Relationship between left atrial isolated surface area and early-term recurrence in patients with persistent atrial fibrillation after cryoballoon ablation.

OBJECTIVE: To investigate the effect of pulmonary vein antrum enlargement combined with left atrial roof cryoballoon ablation in patients with persistent atrial fibrillation (PeAF) by analyzing the relationship between left atrial isolation area surface area (ISA) and early postoperative recurrence. METHODS: 93 patients with PeAF were classified into recurrence and non-recurrence groups according to the results of the 1-year follow-up. Three-dimensional electroanatomical labeling map was constructed and merged with that of the left atrial pulmonary vein CTA, and the ISA and the left atrial surface area (LASA) were measured and analyzed to determine the relationship between ISA/LASA in relation to early postoperative recurrence. RESULTS: 93 patients were included and followed up for 1 year with AF-free recurrence rate of 75.3%. The ISA of the recurrence group was lower than that of the non-recurrence group. Left atrial internal diameter (LAD), left common pulmonary vein, the ISA, the ISA/LASA and early-term recurrence had statistical significance in both groups. The factors that significantly predicted early-term recurrence were left common pulmonary vein and the ISA/LASA. ISA/LASA (HR 0, 95% CI 0-0.005, P = 0.008) and left common pulmonary vein trunk (HR 7.754, 95% CI 2.256-25.651, P = 0.001) were the independent risk factors for early recurrence. ROC curve analysis showed that ISA/LASA predicted the best early recurrence after operation with a cut-off value of 15.2%. CONCLUSION: A greater ISA/LASA reduces early recurrence after cryoablation in patients with PeAF. An ISA/LASA of 15.2% may be the best cut-off value for predicting early recurrence after cryoablation for PeAF.

Indocyanine green fluorescence identification of the intersegmental plane by the target segmental vein-first single-blocking during thoracoscopic segmentectomy.

BACKGROUND: Innovative attempt to explore the feasibility and accuracy of using indocyanine green fluorescence (ICGF) to identify the intersegmental plane by the target segmental veins preferential ligation during thoracoscopic segmentectomy. METHODS: A retrospective analysis was conducted on clinical data of 32 consecutive patients who underwent thoracoscopic segmentectomy with intersegmental plane identification using both ICGF and inflation-deflation method after target segmental veins prioritized blocking at Nanjing Chest Hospital from December 2022 to June 2023. Preoperative three-dimensional reconstruction was used to identify the target segment and the anatomical structure of the arteries, veins, and bronchi. After ligating the target segmental veins during surgery, the first intersegmental plane was immediately identified and marked with an electrocoagulation device using an inflation-deflation method. Subsequently, the second intersegmental plane was determined using the ICGF method. Finally, the consistency of the two intersegmental planes was evaluated. RESULTS: All the 32 patients successfully completed thoracoscopic segmentectomy without ICG-related complications and perioperative death. The average operation time was (98.59 ± 20.72) min, the average intraoperative blood loss was (45.31 ± 35.65) ml, and the average postoperative chest tube removal time was (3.5 ± 1.16) days. The average postoperative hospital stay was (4.66 ± 1.29) days, and the average tumor margin width was (26.96 ± 5.86) mm. The intersegmental plane determined by ICGF method was basically consistent with inflation-deflation method in all patients. CONCLUSION: The ICGF can safely and accurately identify the intersegmental plane by target segmental veins preferential ligation during thoracoscopic segmentectomy, which is a beneficial exploration and important supplement to the simplified thoracoscopic anatomical segmentectomy.

Empirical superior vena cava electrical isolation guided by quantitative ablation index improves outcomes of radiofrequency catheter ablation for paroxysmal atrial fibrillation.

BACKGROUND: The value of empirical superior vena cava isolation (SVCI) following pulmonary vein isolation (PVI) to improve the efficacy of radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) remains controversial. OBJECTIVE: To evaluate the efficacy and safety of quantitative ablation index (AI)-guided empirical SVCI, in addition to PVI, for patients with PAF. METHODS: Patients with symptomatic PAF who underwent RFCA between October 2021 and May 2023 were retrospectively analysed. Patients were categorised into PVI-only group and PVI+SVCI group based on the intraoperative ablation strategy. RFCA was guided by quantitative AI in both groups. Regular clinical follow-ups were conducted to detect AF recurrence, defined as any episode of atrial fibrillation, atrial flutter or atrial tachycardia lasting >30 s. RESULTS: A total of 246 patients were enrolled, with 108 patients in the PVI group and 138 patients in the PVI+SVCI group. Compared with the PVI group, patients in the PVI+SVCI group had a higher prevalence of coronary artery disease (p=0.04), stroke (p=0.02) and a smaller left atrial diameter (p<0.01). After a follow-up period of 16±6 months, the ablation success rate was significantly higher in the SVCI+PVI group compared with the PVI group (91.3% vs 81.5%, p=0.02). Multivariable logistic regression analysis indicated that SVCI was an independent predictor of reduced AF recurrence postablation (Relative Risk [RR] 0.4, 95% CI 0.19 to 0.90, p=0.026). No significant difference in complication rates was observed between the groups. CONCLUSION: Quantitative AI-guided empirical SVCI, in addition to PVI, improves the success rate of RFCA for PAF without increasing the risk of complications.

The value of computed tomography angiography for evaluation of left atrial enlargement in patients with persistent atrial fibrillation.

BACKGROUND: The post-processing technology of CTA offers significant advantages in evaluating left atrial enlargement (LAE) in patients with persistent atrial fibrillation (PAF). This study aims to identify parameters for rapidly and accurately diagnosing LAE in patients with PAF using CT cross-sections. METHODS: Left atrial pulmonary venous (PV) CT was performed to 300 PAF patients with dual-source CT, and left atrial volume (LAV), left atrial anteroposterior diameter (LAD1), left atrial transverse diameter (LAD2), and left atrial area (LAA) were measured in the ventricular end systolic (ES) and middle diastolic (MD). LA index (LAI) = LA parameter/body surface area (BSA). Left atrial volume index (LAVIES) > 77.7 ml/m2 was used as the reference standard for the LAE diagnosis. RESULTS: 227 patients were enrolled in the group, 101 (44.5%) of whom had LAE. LAVES and LAVMD (r = 0.983), LAVIES and LAVIMD (r = 0.984), LAAES and LAVIES (r = 0.817), LAAMD and LAVIES (r = 0.814) had strong positive correlations. The area under curve (AUC) showed that all measured parameters were suitable for diagnosing LAE, and the diagnostic efficacy was compared as follows: LAA/LAAI> LAD> the relative value index of LAD, LAD2> LAD1. LAA and LAAI demonstrated comparable diagnostic efficacy, with LAA being more readily available than LAAI. CONCLUSIONS: The axial LAA measured by CTA can be served as a parameter for the rapid and accurate diagnosis of LAE in patients with PAF.

Let's put the clues together and find the aetiology in this patient with dilated right heart!

A 39-year-old woman with intermittent palpitations, psoriasis, and a family history of sudden death presented with dilated right heart chambers and an enlarged coronary sinus. Despite a normal bubble study, further evaluation with transesophageal echocardiography revealed an abnormal pulmonary venous return: the left pulmonary veins drained into the coronary sinus. Cardiac computed tomography confirmed this finding, suggesting a partial abnormal pulmonary venous return as the underlying issue. Cardiac catheterization indicated increased pulmonary artery flow with normal pulmonary vascular resistance. The patient was referred for surgery. In this pathway involving the differential diagnosis of right heart dilatation, despite a confusing history and conflicting findings, echocardiographic clues led to the diagnosis.

Electrophysiology lab efficiency using cryoballoon for pulmonary vein isolation in Latin America: A sub-analysis of the Cryo Global Registry Study.

Objective: Cryoballoon ablation for pulmonary vein isolation is a time-efficient procedure that can alleviate stress on electrophysiology lab resources. This analysis modeled the impact of cryoballoon ablation on electrophysiology lab operation using data from Latin America. Methods: Data from centers in Argentina, Mexico, Colombia, and Chile of the were used as inputs for an electrophysiology lab efficiency simulation model. The model used the assumption that either two (today's electrophysiology lab operations) or three (including electrophysiology lab operational changes) cryoballoon ablation procedures could be performed per day. The endpoints were the percentage of days that resulted in 1) overtime and 2) time left for an extra non-ablation electrophysiology procedure. Results: Data from a total of 232 procedures from six Latin American centers were included in the analysis. The average electrophysiology lab occupancy time for all procedures in Latin America was 132 ± 62 minutes. In the Current Scenario (two procedures per day), 7.4% of simulated days resulted in overtime, and 81.4% had enough time for an extra electrophysiology procedure. In the Enhanced Productivity Scenario (three procedures per day), 16.4% of days used overtime, while 67.4% allowed time for an extra non-ablation electrophysiology procedure. Conclusions: Using real-world, Latin American-specific data, we found that with operational changes, three ablation procedures could feasibly be performed daily, leaving time for an extra electrophysiology procedure on more than half of days. Thus, use of cryoballoon ablation is an effective tool to enhance electrophysiology lab efficiency in resource-constrained regions such as Latin America.

Objetivos: La ablación con criobalón para el aislamiento de venas pulmonares es un procedimiento que ahorra tiempo y puede ahorrar recursos del laboratorio de electrofisiología. Este análisis modeló el impacto de la ablación con criobalón en el funcionamiento del laboratorio de electrofisiología utilizando datos de América Latina. Métodos: Los datos de los centros de Argentina, México, Colombia y Chile del se utilizaron como datos de entrada para un modelo de simulación de la eficiencia del laboratorio de electrofisiología. El modelo partió del supuesto de que se podían realizar dos (operaciones actuales del laboratorio de electrofisiología) o tres (incluidos los cambios operativos del laboratorio de electrofisiología) procedimientos de ablación con criobalón por día. Los criterios de valoración eran el porcentaje de días en los que se producían 1) horas extraordinarias y 2) tiempo restante para un procedimiento electrofisiológico adicional no relacionado con la ablación. Resultados: Se incluyeron en el análisis los datos un total de 232 procedimientos de seis centros latinoamericanos. El tiempo medio de ocupación del laboratorio de electrofisiología para todos los procedimientos en Latinoamérica fue de 132 ± 62 minutos. En el escenario actual (dos procedimientos por día), el 7,4% de los días simulados resultaron en horas extras, y el 81,4% tuvo tiempo suficiente para un procedimiento de electrofisiología adicional. En el escenario de productividad mejorada (tres procedimientos por día), el 16,4% de los días utilizó horas extraordinarias, mientras que el 67,4% dispuso de tiempo suficiente para un procedimiento electrofisiológico extra sin ablación. Conclusiones: Utilizando datos del mundo real específicos de América Latina, descubrimos que, aplicando cambios operativos, es factible realizar tres procedimientos de ablación al día, lo que deja tiempo para un procedimiento de electrofisiología adicional en más de la mitad de los días. Por lo tanto, el uso de la ablación con criobalón es una herramienta eficaz para mejorar la eficiencia de los laboratorios de electrofisiología en regiones con recursos limitados como América Latina.

Alveolar capillary dysplasia complicated by subglottic stenosis.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV) is an interstitial lung disease. In ACDMPV, respiratory impairment with severe pulmonary hypertension occurs from the early hours of life. Anomalies in the cardiovascular, gastrointestinal and genitourinary systems have been reported. However, little is known about upper airway abnormalities. We encountered a genetically diagnosed ACDMPV infant who presented with subglottic and bronchial stenosis. The prenatal diagnosis was hypoplastic left heart syndrome. Her respiratory condition worsened at 16 hours of life. We found subglottic stenosis when intubating. She died on day 7. Autopsy imaging with CT scan showed bilateral main bronchial stenosis. Chromosomal microarray revealed a 531 kb deletion in chromosome 16q24.1, including FOXF1.

Multimodal ultrasound imaging for patent foramen ovale and pulmonary arteriovenous malformation in patients with cryptogenic stroke or migraine: A prospective diagnostic study.

Right-to-left shunt (RLS) caused by patent foramen ovale (PFO) and pulmonary arteriovenous malformations (PAVM) have been associated with a variety of diseases, and reliable techniques for detecting RLS are essential for diagnosis. This study aimed to compare the diagnostic accuracy of multimodal ultrasound imaging, including transthoracic echocardiography (TTE) plus contrast transthoracic echocardiography (CTTE) and transesophageal echocardiography (TEE) plus contrast transesophageal echocardiography (CTEE) for PFO and PAVM in patients with cryptogenic stroke or migraine. This prospective study enrolled patients with cryptogenic stroke or migraine admitted to First Hospital of Shanxi Medical University between July 2018 and April 2023. The TTE + CTTE + TEE + CTEE multimodal ultrasound imaging was defined as the gold standard. A total of 230 patients with cryptogenic stroke (108) or migraine (122) were enrolled. The TEE + CTEE generated a better area under the receiver operator characteristic (ROC) curves (AUC) than TTE + CTTE [0.995 (0.988-1.000) vs 0.975 (0.767-0.984), P < .001], indicating better identification of PFO and PAVM. The sensitivity and specificity of the TTE + CTTE were 89.4% and 85.7%, respectively, whereas the sensitivity and specificity of TEE + CTEE were 99.1% and 100%, respectively. The missed diagnosis rate of TTE + CTTE and TEE + CTEE was 65.7 % and 12.5%, respectively. The combination of TEE + CTEE may be a more reliable and sensitive tool to detect PFO and PAVM than TTE + CTTE in patients with cryptogenic stroke or migraine.

Clinical value of artificial intelligence 3D echocardiography in evaluating left atrial volume and pulmonary vein structure in patients with atrial fibrillation.

OBJECTIVE: To explore the clinical value of 3D Echocardiography (3DE) in evaluating the changes of left atrial volume and pulmonary vein structure in patients with Atrial Fibrillation (AF). METHODS: Clinical data were collected from 54 AF patients. Left Atrial Anteroposterior Diameter (LADap), Left Atrial left and right Diameter (LADml), and Left Atrial upper and lower Diameter (LADsi) were measured; the maximum Left Atrial Volume (LAVmax), minimum Left Atrial Volume (LAVmin), left atrial presystolic volume (LAVpre), and Cross-Sectional Area (CSA) of each pulmonary vein were analyzed. Passive Ejection Fraction (LAPEF) was calculated. The differences in left atrial volume and pulmonary vein structure between patients with AF and healthy people were compared, and the correlation between the indexes was analyzed. The diagnostic value of the above indicators for AF patients was analyzed. RESULTS: LADap, LADml, LADsi, LAVmax, LAVmin, LAVpre, LAPEF, LSPV CSA, LIPV CSA, RSPV CSA, and RIPV CSA of AF patients were significantly higher. There was a significant positive correlation between left atrial diameter and pulmonary vein structure. There was a significant positive correlation between left atrial volume and pulmonary vein structure. There was a negative correlation between LAPEF and pulmonary vein structure. LADap, LADml, LADsi, LAVmax, LAVmin, LAVpre, LAPEF, LSPV CSA, LIPV CSA, RSPV CSA, and RIPV CSA had a diagnostic value for AF patients. CONCLUSION: 3DE is applicable for evaluating left atrial volume and pulmonary vein structure in patients with AF.

Evaluation of the associations of pulmonary vein vertical diameter, cardiothoracic ratio, and atrial fibrillation combined hiatal hernia.

Recent studies have suggested that there may be a relationship between hiatal hernia (HH) and atrial fibrillation (AF), but the specific mechanism is unclear. The aim of this study was to explore the clinical characteristics associated with HH and AF and to identify the potential relationship between the 2 diseases. The study comprised 180 patients with HH, of which 54 had AF. Every patient had chest computed tomography to quantify the cardiothoracic ratio, HH volume, thoracic cavity volume, and diameters of the pulmonary veins. The clinical data of all patients was acquired through an electronic medical record system. Patients who experienced AF had a noticeably smaller total pulmonary vein vertical diameter (TPVVD) and a higher cardiothoracic ratio compared to those who only had HH. Logistic multivariate regression study demonstrated a significant association between TPVVD, cardiothoracic ratio, and AF in individuals with HH. This study established a correlation between TPVVD, cardiothoracic ratio, and HH in conjunction with AF. Patient with HH who had a thinner TPVVD and a bigger cardiothoracic ratio were found to have a greater likelihood of suffering from AF.

Comparing simultaneous hybrid ablation with stand-alone thoracoscopic surgical ablation for the treatment of non-paroxysmal atrial fibrillation: a prospective randomized controlled trial.

AIMS: Advanced atrial fibrillation (AF) is currently a dilemma for electrophysiologists when choosing a minimally invasive treatment strategy. Previous studies have demonstrated the outcome of either catheter ablation or thoracoscopic surgical ablation (SA) is unsatisfactory in these patients. Whether hybrid ablation (HA) could improve outcomes in these patients is unknown. The purpose of this study was to evaluate the clinical efficacy of HA for the treatment of advanced AF. METHODS AND RESULTS: A randomized controlled trial was designed to enrol patients with persistent AF (PerAF) and enlarged left atrium or long-standing persistent AF (LSPAF) who were randomized to HA or thoracoscopic SA at a 1:1 ratio. The primary endpoint was freedom from any recurrence of AF off antiarrhythmic drugs (AADs) 12 months after operation. The primary endpoint was monitored by 7-day electrocardiogram monitoring devices. One hundred patients were enrolled. The mean age was 58.5 ± 7.6 years, and the mean left atrial diameter (LAD) was 50.1 ± 6.1 mm. At 12 months, freedom from AF off AADs was recorded in 71.4% (35/49) of patients in HA group and 45.8% (22/48) in SA group [odds ratio 2.955, 95% confidence interval (1.275-6.848), P = 0.014]. HA significantly reduced patients' AF burden (30.2% in SA group and 14.8% in HA group, P = 0.048) and the LAD (mean differences: -5.53 ± 4.97 mm in HA group and -3.27 ± 5.20 mm in SA group, P = 0.037) at 12 months after operation. CONCLUSION: In patients with PerAF and enlarged left atrium or LSPAF, HA achieved better freedom from AF after 1 year of follow-up compared with thoracoscopic SA.

Shortened radiofrequency delivery time to optimize efficiency and safety of pulmonary vein isolation with the radiofrequency balloon: insights from the COLLABORATE registry.

AIMS: Previous clinical studies on pulmonary vein isolation (PVI) with a radiofrequency balloon (RFB) reported safe and effective procedures using conventional ablation settings with 20/60 s RF delivery via posterior/anterior (PST/ANT) electrodes. The latest evidence suggests that reducing the application time to 15 s (s) on the posterior wall when facing the oesophageal region is as effective as applying 20 s. To prospectively assess whether reducing RF time on PST/ANT segments to 15/45 s can ensure sufficient quality of lesion metrics and compare the new shortened ablation settings with the conventional one in terms of safety, and effectiveness at 1-year. METHODS AND RESULTS: A total of 641 patients from seven European centres were enrolled in a collaborative registry, with 374 in the conventional RF delivery group and 267 in the shortened RF delivery group. Procedural outcomes, lesion metrics, and safety profiles were assessed and compared between the groups. Freedom of any atrial tachycarrythmias at one year was 85.4% and 88.2% in the SHRT and CONV groups, respectively. The shortened RF delivery strategy was associated with significantly shorter procedure times (median 63.5 vs. 96.5 min, P < 0.001) and shortened fluoroscopy exposure (median 10.0 vs. 14.0 min, P < 0.001) compared to conventional delivery. Efficacy metrics, including first-pass isolation rates and time to isolation, were comparable between groups. Shortened RF delivery was associated with a lower incidence of procedural complications (1.4% vs. 5.3%, P = 0.04) and optimized thermal characteristics. CONCLUSION: Analyses from the COLLABORATE registry demonstrate that shortening RF energy delivery times to 15/45 s (PST/ANT) during PVI with the RFB resulted in comparable freedom from recurrent atrial tachyarrhythmia compared to conventional delivery times with comparable efficiency and safety.

Pulsed Field Ablation to Treat Paroxysmal Atrial Fibrillation: Safety and Effectiveness in the AdmIRE Pivotal Trial.

BACKGROUND: Evidence from clinical trials of early pulsed field ablation (PFA) systems in treating atrial fibrillation has demonstrated their promising potential to reduce complications associated with conventional thermal modalities while maintaining efficacy. However, the lack of a fully integrated mapping system, a staple technology of most modern electrophysiology procedures, poses limitations in lesion creation and workflow options. A novel variable-loop PFA catheter integrated with an electroanatomic mapping system has been developed that allows for real-time nonfluoroscopic procedural guidance and lesion indexing as well as feedback of tissue-to-catheter proximity. AdmIRE (Assessment of Safety and Effectiveness in Treatment Management of Atrial Fibrillation With the Bosense-Webster Irreversible Electroporation Ablation System), a multicenter, single-arm, Food and Drug Administration investigational device exemption study, evaluated the long-term safety and effectiveness of this integrated PFA system in a large United States-based drug-refractory symptomatic paroxysmal atrial fibrillation patient population. METHODS: Using the PFA catheter with a compatible electroanatomic mapping system, patients with drug-refractory symptomatic paroxysmal atrial fibrillation underwent pulmonary vein isolation. The primary safety end point was primary adverse event within 7 days of ablation. The primary effectiveness end point was a composite end point that included 12-month freedom from documented atrial tachyarrhythmia (ie, atrial fibrillation, atrial tachycardia, atrial flutter) episodes, failure to achieve pulmonary vein isolation, use of a nonstudy catheter for pulmonary vein isolation, repeat procedure (except for one redo during blanking), taking a new or previously failed class I or III antiarrhythmic drug at higher dose after blanking, or direct current cardioversion after blanking. RESULTS: At 30 centers, 277 patients with paroxysmal atrial fibrillation (61.5±10.3 years of age; 64.3% male) in the pivotal cohort underwent PFA. More than 25% of the procedures were performed without fluoroscopy. Median (Q1, Q3) pulmonary vein isolation procedure, fluoroscopy, and transpired PFA application times were 81.0 (61.0, 112.0), 7.1 (0.00, 14.3), and 31.0 (24.8, 40.9) minutes, respectively. The primary adverse event rate was 2.9% (8 of 272), with the most common complication being pericardial tamponade. The 12-month primary effectiveness end point was 74.6%. The 1-year freedom from atrial fibrillation, atrial tachycardia, or atrial flutter recurrence rate after blanking was 75.4%. Substantial improvements in quality of life were observed as early as 3 months after the procedure, concurrent with a reduction in multiple health care use measures. CONCLUSIONS: AdmIRE confirmed the safety and effectiveness of the variable-loop PFA catheter, with short procedure and PFA application times and low fluoroscopy exposure. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05293639.

Pulmonary Vein in a Pinch.

The pulmonary veins normally drain into the left atrium, with the superior pulmonary veins typically situated anterior and inferior to the right pulmonary arteries. However, anomalies can happen. We encountered an exceedingly rare pulmonary vascular anomaly for a patient presenting with atypical chest pain, where the right superior pulmonary vein aberrantly ran posterior to the right pulmonary artery (RPA) and became compressed between the RPA and the right main bronchus. Coronary computed tomography angiography identified this specific pulmonary vein anomaly but revealed unremarkable coronary arteries.

Enhanced Late INa Induces Intracellular Ion Disturbances and Automatic Activity in the Guinea Pig Pulmonary Vein Cardiomyocytes.

The effects of enhanced late INa, a persistent component of the Na+ channel current, on the intracellular ion dynamics and the automaticity of the pulmonary vein cardiomyocytes were studied with fluorescent microscopy. Anemonia viridis toxin II (ATX- II), an enhancer of late INa, caused increases in the basal Na+ and Ca2+ concentrations, increases in the number of Ca2+ sparks and Ca2+ waves, and the generation of repetitive Ca2+ transients. These phenomena were inhibited by eleclazine, a blocker of the late INa; SEA0400, an inhibitor of the Na+/Ca2+ exchanger (NCX); H89, a protein kinase A (PKA) inhibitor; and KN-93, a Ca2+/calmodulin-dependent protein kinase II (CaMKII) inhibitor. These results suggest that enhancement of late INa in the pulmonary vein cardiomyocytes causes disturbance of the intracellular ion environment through activation of the NCX and Ca2+-dependent enzymes. Such mechanisms are probably involved in the ectopic electrical activity of the pulmonary vein myocardium.

Atrial thrombus after total anomalous pulmonary venous connection repair.

A 6-year-old boy had previously undergone total anomalous pulmonary venous connection repair and postoperative pulmonary vein stenosis release. Magnetic resonance imaging revealed blood stasis caused by a collision between the inflow from the pulmonary veins and the outflow from the left atrial appendage. A surgical specimen revealed evidence of advanced thrombus attachment. Infra-cardiac total anomalous pulmonary venous connection with an antler appearance may be a risk factor for thrombus formation in the left atrial appendage and for postoperative pulmonary venous stenosis due to blood flow collision in the left atrium after total anomalous pulmonary venous connection repair.

Comprehensive review of pulmonary vein stenosis post-atrial fibrillation ablation: diagnosis, management, and prognosis.

Pulmonary vein stenosis (PVS) can occasionally occur in the follow-up after pulmonary vein isolation (PVI) for atrial fibrillation (AF). During PVI, ablation is performed at the PV ostium or distal part, leading to tissue damage. This damage can result in fibrosis of the necrotic myocardium, proliferation, and thickening of the vascular intima, as well as thrombus formation, further advancing PVS. Mild-to-moderate PVS often remains asymptomatic, but severe PVS can cause symptoms, such as dyspnea, cough, fatigue, decreased exercise tolerance, chest pain, and hemoptysis. These symptoms are due to pulmonary hypertension and pulmonary infarction. Imaging evaluations such as contrast-enhanced computed tomography are essential for diagnosing PVS. Early suspicion and detection are necessary, as underdiagnosis can lead to inappropriate treatment, disease progression, and poor outcomes. The long-term prognosis of PVS remains unclear, particularly regarding the impact of mild-to-moderate PVS over time. PVS treatment focuses on symptom management, with no established definitive solutions. For severe PVS, transcatheter PV angioplasty is performed, though the risk of restenosis remains high. Restenosis and reintervention rates have improved with stent implantation compared with balloon angioplasty. The role of subsequent antiplatelet therapy remains uncertain. Dedicated evaluation is essential for accurate diagnosis and appropriate management to avoid significant long-term impacts on patient outcomes.

Clinical impact of cryoballoon posterior wall isolation using the cross-over technique in persistent atrial fibrillation.

BACKGROUND AND AIMS: Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW. METHODS: This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of pulmonary vein isolation (PVI) + PWI (108 patients) or PVI-only (86 patients) using the CB. The cross-over technique was applied in all LAPWI. RESULTS: For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (right to left [R→L] 4.3 ± 1.1 and left to right [L→R] 4.3 ± 1.1) and 9.1 ± 1.2 (R→L 4.6 ± 1.6 and L→R 4.5 ± 1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI + PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow-up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI + PWI group and 72.9% of the PVI-only group (p = .011). CONCLUSIONS: LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.

Pulsed-field- vs. cryoballoon-based pulmonary vein isolation: lessons from repeat procedures.

AIMS: Pulsed-field ablation (PFA) is an emerging technology to perform pulmonary vein isolation (PVI). Initial data demonstrated high safety and efficacy. Data on long-term PVI durability and reconduction patterns in comparison to established energy sources for PVI are scarce. We compare findings in repeat ablation procedures after a first PFA to findings in repeat ablation procedures after a first cryoballoon ablation (CBA) based PVI. METHODS AND RESULT: A total of 550 consecutively enrolled patients underwent PFA or CBA index PVI. Repeat ablations in patients with symptomatic atrial arrhythmia recurrences were analysed. A total of 22/191 (12%) patients after index PFA-PVI and 44/359 (12%) after CBA-PVI underwent repeat ablation. Reconduction of any pulmonary vein (PV) was detected by multipolar spiral mapping catheter at each PV with careful evaluation of PV potentials and by 3D-mapping in 16/22 patients (73%) after PFA-PVI and in 33/44 (75%) after CBA-PVI (P = 1.000). Of 82 initially isolated PVs after PFA-PVI, 31 (38%) were reconducting; of 169 isolated PVs after CBA-PVI, 63 (37%) were reconducting (P = 0.936). Clinical atrial tachycardia occurred similarly in patients after PFA (5/22; 23%) and CBA (7/44; 16%; P = 0.515). Roof lines were set more often after PFA- (8/22; 36%) compared with CBA-PVI (5/44; 11%; P = 0.023). Repeat procedure duration [PFA: 87 (76, 123) min; CBA: 93 (75, 128) min; P = 0.446] was similar and fluoroscopy time [PFA: 11 (9, 14) min; CBA: 11 (8, 14) min; P = 0.739] equal between groups at repeat ablation. CONCLUSION: During repeat ablation after previous PFA- or CBA-based PVI, electrical PV-reconduction rates and patterns were similar.