[Atrial fibrillation and heart failure]. / Vorhofflimmern und Herzinsuffizienz.

Atrial fibrillation and heart failure are among the most common cardiovascular diseases and have a significant impact on the mortality and morbidity of affected patients. From a pathophysiological perspective, the two diseases are closely related and often perpetuate each other. Therefore, effective management of atrial fibrillation is now a central component of modern heart failure treatment. Based on current data, sinus rhythm should primarily be permanently maintained in patients with systolic heart failure. Catheter ablation has recently proven to be advantageous over purely pharmacological therapy and is therefore the treatment of choice for many patients with heart failure and atrial fibrillation. In patients with diastolic heart failure (heart failure with preserved ejection fraction [HFpEF]), the effect of catheter ablation is less clear. Data from randomized studies are urgently needed in order to further assess efficacy in this population.

Effectiveness of sodium-glucose co-transporter 2 inhibitors on atrial fibrillation recurrence after catheter ablation: A systemic review and meta-analysis.

BACKGROUND: Studies have revealed the beneficial effects of sodium-glucose co-transporter 2 inhibitors (SGLT2i) for the treatment of heart failure (HF) regardless of the presence of diabetes. Besides, SGLT2i can decrease the incidence of atrial fibrillation (AF) in a broad population. However, the effects of SGLT2i on AF recurrence following catheter ablation (CA) remain uncertain. Therefore, this meta-analysis was undertaken to elucidate the effects of SGLT2i on AF recurrence after CA in AF patients. METHODS: A comprehensive search of PubMed, Embase, and Cochrane library was conducted for relevant studies, encompassing data from inception until March 20, 2024. The data were pooled using a fixed-effects model if the I2 value was <50%; otherwise, a random-effects model was adopted. RESULTS: One randomized controlled trial (RCT) and five observational studies involving 5623 patients with AF who underwent CA were included. SGLT2i treatment was associated with a significantly lower rate of AF recurrence (odds ratio [OR] = 0.45, 95% confidence interval [CI]: 0.31-0.66). Subgroup analysis demonstrated that patients treated with SGLT2i exhibited a lower incidence of AF recurrence compared to those treated with dipeptidyl peptidase-4 inhibitors (DPP4i). The favorable effects of SGLT2i on AF recurrence were more pronounced in male patients and patients with persistent AF. CONCLUSIONS: This meta-analysis provided evidence supporting the effectiveness of SGLT2i in reducing the risk of AF recurrence after CA in AF patients. SGLT2i may serve as an additional therapy option in this population.

Association of Paroxysmal Versus Persistent Atrial Fibrillation with In-hospital Outcomes and 30-day Readmission After Inpatient Atrial Fibrillation Ablation.

Knowledge of the impact of paroxysmal and persistent atrial fibrillation (AF) after catheter ablation on in-hospital outcomes and 30-day readmission remains limited. This study aimed to evaluate the procedural outcomes and 30-day readmission rates among patients with paroxysmal or persistent AF who were hospitalized for AF ablation. Using the Nationwide Readmissions Database, our study included patients aged ≥18 years with AF who were hospitalized and underwent catheter ablation during 2017-2020. Then, we compared the in-hospital procedural outcomes and 30-day readmission rates between patients with paroxysmal and persistent AF, respectively. Our study included 7310 index admissions for paroxysmal AF ablation and 9179 index admissions for persistent AF ablation. According to our analysis, there was no significant difference in procedural complications-namely, cerebrovascular accident, vascular complications, major bleeding requiring blood transfusion, phrenic nerve palsy, pericardial complications, and systemic embolization-between the persistent and paroxysmal AF groups. There was also no significant difference in early mortality between these groups (0.5% vs. 0.7%; P = .22). Persistent AF patients had significantly higher rates of prolonged index hospitalization (9.9% vs. 7.2%; P < .01) and non-home discharge (4.8% vs. 3.1%; P < .01). The 30-day readmission rates were comparable in both groups (10.0% vs. 9.5%; P = .34), with recurrent AF and heart failure being two of the most common causes of cardiac-related readmissions. Catheter ablation among hospitalized patients with paroxysmal or persistent AF resulted in no significant difference in procedural complications, early mortality, or 30-day readmission. This suggests that catheter ablation of AF can be performed with a relatively similar safety profile for both paroxysmal and persistent AF.

Oesophago-pericardial fistula after catheter ablation of atrial fibrillation: a case report.

Background: Oesophageal fistula is a rare complication of catheter ablation of atrial fibrillation with most fistulas being atrio-oesophageal fistulas, but oesophageal-pericardial fistula can also happen in the absence of atrial perforation. Case summary: A 68-year-old male patient presented with chest pain 10 days after catheter ablation of paroxysmal atrial fibrillation. He was discharged after an initial negative workup that included a CT chest without contrast. He later presented again with severe chest pain and fever and was found to have an oesophageal-pericardial fistula. He underwent surgical and endoscopic treatment with good recovery. Discussion: Patients with oesophago-pericardial fistulas often have delayed presentation 1-4 weeks after the ablation procedure. Early diagnosis can be challenging. CT with oral and intravenous contrast is often used for diagnosis. Treatment often includes antibiotics, surgical or interventional drainage of infected spaces with oesophageal repair, clipping or stenting. In contrast to atrio-oesophageal fistulas that carry a high mortality rate, mortality for oesophago-pericardial fistulas appears to be much lower.

Efficacy and safety of focal pulsed-field ablation for ventricular arrhythmias: two-centre experience.

BACKGROUND AND AIMS: A pulsed electric field(PF) energy source is a novel potential option for catheter ablation of ventricular arrhythmias(VA) as it can create deeper lesions, particularly in scarred tissue. However, very limited data exist on its efficacy and safety. This prospective observational study reports the initial experience with VA ablation using focal PF. METHODS: The study population consisted of 44patients (16 women, aged 61±14years) with either frequent ventricular premature complexes (VPC) (48%) or scar-related ventricular tachycardia (VT) (52%). Ablation was performed using an irrigated 4-mm tip catheter and a commercially available PF generator. RESULTS: On average, 16±15PF applications (25A) were delivered per patient. Acute success was achieved in 84% of patients as assessed by elimination of VPC or reaching non-inducibility of VT. In 3 cases (7%), a transient conduction system block was observed during PF applications remotely from the septum. Root analysis revealed that this event was caused by current leakage from the proximal shaft electrodes in contact with the basal interventricular septum. Acute elimination of VPC was achieved in 81% patients and non-inducibility of VT in 83% patients. At the three-month follow-up, persistent suppression of the VPC was confirmed on Holter monitoring in 81% patients. In the VT group, the mean follow-up was 116±75days and a total of 52% patients remained free of any VA. CONCLUSION: PF catheter ablation of a broad spectrum of VA is feasible with acute high efficacy, however, the short-term follow-up is less satisfactory for patients with scar-related VT.

Symptoms of gastroesophageal reflux disease predicts low voltage zones in the posteroinferior left atrium in patients with persistent atrial fibrillation.

Background: The presence of low voltage zones (LVZs) in the left atrium (LA) is associated with the recurrence of atrial fibrillation (AF) after pulmonary vein isolation. Numerous studies have posited a link between gastroesophageal reflux disease (GERD) and AF, attributing this relationship to the anatomical proximity of the esophagus to the posteroinferior wall of the LA. Objective: The objective of this study was to investigate whether GERD can predict the presence of LVZs in the posteroinferior wall of the LA. Methods: Five hundred fifty-one patients with persistent AF, scheduled for their first AF ablation procedure, were prospectively enrolled. Voltage maps were collected using a multipolar catheter, and LVZs were defined as areas measuring ≥3 cm2 with a peak-to-peak bipolar voltage of <0.5 mV. Information on GERD symptoms was collected from the participants through a self-administered questionnaire. Results: Long-standing persistent AF was present in 22.3% of the total cohort. GERD was present in 29% of patients and LVZs in the posteroinferior wall in 12.7%. In the multivariable analysis, patients with GERD were found to have more than twice the odds (odds ratio 2.26; 95% confidence interval 1.24-4.13; P = .008) of exhibiting LVZs in the posteroinferior wall of the LA than patients without GERD. GERD was not associated with LVZs in any other region of the LA. Conclusion: GERD was found to be independently associated with LVZs in the posteroinferior LA. This association may be attributable to inflammation and may partly explain the link between GERD and AF.

Comparison between Remotely Supported Nurse-led Electro-Anatomic Mapping and Standard Onsite Engineer Support for Electrophysiological Procedures.

AIMS: Catheter ablations of complex cardiac arrhythmias are currently guided by electro-anatomic mapping systems. The aim of this study was to compare two different approaches: remotely supported nurse-led electro-anatomic mapping with standard onsite engineer support. METHODS AND RESULTS: In this retrospective observational study, 166 patients with complex and non-complex procedures were included. 82 patients benefited from electro-anatomic mapping with remotely supported nurse-led mapping (mean age: 62±16years), while the approach for 84 patients was with standard onsite engineer support (mean age: 56±19 years). Procedural characteristics, acute results and complication rates were compared between both groups and showed similar results.Complex and non-complex procedures were conducted in both groups, including left atrial and ventricular procedures. As ventricular tachycardia and accessory pathway ablations were more frequently conducted with standard onsite engineer support, we separately analyzed the largest subgroup, 105 patients with atrial fibrillation, left atrial flutter and left atrial tachycardia. Patients in this subgroup had comparable baseline characteristics, procedure times and procedural success. Nevertheless, there were longer ablation times and more utilization of fluoroscopy in the onsite group, most likely due to more complex procedures. CONCLUSION: Our results underline the practicality of remotely supported nurse-led electro-anatomic mapping. The latter approach proved to be a safe alternative to onsite engineer support. Due to its advantages, particularly for insular settings, it will likely play a greater role in the future.

Left atrial remodeling and voltage-guided ablation outcome in persistent atrial fibrillation patients according to CHA2DS2-VASc score.

BACKGROUND: CHA2DS2-VASc score-related differences have been reported in atrial fibrotic remodeling and prognosis of atrial fibrillation (AF) patients after ablation. There are currently no data on the efficacy of low voltage zone (LVZ)-guided ablation in persistent AF patients according to CHA2DS2-VASc score. We assessed in a cohort of persistent AF patients the extent of LVZ, the regional distribution of LA voltage and the outcome of LA voltage-guided substrate ablation in addition to PVI according to CHA2DS2-VASc score. METHODS: 138 consecutive persistent AF patients undergoing a first voltage-guided catheter ablation were enrolled. 58 patients with CHAD2DS2-VASc score ≥ 3 and 80 patients with CHAD2DS2-VASc score ≤ 2 were included. LA voltage maps were obtained using 3D-electroanatomical mapping system in sinus rhythm. LVZ was defined as < 0.5 mV. RESULTS: In the high CHAD2DS2-VASc score group, LA voltage was lower (1.5 [1.1-2.5] vs. 2.3 [1.5-2.8] mV, p = 0.02) and LVZs were more frequently identified (40% vs. 18%), p < 0.01). Female with CHA2DS2-VASc score ≥ 3 (p = 0.031), LA indexed volume (p = 0.009) and P-wave duration ≥ 150 ms (p = 0.001) were predictors of LVZ. After a 36-month follow-up, atrial arrhythmia-free survival was similar between the two groups (logrank test, P = 0.676). CONCLUSIONS: AF patients with CHAD2DS2-VASc score ≥ 3 display more LA substrate remodeling with lower voltage and more LVZs compared with those with CHAD2DS2-VASc score ≤ 2. Despite this atrial remodeling, they had similar and favorable 36 months results after one single procedure. Unlike male with CHAD2DS2-VASc score ≥ 3, female with CHAD2DS2-VASc score ≥ 3 was predictor of LVZ occurrence.

Real world risk of discontinuing oral anticoagulation after successful catheter ablation for atrial fibrillation.

Background: Many patients with atrial fibrillation (AF) discontinued oral anticoagulation (OAC) therapy after successful catheter ablation. We aimed to determine the real-world risks and consequences of discontinuing OAC use after catheter ablation for AF. Methods: Patients who underwent successful catheter ablation for AF from January 2004 to December 2020 were divided into continued long-term OAC (On-OAC, n = 1062) and discontinued (Off-OAC, n = 1055) groups. The long-term outcomes including thromboembolic events, major bleeding, all-cause mortality and major adverse cardiovascular events (MACE), were compared between the two groups. Results: The CHA2DS2-VASc score was 3.44 ± 1.12. After a mean follow-up of 37.09 months, thromboembolism risk was higher and major bleeding risk was lower in the Off-OAC than in the On-OAC group (Both log-rank P < 0.001). CHA2DS2-VASc score-stratified subgroup analysis showed similar cumulative event rates between the two groups in men and women with scores of 2 and 3 (intermediate risk for stroke), respectively, (P > 0.05), except for a higher major bleeding rate in the On-OAC group (P = 0.002). Patients at high risk for stroke (men and women with scores ≥3 and ≥ 4) had better non-thromboembolic and non-MACE results (Both log-rank P < 0.05). Conclusion: Men with a CHA2DS2-VASc score of 2 and women with a score of 3 had a relatively low incidence of stroke events after successful catheter ablation for AF and may be safe for anticoagulation cessation. Greater benefits from long-term OAC were observed in men with CHA2DS2-VASc score ≥3 and women with score ≥4.

Factors influencing early recurrence of atrial fibrillation among elderly patients following radiofrequency catheter ablation and the impact of different antiarrhythmic regimens.

Background: Patients with atrial fibrillation (AF) who undergo radiofrequency catheter ablation (RFCA) necessitate the administration of antiarrhythmic drugs to prevent early recurrence. The clinical outcomes among these patients may be influenced by varying antiarrhythmic regimens. Objectives: To identify the risk factors associated with early recurrence and compare the clinical outcomes among different antiarrhythmic regimens in elderly patients with AF following radiofrequency catheter ablation (RFCA) during a 3-month period. Methods: A retrospective observational study encompassed 420 elderly patients with AF following RFCA. Baseline data were collected during the initial postoperative visit and clinical outcomes were carefully monitored over a 3-month follow-up period. Logistic regression and Cox-proportional hazard regression analyses were performed to investigate the relationship between various antiarrhythmic regimens and the clinical outcomes. Results: Multivariate logistic regression analysis revealed that age (p = 0.001), left atrial diameter (p < 0.001), left ventricular diameter (p = 0.015), reactive hyperemia index (RHI) (p < 0.001), antiarrhythmic drug (p < 0.001) and hs-cTnI (p = 0.017) were independent risk factors of early recurrence. Furthermore, in cox survival regression analysis model, survival rate of early recurrence in the amiodarone group was higher than in the propafenone group (HR 2.30, 95%CI 1.17-4.53, p = 0.016) and in the sotalol group (HR 3.60, 95%CI 2.17-5.95, p < 0.001). Compared to the amiodarone group, the incidence of liver dysfunction was lower in the dronedarone group (p = 0.046) and the propafenone group (p = 0.021). The incidence of bradyarrhythmia (p = 0.003), QT interval prolongation (p = 0.035) and atrioventricular transmission block (p = 0.021) were higher in the sotalol group than in the amiodarone group. Conclusion: RHI was identified as an independent risk factor for early recurrence among elderly AF patients after RFCA. Compared to amiodarone, propafenone and sotalol exhibited an elevated risk of early recurrence. Although there was no significant difference in early recurrence between amiodarone and dronedarone, dronedarone emerged as the preferred option due to its lower frequency of adverse drug reactions than amiodarone.

Septal late enhancement by cardiac CT is associated with repeat ablation in nonischemic cardiomyopathy patients.

INTRODUCTION: Scar substrate in nonischemic cardiomyopathy (NICM) patients is often difficult to identify. Advances in cardiac imaging, especially using late iodine-enhanced computed tomography (LIE-CT), allow better characterization of scars giving rise to ventricular tachycardia (VT). Currently, there are limited data on clinical correlates of CT-derived scar substrates in NICM. We sought assess the relationship between scar location on LIE-CT and outcomes after radiofrequency catheter ablation (RFCA) in NICM patients with VT. METHODS: From 2020 to 2022, consecutive patients with NICM undergoing VT RFCA with integration of cardiac CT scar modeling (inHeart, Pessac, France) were included at two US tertiary care centers. The CT protocol included both arterial-enhanced imaging for anatomical modeling and LIE-CT for scar assessment. The distribution of substrate on CT was analyzed in relation to patient outcomes, with primary endpoints being VT recurrence and the need for repeat ablation procedure. RESULTS: Sixty patients were included (age 64 ± 12 years, 90% men). Over a median follow-up of 120 days (interquartile range [IQR]: 41-365), repeat ablation procedures were required in 32 (53%). VT recurrence occurred in 46 (77%), with a median time to recurrence of 40 days (IQR: 8-65). CT-derived total scar volume positively correlated with intrinsic QRS duration (r = .34, p = 0.008). Septal scar was found on CT in 34 (57%), and lateral scar in 40 (7%). On univariate logistic regression, septal scar was associated with increased odds of repeat ablation (odds ratio [OR]: 2.9 [1.0-8.4]; p = 0.046), while lateral scar was not (OR: 0.9 [0.3-2.7]; p = 0.855). Septal scar better predicted VT recurrence when compared to lateral scar, but neither were statistically significant (septal scar OR: 3.0 [0.9-10.7]; p = 0.078; lateral scar OR: 1.7 [0.5-5.9]; p = 0.391). CONCLUSION: In this tertiary care referral population, patients with NICM undergoing VT catheter ablation with septal LIE-CT have nearly threefold increased risk of need for repeat ablation.

Efficacy of Commonly Used 3D Mapping Systems in Acute Success Rates of Catheter Ablation Procedures.

Introduction: This systematic review aims to summarize the procedural arrhythmia termination rates in catheter ablation (CA) procedures of atrial or ventricular arrhythmias using the commonly used mapping systems (CARTO, Rhythmia and EnSite/NavX). Materials and Methods: A systematic search in MEDLINE and Cochrane databases through February 2021 was performed. Results: With regard to atrial fibrillation ablation procedures, acute success rates ranged from 15.4 to 96.0% and 9.1 to 100.0% using the CARTO and EnSite/NavX mapping systems, respectively; acute atrial tachycardia (AT) termination to sinus rhythm ranged from 75 to 100% using the CARTO system. The acute success rate for different types of AT ranged from 75 to 97% using Rhythmia, while the NavX mapping system was also found to have excellent efficacy in the setting of AT, with acute arrhythmia termination rates ranging from 73 to 99%. With regard to ventricular tachycardia, in the setting of ischaemic cardiomyopathy, acute success rates ranged from 70 to 100% using CARTO and 64% using EnSite/NavX systems. The acute success rate using the Rhythmia system ranged from 61.5 to 100.0% for different clinical settings. Conclusions: Mapping systems have played a crucial role in high-density mapping and the observed high procedural success rates of atrial and ventricular CA procedures. More data are needed for the comparative efficacy of mapping systems in acute arrhythmia termination, across different clinical settings.

The Ablate-by-LAWT multicentre prospective study: Personalized paroxysmal atrial fibrillation ablation with ablation index adapted to local left atrial wall thickness.

BACKGROUND: Personalized radiofrequency (RF) ablation for paroxysmal atrial fibrillation (PAF), adapting the ablation index (AI) to local left atrial wall thickness (LAWT), proved to be highly efficient maintaining high arrhythmia-free survival rates. However, multicentre data are lacking. This multicentre, prospective, non-randomized study was conducted at 5 tertiary hospitals and sought to assess the safety, efficacy, and reproducibility of the LAWT-guided ablation for PAF. METHODS: Consecutive patients referred for first-time PAF were prospectively enrolled. The LAWT maps were obtained from preprocedural multidetector computed tomography and integrated into the navigation system. AI was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the pulmonary veins (PVs). RESULTS: A total 109 patients (60.1 ± 9.4 years, 64.2% male) were enrolled. Median procedure time was 61.7 min (48.4-83.8), fluoroscopy time was 1.0 min (0.4-3.3), and RF time was 13.9 min (12.3-16.8). Median AI tailored to the local LAWT was 393 (374-412) for the anterior wall and 340 (315-378) for the posterior wall. Right and left PVs first-pass isolation was achieved in 89% and 91.7% of the patients, respectively. At 12-month follow-up, freedom from any atrial arrhythmia was 93.4% (95% CI 88.7-98.1), without differences across centres (P = 0.169). One patient experienced femoral artery pseudoaneurysm, with no other serious procedural-related complication. CONCLUSION: The Ablate-by-LAWT study proved that LAWT-guided PV isolation for PAF is safe, effective, and efficient in a multicentre setting. Twelve-month recurrence-free survival exceeded 90% (NCT04218604).

QT Prolongation and Torsade De Pointes After Catheter Ablation for Persistent Atrial Fibrillation in a Patient With Tachycardia-Induced Cardiomyopathy: A Case Report.

Atrial fibrillation (AF) is the most common cause of tachycardia-induced cardiomyopathy (TIC). A 75-year-old woman was referred to our hospital for catheter ablation for persistent AF. On admission, transthoracic echocardiography (TTE) revealed diffuse left ventricular (LV) hypokinesis, which was suspected to be due to TIC. Catheter ablation was performed on the fifth day of hospitalization, and Torsade de Pointes (TdP) appeared on the sixth day. The serum concentration of bepridil and potassium was below the reference level. An electrocardiogram revealed marked QT prolongation, giant-negative T waves, and T-wave alternans on the seventh day of hospitalization. Cardiac magnetic resonance imaging with no contrast indicated diffuse mild LV hypokinesis, mild prolonged native T1, and no evidence of myocardial edema at T2. Coronary angiography revealed normal coronary arteries, and the ergonovine stress test results were negative. The results for five long QT syndrome susceptibility genes, including the three major genes, were negative. Subsequently, QT prolongation, giant-negative T waves, and LV dysfunction improved without treatment. This case report highlights the importance of risk management for AF patients with TIC scheduled for catheter ablation and carefully evaluating the risks of QT prolongation. Moreover, patients with TIC can experience marked QT prolongation and TdP during the perioperative period of catheter ablation. Therefore, caution should be required.