[Update atrial fibrillation: the 2020 ESC guidelines and recent data on early rhythm control]. / Update Vorhofflimmern: Die ESC-Leitlinien 2020 sowie aktuelle Daten zur frühen antiarrhythmischen Therapie.

Atrial fibrillation (AF) can be a significant burden for patients as well as the health care system. Every third 55-year-old will develop AF. Despite improvements of disease management, a significant risk for cardiovascular events remains. The current AF guidelines of the European Society of Cardiology focus on an integrative therapy approach. The new algorithm "CC to ABC" comprises recommendations for diagnosis ("confirm" and "characterise") and treatment ("avoid stroke", "better symptom control", "comorbidities") of AF. Direct oral anticoagulants administered according to the CHA2DS2-VASc score remain the corner stones of stroke prevention. Besides the concept of heart rate control, rhythm control therapy like antiarrhythmic drugs or catheter ablation is recommended to relieve symptoms and in certain patient groups for the improvement of prognosis. Therapy of comorbidities and reduction of risk factors like hypertension, diabetes mellitus, obesity and obstructive sleep apnoea should be part of any comprehensive treatment approach. The results of the randomized, prospective EAST-AFNET 4 trial were published in August 2020. The trial shows that an early rhythm control therapy can lead to a reduction of cardiovascular mortality and incidence of stroke additionally to guideline-based AF management. Given the safety profile and potential positive effects of antiarrhythmic drugs and catheter ablation, early initiation of rhythm control therapy should be considered in every patient during the first months after diagnosis of AF.

Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: Treatment Strategy, Characteristics of Consecutive Atrial Tachycardia and Long-Term Outcome.

Background Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and is associated with a deterioration of clinical status. Ablation of symptomatic AF is an established therapy, but in HCM, the characteristics of recurrent atrial arrhythmias and the long-term outcome are uncertain. Methods and Results Sixty-five patients with HCM (aged 64.5±9.9 years, 42 [64.6%] men) underwent AF ablation. The ablation strategy included pulmonary vein isolation in all patients and ablation of complex fractionated atrial electrograms or subsequent atrial tachycardias (AT) if appropriate. Paroxysmal, persistent AF, and a primary AT was present in 13 (20.0%), 51 (78.5%), and 1 (1.5%) patients, respectively. Twenty-five (38.4%) patients developed AT with a total number of 54 ATs. Stable AT was observed in 15 (23.1%) and unstable AT in 10 (15.3%) patients. The mechanism was characterized as a macroreentry in 37 (68.5%), as a localized reentry in 12 (22.2%), a focal mechanism in 1 (1.9%), and not classified in 4 (7.4%) ATs. After 1.9±1.2 ablation procedures and a follow-up of 48.1±32.5 months, freedom of AF/AT recurrences was demonstrated in 60.0% of patients. No recurrences occurred in 84.6% and 52.9% of patients with paroxysmal and persistent AF, respectively (P<0.01). Antiarrhythmic drug therapy was maintained in 24 (36.9%) patients. Conclusions AF ablation in patients with HCM is effective for long-term rhythm control, and especially patients with paroxysmal AF undergoing pulmonary vein isolation have a good clinical outcome. ATs after AF ablation are frequently observed in HCM. Freedom of atrial arrhythmia is achieved by persistent AF ablation in a reasonable number of patients even though the use of antiarrhythmic drug therapy remains high.

Outcome after tailored catheter ablation of atrial tachycardia using ultra-high-density mapping.

INTRODUCTION: Tailored catheter ablation of atrial tachycardias (ATs) is increasingly recommended as a potentially easy treatment strategy in the era of high-density mapping (HDM). As follow-up data are sparse, we here report outcomes after HDM-guided ablation of ATs in patients with prior catheter ablation or cardiac surgery. METHODS AND RESULTS: In 250 consecutive patients (age 66.5 ± 0.7 years, 58% male) with ATs (98% prior catheter ablation, 13% prior cardiac surgery) an HDM-guided catheter ablation was performed with the support of a 64-electrode mini-basket catheter. A total of 354 ATs (1.4 ± 0.1 ATs per patient; mean cycle length 304 ± 4.3 ms; 64% macroreentry, 27% localized reentry, and 9% focal) with acute termination of 95% were targeted in the index procedure. A similar AT as in the index procedure recurred in five patients (2%) after a median follow-up time of 535 days (interquartile range (IQR) 25th-75th percentile: 217-841). Tailored ablation of reentry ATs with freedom from any arrhythmia was obtained in 53% after a single procedure and in 73% after 1.4 ± 0.4 ablation procedures (range: 1-4). A total of 228 patients (91%) were free from any arrhythmia recurrence after 210 days (IQR: 152-494) when including optimal usual care. CONCLUSIONS: Tailored catheter ablation of ATs guided by HDM has a high acute success rate. The recurrence rate of the index AT is low. In patients with extensive atrial scaring further ablation procedures need to be considered to achieve freedom from any arrhythmia.