Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry.

BACKGROUND: Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking. OBJECTIVES: The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation. METHODS: Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated. RESULTS: Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days). CONCLUSIONS: This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery.

Programming of implantable cardioverter defibrillators for primary prevention: outcomes at centers with high vs. low concordance with guidelines.

BACKGROUND: While ICD therapy reduction programming strategies are recommended in current multi-society guidelines, concerns remain about a possible trade-off between the benefits of ICD therapy reduction and failure to treat episodes of ventricular arrhythmias. The study is to evaluate the outcomes of primary prevention patients followed in centers with high and low concordance with the 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement and 2019 focused update on optimal ICD programming and testing guidelines. METHODS: Consecutive patients with primary prevention ICD implantation from two centers between 2014 and 2016 were included. One center was classified as high guideline concordance center (HGC) with 47% (146/310) of patients with initial ICD concordant with the guidelines, and the other center was classified as low guideline concordance center (LGC) with only 1% (2/178) of patients with guideline-concordant initial ICD programming. Cox proportional hazard models were used to assess risk of first ICD therapy (ATP or shock), first ICD shock, and mortality. RESULTS: A total of 488 patients were included (mean age, 66 ± 13 years). During a mean follow-up of 1.9 ± 0.9 years, patients followed at HGC were 63% less likely to receive any ICD therapy (adjusted HR [aHR] 0.37, 95% CI 0.42-0.99). There were no significant differences in the rate of first ICD shock (aHR 0.72, 95% CI 0.34-1.52) or mortality (aHR 1.19, 95% CI, 0.47-3.05). CONCLUSIONS: Compared to primary prevention patients followed at LGC, primary prevention ICD patients followed at HGC received a significantly lower rate of ICD therapy, mainly from ATP reduction, without a difference in mortality during follow-up.

Independent predictors of in-hospital mortality and the need for intensive care in hospitalized non-critical COVID-19 patients: a prospective cohort study.

One of the most helpful strategies to deal with ongoing coronavirus pandemics is to use some prudence when treating patients infected with SARS-CoV-2. We aimed to evaluate the clinical, demographic, and laboratory parameters that might have predictive value for in-hospital mortality and the need for intensive care and build a model based on them. This study was a prospective, observational, single-center study including non-critical patients admitted to COVID-19 wards. Besides classical clinic-demographic features, basic laboratory parameters obtained on admission were tested, and then new models for each outcome were developed built on the most significant variables. Receiver operating characteristics (ROC) analyses were performed by calculating each model's probability. A total of 368 non-critical hospitalized patients were recruited, the need for ICU care was observed in 70 patients (19%). The total number of patients who died in either ICU or wards was 39 (10.6%). The first two models (based on clinical features and demographics) were developed to predict ICU and death, respectively; older age, male sex, active cancer, and low baseline saturation were noted to be independent predictors. The area under the curve values of the first two models were noted 0.878 and 0.882 (p < .001; confidence interval [CI] 95% [0.837-0.919], p < .001; CI 95% [0.844-0.922]). Following two models, the third and fourth were based on laboratory parameters with clinic-demographic features. Initial lower sodium and lower albumin levels were determined as independent factors in predicting the need for ICU care; higher blood urea nitrogen and lower albumin were independent factors in predicting in-hospital mortality. The area under the curve values of the third and fourth model was noted 0.938 and 0.929, respectively (p < .001; CI 95% [0.912-0.965], p < .001; CI 95% [0.895-962]). By integrating the widely available blood tests results with simple clinic demographic data, non-critical patients can be stratified according to their risk level. Such stratification is essential to filter the patients' non-critical underlying diseases and conditions that can obfuscate the physician's predictive capacity.

Lead damage after cardiac implantable device replacement procedure: Comparison between electrical plasma tool and electrocautery.

BACKGROUND: Lead damage is a complication caused by lead manipulation or heating damage from conventional electrocautery (EC) after cardiovascular implantable electronic device (CIED) replacement. Application of electrical plasma (PEAK PlasmaBlade) is a new technology that reportedly reduces this risk. OBJECTIVES: This study was designed to compare the effect of EC versus PEAK PlasmaBlade on lead parameters and complications after generator replacement procedures. METHODS: We retrospectively studied 410 consecutive patients (840 leads) who underwent CIED replacement using EC (EC group) and 410 consecutive patients (824 leads) using PEAK PlasmaBlade (PlamaBlade group). Pacing lead impedance, incidence of lead damage, and complications were compared between both groups. RESULTS: Lead impedance increased in 393 leads (46.8%) in the EC group versus 282 leads (34.2%) in the PlasmaBlade group (p < .01) with average percent changes of 6.7% and 4.0% (p < .01), respectively. Lead impedance decreased in 438 leads (52.1%) in the EC group versus 507 leads (61.5%) in the PlasmaBlade group (p < .01) with average percent changes of -5.7% and -7.1% (p < .01), respectively. Lead damage requiring lead revision occurred in five leads (0.6%) or after five procedures (1.2%) in the EC group compared to three leads (0.4%, p = .50) or after three procedures (0.7%, p = .48) in the PlasmaBlade group. There were no significant differences in the procedural-related complications between the EC group (nine patients, 2.2%) and the PlasmaBlade group (five patients, 1.2%, p = .28). CONCLUSION: Conventional electrocautery can potentially damage lead insulations. However, this study shows that when used carefully electrocautery is as safe as the PEAK PlasmaBlade™.

Sex-specific efficacy and safety of cryoballoon versus radiofrequency ablation for atrial fibrillation: An individual patient data meta-analysis.

BACKGROUND: Atrial fibrillation (AF) is a growing health burden, and pulmonary vein isolation (PVI) using cryoballoon (CB) or radiofrequency (RF) represents an attractive therapeutic option. Sex-specific differences in the epidemiology, pathophysiology, and clinical presentation of AF and PVI are recognized. OBJECTIVE: We aimed at comparing the efficacy, safety, and procedural characteristics of CB and RF in women and men undergoing a first PVI procedure. METHODS: We searched for randomized controlled trials and prospective observational studies comparing CB and RF ablation with at least 1 year of follow-up. After merging individual patient data from 18 data sets, we investigated the sex-specific (procedure failure defined as recurrence of atrial arrhythmia, reablation, and reinitiation of antiarrhythmic medication), safety (periprocedural complications), and procedural characteristics of CB vs RF using Kaplan-Meier and multilevel models. RESULTS: From the 18 studies, 4840 men and 1979 women were analyzed. An analysis stratified by sex correcting for several covariates showed a better efficacy of CB in men (hazard ratio for recurrence 0.88; 95% confidence interval 0.78-0.98, P = .02) but not in women (hazard ratio 0.98; 95% confidence interval 0.83-1.16; P = .82). For women and men, the energy source had no influence on the occurrence of at least 1 complication. For both sexes, the procedure time was significantly shorter with CB (-22.5 minutes for women and -27.1 minutes for men). CONCLUSION: CB is associated with less long-term failures in men. A better understanding of AF-causal sex-specific mechanisms and refinements in CB technologies could lead to higher success rates in women.

Cryoballoon antral pulmonary vein isolation vs contact force-sensing radiofrequency catheter ablation for pulmonary vein and posterior left atrial isolation in patients with persistent atrial fibrillation.

BACKGROUND: The role of cryoballoon ablation (CBA) for antral pulmonary vein isolation (APVI) has not been well established in persistent atrial fibrillation (PerAF). Isolation of the left atrial posterior wall (BOX) after APVI has been suggested to improve the efficacy of radiofrequency catheter ablation (RFA) in PerAF. OBJECTIVE: The purpose of this study was to compare characteristics and clinical outcomes of APVI by CBA vs APVI + BOX by contact force-guided RFA (CF-RFA) in patients with PerAF. METHODS: APVI was performed in 167 consecutive patients with PerAF (mean age 64 ± 9 years; left atrial diameter 46 ± 6 mm) using CBA (n = 90) or CF-RFA (n = 77). After APVI, a roofline was created in 33 of 90 patients (37%) in the CBA group and BOX was performed in all 77 patients in the CF-RFA group. RESULTS: During 21 ± 10 months of follow-up after a single ablation procedure, 37 of 90 patients (41%) in the CBA group (APVI) and 39 of 77 (51%) in the CF-RFA group (APVI + BOX) remained in sinus rhythm without antiarrhythmic drugs (AADs) (P = .22). During repeat ablation, APVI + BOX using CF-RFA was performed in 20 of 90 patients (22%) and in 18 of 77 patients (23%) who initially underwent CBA or CF-RFA, respectively. At 19 ± 10 months after repeat ablation, sinus rhythm was maintained in 55 of 90 patients (61%) and 52 of 77 patients (68%) in the CBA and CF-RFA groups without AADs, respectively (P = .39). CONCLUSION: In PerAF, an initial approach of APVI by CBA or APVI + BOX by CF-RFA has a similar efficacy of 40%-50% without AADs. After repeat ablation for APVI + BOX by CF-RFA in ∼25%, sinus rhythm is maintained in 60%-70% of patients without AADs.

Ablation of paroxysmal atrial fibrillation using a second-generation cryoballoon catheter or contact-force sensing radiofrequency ablation catheter: A comparison of costs and long-term clinical outcomes.

INTRODUCTION: Although noninferiority of cryoballoon ablation (CBA) and radiofrequency catheter ablation for antral pulmonary vein isolation (APVI) has been reported in patients with paroxysmal atrial fibrillation (PAF), it is not clear whether contact force sensing (CF-RFA) and CBA with the second-generation catheter have similar procedural costs and long-term outcomes. The objective of this study is to compare the long-term efficacy and cost implications of CBA and CF-RFA in patients with PAF. METHODS AND RESULTS: A first APVI was performed in 146 consecutive patients (age: 63 ± 10 years, men: 95 [65%], left atrial diameter: 42 ± 6 mm) with PAF using CBA (71) or CF-RFA (75). Clinical outcomes and procedural costs were compared. The mean procedure time was significantly shorter with CBA than with CF-RFA (98 ± 39 vs. 158 ± 47 minutes, P < 0.0001). Despite a higher equipment cost in the CBA than the CF-RFA group, the total procedure cost was similar between the two groups (P = 0.26), primarily driven by a shorter procedure duration that resulted in a lower anesthesia cost. At 25 ± 5 months after a single ablation procedure, 51 patients (72%) in the CBA, and 55 patients (73%) in the CF-RFA groups remained free from atrial arrhythmias without antiarrhythmic drug therapy (P = 0.84). CONCLUSIONS: The procedure duration was approximately 60 minutes shorter with CBA than CF-RFA. The procedural costs were similar with both approaches. At 2 years after a single procedure, CBA and CF-RFA have similar single-procedure efficacies of 72-73%.

Nerve conduction studies are safe in patients with central venous catheters.

INTRODUCTION: It is unknown if central venous catheters bypass the skin's electrical resistance and engender a risk of nerve conduction study-induced cardiac arrhythmia. The objective of this study is to determine if nerve conduction studies affect cardiac conduction and rhythm in patients with central venous catheters. METHODS: Under continuous 12-lead electrocardiogram monitoring, subjects with and without central venous catheters underwent a series of upper extremity nerve conduction studies. A cardiologist reviewed the electrocardiogram tracings for evidence of cardiac conduction abnormality or arrhythmia. RESULTS: Ten control subjects and 10 subjects with central venous catheters underwent the nerve conduction study protocol. No malignant arrhythmias or conduction abnormalities were noted in either group. CONCLUSIONS: Nerve conduction studies of the upper extremities, including both proximal stimulation and repetitive stimulation, do not appear to confer increased risk of cardiac conduction abnormality in those patients with central venous catheters who are not critically ill or have a prior history of arrhythmia. Muscle Nerve 56: 321-323, 2017.

Role of adenosine after antral pulmonary vein isolation of paroxysmal atrial fibrillation: A randomized controlled trial.

BACKGROUND: Adenosine can reveal dormant pulmonary vein (PV) conduction after PV isolation (PVI) in patients with paroxysmal atrial fibrillation (AF). However, the impact of elimination of adenosine-provoked dormant PV conduction after PVI has not been formally evaluated. OBJECTIVE: The purpose of this study was to determine whether ablation of PV reconnections unmasked by adenosine improves outcomes. METHODS: Patients with paroxysmal AF (n = 129) were randomized to receive either adenosine (n = 61) or no adenosine (n = 68) after PVI. Dormant conduction revealed by adenosine after PVI was ablated until all adenosine-mediated reconnections were eliminated. Thereafter, both groups received isoproterenol. RESULTS: Acute reconnection was seen in 23 patients (37%) in the adenosine group. There was a significant difference between the number of PVs reconnected if patients were given adenosine >60 minutes after initial PVI compared to those who received adenosine <60 minutes after initial PVI (3/32 [9.4%] vs 24/32 [75%], P <.0001). Patients who did not receive adenosine had more PV reconnections after isoproterenol infusion compared to patients in the adenosine group (17/68 [25.0%] vs 5/61 [8.2%], P = .018). There was no difference in the rate of AF recurrence in patients who received adenosine (24/61 [39%]) compared to control patients (23/68 [34%], log-rank P = .83). CONCLUSION: Adenosine can reveal dormant conduction in more than one-third of patients with paroxysmal AF undergoing PVI. However, adenosine administration, and additional ablation of the resultant connections, does not improve long-term outcomes compared to a protocol that includes isoproterenol infusion.

Interventional cardiology. Monitoring catheter ablation of AF--the European perspective.

Data from a prospective, European registry of patients undergoing catheter ablation of atrial fibrillation have now been published. The 1-year outcomes of this large, multinational study highlight variation in the concomitant use of antiarrhythmic drugs, and the need for rigorous clinical follow-up after ablation, with extended electrocardiographic monitoring.

Effects of sex on the incidence of cardiac tamponade after catheter ablation of atrial fibrillation: results from a worldwide survey in 34 943 atrial fibrillation ablation procedures.

BACKGROUND: Cardiac tamponade is the most dramatic complication observed during atrial fibrillation (AF) ablation and the leading cause of procedure-related mortality. Female sex is a known risk factor for complications during AF ablation; however, it is unknown whether women have a higher risk of tamponade. METHODS AND RESULTS: A systematic Medline search was used to locate academic electrophysiological centers that reported cases of tamponade occurring during AF ablation. Centers were asked to provide information on cases of acute tamponade according to sex and their mode of management including any case of related mortality. Nineteen electrophysiological centers provided information on 34 943 ablation procedures involving 25 261 (72%) men. Overall, 289 (0.9%) cases of tamponade were reported: 120 (1.24%) in women and 169 (0.67%) in men (odds ratio, 1.83; P<0.001). There was a reciprocal association between center volume and the occurrence of tamponade with substantially lower risk in high-volume centers. Most cases of tamponade occurred during catheter manipulation or ablation; women tended to develop more tamponades during transseptal catheterization. No sex difference in the mode of management was observed. However, 16% cases of tamponade required surgery with lower rates in high-volume centers. Three cases of tamponade (1%) culminated in death. CONCLUSIONS: Tamponade during AF ablation procedures is relatively rare. Women have an ≈2-fold higher risk for developing this complication. The risk of tamponade among women decreases substantially in high-volume centers. Surgical backup and acute management skills for treating tamponade are important in centers performing AF ablation.

Effect of radiation therapy on permanent pacemaker and implantable cardioverter-defibrillator function.

BACKGROUND: Radiation therapy's (RT's) effects on cardiac implantable electronic devices (CIEDs) such as implantable cardioverter-defibrillators (ICDs) and pacemakers (PMs) are not well established, leading to device removal or relocation in preparation for RT. OBJECTIVE: To determine the effect of scattered RT on CIED performance. METHODS: We analyzed 69 patients--50 (72%) with PMs and 19 (28%) with ICDs--receiving RT at the University of Michigan. Collected data included device model, anatomic location, and treatment beam energies, treatment type, and estimated dose to the device. Patients were treated with either high-energy (16-MV) and/or low-energy (6 MV) photon beams with or without electron beams (6-16 MeV). The devices were interrogated with pre- and post-RT and/or weekly with either in-treatment or home interrogation, depending on the patient's dependence on the device and the estimated or measured delivered dose. Outcomes analyzed were inappropriate ICD therapies, device malfunctions, or device-related clinical events. RESULTS: The PMs were exposed to 84.4 ± 99.7 cGy of radiation, and the ICDs were exposed to 92.1 ± 72.6 cGy of radiation. Two patients with ICDs experienced a partial reset of the ICD with the loss of historic diagnostic data after receiving 123 and 4 cGy, respectively. No device malfunction or premature battery depletion was observed at 6-month follow-up from RT completion. CONCLUSIONS: CIED malfunction due to indirect RT exposure is uncommon. Regular in-treatment or home interrogation should be done to detect and treat these events and to ensure that diagnostic data are preserved.

Impact of preprocedural imaging on outcomes of catheter ablation in patients with atrial fibrillation.

PURPOSE: This study aims to determine the impact of preprocedural imaging using computerized tomography (CT) or magnetic resonance imaging (MRI) with 3-D reconstruction on procedural efficiency, efficacy, complications and clinical outcome in patients who undergo radiofrequency catheter ablation (RFA) to eliminate atrial fibrillation (AF). METHODS: In this registry, a CT (n = 161) or MRI (n = 37) was obtained prior to RFA in 198 of 333 consecutive patients (age 61 ± 10 years) with paroxysmal (172) or persistent (161) AF. Antral pulmonary vein isolation was performed in all patients using an open-irrigation-tip catheter with a 3-D electroanatomical navigation system. Procedural and clinical outcomes were compared among patients who underwent RFA with and without preprocedural imaging. RESULTS: The mean duration of the procedure (246 ± 47 vs. 242 ± 40 min, P = 0.55), fluoroscopy (47 ± 13 vs. 50 ± 10 min, P = 0.16), and total RF application (83 ± 27 vs. 78 ± 23 min, P = 0.17) were similar among patients who did and did not have preprocedural imaging. The likelihood of a complication also was similar (5/198 [3%] vs. 4/135 [3%], P = 1.0). A repeat ablation was performed in 95/198 (48%) and 61/135 (45%) of the patients who did and did not have imaging study, respectively (P = 0.62). At 22 ± 9 months, after a mean of 2 ± 1 procedures, 140/198 (71%) and 101/135 (75%) of the patients who did and did not have preprocedural imaging were in sinus rhythm (P = 0.4). CONCLUSIONS: Preprocedural awareness of pulmonary venous and left atrial anatomy does not appear to have an effect on procedural efficiency or clinical outcomes in patients who undergo catheter ablation for AF.

Left atrial volume and dominant frequency of atrial fibrillation in patients undergoing catheter ablation of persistent atrial fibrillation.

BACKGROUND: Prior studies have suggested that left atrial (LA) volume and frequency of atrial fibrillation (AF) are associated with suboptimal outcomes in patients undergoing catheter ablation of AF. However, the interaction of these factors and their relative impact on outcome are not clear. METHODS: Seventy-nine consecutive patients underwent catheter ablation of persistent AF. LA volume was determined by echocardiography. Electrograms from the LA appendage (LAA), coronary sinus (CS), and lead V(1) were obtained before ablation, and the dominant frequency (DF) was determined by fast Fourier transformation. The ablation strategy consisted of pulmonary vein isolation, electrogram-guided, and linear ablation. RESULTS: The mean LA volume indexed, LA voltage, and DF in the LAA were 48 ± 16 mL/m(2), 0.58 ± 0.20 mV, and 6.3 ± 0.8 Hz, respectively. There was a significant inverse correlation between LA volume and DF in the CS (P < 0.0001, R = -0.51). The mean LA amplitude also correlated with DF in the LAA (P = 0.0008, R = 0.37). In 38 patients (48%), AF terminated during catheter ablation. Sixty-six of the 79 patients (84%) are arrhythmia-free without antiarrhythmic drugs at a mean follow-up of 14 ± 7 months after the last procedure. Advancing age was associated with recurrence (odds ratio (OR), 1.2; 95% confidence interval (CI), 1.02 to 1.42; P = 0.02), and duration of radiofrequency energy delivery was associated with a favorable outcome (OR, 0.93; 95% CI, 0.86 to 0.99; P = 0.04). CONCLUSION: Atrial enlargement is associated with a lower AF frequency. Age and RF duration seem to be better predictors of outcome than LA volume or AF frequency.

Predictors of successful catheter ablation of ventricular arrhythmias arising from the papillary muscles.

BACKGROUND: Ablation of arrhythmias arising from the papillary muscles (PAPs) is challenging. OBJECTIVE: The purpose of this study was to assess the predictors of successful catheter ablation in patients with ventricular arrhythmias arising from the PAPs. METHODS: Forty consecutive patients (15 women, mean age 51 ± 14 years, left ventricular ejection fraction 0.46 ± 0.13) with refractory PAP arrhythmias underwent mapping and ablation. Catheter stability was assessed with intracardiac echocardiography. Activation mapping and/or pace mapping were performed to identify the site of origin. Electrophysiological data and anatomic characteristics were assessed in patients with effective versus ineffective ablation. Catheter stability was assessed with intracardiac echocardiography. RESULTS: Radiofrequency ablation was acutely effective in eliminating the targeted arrhythmia in 31 patients (78%). The presence of Purkinje potentials at the site of origin of the targeted arrhythmia was associated with an effective outcome (48% vs. 0%; P = .01). The mass of the arrhythmogenic PAPs in the left ventricle was significantly larger in patients with failed versus effective ablation (4.7 ± 2.2 g vs. 2.3 ± 0.6 g; P < .0001). Also, the presence of a matching pace map at the earliest endocardial activation time was associated with an effective procedure (71% vs. 22%; P = .02) CONCLUSION: The presence of Purkinje potentials at the site of origin and a smaller size of the PAP are associated with successful ablation of PAP arrhythmias.

Prevalence of fever in patients undergoing left atrial ablation of atrial fibrillation guided by barium esophagraphy.

BACKGROUND: Real-time esophageal imaging is critical in avoiding esophageal injury. However, the safety of esophageal imaging with barium has not been specifically explored. METHODS: Three hundred seventy consecutive patients underwent left atrial (LA) ablation of atrial fibrillation (AF) under conscious sedation. One hundred eighty-five patients (50%) underwent the ablation procedure with, and 185 patients (50%) underwent the procedure without administration of barium. Fever, as a surrogate for aspiration, was defined as a maximal temperature >or=100 degrees F within the first 24 hours following the ablation procedure. RESULTS: Thirty of the 370 patients (8%) developed fever within 24 hours after LA ablation. The prevalence of fever was 9% (17/185) among patients who received barium and 7% (13/185) among those who did not receive barium (P = 0.6). Evaluation revealed the following causes of fever in 14 of the 30 patients (47%) with no difference in prevalence between the 2 groups: pericarditis, venous thromboembolism, hematoma, and infiltrate on chest radiography. Multivariate analysis failed to reveal any factors associated with development of fever. None of the patients experienced serious complications such as respiratory failure or atrioesophageal fistula. CONCLUSIONS: Fever may occur in approximately 10% of patients undergoing LA ablation of AF. Administration of barium is not associated with fever or other complications such as aspiration pneumonia. Real-time imaging of the esophagus with barium administration in conjunction with conscious sedation appears to be safe.

A randomized assessment of the incremental role of ablation of complex fractionated atrial electrograms after antral pulmonary vein isolation for long-lasting persistent atrial fibrillation.

OBJECTIVES: This study sought to determine whether ablation of complex fractionated atrial electrograms (CFAEs) after antral pulmonary vein isolation (APVI) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation (AF). BACKGROUND: Ablation of CFAEs has been reported to eliminate persistent AF. However, residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence. METHODS: In this randomized study, 119 consecutive patients (mean age 60 +/- 9 years) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter. Antral pulmonary vein isolation resulted in termination of AF in 19 of 119 patients (Group A, 16%). The remaining 100 patients who still were in AF were randomized to no further ablation and underwent cardioversion (Group B, n = 50) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration (Group C, n = 50). RESULTS: Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients (18%) in Group C. At 10 +/- 3 months after a single ablation procedure, 18 of 50 (36%) in Group B and 17 of 50 (34%) in Group C were in sinus rhythm without antiarrhythmic drugs (p = 0.84). In Group A, 15 of 19 patients (79%) were in sinus rhythm. A repeat ablation procedure was performed in 34 of 100 randomized patients (for AF in 30 and atrial flutter in 4). At 9 +/- 4 months after the final procedure, 34 of 50 (68%) in Group B and 30 of 50 (60%) in Group C were in sinus rhythm without antiarrhythmic drugs (p = 0.40). CONCLUSIONS: Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF.