Strategies for the Design and Construction of Nature-Inspired & Living Laboratory (NILL 1.0)TM Buildings.

This article explores the growing prominence of nature-inspired design philosophies in the context of sustainability and human well-being within the built environment and focuses on their application within laboratory buildings. Biomimicry and biophilic design are highlighted as key nature-inspired design approaches, with biomimicry drawing inspiration from nature for innovations and biophilic design promoting human health through enhancing the connection with the surrounding natural elements. This paper further discusses living building strategy as an emerging method for creating dynamic and adaptable spaces by prioritizing user experience through co-creation and focusing on sustainable and regenerative structures. The potential of integrating these approaches is emphasized using laboratory buildings as an example, with nature-inspired and living laboratories serving as models for future built environments that promote both environmental responsibility and a positive human experience. Accordingly, this work aims to investigate the design and construction of laboratory buildings based on nature-inspired design strategies and the living building concept. Moreover, the paper discusses the application of biomimicry and living building concepts within laboratory buildings as a novel contribution to the body of knowledge, and concludes by proposing the Nature-inspired & Living Laboratory (NILL 1.0)TM Building Assessment index to serve as a guideline for the design and construction of laboratory buildings using nature as an inspiration and the analogy of human body systems.

An IoT-Based Road Bridge Health Monitoring and Warning System.

Recent earthquakes worldwide have led to significant loss of life and structural damage to infrastructure, especially road bridges. Existing bridge monitoring systems have limitations, including restricted detection capabilities, subjectivity, human error, labor-intensive inspections, limited access to remote areas, and high costs. Aging infrastructures pose a critical concern for organizations and government funding policies, showing signs of decay and impending structural failure. To address these challenges, this research proposes an IoT-based bridge health status monitoring and warning system that is wireless, low-cost, durable, and user-friendly. The proposed system builds upon engineering standards and guidelines to classify bridge health status into categories ranging from excellent to collapse condition. It incorporates deflection, vibration, temperature, humidity, and infrared sensors, combined with IoT and a fuzzy logic algorithm. The primary objective is to reduce bridge maintenance costs, extend lifespans, and enhance transportation safety through an early warning system via a mobile application. Additionally, a Google Maps interface has been developed to display bridge conditions along with real-time traffic video. To validate the proposed system, a 3-D prototype model was constructed and tested. Practical testing of the fuzzy logic algorithm aligned with the simulation outcomes, demonstrating expected accuracy in determining bridge health status.

Applications of Biomimicry in Architecture, Construction and Civil Engineering.

Globally, the construction sector is regarded as one of the major contributors to greenhouse gas emissions, energy consumption, freshwater usage, resource utilization, and solid waste generation. With a constantly growing population and increased urbanization, this is only predicted to rise. Thus, achieving sustainable development in the construction sector has become an urgent necessity. The adoption of biomimicry in the construction sector is one of the most innovative concepts towards the shift into sustainable practices in construction. However, it has been noticed that the concept of biomimicry is very broad, relatively new, and abstract. Thus, after reviewing previously conducted research on the subject, a noticeable lack of knowledge on the effective implementation of the biomimicry concept was found to be present. Therefore, this research seeks to fill this knowledge gap whereby it aims to explore the development of the biomimicry concept in the field of architecture, building construction, and civil engineering with a systematic review approach of research related to biomimicry in these three fields. This aim is guided by an objective of developing a clear understanding of the application of the biomimicry concept in architecture, building construction, and civil engineering fields. The timeframe considered for this review is between 2000 and 2022. The qualitative exploratory nature of this research focuses on reviewing databases such as Science Direct, ProQuest, Google Scholar, and MDPI, as well as book chapters, editorials, and official websites to extract relevant information using an eligibility criterion of title and abstract review, inclusion of key terms, and detailed review of chosen articles. This study will improve the understanding of the biomimicry concept and how it can be applied in the built environment.

Periprocedural and long-term safety and feasibility of direct oral anticoagulants in patients with biological valve undergoing radiofrequency catheter ablation for atrial fibrillation: a prospective multicenter study.

BACKGROUND: Direct oral anticoagulants (DOACs) are contraindicated in patients with atrial fibrillation (AF) and mechanical cardiac valves. However, safety and efficacy are controversial in patients with biological cardiac valves. OBJECTIVE: We report the safety and feasibility of periprocedural and long-term treatment with DOACs in patients with biological valves undergoing ablation for AF. METHODS: A total of 127 patients with AF and biological cardiac valve undergoing CA on uninterrupted DOAC were matched by gender and age with 127 patients with AF and biological cardiac valves undergoing CA on uninterrupted warfarin. All patients were anticoagulated for at least 3-4 weeks prior to ablation with either rivaroxaban (70%) or apixaban (30%), which were continued for at least 3 months and subsequently based on CHA2DS2-VASc score. RESULTS: Mean age of the study population was 63.0 ± 10.9 with 66% being male. The majority of patients on NOACs had aortic valve replacement (59%), while mitral valve was replaced in 41% of patients, which did not differ from the matched cohort on coumadin (aortic valve 57% and mitral valve 43%, (p = 0.8) (p = 0.8), respectively). The CHADS2 score was ≥ 2 in 90 patients (71.0%) on DOAC and 86 patients in (68%) the control (p = 0.6) group. Patients underwent ablation predominantly with uninterrupted rivaroxaban [89 (70%)], while the remaining 38 patients (30%) underwent ablation while on apixaban. Two groin hematomas were observed periprocedurally in both groups. No stroke/transient ischemic attack (TIA) was observed both periprocedurally and at long-term follow-up in either group. CONCLUSION: Periprocedural and long-term administration of DOACs in patients with biological cardiac valves undergoing AF ablation appears as safe as warfarin therapy.

Venous access-site closure with vascular closure device vs. manual compression in patients undergoing catheter ablation or left atrial appendage occlusion under uninterrupted anticoagulation: a multicentre experience on efficacy and complications.

AIMS: Manual compression (MC), widely used to achieve venous access haemostasis, needs prolonged immobilization and extended time-to-haemostasis. Vascular closure devices (VCD) have been reported to have significantly shorter time to haemostasis and ambulation in arterial access-site management. The current study aimed to evaluate the safety and efficacy as well as rate of urinary tract complications in patients receiving MC vs. VCD for venous access-site closure. METHODS AND RESULTS: A total of 803 consecutive patients undergoing catheter ablation or left atrial appendage closure were classified into the VCD (n = 304) and the MC (n = 499) group, based on the methods used for haemostasis at the venous access site. Foley catheter was used for bladder-emptying in all MC cases and 15 VCD patients. At one site, VCD group patients with experience of MC in prior ablations were asked to describe their overall satisfaction level after comparing the past experience with the present. Haemostasis was achieved effectively in both populations. No VCD cases required >2 h bed rest, whereas 7 (1.4%) patients in the MC group needed prolonged immobilization (P = 0.04). Significantly higher incidence of access-site haematoma (P = 0.004) and urinary complications (P < 0.05) were observed in the MC group. Majority of VCD patients (68%) with prior experience of MC for haemostasis expressed satisfaction over the early ambulation and ability to void urine without bladder catheterization. CONCLUSION: Vascular closure devices provided effective haemostasis, while reducing the access-site complications, ambulation time, and urinary complications.

Evidence of relevant electrical connection between the left atrial appendage and the great cardiac vein during catheter ablation of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. OBJECTIVE: The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). METHODS: A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. RESULTS: In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. CONCLUSION: These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

Impact of weight loss on ablation outcome in obese patients with longstanding persistent atrial fibrillation.

AIMS: This study investigated the impact of weight loss in longstanding persistent (LSPAF) patients undergoing catheter ablation (CA). METHODS: Ninety consecutive obese LSPAF patients were approached; 58 volunteered to try weight loss interventions for up to 1 year (group 1), while 32 patients declined weight loss interventions and were included as a control (group 2). Both groups remained on antiarrhythmic drugs. If they continued to experience AF, CA was performed. Body weight was measured at 6-month intervals and arrhythmia status was assessed by event recorder, electrocardiogram (ECG), and Holter monitoring. Symptom severity and quality of life (QoL) were evaluated by AFSS and SF-36 survey, respectively. A scoring algorithm with two summary measures, physical component score (PCS) and mental component score (MCS), was prepared for QoL analysis. RESULTS: Significant reduction in body weight (median -24.9 (IQR -19.1 to -56.7) kg, P < 0.001) was observed in the group 1 patients, while no such change was seen in group 2. The PCS and MCS scores improved significantly in group 1 only, with a change from baseline of 8.4 ± 3 (P = 0.013) and 12.8 ± 8.2 (P < 0.02). However, AF symptom severity remained unchanged from baseline in both groups (P = 0.84). All 90 patients eventually underwent CA and received PVAI+ posterior wall+ non-PV triggers ablation. At 1-year follow-up after single procedure, 37 (63.8%) in group 1 and 19 (59.3%) patients in group 2 remained arrhythmia-free off AAD (P = 0.68). CONCLUSION: In this prospective analysis, in LSPAF patients weight loss improved QoL but had no impact on symptom severity and long-term ablation outcome.

Procedural findings and ablation outcome in patients with atrial fibrillation referred after two or more failed catheter ablations.

INTRODUCTION: This study reports the procedural findings and ablation outcome in AF patients referred after ≥2 failed PV isolation (PVI). METHODS: Three hundred and five consecutive AF patients referred after ≥2 PVI were included in the analysis. High-dose isoproterenol challenge was used to identify PV reconnection and non-PV triggers; the latter were ablated based on the operator's discretion during the index procedure. At the repeat procedure, non-PV triggers were ablated in all. Empirical isolation of LA appendage (LAA) and coronary sinus (CS) was performed if the PVs were silent and no non-PV triggers were detected. RESULTS: PV reconnection was detected in 226 and non-PV triggers were identified or empirically isolated in 285 patients during the index procedure. At follow-up, 182 (60%) patients were recurrence-free off-AAD; the success rate with and without non-PV ablation was 81% vs. 8% (P < 0.0001). 104 patients underwent repeat procedure with non-PV trigger ablation in all. At 1 year, 90% were arrhythmia free off-AAD in non-PV ablation group, and 72% who did not receive non-PV triggers ablation at the index procedure (P = 0.035). The success rate of empirical LAA and CS isolation was 78.5% and 82% after the index and repeat procedure, respectively. CONCLUSION: In patients experiencing AF recurrence after multiple failed PVI, despite PV reconnection, non-PV triggers were found to be responsible for AF maintenance in the majority and ablating those triggers increased ablation success. Additionally, in the presence of permanent PVI and no non-PV triggers on isoproterenol, empirical isolation of LAA and CS provided high rate of arrhythmia-free survival.

Long-term follow-up of patients with paroxysmal atrial fibrillation and severe left atrial scarring: comparison between pulmonary vein antrum isolation only or pulmonary vein isolation combined with either scar homogenization or trigger ablation.

AIMS: Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF (PAF) and severe LA scarring identified by 3D mapping, undergoing pulmonary vein isolation (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI+ ablation of the non-PV triggers. METHODS AND RESULTS: Totally, 177 consecutive patients with PAF and severe LA scarring were included. Patients underwent PVAI only (n = 45, Group 1), PVAI+ scar homogenization (n = 66, Group 2) or PVAI+ ablation of non-PV triggers (n = 66, Group 3) based on operator's choice. Baseline characteristics were similar across the groups. After first procedure, all patients were followed-up for a minimum of 2 years. The success rate at the end of the follow-up was 18% (8 pts), 21% (14 pts), and 61% (40 pts) in Groups 1, 2, and 3, respectively. Cumulative probability of AF-free survival was significantly higher in Group 3 (overall log-rank P <0.01, pairwise comparison 1 vs. 3 and 2 vs. 3 P < 0.01). During repeat procedures, non-PV triggers were ablated in all. After average 1.5 procedures, the success rates were 28 (62%), 41 (62%), and 56 (85%) in Groups 1, 2, and 3, respectively (log-rank P< 0.001). CONCLUSIONS: In patients with PAF and severe LA scarring, PVAI+ ablation of non-PV triggers is associated with significantly better long-term outcome than PVAI alone or PVAI+ scar homogenization.

Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation: BELIEF Trial.

BACKGROUND: Longstanding persistent (LSP) atrial fibrillation (AF) is the most challenging type of AF. In addition to pulmonary vein isolation, substrate modification and triggers ablation have been reported to improve freedom from AF in patients with LSPAF. OBJECTIVES: This study sought to assess whether the empirical electrical isolation of the left atrial appendage (LAA) could improve success at follow-up. METHODS: This was an open-label, randomized study assessing the effectiveness of empirical electrical left atrial appendage isolation for the treatment of LSPAF. Patients were randomly assigned to undergo empirical electrical left atrial appendage isolation along with extensive ablation (group 1; n = 85) or extensive ablation alone (group 2; n = 88). Recurrence of atrial arrhythmias was the primary endpoint. Secondary endpoints included cardiac-related hospitalization, all-cause mortality, and stroke at follow-up. RESULTS: Major clinical characteristics were not different between the 2 groups. At 12-month follow-up, 48 (56%) patients in group 1 and 25 (28%) in group 2 were recurrence free after a single procedure (unadjusted hazard ratio [HR] for recurrence with standard ablation: 1.92; 95% confidence interval [CI]: 1.3 to 2.9; log-rank p = 0.001). After adjusting for age, sex, and left atrial size, standard ablation was predictive of recurrence (HR: 2.22; 95% CI: 1.29 to 3.81; p = 0.004). During repeat procedures, empirical electrical left atrial appendage isolation was performed in all patients. After an average of 1.3 procedures, cumulative success at 24-month follow-up was reported in 65 (76%) in group 1 and in 49 (56%) in group 2 (unadjusted HR: 2.24; 95% CI: 1.3 to 3.8; log-rank p = 0.003). CONCLUSIONS: This randomized study showed that both after a single procedure and after redo procedures in patients with LSPAF, empirical electrical isolation of the LAA improved long-term freedom from atrial arrhythmias without increasing complications. (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Longstanding Persistent Atrial Fibrillation Undergoing Catheter Ablation [BELIEF]; NCT01362738).

Scar Homogenization Versus Limited-Substrate Ablation in Patients With Nonischemic Cardiomyopathy and Ventricular Tachycardia.

BACKGROUND: Scar homogenization improves long-term ventricular arrhythmia-free survival compared with standard limited-substrate ablation in patients with post-infarction ventricular tachycardia (VT). Whether such benefit extends to patients with nonischemic cardiomyopathy and scar-related VT is unclear. OBJECTIVES: The aim of this study was to assess the long-term efficacy of an endoepicardial scar homogenization approach compared with standard ablation in this population. METHODS: Consecutive patients with dilated nonischemic cardiomyopathy (n = 93), scar-related VTs, and evidence of low-voltage regions on the basis of pre-defined criteria on electroanatomic mapping (i.e., bipolar voltage <1.5 mV) underwent either standard VT ablation (group 1 [n = 57]) or endoepicardial ablation of all abnormal potentials within the electroanatomic scar (group 2 [n = 36]). Acute procedural success was defined as noninducibility of any VT at the end of the procedure; long-term success was defined as freedom from any ventricular arrhythmia at follow-up. RESULTS: Acute procedural success rates were 69.4% and 42.1% after scar homogenization and standard ablation, respectively (p = 0.01). During a mean follow-up period of 14 ± 2 months, single-procedure success rates were 63.9% after scar homogenization and 38.6% after standard ablation (p = 0.031). After multivariate analysis, scar homogenization and left ventricular ejection fraction were predictors of long-term success. During follow-up, the rehospitalization rate was significantly lower in the scar homogenization group (p = 0.035). CONCLUSIONS: In patients with dilated nonischemic cardiomyopathy, scar-related VT, and evidence of low-voltage regions on electroanatomic mapping, endoepicardial homogenization of the scar significantly increased freedom from any recurrent ventricular arrhythmia compared with a standard limited-substrate ablation. However, the success rate with this approach appeared to be lower than previously reported with ischemic cardiomyopathy, presumably because of the septal and midmyocardial distribution of the scar in some patients.

Pulmonary Vein Antrum Isolation in Patients With Paroxysmal Atrial Fibrillation: More Than a Decade of Follow-Up.

BACKGROUND: We report the outcome of pulmonary vein (PV) antrum isolation in paroxysmal atrial fibrillation (AF) patients over more than a decade of follow-up. METHODS AND RESULTS: A total of 513 paroxysmal AF patients (age 54±11 years, 73% males) undergoing catheter ablation at our institutions were included in this analysis. PV antrum isolation extended to the posterior wall between PVs plus empirical isolation of the superior vena cava was performed in all. Non-PV triggers were targeted during repeat procedure(s). Follow-up was performed quarterly for the first year and every 6 to 9 months thereafter. The outcome of this study was freedom from recurrent AF/atrial tachycardia. At 12 years, single-procedure arrhythmia-free survival was achieved in 58.7% of patients. Overall, the rate of recurrent arrhythmia (AF/atrial tachycardia) was 21% at 1 year, 11% between 1 and 3 years, 4% between 3 and 6 years, and 5.3% between 6 and 12 years. Repeat procedure was performed in 74% of patients. Reconnection in the PV antrum was found in 31% of patients after a single procedure and in no patients after 2 procedures. Non-PV triggers were found and targeted in all patients presenting with recurrent arrhythmia after ≥2 procedures. At 12 years, after multiple procedures, freedom from recurrent AF/atrial tachycardia was achieved in 87%. CONCLUSIONS: In patients with paroxysmal AF undergoing extended PV antrum isolation, the rate of late recurrence is lower than what previously reported with segmental or less extensive antral isolation. However, over more than a decade of follow-up, nearly 14% of patients developed recurrence because of new non-PV triggers.

Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device: Results From the AATAC Multicenter Randomized Trial.

BACKGROUND: Whether catheter ablation (CA) is superior to amiodarone (AMIO) for the treatment of persistent atrial fibrillation (AF) in patients with heart failure is unknown. METHODS AND RESULTS: This was an open-label, randomized, parallel-group, multicenter study. Patients with persistent AF, dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator, New York Heart Association II to III, and left ventricular ejection fraction <40% within the past 6 months were randomly assigned (1:1 ratio) to undergo CA for AF (group 1, n=102) or receive AMIO (group 2, n=101). Recurrence of AF was the primary end point. All-cause mortality and unplanned hospitalization were the secondary end points. Patients were followed up for a minimum of 24 months. At the end of follow-up, 71 (70%; 95% confidence interval, 60%-78%) patients in group 1 were recurrence free after an average of 1.4±0.6 procedures in comparison with 34 (34%; 95% confidence interval, 25%-44%) in group 2 (log-rank P<0.001). The success rate of CA in the different centers after a single procedure ranged from 29% to 61%. After adjusting for covariates in the multivariable model, AMIO therapy was found to be significantly more likely to fail (hazard ratio, 2.5; 95% confidence interval, 1.5-4.3; P<0.001) than CA. Over the 2-year follow-up, the unplanned hospitalization rate was (32 [31%] in group 1 and 58 [57%] in group 2; P<0.001), showing 45% relative risk reduction (relative risk, 0.55; 95% confidence interval, 0.39-0.76). A significantly lower mortality was observed in CA (8 [8%] versus AMIO (18 [18%]; P=0.037). CONCLUSIONS: This multicenter randomized study shows that CA of AF is superior to AMIO in achieving freedom from AF at long-term follow-up and reducing unplanned hospitalization and mortality in patients with heart failure and persistent AF. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00729911.

Is transesophageal echocardiogram mandatory in patients undergoing ablation of atrial fibrillation with uninterrupted novel oral anticoagulants? Results from a prospective multicenter registry.

BACKGROUND: Transesophageal echocardiography (TEE) is recommended in patients undergoing atrial fibrillation (AF) ablation, but use of this strategy is variable. OBJECTIVE: To evaluate whether TEE is necessary before AF ablation in patients treated with novel oral anticoagulants (NOACs). METHODS: We performed a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted NOACs (apixaban and rivaroxaban). All patients were on NOACs for at least 4 weeks before ablation. Heparin bolus was administered to all patients before transseptal catheterization to maintain a target activated clotting time above 300 seconds. A subset of 86 patients underwent brain diffuse magnetic resonance imaging (dMRI) to detect silent cerebral ischemia (SCI). RESULTS: A total of 970 patients (514 [53%] apixaban patients and 456 [47%] rivaroxaban patients) were enrolled for this study. The mean age was 69.5 ± 9.0 years, with 824 patients (85%) having nonparoxysmal AF, and 636 patients (65.6%) were male. The average CHA2DS2-VASc score was 3.01 ± 1.3 and CHADS2 score was ≥2 in 609 patients (62.8%). Intracardiac echocardiogram ruled out left atrial appendage thrombus in all patients whose left atrial appendage was visualized (692, 71%), and detected "smoke" in 407 patients (42%). SCI at postprocedure dMRI was detected in 2.3% (2/86). One thromboembolic event (transient ischemic attack) (0.10%) with positive dMRI occurred in a patient on uninterrupted rivaroxaban with longstanding persistent AF. CONCLUSION: Our study illustrates that performing AF ablation while on uninterrupted apixaban and rivaroxaban without TEE is feasible and safe. This finding has important clinical and economic relevance.

Management of Periprocedural and Early Pericardial Effusions With Tamponade Following Ablation of Atrial Fibrillation With Uninterrupted Factor Xa Inhibitors: A Case Series.

INTRODUCTION: Because of the absence of a dedicated reversal agent, the outcome of pericardial effusion (PE) following procedures performed with uninterrupted apixaban or rivaroxaban is unknown. We report the characteristics of PEs presenting with tamponade in patients undergoing AF ablation with uninterrupted factor Xa inhibition (FXaI) to understand their management and prognosis. METHODS AND RESULTS: We performed a multicenter cross-sectional survey in 10 centers across the United States. Patient data were obtained by chart review. In all patients the procedure was performed with uninterrupted FXaI. A total of 16 PEs requiring intervention were reported from 5 centers. Two patients were on apixaban 5 mg BD, the remaining on rivaroxaban 20 mg OD. Eleven PEs occurred in the periprocedural setting, and 5 PEs occurred from 1 to 28 days after the procedure. Pericardiocentesis and drainage were performed in all cases. Protamine and 4-factor prothrombin complex concentrate (4F-PCC) were given in all periprocedural cases. Two patients required surgery: in one case coagulation of the pericardial blood prevented effective drainage, and in the other bleeding was secondary to a steam pop-induced atrial tear. None of the postprocedural cases required FXaI reversal and the dose of rivaroxaban was temporarily reduced. No fatal outcomes or thromboembolic events were reported. CONCLUSION: Pericardiocentesis and drainage with FXaI reversal proved effective in the management of acute PEs with tamponade occurring periprocedurally in patients undergoing AF ablation with uninterrupted FXaI. Early postprocedural effusions can be treated with pericardiocentesis without the need of a reversal agent.

Importance of non-pulmonary vein triggers ablation to achieve long-term freedom from paroxysmal atrial fibrillation in patients with low ejection fraction.

BACKGROUND: Whether ablation of non-pulmonary vein (PV) triggers after pulmonary vein antrum isolation (PVAI) improves the long-term procedure outcome in patients with paroxysmal atrial fibrillation (PAF) and left ventricular systolic dysfunction is unknown. OBJECTIVE: We sought to evaluate whether a more extensive ablation procedure improves outcomes at follow-up. METHODS: Consecutive patients with PAF refractory to antiarrhythmic drugs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: patients with left ventricular ejection fraction (LVEF) ≤35% (group I; n = 175) and patients with LVEF ≥50% (group II; n = 545). Patients in group I were further divided according to whether additional ablation of non-PV triggers was performed (group IA; n = 88) or not (group IB; n = 87). Long-term ablation success off antiarrhythmic drugs after a single procedure was analyzed. RESULTS: Patients in group I had more non-PV triggers than did patients in group II (69.1% vs 26.6%; P < .001). During a follow-up of 15.8 ± 4.7 months, fewer patients in group I remained free from recurrences than those in group II (53.7% vs 81.7%; P < .001). Long-term ablation success was higher in group IA than in group IB (75.0% vs 32.2%; P < .001) and similar to that in group II (75.0% vs 81.7%; P = .44). In multivariate analysis, LVEF ≤35% (hazard ratio 1.68; P = .003) and non-PV triggers (hazard ratio 3.12; P < .001) were independent predictors of recurrences. CONCLUSION: In patients with PAF and left ventricular systolic dysfunction, ablation of non-PV triggers in addition to PVAI significantly improves their long-term procedure outcome.