Safety profile of near-zero fluoroscopy atrial fibrillation ablation with non-fluoroscopic catheter visualization: experience from 1000 consecutive procedures.

Aims: Efforts to reduce radiation exposure during catheter ablation procedures have included the use of various technological measures. Significant results have been achieved to the point where near lead-free procedures in routine clinical practice has become a realistic goal. The integration of MediGuide technology [non-fluoroscopic catheter visualization technology (NFCV)] and three-dimensional electroanatomical mapping is one of the methods developed in response to radiation reduction initiatives. We aimed to evaluate the impact of this NFCV technology on atrial fibrillation (AF) catheter ablation in terms of reduction in procedural and radiation time as well as safety aspects. Methods and results: Between March 2012 and March 2017, a total of 1000 patients underwent AF ablation using NFCV. Patient and procedural data and complications within the first 3 months were entered into a prospective registry and analysed. We assessed procedure time, fluoroscopy time, and dose and complications. In a cohort of 1000 patients (62.9 ± 11 years; 72% men; left ventricular ejection fraction 57%; and left atrial diameter 43.2 mm), the median procedure time was 120 min, median fluoroscopy time was 0.90 min, and the median fluoroscopy dose of was 345.1 cGy · cm2. Stratification of the first (Group 1) and the last 250 (Group 2) cases showed significant improvement in the median procedure time (140-110 min) and reduction in the median fluoroscopy time (6-0.5 min) and the median dose (2263-151.9 cGy · cm2). The overall complication rate was 2.0%. Conclusion: The use of NFCV technology enables safe, consistent, and 'near lead-free' performance of AF ablation in routine clinical practice.

Individually tailored vs. standardized substrate modification during radiofrequency catheter ablation for atrial fibrillation: a randomized study.

Aims: This randomized single-centre study sought to compare the efficacy and safety of pulmonary vein isolation (PVI) plus voltage-guided ablation vs. PVI with or without linear ablation depending on the type of atrial fibrillation (AF). Methods and results: Overall, 124 ablation-naive patients with paroxysmal or persistent AF were randomized to PVI with (persistent AF) or without (paroxysmal AF) additional linear ablation (control group) vs. PVI plus ablation of low-voltage areas (LVAs) irrespective of AF type. Bipolar voltage mapping was performed during stable sinus rhythm. An LVA consisted of ≥ 3 adjacent mapping points that each had a peak-to-peak amplitude ≤0.5 mV. After a mean follow-up of 12 ± 3 months, significantly more patients in the LVA ablation group were free from atrial arrhythmia recurrence >30 s off antiarrhythmic drugs (AADs) after a single procedure (primary endpoint) compared with control group patients [40/59 (68%) vs. 25/59 (42%), log-rank P = 0.003]. Arrhythmia-free survival on or off AADs was found in 33/59 control group patients (56%) and in 41/59 LVA ablation group patients (70%) (adjusted log-rank P = 0.10). During the 7 day Holter monitoring period at 12 months, significantly more patients in the LVA ablation group were free from arrhythmia recurrence on or off AADs [45/50 (90%) vs. 33/46 (72%), P = 0.04]. No between-group differences were observed regarding procedure duration, fluoroscopy time, and major complications. Conclusion: In this single-centre study, individually tailored substrate modification guided by voltage mapping was associated with a significantly higher arrhythmia-free survival rate compared with a conventional approach applying linear ablation according to AF type.

Asymmetrical left atrial remodelling in atrial fibrillation: relation with diastolic dysfunction and long-term ablation outcomes.

AIMS: The association between anatomical left atrial (LA) remodelling and ventricular diastolic dysfunction (DD) in atrial fibrillation (AF) patients is not well studied. We aimed to examine the effect of DD on anatomic LA remodelling and their relation with ablation outcomes. METHODS AND RESULTS: In 104 patients (58 ± 10 years, 69% male) referred for AF ablation, LA volume (LAV) was determined by computed tomography. A cutting plane, between the pulmonary vein (PV) ostia and the appendage and parallel to the posterior wall, divided LAV into anterior- (LA-A) and posterior-LA parts. The ratio of LA-A and LAV was defined as the LA asymmetry index (ASI). According to the current guidelines, the presence of DD was evaluated by echocardiography. Regression analysis was used to identify predictors of asymmetry changes and long-term success. Univariate linear regression revealed that ASI is associated with LAV, the presence of DD, and mitral regurgitation. Asymmetry index was higher in patients with DD (n = 35, 62 ± 5 vs. 59 ± 6%, P = 0.013) or mitral regurgitation (n = 67, 61 ± 6 vs. 58 ± 5%, P = 0.025). Multiple linear regression analysis showed that DD (B = 2.6, ß = 0.207, 95% confidence interval, CI: 0.167-5.011, P = 0.036) and LAV (B = 0.037, ß = 0.211, 95% CI: 0.003-0.071, P = 0.033) were the only factors independently associated with ASI (adjusted r2 = 0.92, F = 6.2, P = 0.003). Regression analysis showed that AF recurrence (33% after 24 months) is associated with asymmetric LA changes, while DD is not. CONCLUSIONS: Left atrial symmetry changes are associated with DD and dilatation. Since DD could cause LA remodelling, appropriate early treatment should be considered for AF patients with DD, before geometrical changes occur.

Mapping-guided characterization of mechanical and electrical activation patterns in patients with normal systolic function using a sensor-based tracking technology.

AIMS: In times of evolving cardiac resynchronization therapy, intra-procedural characterization of left ventricular (LV) mechanical activation patterns is desired but technically challenging with currently available technologies. In patients with normal systolic function, we evaluated the feasibility of characterizing LV wall motion using a novel sensor-based, real-time tracking technology. METHODS AND RESULTS: Ten patients underwent simultaneous motion and electrical mapping of the LV endocardium during sinus rhythm using electroanatomical mapping and navigational systems (EnSite™ NavX™ and MediGuide™, SJM). Epicardial motion data were also collected simultaneously at corresponding locations from accessible coronary sinus branches. Displacements at each mapping point and times of electrical and mechanical activation were combined over each of the six standard LV wall segments. Mechanical activation timing was compared with that from electrical activation and preoperative 2D speckle tracking echocardiography (echo). MediGuide-based displacement data were further analysed to estimate LV chamber volumes that were compared with echo and magnetic resonance imaging (MRI). The lateral and septal walls exhibited the largest (12.5 [11.6-15.0] mm) and smallest (10.2 [9.0-11.3] mm) displacement, respectively. Radial displacement was significantly larger endocardially than epicardially (endo: 6.7 [5.0-9.1] mm; epi: 3.8 [2.4-5.6] mm), while longitudinal displacement was significantly larger epicardially (endo: 8.0 [5.0-10.6] mm; epi: 10.3 [7.4-13.8] mm). Most often, the anteroseptal/anterior and lateral walls showed the earliest and latest mechanical activations, respectively. 9/10 patients had concordant or adjacent wall segments of latest mechanical and electrical activation, and 6/10 patients had concordant or adjacent wall segments of latest mechanical activation as measured by MediGuide and echo. MediGuide's LV chamber volumes were significantly correlated with MRI (R2= 0.73, P < 0.01) and echo (R2= 0.75, P < 0.001). CONCLUSION: The feasibility of mapping-guided intra-procedural characterization of LV wall motion was established. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov; Unique identifier: CT01629160.

Successful Repeat Catheter Ablation of Recurrent Longstanding Persistent Atrial Fibrillation With Rotor Elimination as the Procedural Endpoint: A Case Series.

BACKGROUND: There remains a lack of consensus regarding the ideal ablation strategy for atrial fibrillation (AF), particularly in patients with persistent or longstanding persistent AF. Given increasing evidence from clinical imaging studies that rotors sustain AF, rotor elimination may be a desirable procedural endpoint. However, there is no description to date of the clinical outcomes using rotor elimination during ablation as the procedural endpoint. Moreover, a series of studies question whether procedural AF termination is a desirable endpoint for ablation after many forms of AF ablation. METHODS AND RESULTS: We report a single-center experience of rotor elimination during AF ablation using Focal Impulse and Rotor Mapping (FIRM), describing 20 consecutive patients with case descriptions of 3 patients with recurrent longstanding persistent AF after prior ablation. In all cases, endocardial mapping using a 64-electrode basket catheter was performed to identify rotors, which were eliminated using radiofrequency catheter ablation. After it was verified that all identified rotors were eliminated, standard ablation consisting of PV isolation was performed. Notably, persistent AF terminated in only 1/20 (5%) patients. However, after a follow-up of 6 months, single-procedure freedom from AF was 80% (16/20 patients) with only 1 patient on antiarrhythmic drugs. All three patients in the highlighted series are AF free despite the lack of acute procedural AF termination. CONCLUSIONS: Patients with persistent AF including those with unsuccessful prior ablation can be treated successfully by rotor targeted ablation, using the elimination of all rotors rather than acute AF termination as the procedural endpoint.

Differences in predictors of implantable cardioverter-defibrillator therapies in patients with ischaemic and non-ischaemic cardiomyopathies.

AIMS: Implantable cardioverter-defibrillators (ICDs) have been shown to reduce mortality in patients with both ischaemic and non-ischaemic cardiomyopathy by terminating life-threatening arrhythmias. However, such arrhythmic events are unequally distributed among different patient subgroups. We aimed to evaluate predictors of appropriate ICD therapies as a step towards risk stratification in a real-world cohort. METHODS AND RESULTS: The prevalence and predictors of appropriate ICD therapies were analysed in 330 consecutive patients (mean age 65 ± 11, 81% male) with implanted ICDs due to ischaemic (n = 204) or dilated (n = 126) cardiomyopathy. During a mean follow-up of 19 ± 9 months, 1545 appropriate ICD therapies (antitachycardia pacing and shocks) were detected in 94 patients (29%). In multivariate analysis applied on the whole cohort, the presence of atrial fibrillation [AF: odds ratio (OR) = 1.906, confidence interval (CI) = 1.143-3.177, P = 0.013] and secondary prevention indication (OR = 1.963, CI = 1.123-3.432, P = 0.018) was associated with ICD therapy. The presence of cardiac resynchronization therapy (CRT) had a protective value (OR = 0.563, CI = 0.327-0.968, P = 0.038). Moreover, the predictors were different depending on the aetiology of the cardiomyopathy: in the ischaemic group, only secondary prevention indication (OR = 2.0, CI = 1.029-3.891, P = 0.041) and the presence of a biventricular system (OR = 0.359, CI = 0.163-0.794, P = 0.011) remained significant, while in the non-ischaemic group, an association with AF was observed (OR = 4.281, CI = 1.632-11.231, P = 0.003). CONCLUSION: The aetiology of cardiomyopathy should be taken into consideration for the therapy of ICD patients. The protective role of CRT devices should be pointed out in ischaemic cardiomyopathy (ICM) and a more rigorous antiarrhythmic treatment should be considered for ICM patients with secondary prevention or for dilated cardiomyopathy patients with AF.

Outcomes in catheter ablation of ventricular tachycardia in dilated nonischemic cardiomyopathy compared with ischemic cardiomyopathy: results from the Prospective Heart Centre of Leipzig VT (HELP-VT) Study.

BACKGROUND: Data on the outcomes of ventricular tachycardia (VT) ablation in nonischemic dilated cardiomyopathy (NIDCM) are insufficient. The Heart Center of Leipzig VT (HELP-VT) study was conducted prospectively to compare outcomes after radiofrequency catheter ablation of VT in patients with NIDCM compared with ischemic cardiomyopathy (ICM). METHODS AND RESULTS: Two hundred twenty-seven patients, 63 with NIDCM and 164 with ICM, presenting with sustained VT were ablated with radiofrequency catheter ablation. Noninducibility of any clinical and nonclinical VT was achieved in 66.7% of NIDCM and in 77.4% of ICM patients. Ablation of the clinical VT only was achieved in 18.3% of ICM and in 22.2% of NIDCM patients. There was no statistically significant difference in short-term outcomes between the 2 groups. At the 1-year follow-up, VT-free survival in NIDCM was 40.5% compared with 57% in ICM. In univariate analysis, the hazard ratio for VT recurrence was significantly higher for NIDCM (1.62; 95% confidence interval, 1.12- 2.34; P=0.01). In both the ICM and NIDCM subgroups, procedure failure and incomplete procedural success were independent predictors of VT recurrence. CONCLUSIONS: Although the short-term success rates after VT ablation in NIDCM and ICM patients were similar, the long-term outcomes in NIDCM patients were significantly worse. Complete VT noninducibility at the end of the ablation is associated with beneficial long-term outcome in NIDCM. Pursuing compete elimination of all inducible VTs is desirable and may improve the long-term success in NIDCM.

Sensor-based electromagnetic navigation to facilitate implantation of left ventricular leads in cardiac resynchronization therapy.

INTRODUCTION: Implantation of cardiac resynchronization therapy (CRT) devices can be challenging, time consuming, and fluoroscopy intense. To facilitate placement of left ventricular (LV) leads, a novel electromagnetic navigation system (MediGuide™, St. Jude Medical, St. Paul, MN, USA) has been developed, displaying real-time 3-D location of sensor-embedded delivery tools superimposed on prerecorded X-ray cine-loops of coronary sinus venograms. We report our experience and advanced progress in the use of this new electromagnetic tracking system to guide LV lead implantation. METHODS AND RESULTS: Between January 2012 and December 2013, 71 consecutive patients (69 ± 9 years, 76% male) were implanted with a CRT device using the new electromagnetic tracking system. Demographics, procedural data, and periprocedural adverse events were gathered. The impact of the operator's experience, optimized workflow, and improved software technology on procedural data were analyzed. LV lead implantation was successfully achieved in all patients without severe adverse events. Total procedure time measured 87 ± 37 minutes and the median total fluoroscopy time (skin-to-skin) was 4.9 (2.5-7.8) minutes with a median dose-area-product of 476 (260-1056) cGy*cm(2) . An additional comparison with conventional CRT device implantations showed a significant reduction in fluoroscopy time from 8.0 (5.8; 11.5) to 4.5 (2.8; 7.3) minutes (P = 0.016) and radiation dose from 603 (330; 969) to 338 (176; 680) cGy*cm(2) , respectively (P = 0.044 ). CONCLUSION: Use of the new navigation system enables safe and successful LV lead placement with improved orientation and significantly reduced radiation exposure during CRT implantation.

Cardiogenic Stroke Despite Low CHA2 DS2 -VASc Score: Assessing Stroke risk by Left Atrial Appendage Anatomy (ASK LAA).

INTRODUCTION: In patients with atrial fibrillation (AF), LAA morphology has been suggested to modify thromboembolic event (TE) risk. We tested the hypothesis that TE in low-risk patients is associated with LAA characteristics. METHODS: Of 2,069 patients who underwent AF ablation, 25 (1.2%) had a prior TE and a low CHA2 DS2 -VASc score (≤1). Those patients were matched for the CHA2 DS2 -VASc criteria with 75 event-free patients and CT data were compared. LAA measurements, morphology (Cactus, Chicken-Wing, Windsock, Cauliflower), and takeoff of the superior and inferior edge in relation (higher or lower) to the respective takeoff of the adjacent pulmonary vein (PV) were determined. LAA flow in relation to heart rate was also compared. RESULTS: Univariate analysis showed that TE patients had a higher incidence of superior LAA takeoff (i.e., higher than the left superior PV; 28% vs. 4%, P = 0.002) and a higher incidence of hyperlipidemia (40% vs. 17%, P = 0.028), while LAA morphologies, inferior takeoff, and other LAA characteristics were similar between groups. Logistic regression revealed that a superior LAA takeoff (OR: 9.1, 95% CI: 2.1-38.6, P = 0.003) was the only independent predictor of TE. There was a negative correlation between heart rate and LAA flow (r = -0.2 cm/s pro bpm, P = 0.048), that was even more pronounced for the superior LAA takeoff (r = -0.67 cm/s pro bpm, P = 0.035). CONCLUSION: A higher LAA takeoff is associated with a tachycardia-mediated thrombogenic flow and an increased thromboembolic risk. These findings may have implications for anticoagulation management of AF patients with low CHA2 DS2 -VASc scores and higher LAA takeoff.

Procedural Outcomes and Survival After Catheter Ablation of Ventricular Tachycardia in Relation to Electroanatomical Substrate in Patients With Nonischemic-Dilated Cardiomyopathy: The Role of Unipolar Voltage Mapping.

INTRODUCTION: In patients with ischemic cardiomyopathy the size of bipolar low-voltage areas (LVA) in electroanatomical maps (EAM) was associated with poorer outcomes after catheter ablation (CA) of ventricular tachycardia (VT). However, the effect of LVA size on the survival after VT ablation in patients with nonischemic dilated cardiomyopathy (NIDCM) has not been studied. METHODS AND RESULTS: In 55 patients with NIDCM (48 male, age 61 ± 16 years, ejection fraction 32 ± 13%) an EAM to delineate the bipolar and unipolar LVAs was performed in 52 (94.5%) patients endocardially, in 24 (43.6%) patients epicardially, and in 21 (38.2%) patients on both surfaces. Additionally, activation mapping of the VT was possible in 22 (40%) patients. CA with lines transecting the scar and targeting late potentials was performed in all patients. Complete VT noninducibility at the end was achieved in 40 (72.7%) patients. During the median follow-up of 22 (interquartile range IQR 6, 34) months, VT recurrences were observed in 30 (54.5%) and cardiac death in 14 (25.5%) patients. The ROC analysis revealed that the size of endocardial unipolar LVA (<8.3 mV) was associated with cardiac death (AUC 0.89, 95% CI 0.79-0.98, P <0.0001). UVA = 145 cm2 discriminates for cardiac death with 83% sensitivity and 78% specificity. Endocardial UVA > 145 cm2 was a predictor for cardiac death (adjusted HR = 6.9; P = 0.014) and UVA ≥ 54% (of total endocardial LV surface) for VT recurrence (adjusted HR = 3.5; P = 0.016). CONCLUSION: The size of endocardial unipolar LVA (<8.3 mV) was a strong and independent predictor for cardiac mortality and VT recurrence in patients with NIDCM.

Efficacy and safety of remote magnetic catheter navigation vs. manual steerable sheath-guided ablation for catheter ablation of atrial fibrillation: a case-control study.

AIMS: Data comparing remote magnetic catheter navigation (RMN) to manual catheter navigation (MCN) using steerable sheath for ablation of atrial fibrillation (AF) is lacking. The aim of the present case-control study was to seek AF recurrence data after AF ablation using RMN in comparison to MCN using steerable sheath in patients with either paroxysmal or persistent AF. METHODS AND RESULTS: This study comprised 140 patients with AF (50% paroxysmal). Seventy were ablated utilizing RMN and 70 with MCN. Primary endpoint was defined as the time to first recurrence after index procedure. After 28.8 ± 18.9 months of follow-up, more patients in the MCN group using steerable sheath remained free of recurrence compared with RMN group [(59.1 vs. 40%, respectively, P = 0.031), in patients with persistent AF P = 0.057, while in patients with paroxysmal AF, P = 0.18]. Index procedure time (223.6 ± 44.2 vs. 170.8 ± 51.8 min, P < 0.001) and radiofrequency application time (75.4 ± 20.9 vs. 56.6 ± 24.9 min, P < 0.001) were longer in the RMN group; however, the respective total fluoroscopy time (13.7 ± 7.8 vs. 36.6 ± 12.7 min, P < 0.001) was significantly shorter. In multivariable Cox-regression analysis, RMN was the only factor independently associated with shorter time to first recurrence during follow-up (P = 0.048). Complication rate did not differ significantly between groups (P = 0.056), although the incidence of significant pericardial effusion was higher in the MCN group (3 cases vs. 0 in RMN group). CONCLUSION: Although in patients with persistent AF, the recurrence rate is higher in RMN group, the outcome is comparable between RMN and MCN groups in patients with paroxysmal AF. A multicentre prospective randomized study is warranted to clarify this issue.

Ablation of typical atrial flutter using a non-fluoroscopic catheter tracking system vs. conventional fluoroscopy--results from a prospective randomized study.

AIMS: Reduction of radiation exposure using a sensor-based non-fluoroscopic catheter tracking (NFCT) system (MediGuide™, St Jude Medical, Inc.) was recently demonstrated by retrospective comparisons. We aimed to prospectively compare the effects of using NFCT vs. standard fluoroscopy on procedural parameters in patients undergoing radiofrequency ablation of typical atrial flutter. METHODS AND RESULTS: We prospectively randomized 40 patients undergoing cavotricuspid isthmus ablation for typical atrial flutter to either NFCT (n = 20) or conventional fluoroscopy (CONV, n = 20). Procedural parameters such as fluoroscopy time, radiation dose, and procedure duration, as well as periprocedural complications were compared. There were no statistically significant differences in baseline characteristics between the two groups. Bidirectional isthmus block was achieved in all patients. Fluoroscopy time was significantly reduced in the NFCT group {0.3 [inter-quartile range (IQR) 0.2; 0.48] min} when compared with CONV [5.7 (IQR 4.2; 11.5) min] (P < 0.001). This resulted in a significant reduction in radiation dose in patients randomized to NFCT [17.4 (IQR 11; 206.6) cGy cm(2)] vs. the CONV group [418.4 (IQR 277; 812.2) cGy cm(2)] (P < 0.001). There were no significant differences in procedure duration between the NFCT group [49.5 (IQR 37; 65) min] when compared with the CONV group [33.5 (IQR 26.3; 55.5) min] (P = 0.053). No adverse events were recorded. Freedom from atrial flutter at 6 months of follow-up was 19/20 (95%) in the NFCT and 18/20 (90%) in the CONV group (n.s.). CONCLUSION: In this first prospective randomized study, by comparing NFCT with standard fluoroscopy in patients undergoing radiofrequency ablation of typical atrial flutter, NFCT significantly reduced both radiation dose and fluoroscopy time with no effects on procedural duration. These findings support the incorporation of NFCT in routine clinical use.

Patient discomfort following catheter ablation and rhythm device surgery.

AIMS: Proper management of post-interventional pain relieves unwarranted patient distress and enhances patient satisfaction. There have been only a limited number of investigations into patient discomfort following electrophysiological interventions. This study aims to quantify pain after interventional procedures, including ablation of atrial fibrillation (AF) or ventricular tachycardia (VT), as well as implant or explant of pacemakers or implantable cardioverter defibrillators. METHODS AND RESULTS: One-hundred and two consecutive patients (mean age 66 years, 70 men) were asked to quantify post-interventional pain on a numeric rating scale (NRS 0-10) every 2 h during a period of 24 h after their intervention (49 ablations in deep propofol sedation, 53 device surgeries in local anaesthesia with mepivacaine 1%) and to specify the type of pain. Pain was classified as moderate to severe in case of NRS > 3. Post-operative pain medication included non-opioid and opioid analgesics as per the treating physicians' discretion. Sixty-one patients (60%) suffered from moderate-to-severe pain within the first 24 h after the procedure, despite the use of analgesics in 47 patients (46%). Pain was present in an early period (0-6 h) in 54% and in a late period (8-24 h) in 40% of patients. Patients complained of back pain (44%), pain at the site of the device pocket (39%), pain at the groin after puncture (7%), and pericarditic pain (5%). Multivariate analysis identified female gender (P = 0.046) associated with early post-interventional pain while age, diabetes mellitus, body mass index, type of intervention, and procedure time were not related to early or late post-interventional pain. CONCLUSION: The findings highlight the high prevalence and the poor predictability of moderate-to-severe post-interventional pain within the first 24 h after catheter ablation and cardiac device surgery procedures, despite the use of peri-interventional analgesics. These findings highlight the need for more careful pain assessment and management programmes.

Precordial QRS amplitude ratio predicts long-term outcome after catheter ablation of electrical storm due to ventricular tachycardias in patients with arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Radiofrequency catheter ablation is currently considered as the therapeutic option of choice in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) and recurrent ventricular tachycardia (VT). METHODS: This study intended to assess the long-term outcome of catheter ablation in patients with ARVC and electrical storm. The specific objective was to assess the relationship between precordial QRS amplitude ratio and outcome of catheter ablation in these patients. RESULTS: Twenty-eight patients (19 men, age 52.3±14.2years) underwent 48 catheter ablation procedures (range 1-6, six epicardial). During a mean follow-up of 18.7±15.1months, 13 patients (46.5%) experienced VT recurrence. Age >50years and ∑QRSmvV1-V3/∑QRSmvV1-V6≤0.48 but not right ventricular size and acute ablation outcome were associated with VT recurrence during the follow up. CONCLUSION: Age >50years and ∑QRSmvV1-V3/∑QRSmvV1-V6≤0.48 predict recurrence of VT after successful radiofrequency catheter ablation of VT in patients with ARVC and electrical storm.

Atrial arrhythmias following surgical AF ablation: electrophysiological findings, ablation strategies, and clinical outcome.

BACKGROUND: Intraoperative atrial fibrillation (AF) ablation during cardiac surgery is a well-established treatment. However, tachycardia mechanisms, ablation strategies, and long-term follow-up of atrial arrhythmias (AA) following intraoperative AF ablation (AFA) have not been previously studied in a large cohort of patients. OBJECTIVE: Eighty-two patients (48 male, median age of 65 years) with symptomatic recurrence of AA following intraoperative AFA underwent radiofrequency catheter ablation. METHODS: Regular atrial tachycardias (AT) were mapped using 3-dimensional (3D) color-coded entrainment/activation mapping and eliminated by linear ablation. Pulmonary vein (PV)-isolation (PVI) was achieved in patients with left atrium-PV (LAPV) conduction after AT elimination. RESULTS: In 85 (83%) out of a total of 103 regular ATs, the entire reentrant circuits were localized perimitrally (n = 27), around PVs (left PV [LPV] or right PV [RPV]; n = 9), around left atrial appendage (LAA; n = 1), on left-sided atrial septum (n = 8), on atrioventricular nodal area (n = 1), on the posterior wall of LA (n = 1), along roof-septum-inferoposterior wall (n = 8), at coronary sinus ostium (n = 2), upper loop in RA (n = 1), and as cavotricuspid isthmus-dependent reentrant ATs (n = 27). Sixty-five (79%) patients received PVI. Noninducibility of any AT was reached at the end of all procedures. During a median follow-up time of 18 months, 69 patients (87%) were free of AA. CONCLUSION: Reentrant AT appears in the majority of patients with recurrence of AA following intraoperative AFA. Detailed 3D color-coded entrainment mapping was successfully obtained in the majority of patients suffering from reentrant AT after intraoperative AFA, facilitated the accurate identification of the entire reentrant circuit and selection of optimal ablation lines.

Impact of single atrial fibrillation catheter ablation on implantable cardioverter defibrillator therapies in patients with ischaemic and non-ischaemic cardiomyopathies.

AIMS: Atrial fibrillation (AF) is associated with frequent appropriate and inappropriate implantable cardioverter defibrillator (ICD) therapies. Catheter ablation of AF has been shown to reduce AF burden and improve left ventricular function in heart failure patients but the impact on ICD therapies has not yet been studied. The aim of this study was to test the hypothesis that AF ablation reduces ICD therapies in patients with cardiomyopathies. METHODS AND RESULTS: In 73 consecutive patients (mean age 59 ± 10 years, 85% male) with previously implanted ICD due to ischaemic (n = 30) or dilated cardiomyopathy (n = 43) undergoing AF ablation, the prevalence and frequency of ICD therapies before and after AF ablation were compared. During the total follow-up of 3.3 ± 3 years prior to AF ablation, 5.1 ± 14.7 therapies per patient-year were delivered as opposed to 1.8 ± 10.9 in a period of 1.1 ± 0.9 years after ablation (P = 0.002). Prior to AF ablation, 39 patients (53%) received at least one ICD therapy when compared with 15 patients (21%) after ablation. Atrial fibrillation ablation was associated with freedom from any therapy regardless of appropriateness (odds ratio, OR, 0.366, CI 0.164-0.816, P = 0.014, adjusted for follow-up). Appropriate shocks significantly decreased from 0.3 ± 1.3 to 0.1 ± 0.5 per patient-year (P = 0.030). While heart failure medication and use of antiarrhythmic drugs were comparable during the entire follow-up, a statistically significant improvement of left ventricular ejection fraction (LVEF) from 36.9 ± 12.3% to 40.7 ± 6.7% (P = 0.008) was observed after AF ablation. CONCLUSIONS: In patients with ischaemic or dilated cardiomyopathy, catheter ablation of AF is associated with the reduction of inappropriate and appropriate ICD therapies and improvement of LVEF.

Treatment with novel oral anticoagulants in a real-world cohort of patients undergoing cardiac rhythm device implantations.

AIMS: The safety and efficacy of novel oral anticoagulants in patients with atrial fibrillation undergoing pacemaker or implantable cardioverter-defibrillator interventions have not been clearly defined. Therefore, we compared the incidence of bleeding and thrombo-embolic complications following cardiac rhythm device (CRD) implantations under dabigatran vs. rivaroxaban in a real-world cohort. METHODS AND RESULTS: We analysed 176 consecutive procedures performed in 93 patients treated peri-interventionally with dabigatran and 83 patients with rivaroxaban, respectively. Post-operative bleeding complications and thrombo-embolic events occurring within 30 days were compared. There were no significant differences in baseline characteristics between patients in the dabigatran and the rivaroxaban group. Most of the patients in both the groups received dual chamber or cardiac resynchronization devices (71 vs. 78%) as opposed to single-chamber systems (29 vs. 22%). In the dabigatran group, two (2%) bleeding complications (two pocket haematomas) were observed in comparison with four (5%, three pocket haematomas and one pericardial effusion) in the rivaroxaban group (P = 0.330). Three complications in the rivaroxaban group necessitated surgical intervention as opposed to none in the dabigatran group (P = 0.064). One case of a transient ischaemic attack occurred in the dabigatran group (P = 0.343). CONCLUSION: Bleeding and thrombo-embolic complications in patients treated with dabigatran or rivaroxban are rare. Further and larger studies are warranted to define the optimal anticoagulation management in patients with a need for oral anticoagulation and CRD interventions.

Comparison of dabigatran and uninterrupted warfarin in patients with atrial fibrillation undergoing cardiac rhythm device implantations. Case-control study.

BACKGROUND: The incidence of postoperative complications following pacemaker or implantable cardioverter-defibrillator implantations in patients treated with new oral anticoagulation agents has not been studied. Here we present a first comparison of complications after cardiac rhythm device (CRD) implantations in patients with atrial fibrillation (AF) treated with dabigatran or uninterrupted warfarin. METHODS AND RESULTS: Using a case-control study design, we compared complications within 30 days after 236 CRD procedures performed under uninterrupted warfarin (n=118) or interrupted dabigatran (n=118).There were no significant differences in the baseline characteristics of both groups. In the warfarin group, 9 (8%) pocket hematomas were observed vs. 3 (3%) in the dabigatran group (P=0.075). Two complications in the warfarin group necessitated surgical intervention as opposed to none in the dabigatran group (P=0.156). The postprocedural blood loss expressed as a drop in hemoglobin was significantly greater in the warfarin group (-0.9±0.7 vs. -0.5±0.4 mmol/L, P=0.023). In the dabigatran group, 1 case of transient ischemic attack occurred. The mean time to hospital discharge was shorter in patients treated with dabigatran (2.5±2.3 vs. 3.8±4.1 days, P=0.02). CONCLUSIONS: The incidence and severity of bleeding complications may be lower in patients treated with periprocedurally discontinued dabigatran when compared with uninterrupted warfarin therapy. Further evaluation of peri-interventional complications and establishment of an optimal anticoagulation management protocol are needed.

Comparison of Dabigatran and Uninterrupted Warfarin in Patients With Atrial Fibrillation Undergoing Cardiac Rhythm Device Implantations.

Background:The incidence of postoperative complications following pacemaker or implantable cardioverter-defibrillator implantations in patients treated with new oral anticoagulation agents has not been studied. Here we present a first comparison of complications after cardiac rhythm device (CRD) implantations in patients with atrial fibrillation (AF) treated with dabigatran or uninterrupted warfarin.Methods and Results:Using a case-control study design, we compared complications within 30 days after 236 CRD procedures performed under uninterrupted warfarin (n=118) or interrupted dabigatran (n=118).There were no significant differences in the baseline characteristics of both groups. In the warfarin group, 9 (8%) pocket hematomas were observed vs. 3 (3%) in the dabigatran group (P=0.075). Two complications in the warfarin group necessitated surgical intervention as opposed to none in the dabigatran group (P=0.156). The postprocedural blood loss expressed as a drop in hemoglobin was significantly greater in the warfarin group (-0.9±0.7 vs. -0.5±0.4 mmol/L, P=0.023). In the dabigatran group, 1 case of transient ischemic attack occurred. The mean time to hospital discharge was shorter in patients treated with dabigatran (2.5±2.3 vs. 3.8±4.1 days, P=0.02).Conclusions:The incidence and severity of bleeding complications may be lower in patients treated with periprocedurally discontinued dabigatran when compared with uninterrupted warfarin therapy. Further evaluation of peri-interventional complications and establishment of an optimal anticoagulation management protocol are needed.

[Initial ablation of atrial fibrillation-Is pulmonary vein isolation sufficient? : Pro and contra]. / Erstablation von Vorhofflimmern − reicht nur eine Pulmonalvenenisolation? : Pro und Contra.

Pulmonary vein isolation (PVI) is currently the gold standard for the ablation of atrial fibrillation (AF). Although this procedure shows good success rates, the recurrence rates after PVI alone are significantly higher in advanced AF and in the presence of comorbidities. Therefore, it is important to consider additional arrhythmogenic mechanisms outside the pulmonary veins, depending on the individual case, in order to improve the patients' outcome.