Conduction time around the mitral valve annulus has the potential to rule out postablation perimitral atrial tachycardia.

INTRODUCTION: It would be helpful in determining ablation strategy if the occurrence of perimitral atrial tachycardia (PMAT) could be predicted in advance. We investigated whether estimated perimitral conduction time (E-PMCT), namely, twice the time between coronary sinus (CS) pacing and the ensuing wave-front collision at the opposite side of the mitral annulus, correlated with the cycle length of PMAT and could predict future PMAT. METHODS AND RESULTS: We retrospectively (retrospective cohort) and prospectively (validation cohort) investigated atrial fibrillation patients who had received pulmonary vein isolation (PVI) and in whom left atrial maps had been created during CS pacing. We calculated their E-PMCT. PMAT was observed either by provocation or during follow-up in 25, AT other than PMAT was observed in 24 (non-PMAT AT group), and 53 patients never displayed any AT (no-AT group) in the retrospective cohort. In the PMAT group of the retrospective cohort, a strong positive correlation was observed between the PMAT CL and E-PMCT (r = .85, p < 0.001). PMAT was never induced nor observed in patients with E-PMCT less than 176 ms, and the best cut-off value for PMAT was 180 ms by receiver-operating characteristic curve analysis. In the validation cohort of 76 patients, the cut-off value of the E-PMAT less than 180 ms predicted noninducibility of PMAT, with a sensitivity of 78.6%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 25.0%. CONCLUSION: Short E-PMCT may predict noninducibility of PMAT and guide a less invasive ablation strategy.

Initial results of transcatheter modification of left atrial appendage by obliteration with device in patients with nonvalvular atrial fibrillation: Real-world data from the TERMINATOR registry.

BACKGROUND: Percutaneous left atrial appendage closure (LAAC) has increased for those who need alternative to long-term anticoagulation with non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS: From September 2019, after initiating WATCHMAN (Boston Scientific, Maple Grove, MN, USA) device implantation, we established Transcatheter Modification of Left Atrial Appendage by Obliteration with Device in Patients from the NVAF (TERMINATOR) registry. Utilizing 729 patients' data until January 2022, we analyzed percutaneous LAAC data regarding this real-world multicenter prospective registry. A total of 729 patients were enrolled. Average age was 74.9 years and 28.5 % were female. Paroxysmal AF was 37.9 % with average CHADS2 3.2, CHA2DS2-VASc 4.7, and HAS-BLED score of 3.4. WATCHMAN implantation was successful in 99.0 %. All-cause deaths were 3.2 %, and 1.2 % cardiovascular or unexplained deaths occurred during follow-up [median 222, interquartile range (IQR: 93-464) days]. Stroke occurred in 2.2 %, and the composite endpoint which included cardiovascular or unexplained death, stroke, and systemic embolism were counted as 3.4 % [median 221, (IQR: 93-464) days]. Major bleeding defined as BARC type 3 or 5 was seen in 3.7 %, and there was 8.6 % of all bleeding events in total [median 219, (IQR: 93-464) days]. CONCLUSIONS: These preliminary data demonstrated percutaneous LAAC with WATCHMAN device might have a potential to reduce stroke and bleeding events for patients with NVAF. Further investigation is mandatory to confirm the long-term results of this strategy using this transcatheter local therapy instead of life-long systemic anticoagulation.

Differences between typical and reverse typical atrial flutter identified by ultrahigh resolution mapping.

BACKGROUND: Although atrial flutter (AFL) is a common arrhythmia that is based on a macro-reentrant tachycardia around the tricuspid annulus, the factors giving rise to typical AFL (t-AFL) versus reverse typical AFL (rt-AFL) are unknown. To investigate the difference between t-AFL and rt-AFL circuits using ultrahigh resolution mapping of the right atrium. METHODS: We investigated 30 isthmus-dependent AFL patients (mean age 71, 28 male) who underwent first-time cavo-tricuspid isthmus (CTI) ablation guided by Boston Scientific's Rhythmia mapping system and divided them into two groups: t-AFL (22 patients) and rt-AFL (8 patients). We compared the anatomy and electrophysiology of their reentrant circuits. RESULTS: Baseline patient characteristics, use of antiarrhythmic drugs, prevalence of atrial fibrillation, AFL cycle length (227.1 ± 21.4 vs. 245.5 ± 36.0 ms, p = .10), and CTI length (31.9 ± 8.3 vs. 31.1 ± 5.2 mm, p = .80) did not differ between the two groups. Functional block was observed at the crista terminalis in 16 patients and at the sinus venosus in 11. No functional block was observed in three patients, all of whom belonged to the rt-AFL group. That is, functional block was observed in 100% of the t-AFL group as opposed to 5/8 (62.5%) of the rt-AFL (p < .05). Slow conduction zones were frequently observed at the intra-atrial septum in the t-AFL group and at the CTI in the rt-AFL group. CONCLUSION: Mapping with ultrahigh-resolution mapping showed differences between t-AFL and rt-AFL in conduction properties in the right atrium and around the tricuspid valve, which suggested directional mechanisms.

Treatment of atrial tachycardia arising after superior transseptal approach mitral valve surgery: Insights from ultra-high-density mapping to prevent atrioventricular block.

INTRODUCTION: Mitral valve surgery employing a superior transseptal approach (STA) is associated with arrhythmogenicity and intra-atrial conduction delay, despite being optimal for visualization of the surgical field. It is sometimes difficult to treat atrial tachycardias (AT) that arise after STA. To investigate AT circuits that arise after STA in detail in order to identify the optimal ablation line, using ultra-high-resolution mapping (UHRM). METHODS: We retrospectively analyzed 12 AT from 10 patients (median age 70 years, nine males) who had undergone STA surgery. The tachycardias were mapped using the Rhythmia mapping system (Boston Scientific, Natick, Massachusetts). RESULTS: The 12 STA-related AT (STA-AT) circuits were classifiable as follows according to location of the optimal ablation line: (1) peri-septal incision STA-AT (n = 3), (2) cavotricuspid isthmus (CTI) dependent STA-AT (n = 7), and (3) biatrial tachycardia (n = 2). Radiofrequency (RF) application terminated 11 of the 12 STA-AT. We found that difference in STA-AT circuit type was due to characteristics of the septal incision line made for STA. UHRM was important in identifying optimal ablation sites that did not create additional conduction disturbances in the right atrium (RA). CONCLUSIONS: ATs after STA involve complex arrhythmia circuits due to multiple and long incision lines in the RA. Accurate understanding of the arrhythmia circuit and sinus conduction in the RA after STA is recommended for treating post-surgical tachycardia in a minimally invasive manner.

Perimitral atrial tachycardias dependent on residual nonligament of Marshall conduction.

INTRODUCTION: Catheter ablation for perimitral atrial tachycardia (PMAT) that persists despite lateral mitral isthmus (LMI) ablation is challenging. The aim of this study was to identify the role of the ligament of Marshall (LOM) in PMATs that persist after LMI conduction block has been created, and evaluate the validity of ethanol infusion into the vein of Marshall (VOM) as treatment. METHODS AND RESULTS: Sixteen consecutive PMATs in 13 patients that persisted despite apparent LMI conduction block, which was confirmed by ultrahigh-resolution mapping and entrainment pacing along the mitral annulus, were analyzed. PMATs were classified into two types based on the location of the endocardial breakthrough site: those utilizing the LOM (n = 13), which had a breakthrough site along with the LOM, and those not utilizing the LOM (n = 3), which had a breakthrough site at an anterior or posterior side of the LOM. Of the 16 PMATs, 5 PMATs (31%) were not suitable for ethanol infusion into the VOM because the LOM was not involved in the tachycardia circuit or because of the anatomy of the VOM. Fourteen PMATs (88%) were successfully terminated solely by breakthrough site ablation. At a mean follow-up period of 12 ± 9 months, 10 (77%) patients have remained free from atrial tachyarrhythmias. CONCLUSION: In cases of PMAT following LMI ablation, epicardial conduction over the LMI can occur independently of the LOM. Ethanol infusion into the VOM in such cases would not abolish residual epicardial conduction. The anatomy of the VOM can also preclude the use of this method.

Association between pericoronary adipose tissue attenuation and outcome after second-generation cryoballoon ablation for atrial fibrillation.

OBJECTIVES: Previous studies reported the association between inflammation and atrial fibrillation (AF). Pericoronary adipose tissue (PCAT) attenuation, PCATA, on cardiac CT angiography (CTA) reflects pericoronary inflammation. We hypothesized that the PCATA predicts AF recurrence after cryoballoon ablation (CBA) for paroxysmal and persistent AF. METHODS: We studied 364 patients (median age, 65 years) with persistent (n = 41) and paroxysmal (n = 323) AF undergoing successful first-session second-generation CBA with pre-ablation cardiac CTA. Three-vessel (3V)-PCATA was defined as the mean CT attenuation value of PCAT of all three major coronary arteries. Predictors of AF recurrence during follow-up were evaluated. RESULTS: AF recurrence after the 3-month blanking period was detected in 90 patients (24.7%) during the median follow-up of 26 (interquartile range, 19-42) months. AF recurrence was associated with prior stroke and statin use, NT-proBNP and high-sensitivity cardiac troponin-I levels, left ventricular dimension, left atrial volume index (LAVI), 3V-PCATA, and early AF recurrence during the blanking period. On multivariable Cox proportional hazard analysis, prior stroke (hazard ratio [HR], 2.208, 95% confidence interval [CI], 1.166-4.180, p = 0.015), LAVI (HR, 1.030, 95% CI, 1.010-1.051, p = 0.003), 3V-PCATA (HR, 1.034, 95% CI, 1.001-1.069, p = 0.046), and early AF recurrence (HR, 2.858, 95% CI, 1.855-4.405, p < 0.001) remained statistically significant. CONCLUSION: Pre-ablation CTA-derived 3V-PCATA, representing pericoronary inflammation, was an independent predictor of recurrence after first-session AF ablation using a second-generation cryoballoon. ADVANCES IN KNOWLEDGE: Assessment of 3V-PCATA may identify patients at high risk of AF recurrence after CBA for AF.

Features Suggesting Preferential Conduction in Pulmonary Artery Ventricular Arrhythmia for Identification of Successful Ablation Sites.

Radiofrequency catheter ablation (RFCA) for pulmonary artery ventricular arrhythmia (PAVA) can be difficult because of the occasional existence of PAVA with preferential conduction.This study described the characteristics of PAVA that demonstrate preferential conduction.We analyzed electrocardiographic and electrophysiological data from 8 patients found to have PAVAs with preferential conduction out of 183 patients (4.4%) with right ventricular outflow tract (RVOT) arrhythmias who underwent RFCA at our hospitals. The PAVA with preferential conduction were classified into two types. In type 1 PAVA, successful ablation sites (success-sites) exhibited discrete prepotentials with an isoelectric line, in which the activation time (AT) was ≥ 50 milliseconds. In type 2 PAVA, excellent pace mapping was achieved at two sites separated by ≥ 20 mm: one in the RVOT free wall and the other at the success-site in the pulmonary artery. Type 1 and 2 PAVA features were considered signs of a short and long preferential conduction pathway, respectively.There were four patients each with type 1 and 2 PAVA. Type 1 PAVA was distinguished by the isoelectric line at success-sites with the mean AT of 78 ± 25.1 milliseconds. In type 2 PAVAs, although the AT at RVOT sites was very short (18.5 ± 10.1 milliseconds), the AT at success-sites was longer than that at the RVOT by 42.3 ± 36.2 milliseconds. Type 2 PAVAs displayed distinct electrocardiogram (ECG) features (R wave in lead I, RR' in inferior leads, and transitional zone in V4) not found in typical PAVA ECGs.PAVA with preferential conduction can manifest in distinct ways on the ECG and intracardiac mapping. Knowledge of these features may facilitate successful RFCA of such PAVA cases.

Individualized left anterior oblique projection based on pigtail catheter visualization facilitates leadless pacemaker implantation.

BACKGROUND: Pacemaker positioning on the right ventricular (RV) septum during implantation is conventionally conducted utilizing two fixed fluoroscopy angles, a 45° left anterior oblique (LAO) and 35° right anterior oblique projection. However, placement location can be suboptimal, especially for leadless pacemakers (LPMs). OBJECTIVE: To evaluate the safety and ease of LPM implantation using individualized LAO projection. METHODS: Consecutive patients undergoing LPM implantation were prospectively included. The angle of the RV septum was recorded for each patient by studying the angle at which an RV pigtail catheter (RV-PC) could be seen edge on. This was then used as the preferred LAO projection angle for that patient. We evaluated the success rate and safety of this method. We also compared the RV septum angle as measured by this method versus that measured by chest CT. RESULTS: Of the 31 patients (mean age 80.6 ± 7.0 years, 15 females), LPM implantation was successful in 30. The pacemaker was implanted on the RV septum in 29 and on the free wall in one. LPM implantation was abandoned for anatomical reasons in one. Complications were limited to a groin arteriovenous fistula and one deep vein thrombosis. The angle of RV septum as measured by pigtail catheter and chest CT was not significantly different (CT: 54.8 ± 6.0°, RV pigtail catheter: 52.9 ± 6.1°, P = .07). CONCLUSIONS: Using an RV-PC to determine the preferred angle of LAO projection facilitates differentiation between the RV septum and free wall, which in turn facilitates optimal LPM placement.

Superior vena cava isolation with 50 W high power, short duration ablation strategy.

INTRODUCTION: The optimal ablation strategy is unknown regarding a superior vena cava isolation (SVCI). This study aimed to examine the feasibility and safety and to analyze the lesion characteristics of the SVCI using high-power, short-duration (HPSD) ablation. METHODS AND RESULTS: A total of 100 patients underwent an index SVCI using HPSD (n = 50, HPSD group) or conventional lower-power and longer-duration (n = 50, LPLD group) ablation, using the Thermocool Smarttouch SF. In the HPSD group, ablation was performed with a power of 50 W for 7 s, and was limited to 4 s at the lateral segment close to the right phrenic nerve. The ablation setting used in the LPLD group was 20-25 W for 20-30 s and was limited to 10-20 W for 15-30 s at the lateral segment when diaphragmatic capture was seen. An electrical SVCI was achieved in all patients. The HPSD group required a significantly shorter procedure time (10.8 ± 3.2 vs. 14.8 ± 6.4 min; p < .01), shorter radiofrequency duration (49 ± 16 vs. 282 ± 124 s; p < .01), fewer lesions (8.3 ± 2.5 vs. 10.4 ± 4.4; p < .01), and lower ablation index (316 ± 38 vs. 356 ± 62; p < .001) than the LPLD group. The incidence of a postprocedural asymptomatic mild diaphragmatic elevation was comparable (2% in the HPSD group vs. 6% in the LPLD group; p = .61). CONCLUSION: The 50-W HPSD ablation strategy allowed for a successful, fast, and safe SVCI with the fewer ablation lesions and the lower ablation index.

Novel Diagnostic Observations of Nodoventricular/Nodofascicular Pathway-Related Orthodromic Reciprocating Tachycardia Differentiating From Atrioventricular Nodal Re-Entrant Tachycardia.

OBJECTIVES: This study sought to assess the performance of current diagnostic criteria and identify additional electrophysiological features differentiating orthodromic reciprocating tachycardia (ORT) with a concealed nodoventricular/nodofascicular (NV/NF) pathway from atrioventricular nodal re-entrant tachycardia (AVNRT). BACKGROUND: Diagnosing sustained supraventricular tachycardia (SVT) despite the occurrence of ventriculoatrial block (VAB) is challenging. METHODS: We analyzed electrograms of 25 sustained SVTs (9 NV/NF-ORTs [n = 7/2] and 16 AVNRTs) with VAB and 91 AVNRTs without VAB (for reference). RESULTS: More than 1 SVT, each with a different ventriculoatrial interval, was commonly induced in AVNRT cases (75%) but not in NV/NF-ORT cases (0%; p = 0.0005). Wenckebach VAB was common in NV/NF-ORTs (78%), but VAB patterns varied in AVNRTs. The His-His interval transiently prolonged in the following beat after the VAB in most AVNRTs but rarely did in NV/NF-ORTs (79% vs. 22%; p = 0.01). NV/NF-ORT was diagnosed by His-refractory premature ventricular contractions (n = 5) and the findings during right ventricular overdrive pacing showing an uncorrected/corrected post-pacing interval (PPI)-tachycardia cycle length (TCL) ≤115/110 ms (n = 5/5), orthodromic His capture (n = 6), and V-V-A (ventricle-ventricle-atrial response) response (n = 3). A single form of induced SVT (positive predictive value [PPV]: 69%; negative predictive value [NPV]: 100%), Wenckebach VAB (PPV: 70%; NPV: 87%), stable His-His interval despite VAB (PPV: 70%; NPV: 85%), orthodromic His capture (PPV: 100%; NPV: 97%), and V-V-A response (PPV: 100%; NPV: 95%) characterized NV/NF-ORT, and a PPI-TCL of ≤125 ms (PPV: 100%; NPV: 100%) characterized NV-ORT. CONCLUSIONS: Induction of a single SVT form, Wenckebach VAB, stable His-His interval despite VAB, orthodromic His capture, and V-V-A response appeared to discriminate NV/NF-ORT from AVNRT, with a PPI-TCL of ≤125 ms discriminating NV-ORT from NF-ORT and AVNRT.

Perfect pace-mapping with different latencies from adjacent sites in bilateral outflow tract leading to successful sequential unipolar ablation.

A 77-year-old man with frequent monomorphic ventricular premature contractions (VPCs) was referred for catheter ablation. Detailed mapping just above the pulmonary valve (PV) revealed tiny fragmented potentials earlier than the VPC onset. Perfect pace-mapping was obtained using high voltage pacing just above the PV and the left aortic sinus of Valsalva, whose stimulus-to-VPC latencies differed by 20 ms. While the ablation at the pulmonary valve could not completely eliminate the VPCs, unipolar sequential ablation on both sides of the outflow tracts led to their successful abolition that was guided by perfect pace-mapping.

Circulatory dynamics changes are an additional predictor of successful pulmonary vein isolation during cryoballoon ablation.

The association between circulatory dynamics changes during cryoballoon applications and a successful pulmonary vein isolation (PVI) is unknown. Seventy atrial fibrillation patients who underwent PVI with 28-mm second-generation cryoballoons and single 3-min freezes were included. Intra-procedural parameters including circulatory dynamics changes during cryoapplications, were compared between 113 successful applications (30 left superior PVs[LSPVs], 30 left inferior PVs[LIPVs], 25 right superior PVs[RSPVs], and 28 right inferior PVs[RIPVs]) and 47 failed applications (10 LSPVs, 9 LIPVs, 8 RSPVs, and 20 RIPVs). In all individual PVs, lower nadir balloon temperatures (MinTemps) and longer thawing times (ThawTimes) significantly predicted a successful PVI. In addition, greater systolic blood pressure drops following releasing the PV occlusion (SBP-drops) significantly predicted a successful right PV PVI, and longer elapse times during SBP-drops significantly predicted a successful RIPV PVI. Composite parameters incorporating MinTemps and ThawTimes, SBP-drops, and ThawTimes showed the highest area under the curve to predict a successful left PV (0.876 for LSPVs, 0.851 for LIPVs) and right PV (0.927 for RSPVs, 0.980 for RIPVs) PVI, respectively. If the ThawTime (≥ 30 s) and SBP-drop (≤ - 21 mmHg) cutoff values were achieved for the RIPVs, the positive predictive value was 100%. In contrast, if both criteria were not achieved for the RIPVs, the negative predictive value was 100%. In the second-generation cryoballoon PVI, the MinTemp and ThawTime were significantly associated with acute success for all four PVs. In addition, SBP-drops further improved the accuracy of predicting a successful right PV PVI, especially of the RIPV.

Epicardial-endocardial breakthrough site ablation: Demonstration of alternative target for perimitral atrial tachycardia.

A 62-year-old man underwent the catheter ablation for persistent atrial tachycardia (AT) with a cycle length of 357 milliseconds. An ultrahigh resolution mapping revealed that this tachycardia was a clockwise perimitral AT despite the conduction was apparently blocked across the lateral mitral isthmus line both at the endocardium and within the coronary sinus. The AT was terminated by the single radiofrequency application at the site below the mitral isthmus line where the endocardial activation breakout was seen. This case suggests that the epicardial-endocardial conduction breakthrough site may be an alternative ablation target in a difficult ablation case of perimitral AT.

Electrocardiographic morphology of multiple ventricular arrhythmias originating from the right ventricular outflow tract: inverse correlation of the amplitude in the inferior leads and anatomic height of the origin.

It is unclear whether the electrocardiogram amplitude in the inferior leads (Amp-I) can always predict the height of the origin of right ventricular outflow tract arrhythmias (RVOT-VAs). We analyzed patients who received catheter ablation of multiple RVOT-VAs in the same session in our hospital from 2011 to 2016. Two distinguished RVOT-VAs, those with anatomically higher origins (HOs) and lower origins (LOs), were identified and compared to measure the longitudinal distance. Amp-I was uniquely determined for each OTVA as the highest amplitude in leads II, III, and aVF and compared between the HO-VAs and LO-VAs. In total, out of 187 patients who underwent catheter ablation of RVOT-VAs, 9 (4.8%) had multiple right OTVAs successfully treated. Four cases (Group A) had HO-VAs (10.8 ± 5.3 mm from an LO) with a lower Amp-I (1.28 ± 0.46 mV) than the LO-VAs (1.81 ± 0.59 mV), whereas the other 4 patients (Group B) had HO-VAs with a higher Amp-I (1.91 ± 0.23 mV) than the LO-VAs (1.26 ± 0.35 mV). In Group A, all HO-VAs originated from the lateral free wall and had notched R waves in the inferior leads, whereas all LOs with higher Amp-Is were located on the septum. In one patient, the HO and LO were at almost the same height, while a VA from a lateral origin had lower notched R waves in the inferior leads. A divided excitation from high lateral origins may result in not only QRS notching, but also a reduction in the QRS amplitude. In patients harboring multiple RVOT-VAs, VAs arising from the high lateral free wall could have lower Amp-Is than VAs from low septal origins.

Catheter ablation of paroxysmal atrial fibrillation in patients with sick sinus syndrome.

Sick sinus syndrome (SSS) frequently coexists with atrial fibrillation (AF). The results of AF ablation in patients with SSS have not been fully evaluated. We retrospectively investigated 65 patients with paroxysmal AF (PAF) and SSS who underwent AF ablation using either radiofrequency (n = 50) or cryoballoon ablation (n = 15) in our institute. Forty-nine (75.4%) patients had a median of 5.6 (4.8-6.0) s of documented sinus pauses prior to the procedure (42 patients on antiarrhythmic drugs), and were observed when AF terminated in 47 patients. Successful pulmonary vein isolation was achieved in all, and substrate modification was added in 3 patients. Freedom from recurrent atrial arrhythmias after single procedures was 58.7, 45.2, and 38.9% at 1, 2, and 3 years after the initial procedure. During a 23.4 (11.1-40.7) month median follow-up and after 1.4 ± 0.6 sessions, 80.6% of patients were free from arrhythmia recurrence; however, permanent pacemaker implantations were required in 9 (13.8%) patients at a median of 5.3 (2.9-21.0) months after initial procedures. The average heart rate did not significantly differ before or a median of 2.5 (1.2-5.3) months post-procedure (76.7 ± 17.4 vs. 73.5 ± 14.6 bpm, p = 0.90). Multivariate analyses revealed that larger left atrial diameters [odds ratio (OR) 1.21, 95% confidential interval (CI) 1.01-1.45, p = 0.042] were independent predictor of AF recurrence, and SSS type 1 was the sole predictor of pacemaker implantations (OR 10.30, 95% CI 1.38-76.7, p = 0.023), respectively. AF ablation obviated permanent pacemaker implantations in the majority of the patients with SSS and PAF, and SSS type 1 was a sole factor predicting pacemaker implantations.

A case of bidirectional conduction block within the superior vena cava induced by cryoballoon pulmonary vein isolation.

A 53-year-old male underwent a pulmonary vein isolation (PVI) of atrial fibrillation (AF) with a second-generation cryoballoon (CB). Although the patient maintained sinus rhythm after the PVI, a superior vena cava (SVC) fibrillation was recorded by a circular-multipolar-electrode catheter positioned inside the SVC that suggested conduction block between the right atrium (RA)-SVC connection. An adenosine triphosphate intravenous injection induced a dormant reconnection of the SVC myocardial sleeve and converted sinus rhythm to an AF rhythm. This case demonstrated that a CB application for the isolation of a right superior pulmonary vein could induce an electrical conduction block between the RA-SVC connection.

Utility of low-dose adenosine triphosphate sensitivity in slow-fast atrioventricular nodal reentrant tachycardia.

PURPOSE: Low-dose adenosine triphosphate (LD-ATP) is useful for diagnosing ATP-sensitive atrial tachycardia. However, the clinical implications of the sensitivity of LD-ATP in atrioventricular nodal reentrant tachycardia (AVNRT) still remain unknown. This study aimed to evaluate the mechanism of LD-ATP sensitivity in slow-fast AVNRT. METHODS: We estimated the sensitivity of LD-ATP in slow-fast AVNRT by a 2-4-mg ATP intravenous injection during the tachycardia. We evaluated the atrial-His (A-H) interval, tachycardia termination mode, prevalence of a lower common pathway (LCP), and successful ablation site in slow-fast AVNRT with LD-ATP sensitivity. LCPs were defined as His-atrial interval differences of at least 5 ms between that during ventricular pacing at the tachycardia cycle length and that during the tachycardia. RESULTS: Twenty-eight patients (mean age = 58 ± 11 years old, 18 females) with slow-fast AVNRT, who underwent catheter ablation of the antegrade slow pathway, were enrolled. Seventeen of 28 (61%) patients had LD-ATP sensitivity defined as termination of the tachycardia and/or a prolongation of the A-H interval of over 30 ms after an LD-ATP injection. The patients with LD-ATP sensitivity had a significantly higher prevalence of an LCP than those without (15/17 vs0/11, P < 0.0001). The successful ablation site in the LD-ATP sensitive group was significantly closer to the His bundle area than that in the LD-ATP nonsensitive group (13.3 ± 3.8 vs 20.5 ± 5.4 mm; distance to His bundle area in the left anterior oblique fluoroscopic view, P < 0.0001). CONCLUSIONS: LD-ATP sensitivity in slow-fast AVNRT may suggest the existence of an LCP. The successful ablation site in patients with LD-ATP sensitivity could be closer to the His bundle region.

Impact of catheter ablation of atrial fibrillation on long-term clinical outcomes in patients with heart failure.

BACKGROUND: Heart failure (HF) promotes atrial fibrillation (AF) and AF worsens HF. This study aimed to investigate the long-term clinical outcomes after AF ablation in patients with HF. METHODS AND RESULTS: A total of 106 consecutive HF patients, including 51 (48.1%) with a reduced left ventricular ejection fraction (LVEF) (HFrEF) and 55 (51.9%) with a preserved LVEF (HFpEF), underwent AF ablation. All patients underwent successful pulmonary vein antrum isolation, and substrate modification was added in 38 (35.8%). The mean follow-up period was 32.4±18.6 months, and mean number of procedures was 1.4±0.5 per patient. Low-dose antiarrhythmic drugs were combined in 29 (27.3%) patients. Freedom from recurrent atrial arrhythmias (ATa), HF-related hospitalizations, and the composite endpoint (all-cause death, stroke, HF-related hospitalizations) at 3 years was 88.7%, 97.6%, and 97.6% in HFrEF patients, and 79.3%, 96.2%, and 91.8% in HFpEF patients, respectively. LVEF normalization (≥50%) was observed in 37 (72.5%) HFrEF patients post-ablation, and a smaller LV diastolic diameter (LVDd) was the sole predictor [odds ratio (OR)=0.863; 95% confidence interval (CI)=0.779-0.955, p=0.005]. Shortening of the LVDd (≥5mm) was observed in 16 (29.1%) HFpEF patients post-ablation, and no recurrence after the initial procedure was the sole predictor (OR=6.229; 95% CI=1.524-25.469, p=0.011). CONCLUSIONS: Catheter ablation of AF could be one of the important therapeutic options in the management of patients with HF combined with AF regardless of the type of HF.

Characteristics of Phrenic Nerve Injury During Pulmonary Vein Isolation Using a 28-mm Second-Generation Cryoballoon and Short Freeze Strategy.

BACKGROUND: The reported incidence of phrenic nerve injury (PNI) varies owing to different definitions, balloon generations, balloon size, freezing regimen, and protective maneuvers. We evaluated the incidence, predictors, and outcome of PNI during cryoballoon pulmonary vein isolation in a large population. METHODS AND RESULTS: Five hundred fifty atrial fibrillation patients underwent pulmonary vein isolation using one 28-mm second-generation cryoballoon and single 3-minute freeze strategy under diaphragmatic compound motor action potential (CMAP) monitoring. A total of 34 (6.2%) patients experienced PNI during the right superior and inferior pulmonary vein ablation in 30 and 4 patients, respectively. Applications were interrupted using double-stop techniques after 136 [104-158] second applications, and a pulmonary vein isolation was already achieved in all but one case. The baseline CMAP amplitude and timing of deflation (CMAPdef) were 0.75±0.30 and 0.17±0.17 mV, respectively. Persistent atrial fibrillation, larger right superior pulmonary vein ostia, and deeper balloon positions were associated with higher incidences of PNI. The CMAPdef predicted a PNI recovery delay, and the best cutoff value for predicting PNI recovery by the next day was 0.20 mV (sensitivity 57.1%, specificity 100%). Among 6 patients undergoing second procedures 8.5 (6.7-15.0) months later, the right superior pulmonary vein was durable in 3 with >120 second applications. Despite active balloon deflation, no significant pulmonary vein stenosis was observed in 15 right superior pulmonary veins evaluated 6 (5-9) months later. No patients had symptoms, and the PNI recovered 1 day and 1 month postprocedure in 21 and 4 patients, respectively. CONCLUSIONS: PNI resulting from cryoballoon ablation was reversible. The double-stop technique is safe, and immediate active deflation following a CMAP decrease appears to be essential for faster PNI recovery.