Acute and long-term outcomes of pulmonary vein isolation and left atrial substrate modification for non-paroxysmal atrial fibrillation: a non-randomized trial.

Background: The long-term success rate of nonparoxysmal atrial fibrillation (AF) treated with pulmonary vein isolation (PVI) alone is not ideal. This may indicate atrial fibrosis as a major cause of recurrence. Therefore, the aim of this study is to investigate the efficacy of left atrial substrate modification (LASM) by targeting low-voltage area. Methods: A total of 157 consecutive patients with drug-refractory nonparoxysmal AF who underwent radiofrequency ablation during hospitalization in the Third People's Hospital of Chengdu from April 2017 to August 2021 were prospectively included. Stepwise ablation was performed in two different orders: LASM first (n=53) and PVI first (n=104) group. All patients underwent ablation during AF, and the procedural endpoint was AF termination during ablation. In the LASM first group, LASM was performed first and if AF was terminated, PVI was not performed. Similarly, in the PVI first groups, LASM was performed if AF was not terminated. The primary outcome were AF termination and freedom from AF. The secondary outcome was adverse events. Cox regression analysis was used to define predictors of AF termination, and Kaplan-Meier analysis was used to assess differences between groups in AF freedom. Results: The baseline characteristics of the two groups were similar. At a median follow-up of 16 months, the 112 patients (39 in LASM first group and 73 in PVI first group) with AF termination had a higher success rate than the 45 patients who had no AF termination (78.6% vs. 57.8%; P<0.01). The AF termination rate (24/53, 45.3% vs. 12/104, 11.5%; P<0.01) and AF freedom (20/24, 83.3% vs. 7/12, 58.3%; P=0.13) by LASM alone was higher than PVI alone. There were 3 cases of heart failure and 1 case of stroke (4/53) in the LASM first group, and 1 case of pericardial tamponade, 5 cases of heart failure and 1 case of stroke (7/104) in the LASM first group (7.5% vs. 6.7%; P>0.05). Conclusions: LASM provides higher immediate success and a slightly better long-term success rate compared to PVI. Patients who terminated AF were more likely to have AF freedom than those who did not. AF termination during procedure may improve symptoms and reduce hospitalization.

Early recurrences after paroxysmal atrial fibrillation ablation: when is the proper timing for reablation?

BACKGROUND: Early recurrences (ERs) within 1 month after paroxysmal atrial fibrillation (AF) ablation are common and may subside in a considerable proportion of patients. Although late reablation after 3 months is recommended, the proper timing for reablation remains undetermined. METHODS AND RESULTS: One hundred and seventeen (31.2%) from the pool of 375 patients experienced ERs at 7.5 ± 5.5 days postablation. They were allocated into two groups randomly: early reablation group (ERe+) (n = 57) and nonearly reablation group (ERe-) (n = 60). Forty patients (70.2%) in ERe+ group underwent early reablation at 28.1 ± 2.7 days postablation. Forty patients (66.7%) in ERe- group underwent late reablation at 98.2 ± 5.2 days postablation. The proportion of reablation was comparable (P = 0.68). ERs subsided in 17 (29.8%) in ERe+ group and in 20 (33.3%) in ERe- group. In ERe+ group, PV reconnection in 36 (80.0%), non-PV foci in six (10.5%), and right or left atrial flutter in five (8.8%) was abolished by ablation. In ERe- group, pulmonary vein (PV) reconnection in 29 (72.5%), non-PV foci in eight (13.3%), and right or left atrial flutter in eight (13.3%) was ablated successfully. The proportion of PV reconnection, nonfoci, and atrial flutter was comparable, P = 0.45, 0.64, and 0.56, respectively. At the end of 16.5 ± 2.0 (ERe+ group) and 15.2 ± 2.6 (ERe- group) months' follow-up, 47 (82.5%) in ERe+ group and 51 (85%) in ERe- group were free of atrial tachyarrhythmias, P = 0.70. CONCLUSIONS: Compared with reablation 2 months later after initial ablation, early reablation at ≈1 month had similar clinical effectiveness. The proper timing for reablation can be set at ≈1 month after initial paroxysmal AF ablation.

Congestive heart failure after extensive catheter ablation for atrial fibrillation: prevalence, characterization, and outcome.

INTRODUCTION: This study sought to describe a new complication of catheter ablation for atrial fibrillation (AF): new onset congestive heart failure (CHF) after extensive ablation for AF. METHODS AND RESULTS: Data from 12 patients developing CHF after ablation were prospectively collected. All patients underwent extensive ablation for AF including circumferential pulmonary venous ablation and complex fractionated atrial electrograms guided ablation. CHF was diagnosed using the following criteria: symptoms or signs of heart failure, elevated BNP, and echocardiographic evidence of left ventricular diastolic dysfunction. Twelve patients (5 persistent and 7 permanent AF) had CHF after extensive ablation out of 484 consecutive AF patients who underwent catheter ablation (prevalence 2.5%). None of these 12 patients had CHF prior to the procedure. The mean onset of the symptoms was 39 ± 14 hours after the index procedure. Dyspnea and pulmonary rales were the most observed symptoms or signs. White blood cell count, serum CRP, BNP, and echocardiographic parameters of left ventricular diastolic dysfunction (E/A, E/E') were significantly increased after the onset of symptoms. All patients had complete recovery with supportive therapy within 3 days of the onset of symptoms. CONCLUSIONS: In this single-center experience, CHF after extensive ablation for AF was a well-recognized complication with a relatively high incidence of 2.5%. Measurement of BNP, CRP, and E/A, E/E' is useful in managing these patients.

Efficacy, safety and outcome of catheter ablation for atrial fibrillation in octogenarians.

BACKGROUND AND OBJECTIVES: Catheter ablation is effective in treating patients with atrial fibrillation (AF). The aim of the study was to evaluate the safety, efficacy and outcome of catheter ablation for AF in octogenarians. METHODS AND RESULTS: 377 consecutive patients were divided into three groups based on age: ≥80 years (group 1; n=49), 70-79 years (group 2; n=151), 60-69 years (group 3; n=177). The efficacy and safety for those three groups were determined. The success rate after one procedure was similar in three groups (70% in group 1, 72% in group2 and 74% in group 3, P=NS) during a mean follow-up of 18 months. Major complication rates were comparable between the three groups. However, the octogenarians were less likely to undergo a repeated procedure than other groups (8% in group 1, 15% in group 2 and 18% in group 3, P<0.05), and were more likely to remain on antiarrhythmic drugs. CONCLUSION: Catheter ablation for AF attempted in octogenarians appears to be effective and with low risk. Ablation results are comparable with those noted in younger patients.