Impact of early vs. delayed atrial fibrillation catheter ablation on atrial arrhythmia recurrences.

BACKGROUND: Catheter ablation is an effective strategy in atrial fibrillation (AF). However, its timing in the course of management remains unclear. The aim of this study was to determine if an early vs. delayed AF ablation strategy is associated with differences in arrhythmia outcomes during 12-month follow-up. METHODS AND RESULTS: One hundred patients with symptomatic AF referred to a tertiary centre for management were randomized in a 1:1 ratio to either an early ablation strategy (within 1 month of recruitment) or a delayed ablation strategy (optimized medical therapy followed by catheter ablation at 12 months post recruitment). The primary endpoint was atrial arrhythmia free survival at 12 months post-ablation. Secondary outcomes included: (i) AF burden, (ii) AF burden by AF phenotype, and (iii) antiarrhythmic drug (AAD) use at 12 months. Overall, 89 patients completed the study protocol (Early vs. Delayed: 48 vs. 41). Mean age was 59 ± 12.9 years (29% women). Pulmonary vein isolation was achieved in 100% of patients. At 12 months, 56.3% of patients in the early ablation group were free from recurrent arrhythmia, compared with 58.6% in the delayed ablation group (HR 1.12, 95% CI 0.59-2.13, P = 0.7). All secondary outcomes showed no significant difference including median AF burden (Early vs. Delayed: 0% [IQR 3.2] vs. 0% [5], P = 0.66), median AF burden amongst paroxysmal AF patients (0% [IQR 1.1] vs. 0% [4.5], P = 0.78), or persistent AF patients (0% [IQR 22.8] vs. 0% [5.6], P = 0.45) or AAD use (33% vs. 37%, P = 0.8). CONCLUSION: Compared with an early ablation strategy, delaying AF ablation by 12 months for AAD management did not result in reduced ablation efficacy.

Tailoring cardiac resynchronisation therapy to non-left bundle branch block: Successful cardiac resynchronisation for right bundle branch block with left posterior fascicular block without implantation of a left ventricular lead.

Despite advances, cardiac resynchronisation therapy (CRT) remains fundamentally orientated to the dyssynchrony of left bundle branch block (LBBB), in which septo-lateral electrical and mechanical delays predominate. For non-LBBB patients response rates to conventional CRT are lower and mortality and rehospitalisation rates are not reduced. Despite this, alternative approaches which tailor CRT to the differing dyssynchrony patterns of non-LBBB have yet to be developed. In the specific non-LBBB subgroup of right bundle branch block (RBBB) with left posterior fascicular block (LPFB), ventricular conduction via the left anterior fascicle results in a unique early lateral, and late septal depolarisation, or lateral to septal left ventricular (LV) delay, an electrical sequence which is followed mechanically. This latero-septal delay is somewhat the reverse of LBBB and was overcome by fusing right ventricular (RV) septal pacing with intrinsic conduction via the left anterior fascicle, achieving successful resynchronisation without implantation of a left ventricular lead. A stable fusion pattern was achieved via the 'Negative AV Hysteresis with Search' algorithm (Abbott, St Paul, Minnesota). Improvement in all standard CRT response indices was achieved at 3 months: QRS duration was reduced from 153 to 106 ms, ejection fraction increased from 14 to 32%, and LV end-systolic and end-diastolic diameters reduced by 19% and 12.5% respectively. NYHA class improved from III-IV to class II. Cardiac resynchronisation for RBBB with LPFB can be successfully achieved with a standard pacemaker or defibrillator without left ventricular lead implantation by fusing RV septal-only pacing with intrinsic conduction.

Cardiorespiratory and autonomic function in epileptic seizures: A video-EEG monitoring study.

PURPOSE: Seizure-induced cardiorespiratory and autonomic dysfunction has long been recognized, and growing evidence points to its implication in sudden unexpected death in epilepsy (SUDEP). However, a comprehensive understanding of cardiorespiratory function in the preictal, ictal, and postictal periods are lacking. METHODS: We examined continuous cardiorespiratory and autonomic function in 157 seizures (18 convulsive and 139 nonconvulsive) from 70 consecutive patients who had a seizure captured on concurrent video-encephalogram (EEG) monitoring and polysomnography between February 1, 2012 and May 31, 2017. Heart and respiratory rates, heart rate variability (HRV), and oxygen saturation were assessed across four distinct periods: baseline (120 s), preictal (60 s), ictal, and postictal (300 s). Heart and respiratory rates were further followed for up to 60 min after seizure termination to assess return to baseline. RESULTS: Ictal tachycardia occurred during both convulsive and nonconvulsive seizures, but the maximum rate was higher for convulsive seizures (mean: 138.8 beats/min, 95% confidence interval (CI): 125.3-152.4) compared with nonconvulsive seizures (mean: 105.4 beats/min, 95% CI: 101.2-109.6; p < 0.001). Convulsive seizures were associated with a lower ictal minimum respiratory rate (mean: 0 breaths/min, 95% CI: 0-0) compared with nonconvulsive seizures (mean: 11.0 breaths/min, 95% CI: 9.5-12.6; p < 0.001). Ictal obstructive apnea was associated with convulsive compared with nonconvulsive seizures. The low-frequency (LF) power band of ictal HRV was higher among convulsive seizures than nonconvulsive seizures (ratio of means (ROM): 2.97, 95% CI: 1.34-6.60; p = 0.008). Postictal tachycardia was substantially prolonged, characterized by a longer return to baseline for convulsive seizures (median: 60.0 min, interquartile range (IQR): 46.5-60.0) than nonconvulsive seizures (median: 0.26 min, IQR: 0.008-0.9; p < 0.001). For postictal hyperventilation, the return to baseline was longer in convulsive seizures (median: 25.3 min, IQR: 8.1-60) than nonconvulsive seizures (median: 1.0 min, IQR: 0.07-3.2; p < 0.001). The LF power band of postictal HRV was lower in convulsive seizures than nonconvulsive seizures (ROM: 0.33, 95% CI: 0.11-0.96; p = 0.043). Convulsive seizures with postictal generalized EEG suppression (PGES; n = 12) were associated with lower postictal heart and respiratory rate, and increased HRV, compared with those without (n = 6). CONCLUSIONS: Profound cardiorespiratory and autonomic dysfunction associated with convulsive seizures may explain why these seizures carry the greatest risk of SUDEP.

Low Rates of Major Complications for Radiofrequency Ablation of Atrial Fibrillation Maintained Over 14 Years: A Single Centre Experience of 2750 Consecutive Cases.

BACKGROUND: Despite technological advances, studies continue to report high complication rates for atrial fibrillation (AF) ablation. We sought to review complication rates for AF ablation at a high-volume centre over a 14-year period and identify predictors of complications. METHODS: We reviewed prospectively collected data from 2750 consecutive AF ablation procedures at our institution using radiofrequency energy (RF) between January 2004 and May 2017. All cases were performed under general anaesthetic with transoesophageal echocardiography (TEE), 3D-mapping and an irrigated ablation catheter. Double transseptal puncture was performed under TEE guidance. All patients underwent wide antral circumferential isolation of the pulmonary veins (30W anteriorly, 25W posteriorly) with substrate modification at operator discretion. RESULTS: Of 2255 initial and 495 redo procedures, ablation strategies were: pulmonary vein isolation (PVI) only 2097 (76.3%), PVI+ LA lines 368 (13.4%), PVI+posterior wall 191 (6.9%), PVI+cavotricuspid isthmus 277 (10.1%). There were 23 major (0.84%) and 20 minor (0.73%) complications. Cardiac tamponade (five cases - 0.18%) and phrenic nerve palsy (one case - 0.04%) rates were very low. Major vascular complications necessitating surgery or blood transfusion occurred in five patients (0.18%). There were no cases of death, permanent disability, atrio-oesophageal fistulae or symptomatic pulmonary vein (PV) stenosis, although there were five TEE probe-related complications (0.18%). Female gender (OR 2.14; 95% CI 1.07-4.26) but not age >70 (OR 1.01) was the only multivariate predictor of complications. CONCLUSIONS: Atrial fibrillation ablation performed at a high-volume centre using RF can be achieved with a low major complication rate in a representative AF population over a sustained period of time.

Deglutition-Induced Atrial Tachycardia Localised with Contact Force-Guided Activation Mapping.

Deglutition-induced atrial tachycardia is a rare arrhythmia with a poor response to medical therapy. Electrophysiological study is challenging due to the dependence of induction on swallowing. We present a novel approach to management of deglutition-induced atrial tachycardia arising from right superior pulmonary vein. Use of minimal conscious sedation and repeated swallow challenge inductions, together with contact force-guided mapping were key determinants of success. We review published cases, discussing potential mechanisms including oesophageal distension and neural reflexes.

The transesophageal echo probe may contribute to esophageal injury after catheter ablation for paroxysmal atrial fibrillation under general anesthesia: a preliminary observation.

INTRODUCTION: The transesophageal echo probe (TEE) is commonly used before and during atrial fibrillation (AF) ablation under general anesthesia (GA). We sought to determine the potential contribution of the TEE probe to esophageal injury after pulmonary vein isolation (PVI) alone for paroxysmal AF. METHODS AND RESULTS: Seventy-six patients undergoing PVI with TEE, PVI/TEE, 16 undergoing PVI without TEE (PVI/No TEE), and 27 undergoing TEE without any left atrial ablation (TEE/No LA ablation) under GA were included. Posterior wall ablation was power (20-25 W) and time limited (electrogram attenuation or ≤30 s). Esophageal capsule endoscopy (n = 206) was performed pre- and post-procedure and at 2 weeks. Esophageal lesions were seen in 30% of PVI/TEE, 0% of patients in the PVI/No TEE (P = 0.009), and 22% of TEE/No LA ablation groups (P = 0.47 vs. PVI/TEE). There were no instances of esophageal bleeding, perforation, or need for gastrointestinal intervention. Self-resolving dysphagia was the only reported symptom (5%). All lesions healed within 2 weeks. There was no significant difference in the location or morphological appearance of esophageal lesions seen in the PVI/TEE versus TEE/No LA ablation groups. CONCLUSIONS: Esophageal lesions were seen in 30% of patients undergoing PVI alone under GA with use of TEE and in a similar proportion (22%) of patients undergoing TEE in the absence of left atrial ablation. This study makes the preliminary observation that one must be cognizant of the TEE probe as a potential contributor to esophageal injury after AF ablation. Larger studies are needed to confirm these findings.

Impact of Posterior Wall Isolation During AF Ablation on the Incidence of Left Atrial Flutter.

BACKGROUND: Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown. OBJECTIVES: The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI + PWI vs PVI + PWI + LCEA. METHODS: Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12 months. RESULTS: In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI + PWI (6.2%) vs PVI alone (3.0%; P < 0.0001) and following PVI + PWI + LCEA vs PVI + PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI + PWI (P = 0.386), and 81.8% post-PVI + PWI + LCEA (P < 0.005). CONCLUSIONS: The incidence of LAMT following PVI + PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic.

Left Ventricular Summit Arrhythmias: State-of-the-Art Review of Anatomy, Mapping, and Ablation Strategies.

The left ventricular summit (LVS) is the most common site of epicardial arrhythmias. Ablation of LVS arrhythmias continue to pose a challenge to the electrophysiologist because of its complex and intimate anatomical location. In this review, we undertake a detailed examination of the intricate anatomy of the LVS alongside a comprehensive synthesis of mapping and ablation strategies used to treat LVS arrhythmias.

Cardiac structural and functional abnormalities in epilepsy: A systematic review and meta-analysis.

OBJECTIVE: Epilepsy is associated with an increased risk of cardiovascular disease and mortality. Whether cardiac structure and function are altered in epilepsy remains unclear. To address this, we conducted a systematic review and meta-analysis of studies evaluating cardiac structure and function in patients with epilepsy. METHODS: We searched the electronic databases MEDLINE, PubMed, COCHRANE, and Web of Science from inception to 31 December 2021. Primary outcomes of interest included left ventricular ejection fraction (LVEF) for studies reporting echocardiogram findings and cardiac weight and fibrosis for postmortem investigations. Study quality was assessed using the National Heart, Lung, and Blood Institute (NHLBI) assessment tools. RESULTS: Among the 10 case-control studies with epilepsy patients (n = 515) and healthy controls (n = 445), LVEF was significantly decreased in epilepsy group compared with controls (MD: -1.80; 95% confidence interval [CI]: -3.56 to -0.04; P = 0.045), whereas A-wave velocity (MD: 4.73; 95% CI: 1.87-7.60; P = 0.001), E/e' ratio (MD: 0.39; 95% CI: 0.06-0.71; P = 0.019), and isovolumic relaxation time (MD: 10.18; 95% CI: 2.05-18.32; P = 0.014) were increased in epilepsy, compared with controls. A pooled analysis was performed in sudden unexpected death in epilepsy (SUDEP) cases with autopsy data (n = 714). Among SUDEP cases, the prevalence of cardiac hypertrophy was 16% (95% CI: 9%-23%); cardiac fibrosis was 20% (95% CI: 15%-26%). We found no marked differences in cardiac hypertrophy, heart weight, or cardiac fibrosis between SUDEP cases and epilepsy controls. SIGNIFICANCE: Our findings suggest that epilepsy is associated with altered diastolic and systolic echocardiogram parameters compared with healthy controls. Notably, SUDEP does not appear to be associated with a higher incidence of structural cardiac abnormalities, compared with non-SUDEP epilepsy controls. Longitudinal studies are needed to understand the prognostic significance of such changes. Echocardiography may be a useful noninvasive diagnostic test in epilepsy population.

Electroanatomic remodeling of the left atrium in paroxysmal and persistent atrial fibrillation patients without structural heart disease.

INTRODUCTION: The nature of the atrial substrate thought to contribute toward maintaining atrial fibrillation (AF) outside the pulmonary veins remains poorly defined. Therefore, our objective was to determine whether patients with paroxysmal and persistent AF have an abnormal electroanatomic substrate within the left atrium (LA). METHODS AND RESULTS: Thirty-one patients with AF (17 paroxysmal AF and 14 persistent AF) were compared with 15 age-matched controls with left-sided supraventricular tachycardia (SVT). High-density 3-dimensional electroanatomic maps were created and the LA was divided into 8 segments for regional analysis. Bipolar voltage, conduction, and effective refractory periods (ERPs) of the posterior LA, left atrial appendage (LAA), and distal coronary sinus (CSd) and percentage complex signals were assessed. In the majority of LA regions, compared with controls, AF patients had: (1) lower mean voltage and a higher percentage low voltage; (2) slower conduction; and (3) more prevalent complex signals. Many of these changes were more marked in the persistent than the paroxysmal AF group. CONCLUSIONS: Patients with AF have lower regional voltage, increased proportion of low voltage, slowed conduction, and increased proportion of complex signals compared to controls. Many of these changes are more pronounced in persistent AF patients, suggesting there may be a progressive nature to the changes. Differences occurred in the absence of structural heart disease. These substrate abnormalities provide further insight into the progressive nature of atrial remodeling and the mechanisms involved in maintenance of AF.

Impact of collimation on radiation exposure during interventional electrophysiology.

AIMS: Fluoroscopy remains a cornerstone imaging technique in contemporary electrophysiology practice. We evaluated the impact of collimation to the 'minimal required field size' on clinically significant parameters of radiation exposure. METHODS AND RESULTS: Radiation dose measured by dose area product (DAP) and radiation dose rate measured by DAP per minute of fluoroscopy were determined for all 571 electrophysiology procedures performed in a single electrophysiology laboratory from January 2010 to December 2010. Data from 205 procedures performed by one interventional electrophysiologist, who instituted a practice of routinely collimating to the minimum required visual fluoroscopy field on a case-by-case basis, were compared with data from 366 procedures performed by the three other experienced interventional electrophysiologists using the laboratory who continued their existing practice of ad hoc collimation. Significant reductions in radiation exposure were seen with the practice of routine maximal collimation. The largest reductions were seen during 'simple' ablation procedures. CONCLUSION: A practice of routinely collimating to the minimum required visual fluoroscopy field results in significant reductions in radiation exposure when compared with a usual approach to collimation. This may have important implications for risk of malignancy in patients and operators.

Low risk of major complications associated with pulmonary vein antral isolation for atrial fibrillation: results of 500 consecutive ablation procedures in patients with low prevalence of structural heart disease from a single center.

OBJECTIVES: To report the major complication rate associated with pulmonary vein antral isolation (PVAI) in a consecutive series of 500 patients from a single center. BACKGROUND: Catheter ablation for atrial fibrillation (AF) is an established procedure for refractory AF. However, the risk of major complications has been reported to range from 3.9% to 4.5% and continues to represent a cause for concern. We hypothesized that these studies may have overestimated the rate of major complications associated with PVAI in patients with a low prevalence of structural heart disease (SHD). METHODS: Data were prospectively collected from 500 consecutive AF ablation procedures on 424 patients (mean age 55 ± 11 years, 79% men, paroxysmal AF-80% and persistent AF-20%, CHADS2 scores of 0, 1, 2, 3 present in 64%, 28%, 7%, 1%, respectively), performed between July 2006 and September 2009. All procedures were performed under general anesthesia with intraoperative transesophageal echo. PVAI was performed using a nonfluoroscopic mapping system with an endpoint of PV isolation. Adjunctive left atrial ablation was performed in 21% of patients only. Major complications were defined from a compilation of those reported in 5 prior studies reporting complications. RESULTS: In 500 procedures, there were no instances of death, stroke/TIA, cardiac tamponade, atrioesophageal fistula, or PV stenosis. Major complications occurred in 4 procedures (0.8%): esophageal hematoma (TEE probe)--2; pharyngeal trauma--1; and retroperitoneal hematoma-1. CONCLUSIONS: AF ablation can be performed safely in young patients without structural heart disease with a low risk (<1%) of major complications when using a strategy of PVAI.

The relationship between complex fractionated electrograms and atrial low-voltage zones during atrial fibrillation and paced rhythm.

AIMS: Mapping of atrial fibrillation (AF) involves identification of low-voltage regions associated with complex fractionated electrograms (CFE) which theoretically represent abnormal substrate and targets for ablation. Whether low-voltage CFE areas also identify abnormal substrate during paced rhythm is unknown. METHODS AND RESULTS: Twelve patients with persistent AF undergoing ablation of AF had high-density three-dimensional electroanatomic maps created during AF and paced rhythm (24 maps) and the mean voltage during AF and paced rhythm was compared for eight segments of the left atrium (LA). The following were correlated during AF and paced rhythm: regional mean voltage; %low voltage (defined as <0.5 mV); and extent of CFE. In addition, the relationship between the extent of CFE in AF: (i) %low voltage and (ii) conduction during paced rhythm were determined. Mean voltage was lower during AF than paced rhythm for all regions and globally (0.7 ± 0.2 mV vs. 2.1 ± 0.6 mV, P < 0.001). The regional and overall %low voltage of the LA was greater during AF than paced rhythm (53 ± 19% vs. 9 ± 2%, P < 0.001). There was no correlation between mean voltage or %low voltage during AF and paced rhythm. Complex fractionated electrograms were prevalent throughout all regions during AF, but did not correlate with %low voltage, fractionation, or slowed conduction during paced rhythm. CONCLUSION: Areas of CFE and low voltage recorded during AF frequently demonstrate normal atrial myocardial characteristics (normal conduction, electrograms, and voltage) during sinus rhythm. Therefore, AF CFE sites do not necessarily identify regions of an abnormal atrial substrate. However, this does not exclude the possibility that CFE might identify a focal driver or source occurring in a region of normal atrial myocardium.

Predictors of acute and long-term success of slow pathway ablation for atrioventricular nodal reentrant tachycardia: a single center series of 1,419 consecutive patients.

BACKGROUND: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common mechanism of supraventricular tachycardia. Slow pathway (SP) ablation is the first-line treatment approach with a high acute success rate and a low risk of inadvertent complete atrioventricular (AV) block. However, there is still some uncertainty as to the most appropriate procedural endpoints and the impact of these on risk of recurrence. We report the acute and long-term results of SP ablation in a large single-center consecutive series and analyze predictors of acute success and late recurrence. METHODS: The study included 1,448 consecutive procedures in 1,419 patients with AVNRT (mean age 49 ± 17 years, 66% women) who underwent SP ablation using a combined electrophysiologic and anatomic approach. Univariate and multivariate analysis was performed for potential predictors of acute success and late recurrence. RESULTS: Acute success was achieved in 98.1%. Transient (first, second, or third degree) AV block occurred during the procedure in 20 (1.41%) patients. One patient (0.07%) had persistent first-degree and transient second-degree AV block after ablation and underwent pacemaker implant at day 21. Of the 1,391 patients with successful ablation, 22 patients (1.5%) developed AVNRT recurrence during a follow-up period of 63 ± 38 months. The only independent predictor of reduced procedural success was the presence of atypical AVNRT (hazard ratio 3.1, P = 0.04). Independent predictors of AVNRT recurrence were age <20 years and female gender (hazard ratios 14.1 and 3.7, respectively). No significant difference in the incidence of late recurrence was observed in patients with or without residual slow-pathway conduction, or according to use of isoproterenol testing or general anesthesia. However, patients with a single echo with recurrence had a significantly larger echo window (median 85 ms) than those without (median 30 ms, P = 0.01). CONCLUSIONS: This study demonstrates in a large consecutive single-center series that SP ablation using radiofrequency energy is a highly effective procedure with an extremely low risk of inadvertent AV block and a low recurrence rate. We found that single-AV nodal echo beats represented a procedural endpoint that did not predict AVNRT recurrence but that a large echo window is associated with recurrence. Recurrence rates in this series were higher in young women, possibly reflecting a more conservative approach to ablation in this age group.

Long-term outcome following ablation of atrial flutter occurring late after atrial septal defect repair.

AIMS: In patients with surgical atrial septal defect (ASD) repair, late atrial flutters (AFLs), including cavotricuspid isthmus (CTI)-dependent and non-CTI-dependent scar-related flutter (AFL), are common. Radiofrequency ablation (RFA) of these arrhythmias has a high acute success rate. We aimed to characterize the long-term freedom from atrial arrhythmias in this population. METHODS: Twenty consecutive patients undergoing RFA for AFL late after ASD repair were included. Electrophysiological assessment included multipolar activation, entrainment, and electroanatomic mapping. Clinical, electrocardiograph, and Holter monitoring follow-up was conducted every 6 months. RESULTS: Mean age was 53 ± 13 years. Time from surgical repair to RFA was 29 ± 15 years. All patients had CTI-dependent AFL (20/20). There were 1.6 ± 0.7 arrhythmias per patient; other arrhythmias included non-CTI-dependent AFL (14), focal atrial tachycardia (two), and atrioventricular nodal reentry tachycardia (two) . Acute success was obtained in 100%. Five patients with recurrent AFL (three CTI dependent, two non-CTI dependent) at 13 ± 8 months had successful repeat RFA. At 3.2 ± 1.6 years follow-up since the last procedure, 90% of patients with successful RFA for AFL remained free of their clinical arrhythmia. However, 30% of the original 20 patients had documented atrial fibrillation (AF) 2.1 ± 1.6 years after the last procedure; five (25%) required AF intervention. One stroke (5%) occurred in the context of late AF. CONCLUSION: RFA of AFL occurring late after surgical ASD repair has a low long-term risk of recurrence, although 25% of patients required two procedures. However, there is a high late incidence of AF (30%), with an additional 25% of patients requiring intervention for AF.

Vagal paroxysmal atrial fibrillation: prevalence and ablation outcome in patients without structural heart disease.

INTRODUCTION: The prevalence of vagal and adrenergic atrial fibrillation (AF) and the success rate of pulmonary vein isolation (PVI) are not well defined. We investigated the prevalence of vagal and adrenergic AF and the ablation success rate of antral pulmonary vein isolation (APVI) in patients with these triggers compared with patients with random AF. METHODS AND RESULTS: Two hundred and nine consecutive patients underwent APVI due to symptomatic drug refractory paroxysmal AF. Patients were diagnosed as vagal or adrenergic AF if >90% of AF episodes were related to vagal or adrenergic triggers; otherwise, a diagnosis of random AF was made. Clinical, electrocardiogram (ECG), and Holter follow-up was every 3 months in the first year and every 6 months afterward and for symptoms. Of 209 patients, 57 (27%) had vagal AF, 14 (7%) adrenergic AF, and 138 (66%) random AF. Vagal triggers were sleep (96.4%), postprandial (96.4%), late post-exercise (51%), cold stimulus (20%), coughing (7%), and swallowing (2%). At APVI, 94.3% of patients had isolation of all veins. Twenty-five (12%) patients had a second APVI. At a follow-up of 21 +/- 15 months, the percentage of patients free of AF was 75% in the vagal group, 86% in the adrenergic group, and 82% for random AF (P = 0.51). CONCLUSION: In patients with PAF and no structural heart disease referred for APVI, vagal AF is present in approximately one quarter. APVI is equally effective in patients with vagal AF as in adrenergic and random AF.