Predictors of successful complex catheter ablation for persistent atrial fibrillation despite failure of targeted procedural arrhythmia termination.

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 < 34.4 mL/m² and significant AFCL increase during the ablation procedure had rather AT than AF recurrences. CONCLUSION: Patients with an arrhythmia-free outcome despite failure of procedural AF termination during complex ablation for persAF are characterized by specific morphological and functional properties that are easy to obtain.

Transapical aortic valve implantation in patients with previous cardiac surgery.

BACKGROUND: This study compared surgical outcomes of patients with previous cardiac surgery undergoing transapical transcatheter aortic valve implantation (PCS-TA-TAVI) with those of patients undergoing transapical transcatheter aortic valve implantation as an initial procedure (initial TA-TAVI) by using propensity analysis. METHODS: From January 2005 through January 2013, 267 consecutive high-risk patients underwent transapical transcatheter aortic valve implantation using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards SAPIEN). Of these, 59 patients underwent PCS-TA-TAVI (coronary artery bypass grafting: n = 31; valve surgery: n = 28), and the remaining 208 had an initial TA-TAVI procedure. Logistic regression analysis was used to identify covariates among 10 baseline patient variables. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 45 patients in the two groups. Operative outcomes were analyzed for differences. Follow-up was 4 ± 2 years and 100% complete. RESULTS: There was no significant difference between PCS-TA-TAVI and initial TA-TAVI patients in operative time, postoperative bleeding, 30-day survival (91% versus 93%), and survival at late follow-up (63% versus 68%; p ≥ 0.28). Overall incidence of early stroke was low with 0% for the PCS-TA-TAVI and 4% for initial TA-TAVI group (p = 0.56). Transapical transcatheter aortic valve implantation was successfully performed in all but 1 patient from the initial TA-TAVI group who required conversion to sternotomy. CONCLUSIONS: Transapical transcatheter aortic valve implantation has simplified surgical treatment of high-risk patients with previous cardiac surgery and severe aortic valve stenosis and is associated with minimal risk of stroke. Furthermore, current data suggest that the presence of previous cardiac surgery does not impair outcomes after transapical transcatheter aortic valve implantation, making this subset of patients particularly applicable for this evolving approach.