Strategies for repeat ablation for atrial fibrillation: A multicentre comparison of nonpulmonary vein versus pulmonary vein target ablation.

INTRODUCTION: Approximately 18% of patients with atrial fibrillation (AF) undergo a repeat ablation within 12 months after their index ablation. Despite the high prevalence, comparative studies on nonpulmonary vein (PV) target strategies in repeat AF ablation are scarce. Here, we describe 12 months efficacy of non-PV and PV target ablations as a repeat ablation strategy. METHODS: A multicentre retrospective, descriptive study was conducted with data of 280 patients who underwent repeat AF ablation. The ablation strategy for repeat ablation was at the operators' discretion. Non-PV target ablation (n = 140) included PV reisolation, posterior wall isolation, mitral line, roofline, and/or complex fractionated atrial electrogram ablation. PV target ablation (n = 140), included reisolation and/or wide atrium circumferential ablation. Patients' demographics and rhythm outcomes during 12 months follow-up were analyzed. RESULTS: At 12 months, more atrial tachyarrhythmias were observed in the non-PV target group (48.6%) compared to the PV target group (29.3%, p = .001). Similarly, a significantly higher AF and atrial tachycardia (AT) recurrence rate was observed after non-PV target ablation compared to PV target ablation (36.4% vs. 22.1% and 22.9% vs. 10.7%). After adjustment, a significantly higher risk of AT recurrence remained in the non-PV target group. Both groups significantly de-escalated antiarrhythmic drug use; de-escalation was more profound after PV target ablation. Patients with isolated PVs during non-PV target ablation had a significantly higher risk for AF recurrence than those with reconnected PVs. CONCLUSION: Compared to PV target ablation, non-PV target repeat ablation did not improve outcomes after 12 months and was independently associated with an increased risk for AT recurrences.

Intermediate-term outcome of cryoballoon ablation of persistent atrial fibrillation and improvements in quality of life of patients.

BACKGROUND: Clinical outcome of pulmonary vein isolation (PVI) has been predominantly focused on the reoccurrence of atrial fibrillation (AF) and the maintenance of sinus rhythm. However, there has been a limited intermediate follow-up on health-related quality-of-life (HRQoL) of patients. Given the relatively high recurrence rate of persistent AF after PVI treatment, it is important to follow up with clinical outcomes on symptom improvement as well as health-related quality-of-life. This study was designed to investigate the recurrence rate of atrial tachyarrhythmia (ATa), AF-related symptoms and HRQoL after PVI in patients with persistent AF who were treated with the second generation cryoballoon. METHODS: Total 148 patients participated in the study who were treated by PVI between 2013 and 2017 for persistent AF. All patients visited the out-patient clinic 2-5 years after PVI. During this visit all patients filled-out an AF Effect on Quality-of-life (AFEQT) questionnaire and a seven-day Holter was applied. All rhythm recordings acquired post ablation were collected and analysed, and the modified European Heart Rhythm Association score (mEHRA) scores were calculated before and after the ablation. RESULTS: The average age of patients was 63±9 year old and 44 (27.9%) were female. Mean CHA2DS2 VASc score was 1.9±1.4, and moderate and severe left atrial (LA) dilation was present in 53 (36.1%) and 15 (10.2%) patients, respectively. After a follow-up of 3.7±1.0 years, 81 (54.7%) patients had an ATa recurrence and 35 (23.6%) patients underwent a repeat LA ablation. However, the mEHRA score significantly improved in 80.4% of the patients (p <0.001), with the median overall AFEQT score of 88.9 [70.4-97.2]. CONCLUSIONS: There is a considerable ATa recurrence rate after PVI of persistent AF at intermediate-term follow-up. However, our data indicate that PVI significantly improved AF-related symptoms and resulted in a high HRQoL for 2-5 years in patients with persistent AF.

Interatrial septum pacing guided by three-dimensional intracardiac echocardiography.

OBJECTIVES: Currently, the interatrial septum (IAS) pacing site is indirectly selected by fluoroscopy and P-wave analysis. The aim of the present study was to develop a novel approach for IAS pacing using intracardiac echocardiography (ICE). BACKGROUND: Interatrial septum pacing may be beneficial for the prevention of paroxysmal atrial fibrillation. METHODS: Cross-sectional images are acquired during a pull-back of the ICE transducer from the superior vena cava into the inferior vena cava by an electrocardiogram- and respiration-gated technique. Both atria are then reconstructed using three-dimensional (3D) imaging. Using an "en face" view of the IAS, the desired pacing site is selected. Following lead placement and electrical testing, another 3D reconstruction is performed to verify the final lead position. RESULTS: Twelve patients were included in this study. The IAS pacing was achieved in all patients including six suprafossal (SF) and six infrafossal (IF) lead locations all confirmed by 3D imaging. The mean duration times of atrial lead implantation and fluoroscopy were 70 +/- 48.9 min and 23.7 +/- 20.6 min, respectively. The IAS pacing resulted in a significant reduction of the P-wave duration as compared to sinus rhythm (98.9 +/- 19.3 ms vs. 141.3 +/- 8.6 ms; p < 0.002). The SF pacing showed a greater reduction of the P-wave duration than IF pacing (59.4 +/- 6.6 ms vs. 30.2 +/- 13.6 ms; p < 0.004). CONCLUSIONS: Three-dimensional ICE is a feasible tool for guiding IAS pacing.

One-year follow-up in a prospective, randomized study comparing radiofrequency and cryoablation of arrhythmias in Koch's triangle: clinical symptoms and event recording.

AIMS: To rely solely on clinical symptoms of recurrent palpitations to evaluate the success of interventional procedures can be misleading. This study was designed to assess the efficacy of event recording in evaluating long-term success in patients treated for atrioventricular nodal reentrant tachycardia (AVNRT) or right posteroseptally located accessory pathways (RPS) either by radiofrequency (RF) or by cryoablation (CA). METHODS AND RESULTS: Sixty-three patients with AVNRT and eight with RPS were randomized. Patients were encouraged to activate an event recorder in the case of recurrent palpitations for the first 3 months. One year after the procedure, patients were asked specific arrhythmia related questions. Thirty-six patients underwent RF and 35 CA. Acute success was finally achieved in 34 (94%) patients in the RF and 33 (94%) in the CA groups. Assessment of long-term success demonstrated a similar proportion of palpitations in the RF and CA groups: 11 (31%) vs. 17 (49%). Only 12 patients activated the event recorder, four patients in RF, including one patient with chest pain, and eight in the CA group. Analysis of recordings revealed recurrent AVNRT or circus movement tachycardia in four patients (one RF and three CA), atrial fibrillation in one RF patient, and sinus tachycardia in six (one RF and five with CA). In addition, a complete 12 lead ECG of a recurrent arrhythmia was made in three RF and two CA patients (in-hospital or after the event recording). A total of seven patients underwent a second procedure (four RF and three CA). Without the event recorder, seven patients would have been misclassified as having recurrent arrhythmia. CONCLUSION: Event recording enhances the sensitivity of detecting arrhythmia recurrences in evaluating therapy efficacy and should be considered in every interventional follow-up study. Analysis of recordings showed that CA is as effective as RF in the treatment of AVNRT and RPS at long-term follow-up.