatomic CTI ablation. The incidence of charring was higher for MVG than for anatomic ablation technique (31.9% vs 18.5/15.3%, P < 0.05), where Pt-Ir tip catheters were 6-fold more susceptible to charring than gold-tip catheters (P < 0.001), likely because of a lower thermal conductivity of the Pt-Ir material. The acute success rate was slightly better for MVG than for anatomic ablation technique (97.2% vs 92.2/91.7%, P = n.s.)., Conclusion: Major procedural parameters are remarkably improved with MVG technique. Gold-tip catheters are substantially less susceptible to charring and may therefore be preferred over Pt-Ir-tip catheters for MVG ablation technique., (© 2012 Wiley Periodicals, Inc.)

Encouraging results of ablation therapy in patients with paroxysmal atrial fibrillation (AF) have prompted changes in professional practice guidelines. The most recent European guidelines have suggested that ablation might be offered as first-line therapy in selected patients. Cryoballoon ablation is a promising technology in interventional AF therapy. Two different sizes of the cryoballoon are currently available: a smaller (23 mm) and a larger (28 mm) balloon relative to the ostial diameter of the pulmonary veins. New tools, the circular mapping catheter and the use of intracardiac echocardiography, provide important periprocedural information. A meta-analysis of previous studies revealed outcome data with an AF-free survival rate of 72.83% at the 1-year follow-up in paroxysmal AF patients undergoing cryoballoon ablation. The most frequent, but reversible complication is phrenic nerve palsy with reported incidences up to 10%. All efforts must be taken to overcome this limitation, since the overall major complication rate tends to be lower in cryoballoon compared to radiofrequency ablation. In persistent AF, reported results in cryoballoon ablation had a limited success rate below 50% after a single procedure. A double balloon approach using both cryoballoon sizes might overcome some of the limitations in persistent AF. Prospective data and randomized studies are required. This article outlines the current status of cryoballoon technology in AF ablation therapy.

Background: Cryoballoon technique is an innovative alternative to radiofrequency ablation for atrial fibrillation (AF). However, with current cryoballoon application techniques, the operator has no access to electrical information for 300 s during the freezing cycle., Objective: The objective of this study is to investigate the novel approach of real-time monitoring of pulmonary vein (PV) potentials throughout freezing using a circular mapping catheter introduced into the central lumen of the cryoballoon catheter., Methods: Patients had paroxysmal or persistent AF. Standard balloon catheters (23 or 28 mm diameter, 10.5 F shaft) were used. A coaxial mapping catheter (shaft diameter 0.9 mm; 15 mm loop with six electrodes) was advanced through the lumen of the cryoballoon catheter, replacing the guide wire. The primary procedural end point was successful PV isolation and real-time PV potential recording. Secondary end points were procedural data, complications, and the time to successful PV isolation., Results: In 141 consecutively enrolled patients, balloon positioning and ablation were successful in 439/568 veins (77%). Real-time recording of PV conduction during the freeze cycle was possible in 235/568 PVs (41%). Main reasons for failure to obtain real-time PV recordings were a distal position of the circular mapping catheter or insufficient catheter-vessel wall contact during ablation. A cutoff value of 83 s to PV isolation was predictive of stable procedural PV isolation without reconduction. One minor hemoptysis was observed possibly related to the mapping catheter., Conclusions: This study, the largest to date, showed that real-time monitoring of PV conduction during cryoballoon freezing can be safely performed with a circular mapping catheter. A cutoff time of 83 s to PV isolation was predictive of sustained procedural PV isolation success without reconduction.

The aim of this study was to evaluate the rate of bleeding, thromboembolic complications, and the rate of stent thrombosis or restenosis in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). In this retrospective analysis, we included patients with AF who underwent PCI with stent implantation from 2003 to 2006. Combinations of aspirin, clopidogrel, and oral anticoagulation with phenprocoumon (OAC) were used for antithrombotic management. Follow-up was performed by telephone interview. Adverse events (AEs) were defined as major bleedings, stroke/transient ischaemic attack, peripheral embolism, stent thrombosis, or restenosis. One hundred and seventeen patients (85 men, mean age 72.0 +/- 8.2 years) were included in the study. Fifty-five patients (47%) received drug-eluting stents, 62 patients (53%) bare-metal stents. After coronary intervention, 53 patients (45.3%) received a combination of aspirin, clopidogrel, and OAC, 64 (54.7%) patients received other antithrombotic regimens. Eighteen patients died during follow-up, 11 patients presumably of cardiac and 7 patients of non-cardiac causes. In total, 26 AEs occurred in 24 of 113 patients (21.2%) during follow-up: 13 major bleedings, 6 cardioembolic complications, 3 stent thromboses, and 4 restenoses. The present study demonstrates an 11.5% rate of major bleedings, a 5.3% rate of thromboembolic events, and a 2.7% rate of stent thromboses in the high-risk group of patients with AF and coronary stent implantation. The decision on different antithrombotic treatment regimens needs to be based on the patients' individual risk until further prospective studies have evaluated the risk-benefit profile of a standardized approach of triple therapy in this high-risk patient group.

Atrial fibrillation and congestive heart failure are frequently associated with complex interactions. Patients with both diseases bear a sophisticated therapeutic challenge for the attending physician. The approach to treat atrial fibrillation differs for patients with and without heart failure in several aspects. Basic requirements are the treatment of the underlying diseases and prophylaxis of thromboembolic complications. Rate and rhythm control are the two main therapeutic strategies for atrial fibrillation according to the current guidelines. Large trials including the recently published AF-CHF study (Atrial Fibrillation - Congestive Heart Failure) failed to demonstrate a difference in mortality for both strategies. Thus, the therapeutic decision is mainly based on the patient's symptoms to improve quality of life. Rate control should be applied to asymptomatic patients or if rhythm control has already failed. If beta-blockers and digoxin have failed to control heart rate, His ablation with pacemaker implantation can be considered. In patients without heart disease, class I antiarrhythmic drugs and, in case of ineffectiveness, amiodarone or catheter ablation are recommended for rhythm control. First data concerning catheter ablation of atrial fibrillation in heart failure are promising and randomized studies are on the way. Rhythm control remains first-line therapy in recent-onset or highly symptomatic paroxysmal or persistent atrial fibrillation patients with and without heart failure.