Strategies for repeat ablation for atrial fibrillation: A multicentre comparison of nonpulmonary vein versus pulmonary vein target ablation.

INTRODUCTION: Approximately 18% of patients with atrial fibrillation (AF) undergo a repeat ablation within 12 months after their index ablation. Despite the high prevalence, comparative studies on nonpulmonary vein (PV) target strategies in repeat AF ablation are scarce. Here, we describe 12 months efficacy of non-PV and PV target ablations as a repeat ablation strategy. METHODS: A multicentre retrospective, descriptive study was conducted with data of 280 patients who underwent repeat AF ablation. The ablation strategy for repeat ablation was at the operators' discretion. Non-PV target ablation (n = 140) included PV reisolation, posterior wall isolation, mitral line, roofline, and/or complex fractionated atrial electrogram ablation. PV target ablation (n = 140), included reisolation and/or wide atrium circumferential ablation. Patients' demographics and rhythm outcomes during 12 months follow-up were analyzed. RESULTS: At 12 months, more atrial tachyarrhythmias were observed in the non-PV target group (48.6%) compared to the PV target group (29.3%, p = .001). Similarly, a significantly higher AF and atrial tachycardia (AT) recurrence rate was observed after non-PV target ablation compared to PV target ablation (36.4% vs. 22.1% and 22.9% vs. 10.7%). After adjustment, a significantly higher risk of AT recurrence remained in the non-PV target group. Both groups significantly de-escalated antiarrhythmic drug use; de-escalation was more profound after PV target ablation. Patients with isolated PVs during non-PV target ablation had a significantly higher risk for AF recurrence than those with reconnected PVs. CONCLUSION: Compared to PV target ablation, non-PV target repeat ablation did not improve outcomes after 12 months and was independently associated with an increased risk for AT recurrences.

Intermediate-term outcome of cryoballoon ablation of persistent atrial fibrillation and improvements in quality of life of patients.

BACKGROUND: Clinical outcome of pulmonary vein isolation (PVI) has been predominantly focused on the reoccurrence of atrial fibrillation (AF) and the maintenance of sinus rhythm. However, there has been a limited intermediate follow-up on health-related quality-of-life (HRQoL) of patients. Given the relatively high recurrence rate of persistent AF after PVI treatment, it is important to follow up with clinical outcomes on symptom improvement as well as health-related quality-of-life. This study was designed to investigate the recurrence rate of atrial tachyarrhythmia (ATa), AF-related symptoms and HRQoL after PVI in patients with persistent AF who were treated with the second generation cryoballoon. METHODS: Total 148 patients participated in the study who were treated by PVI between 2013 and 2017 for persistent AF. All patients visited the out-patient clinic 2-5 years after PVI. During this visit all patients filled-out an AF Effect on Quality-of-life (AFEQT) questionnaire and a seven-day Holter was applied. All rhythm recordings acquired post ablation were collected and analysed, and the modified European Heart Rhythm Association score (mEHRA) scores were calculated before and after the ablation. RESULTS: The average age of patients was 63±9 year old and 44 (27.9%) were female. Mean CHA2DS2 VASc score was 1.9±1.4, and moderate and severe left atrial (LA) dilation was present in 53 (36.1%) and 15 (10.2%) patients, respectively. After a follow-up of 3.7±1.0 years, 81 (54.7%) patients had an ATa recurrence and 35 (23.6%) patients underwent a repeat LA ablation. However, the mEHRA score significantly improved in 80.4% of the patients (p <0.001), with the median overall AFEQT score of 88.9 [70.4-97.2]. CONCLUSIONS: There is a considerable ATa recurrence rate after PVI of persistent AF at intermediate-term follow-up. However, our data indicate that PVI significantly improved AF-related symptoms and resulted in a high HRQoL for 2-5 years in patients with persistent AF.

Dutch Outcome in Implantable Cardioverter-Defibrillator Therapy: Implantable Cardioverter-Defibrillator-Related Complications in a Contemporary Primary Prevention Cohort.

Background One third of primary prevention implantable cardioverter-defibrillator patients receive appropriate therapy, but all remain at risk of defibrillator complications. Information on these complications in contemporary cohorts is limited. This study assessed complications and their risk factors after defibrillator implantation in a Dutch nationwide prospective registry cohort and forecasts the potential reduction in complications under distinct scenarios of updated indication criteria. Methods and Results Complications in a prospective multicenter registry cohort of 1442 primary implantable cardioverter-defibrillator implant patients were classified as major or minor. The potential for reducing complications was derived from a newly developed prediction model of appropriate therapy to identify patients with a low probability of benefitting from the implantable cardioverter-defibrillator. During a follow-up of 2.2 years (interquartile range, 2.0-2.6 years), 228 complications occurred in 195 patients (13.6%), with 113 patients (7.8%) experiencing at least one major complication. Most common ones were lead related (n=93) and infection (n=18). Minor complications occurred in 6.8% of patients, with lead-related (n=47) and pocket-related (n=40) complications as the most prevailing ones. A surgical reintervention or additional hospitalization was required in 53% or 61% of complications, respectively. Complications were strongly associated with device type. Application of stricter implant indication results in a comparable proportional reduction of (major) complications. Conclusions One in 13 patients experiences at least one major implantable cardioverter-defibrillator-related complication, and many patients undergo a surgical reintervention. Complications are related to defibrillator implantations, and these should be discussed with the patient. Stricter implant indication criteria and careful selection of device type implanted may have significant clinical and financial benefits.

Effect of remote monitoring on patient-reported outcomes in European heart failure patients with an implantable cardioverter-defibrillator: primary results of the REMOTE-CIED randomized trial.

AIMS: The European REMOTE-CIED study is the first randomized trial primarily designed to evaluate the effect of remote patient monitoring (RPM) on patient-reported outcomes in the first 2 years after implantation of an implantable cardioverter-defibrillator (ICD). METHODS AND RESULTS: The sample consisted of 595 European heart failure patients implanted with an ICD compatible with the Boston Scientific LATITUDE® RPM system. Patients were randomized to RPM plus a yearly in-clinic ICD check-up vs. 3-6-month in-clinic check-ups alone. At five points during the 2-year follow-up, patients completed questionnaires including the Kansas City Cardiomyopathy Questionnaire and Florida Patient Acceptance Survey (FPAS) to assess their heart failure-specific health status and ICD acceptance, respectively. Information on clinical status was obtained from patients' medical records. Linear regression models were used to compare scores between groups over time. Intention-to-treat and per-protocol analyses showed no significant group differences in patients' health status and ICD acceptance (subscale) scores (all Ps > 0.05). Exploratory subgroup analyses indicated a temporary improvement in device acceptance (FPAS total score) at 6-month follow-up for secondary prophylactic in-clinic patients only (P < 0.001). No other significant subgroup differences were observed. CONCLUSION: Large clinical trials have indicated that RPM can safely and effectively replace most in-clinic check-ups of ICD patients. The REMOTE-CIED trial results show that patient-reported health status and ICD acceptance do not differ between patients on RPM and patients receiving in-clinic check-ups alone in the first 2 years after ICD implantation.ClinicalTrials.gov Identifier: NCT01691586.

One-year follow-up in a prospective, randomized study comparing radiofrequency and cryoablation of arrhythmias in Koch's triangle: clinical symptoms and event recording.

AIMS: To rely solely on clinical symptoms of recurrent palpitations to evaluate the success of interventional procedures can be misleading. This study was designed to assess the efficacy of event recording in evaluating long-term success in patients treated for atrioventricular nodal reentrant tachycardia (AVNRT) or right posteroseptally located accessory pathways (RPS) either by radiofrequency (RF) or by cryoablation (CA). METHODS AND RESULTS: Sixty-three patients with AVNRT and eight with RPS were randomized. Patients were encouraged to activate an event recorder in the case of recurrent palpitations for the first 3 months. One year after the procedure, patients were asked specific arrhythmia related questions. Thirty-six patients underwent RF and 35 CA. Acute success was finally achieved in 34 (94%) patients in the RF and 33 (94%) in the CA groups. Assessment of long-term success demonstrated a similar proportion of palpitations in the RF and CA groups: 11 (31%) vs. 17 (49%). Only 12 patients activated the event recorder, four patients in RF, including one patient with chest pain, and eight in the CA group. Analysis of recordings revealed recurrent AVNRT or circus movement tachycardia in four patients (one RF and three CA), atrial fibrillation in one RF patient, and sinus tachycardia in six (one RF and five with CA). In addition, a complete 12 lead ECG of a recurrent arrhythmia was made in three RF and two CA patients (in-hospital or after the event recording). A total of seven patients underwent a second procedure (four RF and three CA). Without the event recorder, seven patients would have been misclassified as having recurrent arrhythmia. CONCLUSION: Event recording enhances the sensitivity of detecting arrhythmia recurrences in evaluating therapy efficacy and should be considered in every interventional follow-up study. Analysis of recordings showed that CA is as effective as RF in the treatment of AVNRT and RPS at long-term follow-up.

Ablation lesions in Koch's triangle assessed by three-dimensional myocardial contrast echocardiography.

BACKGROUND: Myocardial contrast echocardiography (MCE) allows visualization of radiofrequency (RF) ablation lesions in the left ventricle in an animal model. AIM: To test whether MCE allows visualization of RF and cryo ablation lesions in the human right atrium using three-dimensional echocardiography. METHODS: 18 patients underwent catheter ablation of a supraventricular tachycardia and were included in this prospective single-blind study. Twelve patients were ablated inside Koch's triangle and 6, who served as controls, outside this area. Three-dimensional echocardiography of Koch's triangle was performed before and after the ablation procedure in all patients, using respiration and ECG gated pullback of a 9 MHz ICE transducer, with and without continuous intravenous echocontrast infusion (SonoVue, Bracco). Two independent observers analyzed the data off-line. RESULTS: MCE identified ablation lesions as a low contrast area within the normal atrial myocardial tissue. Craters on the endocardial surface were seen in 10 (83%) patients after ablation. Lesions were identified in 11 out of 12 patients (92%). None of the control patients were recognized as having been ablated. The confidence score of the independent echo reviewer tended to be higher when the number of applications increased. CONCLUSIONS: 1. MCE allows direct visualization of ablation lesions in the human atrial myocardium. 2. Both RF and cryo energy lesions can be identified using MCE.

Effects of septal pacing on P wave characteristics: the value of three-dimensional echocardiography.

Interatrial septum (IAS) pacing has been proposed for the prevention of paroxysmal atrial fibrillation. IAS pacing is usually guided by fluoroscopy and P wave analysis. The authors have developed a new approach for IAS pacing using intracardiac echocardiography (ICE), and examined its effects on P wave characteristics. Cross-sectional images are acquired during pullback of the ICE transducer from the superior vena cava into the inferior vena cava by an electrocardiogram- and respiration-gated technique. The right atrium and IAS are then three-dimensionally reconstructed, and the desired pacing site is selected. After lead placement and electrical testing, another three-dimensional reconstruction is performed to verify the final lead position. The study included 14 patients. IAS pacing was achieved at seven suprafossal (SF) and seven infrafossal (IF) lead locations, all confirmed by three-dimensional imaging. IAS pacing resulted in a significant reduction of P wave duration as compared to sinus rhythm (99.7 +/- 18.7 vs 140.4 +/- 8.8 ms; P < 0.01). SF pacing was associated with a greater reduction of P wave duration than IF pacing (56.1 +/- 9.9 vs 30.2 +/- 13.6 ms; P < 0.01). P wave dispersion remained unchanged during septal pacing as compared to sinus rhythm (21.4 +/- 16.1 vs 13.5 +/- 13.9 ms; NS). Three-dimensional intracardiac echocardiography can be used to guide IAS pacing. SF pacing was associated with a greater decrease in P wave duration, suggesting that it is a preferable location to decrease interatrial conduction delay.

Interatrial septum pacing guided by three-dimensional intracardiac echocardiography.

OBJECTIVES: Currently, the interatrial septum (IAS) pacing site is indirectly selected by fluoroscopy and P-wave analysis. The aim of the present study was to develop a novel approach for IAS pacing using intracardiac echocardiography (ICE). BACKGROUND: Interatrial septum pacing may be beneficial for the prevention of paroxysmal atrial fibrillation. METHODS: Cross-sectional images are acquired during a pull-back of the ICE transducer from the superior vena cava into the inferior vena cava by an electrocardiogram- and respiration-gated technique. Both atria are then reconstructed using three-dimensional (3D) imaging. Using an "en face" view of the IAS, the desired pacing site is selected. Following lead placement and electrical testing, another 3D reconstruction is performed to verify the final lead position. RESULTS: Twelve patients were included in this study. The IAS pacing was achieved in all patients including six suprafossal (SF) and six infrafossal (IF) lead locations all confirmed by 3D imaging. The mean duration times of atrial lead implantation and fluoroscopy were 70 +/- 48.9 min and 23.7 +/- 20.6 min, respectively. The IAS pacing resulted in a significant reduction of the P-wave duration as compared to sinus rhythm (98.9 +/- 19.3 ms vs. 141.3 +/- 8.6 ms; p < 0.002). The SF pacing showed a greater reduction of the P-wave duration than IF pacing (59.4 +/- 6.6 ms vs. 30.2 +/- 13.6 ms; p < 0.004). CONCLUSIONS: Three-dimensional ICE is a feasible tool for guiding IAS pacing.

Transthoracic defibrillation of short-lasting ventricular fibrillation: a randomised trial for comparison of the efficacy of low-energy biphasic rectilinear and monophasic damped sine shocks.

BACKGROUND: Biphasic rectilinear shocks are more effective than monophasic shocks for transthoracic atrial defibrillation and for ventricular arrhythmias during electrophysiological testing. We undertook the present study to compare the efficacy of 100 J rectilinear biphasic waveform shocks with 150 J monophasic damped sine waveform shocks for transthoracic defibrillation of true ventricular fibrillation during defibrillation threshold testing (DFT). The second aim of the study was to analyse the influence of patch positions on the efficacy of defibrillation. METHODS: 50 episodes of 14 patients (age ranging from 37 to 82 years) who underwent DFT testing were randomised for back-up shocks with either a sequence of 100 and 200 J biphasic waveform, or a sequence of 150 and 360 J conventional monophasic shocks. A binary search protocol was used at implantation and before hospital discharge. Patients were also randomised to an anteroposterior position versus a right-anterior-apical position. A crossover was performed between implantation and pre-hospital discharge for biphasic versus monophasic sequence as well as for the 2 different positions. RESULTS: After failed internal shocks, 27 episodes were treated with biphasic, and 23 with monophasic shocks. The first attempt by the external device did not terminate II episodes (2 biphasic, 9 monophasic). The first shock efficacy was significantly greater with biphasic than with monophasic shocks (p < 0.02). The overall success rate was 93% with biphasic shocks and 64% with monophasic shocks. In multivariate regression analysis including patch position, arrhythmia duration, type of waveform, testing order and session, only waveform was associated with successful defibrillation (p < 0.02). CONCLUSION: For transthoracic defibrillation of ventricular fibrillation, low-energy rectilinear biphasic shocks are more effective than monophasic shocks. The position of the defibrillation shock pads has no influence on the biphasic shock efficacy, but anteroposterior pad position is more effective using monophasic shocks.