Clinical impact of aging on outcomes of cardioneuroablation for reflex syncope or functional bradycardia: Results from the cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs-The ELEGANCE multicenter study.

BACKGROUND: Cardioneuroablation (CNA) is a novel treatment for reflex syncope. The effect of aging on CNA efficacy is not fully understood. OBJECTIVE: The purpose of this study was to assess the impact of aging on candidacy and efficacy of CNA for treating vasovagal syncope (VVS), carotid sinus syndrome (CSS), and functional bradyarrhythmia. METHODS: The ELEGANCE (cardionEuroabLation: patiEnt selection, imaGe integrAtioN and outComEs) multicenter study assessed CNA in patients with reflex syncope or severe functional bradyarrhythmia. Patients underwent pre-CNA Holter electrocardiography (ECG), head-up tilt testing (HUT), and electrophysiological study. CNA candidacy and efficacy was assessed in 14 young (18-40 years), 26 middle-aged (41-60 years), and 20 older (>60 years) patients. RESULTS: Sixty patients (37 men; mean age 51 ± 16 years) underwent CNA. The majority (80%) had VVS, 8% had CSS, and 12% had functional bradycardia/atrioventricular block. Pre-CNA Holter ECG, HUT, and electrophysiological findings did not differ across age groups. Acute CNA success was 93%, without differences between age groups (P = .42). Post-CNA HUT response was negative in 53%, vasodepressor in 38%, cardioinhibitory in 7%, and mixed in 2%, without differences across age groups (P = .59). At follow-up (8 months, interquartile range 4-15), 53 patients (88%) were free of symptoms. Kaplan-Meier curves did not show differences in event-free survival between age groups (P = .29). The negative predictive value of a negative HUT was 91.7%. CONCLUSION: CNA is a viable treatment for reflex syncope and functional bradyarrhythmia in all ages, and is highly effective in mixed VVS. HUT is a key step in postablation clinical assessment.

Outcomes of cavotricuspid isthmus-dependent flutter ablation: randomized study comparing single vs. multiple catheter procedures-the SIMPLE study.

BACKGROUND: Catheter ablation is recommended as first-line therapy for patients with symptomatic typical AFl. Although the conventional multi-catheter approach is the standard of care for cavotricuspid isthmus (CTI) ablation, a single-catheter approach was recently described as a feasible alternative. The present study sought to compare safety, efficacy, and efficiency of single vs. multi-catheter approach for atrial flutter (AFl) ablation. METHODS: In this randomized multi-center study, consecutive patients referred for AFl ablation (n = 253) were enrolled and randomized to multiple vs. single-catheter approach for CTI ablation. In the single-catheter arm, PR interval (PRI) on the surface ECG was used to prove CTI block. Procedural and follow-up data were collected and compared between the two arms. RESULTS: 128 and 125 patients were assigned to the single-catheter and to the multi-catheter arms, respectively. In the single-catheter arm, procedure time was significantly shorter (37 ± 25 vs. 48 ± 27 minutes, p = 0.002) and required less fluoroscopy time (430 ± 461 vs. 712 ± 628 seconds, p < 0.001) and less radiofrequency time (428 ± 316 vs. 643 ± 519 seconds, p < 0.001), achieving a higher first-pass CTI block rate (55 (45%) vs. 37 (31%), p = 0.044), compared with the multi-catheter arm. After a median follow-up of 12 months, 11 (4%) patients experienced AFl recurrences (5 (4%) in the single-catheter arm and 6 (5%) in the multi-catheter arm, p = 0.99). No differences were found in arrhythmia-free survival between arms (log-rank = 0.71). CONCLUSIONS: The single-catheter approach for typical AFl ablation is not inferior to the conventional multiple-catheter approach, reducing procedure, fluoroscopy, and radiofrequency time.

Preventive substrate ablation in chronic post-myocardial infarction patients with high-risk scar characteristics for ventricular arrhythmias: rationale and design of PREVENT-VT study.

BACKGROUND: Recent studies showed that an early strategy for ventricular tachycardia (VT) ablation resulted in reduction of VT episodes or mortality. Cardiac magnetic resonance (CMR)-derived border zone channel (BZC) mass has proved to be a strong non-invasive predictor of VT in post-myocardial infarction (MI). CMR-guided VT substrate ablation proved to be safe and effective for reducing sudden cardiac death (SCD) and VA occurrence. METHODS: PREVENT-VT is a prospective, randomized, multicenter, and controlled trial designed to evaluate the safety and efficacy of prophylactic CMR-guided VT substrate ablation in chronic post-MI patients with CMR-derived arrhythmogenic scar characteristics. Chronic post-MI patients with late gadolinium enhancement (LGE) CMR will be evaluated. CMR images will be post-processed and the BZC mass measured: patients with a BZC mass > 5.15 g will be eligible. Consecutive patients will be enrolled at 3 centers and randomized on a 1:1 basis to undergo a VT substrate ablation (ABLATE arm) or optimal medical treatment (OMT arm). Primary prevention ICD will be implanted following guideline recommendations, while non-ICD candidates will be implanted with an implantable cardiac monitor (ICM). The primary endpoint is a composite outcome of sudden cardiac death (SCD) or sustained monomorphic VT, either treated by an ICD or documented with ICM. Secondary endpoints are procedural safety and efficiency outcomes of CMR-guided ablation. DISCUSSION: In some patients, the first VA episode causes SCD or severe neurological damage. The aim of the PREVENT-VT is to evaluate whether primary preventive substrate ablation may be a safe and effective prophylactic therapy for reducing SCD and VA occurrence in patients with previous MI and high-risk scar characteristics based on CMR. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04675073, registered on January 1, 2021.

Scar Characterization to Predict Life-Threatening Arrhythmic Events and Sudden Cardiac Death in Patients With Cardiac Resynchronization Therapy: The GAUDI-CRT Study.

OBJECTIVES: The aim of this study was to analyze whether scar characterization could improve the risk stratification for life-threatening ventricular arrhythmias and sudden cardiac death (SCD). BACKGROUND: Among patients with a cardiac resynchronization therapy (CRT) indication, appropriate defibrillator (CRT-D) therapy rates are low. METHODS: Primary prevention patients with a class I indication for CRT were prospectively enrolled and assigned to CRT-D or CRT pacemaker according to physician's criteria. Pre-procedure contrast-enhanced cardiac magnetic resonance was obtained and analyzed to identify scar presence or absence, quantify the amount of core and border zone (BZ), and depict BZ distribution. The presence, mass, and characteristics of BZ channels in the scar were recorded. The primary endpoint was appropriate defibrillator therapy or SCD. RESULTS: 217 patients (39.6% ischemic) were included. During a median follow-up of 35.5 months (12 to 62 months), the primary endpoint occurred in 25 patients (11.5%) and did not occur in patients without myocardial scar. Among patients with scar (n = 125, 57.6%), those with implantable cardioverter-defibrillator (ICD) therapies or SCD exhibited greater scar mass (38.7 ± 34.2 g vs. 17.9 ± 17.2 g; p < 0.001), scar heterogeneity (BZ mass/scar mass ratio) (49.5 ± 13.0 vs. 40.1 ± 21.7; p = 0.044), and BZ channel mass (3.6 ± 3.0 g vs. 1.8 ± 3.4 g; p = 0.018). BZ mass (hazard ratio: 1.06 [95% confidence interval: 1.04 to 1.08]; p < 0.001) and BZ channel mass (hazard ratio: 1.21 [95% confidence interval: 1.10 to 1.32]; p < 0.001) were the strongest predictors of the primary endpoint. An algorithm based on scar mass and the absence of BZ channels identified 148 patients (68.2%) without ICD therapy/SCD during follow-up with a 100% negative predictive value. CONCLUSIONS: The presence, extension, heterogeneity, and qualitative distribution of BZ tissue of myocardial scar independently predict appropriate ICD therapies and SCD in CRT patients.

Evolución de la mejora en los resultados y las complicaciones de la ablación por catéter de la fibrilación auricular: aprendizaje, técnicas y metodología / Improved outcomes and complications of atrial fibrillation catheter ablation over time: learning curve, techniques, and methodology

Introducción y objetivos. Los resultados y las complicaciones del procedimiento de ablación de fibrilación auricular varían ampliamente entre los diferentes centros. Nuestro objetivo es analizar los resultados y las complicaciones derivadas de este procedimiento en nuestro centro e identificar los factores predictores de éxito y de seguridad. Métodos. Entre 2002 y 2009 se realizó un total de 726 procedimientos de ablación de fibrilación auricular. Basándonos en la aplicación sistemática de un protocolo de anticoagulación y sedación consciente desde enero 2008, podemos establecer dos estrategias de ablación que constituyen dos grupos bien diferenciados: grupo A, constituido por 419 procedimientos realizados antes de enero 2008, y grupo B, formado por 307 procedimientos realizados después. Resultados. El 60,9% de los pacientes no presentaron recurrencia arrítmica tras varios procedimientos durante un seguimiento medio de 8,7 meses. Con un único procedimiento, la tasa total de éxito fue del 41%, significativamente mayor entre los pacientes del grupo B (el 51,6 frente al 35,2% de éxito en el grupo A; p = 0,001). Hubo un total de 31 complicaciones mayores (4,2%); 26 en el grupo A (6,2%) y 5 en el grupo B (1,6%) (p = 0,002). La protocolización del procedimiento fue un factor predictor de la ausencia de complicaciones (odds ratio = 0,406; intervalo de confianza del 95%, 0,214-0,769; p < 0,006). Conclusiones. La aplicación sistemática de un protocolo de anticoagulación y sedación consciente se asocia a la mejora de los resultados y la reducción de las complicaciones en el procedimiento de ablación de fibrilación auricular. Otros factores no evaluados en este estudio, como la curva de aprendizaje de los operadores y la progresiva mejora tecnológica, pueden haber influido en los cambios observados (AU)

Introduction and objectives. The outcomes of atrial fibrillation ablation procedures vary widely between different centers. Our objective was to analyze the results and complications of this procedure in our center and identify factors predicting the efficacy and safety of atrial fibrillation ablation. Methods. In total, 726 atrial fibrillation ablation procedures were performed in our center between 2002 and 2009. Beginning in January 2008, a protocol for anticoagulation and conscious sedation was systematically applied. Outcomes and complications could therefore be compared in 2 well-differentiated groups: group A included 419 procedures performed prior to 2008 and group B included 307 procedures completed after 2008 using the new protocol. Results. During an average follow-up of 8.7 months, 60.9% of patients were arrhythmia-free after one or repeat procedures. After only 1 procedure, the success rate was 41% and significantly higher in group B (51.6% vs 35.2% in group A; P=.001). There were 31 major complications (4.2%), 26 in group A (6.2%) and 5 in group B (1.6%) (P=.002). The implementation of the new protocol was an independent predictor of the absence of complications (odds ratio=0.406; 95% confidence interval, 0.214-0.769; P<.006). Conclusions. Systematic application of an anticoagulation and conscious sedation protocol is associated with improved results and fewer complications of atrial fibrillation ablation. Factors not evaluated in the present study, such as operator experience and ongoing improvements in atrial fibrillation ablation technology, could have influenced these findings (AU)

Improved outcomes and complications of atrial fibrillation catheter ablation over time: learning curve, techniques, and methodology.

INTRODUCTION AND OBJECTIVES: The outcomes of atrial fibrillation ablation procedures vary widely between different centers. Our objective was to analyze the results and complications of this procedure in our center and identify factors predicting the efficacy and safety of atrial fibrillation ablation. METHODS: In total, 726 atrial fibrillation ablation procedures were performed in our center between 2002 and 2009. Beginning in January 2008, a protocol for anticoagulation and conscious sedation was systematically applied. Outcomes and complications could therefore be compared in 2 well-differentiated groups: group A included 419 procedures performed prior to 2008 and group B included 307 procedures completed after 2008 using the new protocol. RESULTS: During an average follow-up of 8.7 months, 60.9% of patients were arrhythmia-free after one or repeat procedures. After only 1 procedure, the success rate was 41% and significantly higher in group B (51.6% vs 35.2% in group A; P=.001). There were 31 major complications (4.2%), 26 in group A (6.2%) and 5 in group B (1.6%) (P=.002). The implementation of the new protocol was an independent predictor of the absence of complications (odds ratio=0.406; 95% confidence interval, 0.214-0.769; P<.006). CONCLUSIONS: Systematic application of an anticoagulation and conscious sedation protocol is associated with improved results and fewer complications of atrial fibrillation ablation. Factors not evaluated in the present study, such as operator experience and ongoing improvements in atrial fibrillation ablation technology, could have influenced these findings.

Low efficacy of atrial fibrillation ablation in severe obstructive sleep apnoea patients.

AIMS: Atrial fibrillation (AF) ablation efficacy varies according to patients' clinical characteristics. Although the association of obstructive sleep apnoea (OSA) and AF is well established, data on AF ablation efficacy in OSA are scarce. The aim of this study was to clarify the effect of OSA on the outcome of AF ablation. METHODS AND RESULTS: A series of 174 consecutive patients without polysomnography submitted to circumferential pulmonary vein ablation were included in the study. All patients were assessed by Berlin Questionnaire (BQ) and underwent an echocardiogram and a clinical evaluation. Patients with a high BQ score, indicating high risk for OSA, participated in a sleep study. Diagnoses were classified according to the apnoea-hypoapnoea index (AHI) as mild (AHI < 10/h), non-severe (AHI < 30/h), or severe (AHI >or= 30/h) OSA. Follow-up consisted of outpatient visits and 24 or 48 h Holter monitoring at 1, 4, and 7 months, and every 6 months thereafter. Any episode of AF or left atrial (LA) flutter was considered recurrence. Fifty-one (29.3%) patients had high BQ scores. The sleep study showed that 17 (9.8%) and 25 (14.4%) of these patients had non-severe and severe OSA, respectively. One-year arrhythmia-free probability after a single ablation procedure was 48.5% in patients with low risk for OSA (low BQ score or AHI < 10/h), 30.4% in the non-severe OSA group (10 < AHI < 30/h) and 14.3% in the severe OSA group (AHI >or= 30). Anteroposterior LA diameter [hazard ratio (HR) = 1.046, 95% confidence interval (CI): 1.005-1.089; P = 0.029] and severe OSA (HR = 1.870, 95% CI: 1.106-3.161; P = 0.019) were the independent predictors of arrhythmia recurrence. CONCLUSION: In patients with AF ablation, the presence of severe OSA is an independent predictor for AF ablation failure.

Circumferential pulmonary vein ablation: does use of a circular mapping catheter improve results? A prospective randomized study.

BACKGROUND: The best method for performing atrial fibrillation (AF) ablation is still under debate. The importance of using a circular mapping (CM) catheter for assessing isolation of the pulmonary vein (PV) antrum on the outcome of the procedure has not been clearly established. OBJECTIVE: The purpose of this study was to evaluate whether use of a CM catheter improves the arrhythmia-free proportion after circumferential pulmonary vein ablation (CPVA). METHODS: A series of 146 consecutive patients (83% males, age 53 +/- 10 years, 53% paroxysmal AF) were randomized to two ablation strategies. In both groups, ipsilateral PV encirclement was performed until disappearance or dissociation of the local electrogram within the surrounded area. In the first group, only the radiofrequency catheter was used to both map and ablate (CPVA group, n = 73). In the other group, a CM catheter was added to assess the electrical activity of the PV antrum (CPVA-CM group, n = 73). An ablation line along the left atrial roof was also created in all patients. RESULTS: Procedural and fluoroscopic times were longer in the CPVA-CM group (P <.05). Severe procedure-related complications occurred in 1 (1.4%) patient in the CPVA group and in 3 (4.1%) patients in the CPVA-CM group (P = .317). After mean follow-up of 9 +/- 3 months, 31 (42.5%) patients in the CPVA group and 47 (64.4%) patients in the CPVA-CM group were arrhythmia-free without antiarrhythmic medication (P = .008). CONCLUSION: Use of a CM catheter to ensure isolation of the PV antrum improved the success of CPVA but increased some procedural requirements.

Left ventricular systolic dysfunction by itself does not influence outcome of atrial fibrillation ablation.

AIMS: The objective of the study was to analyse the influence of left ventricular (LV) ejection fraction (EF) on the outcomes of atrial fibrillation (AF) ablation after a first procedure. Pre-procedural predictors of recurrences after AF ablation can be useful for patient information and selection of candidates. The independent influence of LV systolic dysfunction on recurrence rate has not been studied. METHODS AND RESULTS: A case-control study (1:1) was conducted with a total of 72 patients: 36 cases (depressed LVEF) and 36 controls (normal LVEF). Patients were matched by left atrial diameter (LAD), the presence of arterial hypertension, and other variables that might influence the results (age, gender and paroxysmal vs. persistent AF). There were no statistical differences in the variables used to perform the matching. Patients with depressed LVEF had higher LV end diastolic diameter (55.6 +/- 6.2 vs. 52.4 +/- 5.5, P = 0.03), higher LV end systolic diameter (40.3 +/- 6.9 vs. 32.6 +/- 4.3, P < 0.001), lower LVEF (41.4 +/- 8.0 vs. 63.1 +/- 5.5, P < 0.001) and were more likely to have structural heart disease. After a mean follow-up of 16 +/- 13 months, survival analysis for AF recurrences showed no differences between patients with depressed vs. normal LVEF (50.0 vs. 55.6%, log rank = 0.82). Cox regression analysis revealed LAD to be the only variable correlated to recurrence [OR 1.11 (1.01-1.22), P = 0.03]. Analysis at 6 months showed a significant increase in LVEF (43.23 +/- 7.61 to 51.12 +/- 13.53%, P = 0.01) for the case group. CONCLUSION: LV systolic dysfunction by itself is not a predictor of outcome after AF ablation. LAD independently correlates with outcome in patients with low or normal LVEF.

Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study.

BACKGROUND: Ablation of the pulmonary veins (PVs) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium (LA) to improve the success rate. The study was designed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation (CPVA). METHODS AND RESULTS: CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus. Patients were then randomized into 2 groups. In the first group, superior PVs were connected by linear lesions along the LA roof (CPVA-1 group). In the second group, the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs (CPVA-2 group). The study included 120 patients (53+/-11 years, 77% male, 60% paroxysmal atrial fibrillation, LA of 41.3+/-5.4 mm, 46% with hypertension, and 22% with structural heart disease). After a single ablation procedure and a mean follow-up of 10+/-4 months, 24 (40%) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 (5%) had new-onset LA flutter. In the CPVA-2 group, recurrences were due to atrial fibrillation episodes in 23 patients (38%) and LA flutter in 4 (7%). Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group (log rank P=0.943). CONCLUSIONS: Isolation of the LA posterior wall did not increase the success rate of CPVA.

Cooled-tip vs. 8 mm-tip catheter for circumferential pulmonary vein ablation: comparison of efficacy, safety, and lesion extension.

AIMS: In many laboratories, cooled-tip catheters have replaced 8 mm-tip catheters due to their theoretical advantage of achieving larger lesions and avoiding charring. However, direct comparisons between the catheters in the subset of atrial fibrillation (AF) ablation are scarce. The aim of this study was to compare the efficacy, safety, and lesion extension created by 8 mm-tip vs. cooled-tip catheter with different energy settings for circumferential pulmonary vein ablation (CPVA). METHODS AND RESULTS: A series of 221 consecutive patients with symptomatic AF were included in the study. Circumferential pulmonary vein ablation was performed using an 8 mm-tip catheter (55 W, 50 degrees C) in 90 patients (Group 1), a cooled-tip (30 W, 45 degrees C) in 42 (Group 2), and a cooled-tip (40 W, 45 degrees C) in 89 (Group 3). In a subgroup of 60 patients, troponin I (TpnI), creatinine kinase, and myoglobin values were obtained before and at 12 and 24 h after ablation. At 1 year follow-up, the probability of being arrhythmia-free after a single procedure was 53, 35, and 55% in patients from Groups 1, 2, and 3, respectively. Ablation with a cooled-tip catheter at 30 W led to a higher recurrence rate (P = 0.030) and was identified in Cox regression analysis as an independent predictor of AF recurrence (HR, 1.713; 95% CI, 1.02-2.90; P = 0.045). There were no differences in intra-procedure complications (2.2 vs. 5.6 vs. 4.9%, P = 0.542). The myocardial lesion according to TpnI was smaller in Group 2 (P = 0.02). CONCLUSION: The cooled-tip catheter at 30 W was less efficacious than both the 8 mm catheter and the cooled-tip with a 40 W power setting.

Left atrial contractility is preserved after successful circumferential pulmonary vein ablation in patients with atrial fibrillation.

INTRODUCTION: Circumferential pulmonary vein ablation (CPVA) for atrial fibrillation (AF) consists of creating extensive lesions in the left atrium (LA). The aim of the study was to evaluate changes in LA contractility after ablation and their relationship with procedure outcome. METHODS AND RESULTS: A series of 90 consecutive patients underwent cardiac magnetic resonance imaging (MRI) before and 4-6 months after CPVA. Only patients in sinus rhythm during both imaging acquisitions were included in the study to measure LA end-diastolic (LAmax) and LA end-systolic (LAmin) volumes. Fifty-five patients were finally analyzed (41 men, 52 +/- 11 years, 74% paroxysmal AF). During a mean follow-up of 12 +/- 7 months and after 1.2 +/- 0.3 ablation procedures, 38 patients (69%) were arrhythmia-free (group I), and the remaining 17 patients had recurrences (group II). There was a significant decrease in mean LAmax volume in both groups, whereas mean LAmin volume only decreased in group I. Mean LA ejection fraction (EF) was preserved after CPVA in group I (40 +/- 11% vs 38 +/- 10%; P = 0.27) but decreased in patients with arrhythmia recurrences (37 +/- 10% vs 27 +/- 10%; P < 0.001). In fact, LA EF remained stable or increased in 68% of patients without arrhythmia recurrences. CONCLUSIONS: LAmax volume reduction following CPVA occurs regardless of the clinical efficacy of the procedure, whereas mean LAmin volume only decreased in patients without recurrences. LA EF was preserved or even increased in most patients with successful CPVA.

Selective segmental ostial ablation and circumferential pulmonary veins ablation. Results of an individualized strategy to cure refractory atrial fibrillation.

AIMS: Previous studies have analyzed the efficacy of atrial fibrillation (AF) ablation in series of consecutive patients or comparing methods in a randomized way, without taking account individual patient characteristics. The purpose of this study was to evaluate the results of a strategy based on selecting the ablation method according to patient clinical features in drug-refractory paroxysmal or persistent AF. METHODS AND RESULTS: Patients with left atrial diameter < or =40 mm and runs of atrial tachycardia of more than ten beats during Holter recording were selected for selective segmental ostial ablation (SSOA) in order to disconnect only those pulmonary veins with electrical potentials. The remaining patients underwent circumferential pulmonary veins ablation (CPVA) to modify left atrial substrate by extensive linear lesions. A group of 131 consecutive patients were included. Mean follow-up was 21.5 +/- 15.2 months. In paroxysmal AF, 44 and 55 patients were selected for SSOA and CPVA, respectively, and the efficacy of the procedure was similar in the two groups (77 vs 74%; log-rank test p = NS). In persistent AF, 6 and 26 patients underwent SSOA and CPVA, respectively, and greater efficacy was observed in the second group (17 vs 65%; log-rank test p = 0.004). CONCLUSIONS: Selecting the ablation method according to patient characteristics achieved good results and reduced the overall amount of ablated atrial tissue in patients with paroxysmal AF. However, in persistent AF the SSOA technique showed very limited efficacy despite the previous patient selection and a CPVA-like procedure may be the appropriate choice in all cases.

Pre-procedural predictors of atrial fibrillation recurrence after circumferential pulmonary vein ablation.

AIMS: The success rate of circumferential pulmonary vein ablation (CPVA) to treat atrial fibrillation (AF) ranges from 60 to 90%, depending on the series. The objective of the study was to identify predictors of AF recurrence after a standardized CPVA procedure. METHODS AND RESULTS: A series of 148 consecutive patients undergoing CPVA for symptomatic paroxysmal (60.8%), persistent (23.6%), or permanent (15.5%) AF refractory to antiarrhythmic drugs were included in the study. CPVA with the creation of supplementary block lines along the posterior wall and mitral isthmus was performed and a minimum of 6 months follow-up completed in all patients. Structural heart disease was present in 19.6% and hypertension in 33.8% of patients. After 13.1 +/- 8.4 months follow-up, 73.6% of patients were free of AF recurrences after a mean of 1.18 +/- 0.45 procedures/patient (one procedure in 85.2%, two procedures in 14.8%, and three procedures in 2.7%). Univariable analysis showed that the risk of AF recurrence increases with age (HR 1.03; 95% CI 1.00-1.06, P = 0.031), with the presence of previous hypertension (HR 2.7; 95% CI 1.43-5.07, P = 0.002), and if AF is permanent (HR 2.23; 95% CI 1.08-4.59, P = 0.042). In addition, larger anteroposterior left atrial diameter (LAD) (HR 1.11; 95% CI 1.05-1.18, P = 0.001) and larger left ventricular end-systolic diameter (HR 1.07; 95% CI 1.00-1.15, P = 0.029) prior to the procedure were associated with AF recurrence after CPVA. Cox regression analysis showed that hypertension (OR = 2.8; 95% CI 1.5-5.4; P = 0.002) and LAD (OR = 1.1; 95% CI 1.05-1.19, P < 0.001) were independent predictors of AF recurrence. The mean predicted proportion of patients with AF recurrence after CPVA of the multivariable model showed a linear relationship with the increase in LAD prior to the procedure. The presence of hypertension further increased the mean predicted proportion of patients with AF recurrence at each LAD. CONCLUSION: Hypertension and LAD are independent pre-procedural predictors of AF recurrence after CPVA to treat AF. These data may help in patient selection for AF ablation.

Incidence of pulmonary vein stenosis in patients submitted to atrial fibrillation ablation: a comparison of the Selective Segmental Ostial Ablation vs the Circumferential Pulmonary Veins Ablation.

INTRODUCTION: Pulmonary vein (PV) stenosis is an important complication of the AF ablation and could be underestimated if their assessment is not systematically done. Selective Segmental Ostial Ablation (SSOA) and Circunferential Pulmonary Veins Ablation (CPVA) have demonstrated efficacy in atrial fibrillation (AF) treatment. In this study the real incidence of PV stenosis in patients (pts) submitted to both SSOA and CPVA was compared. METHODS: Those pts with focal activity and normal left atrial size were submitted to SSOA, remaining pts were submitted to CPVA to treat refractory, symptomatic AF. Contrast enhanced magnetic resonance angiography (MRA) was routinely performed in all patients 4 months after the procedure. RESULTS: A series of 73 consecutive patients (mean age of 51 +/- 11 years; 75% male) were included. SSOA was performed in 32 patients, and the remaining 41 patients underwent to CPVA, obtaining similar efficacy rates (72% vs 76% arrythmia free probability at 12 months; log rank test p = NS). Six patients had a significant PV stenosis, all in SSOA group none in CPVA group (18.8% vs 0%; p = 0.005). All patients were asymptomatic and the stenosis was detected in routine MRA. No predictors of stenosis has been identified analysing patient procedure characteristics. CONCLUSION: PV stenosis is a potential complication of SSOA not seen in CPVA. The study confirms than MRA is useful for identifying patients with asymptomatic PV stenosis.