Atrial High-Rate Episodes and Subclinical Atrial Fibrillation: State of the Art and Clinical Questions with Complex Solutions.

Atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (AF) are frequently registered in asymptomatic patients with cardiac implantable electronic devices (CIEDs) and insertable cardiac monitors (ICMs). While an increased risk of thromboembolic events (e.g., stroke) and benefits from anticoagulation have been widely assessed in the setting of clinical AF, concerns persist about optimal clinical management of subclinical AF/AHREs. As a matter of fact, an optimal threshold of subclinical episodes' duration to predict stroke risk is still lacking and recently published randomized clinical trials assessing the impact of anticoagulation on thromboembolic events in this specific setting have shown contrasting results. The aim of this review is to summarize current evidence regarding classification and clinical impact of subclinical AF/AHREs and to discuss the latest evidence regarding the potential benefit of anticoagulation in this setting, highlighting which clinical questions are still unanswered.

Left Pulmonary Vein Trunk Length as a Robust Predictor of Long-Term Success of Atrial Fibrillation Catheter Ablation.

Background: Radiofrequency catheter ablation (RFCA) is a commonly used treatment for atrial fibrillation (AF), but the long-term recurrence rate remains relatively high. Given the inconsistent results regarding the role of left pulmonary vein (PV) ostial anatomy in post-ablative recurrence of RFCA in previous studies, we sought to investigate the role of left PV trunk length using an alternative methodology. Methods: A total of 369 AF patients undergoing catheter ablation were included. The left/right trunk length (LTL/RTL) of the PV was measured from pre-ablative computed tomography (CT) using three-dimensional reconstruction techniques. We constructed three multivariable Cox models, with the inclusion of the LTL, RTL, and no LTL/RTL, and used the Delong test, integrated discrimination index (IDI), and net reclassification index (NRI) to assess model improvement. We identified optimal cut-off values for LTL with the receiver operating characteristic (ROC) curve, and estimated outcomes using the Kaplan-Meier survival curve. We also used subgroup analysis to evaluate interactions. Results: The results of the Delong test, IDI, and NRI indicated that LTL had a favorable impact on the performance of the multivariate model. Subsequently, the multivariate Cox regression analysis identified LTL as a significant risk factor for post-ablative recurrence of AF (adjusted hazard ratio (HR) = 1.08, 95% CI: 1.05-1.12, p < 0.001). According to the ROC curve, the optimal cut-off value for LTL is 11.15 mm, and the Kaplan-Meier estimator revealed different outcomes (p < 0.001). We calculated p for interaction between LTL and other factors, and no significant interaction terms were observed. Conclusions: LTL is a robust prognostic indicator for post-ablative outcome in AF patients receiving RFCA, with a longer LTL indicating a higher risk of recurrence.

The Correlation between Epicardial Adipose Tissue Thickness Measured by Echocardiography and P-Wave Dispersion and Atrial Fibrillation.

Background: Recent studies have indicated a close relationship between the thickness of epicardial adipose tissue (EAT) and the occurrence as well as persistence of atrial fibrillation (AF). However, the pathogenesis of this association is still in the exploratory stage. The aim of this study is to explore the correlation EAT, as measured by echocardiography, and P-wave dispersion (Pd) in the context of atrial fibrillation. Additionally, the study seeks to analyze the utility of EAT at different anatomical sites in identifying individuals who are predisposed to atrial fibrillation. Methods: A total of 136 subjects were enrolled and categorized into groups based on the guidelines: paroxysmal atrial fibrillation group (PAF group), persistent atrial fibrillation group (AF group), and non-atrial fibrillation group. Comprehensive clinical data, including general information and medications that could impact the occurrence of atrial fibrillation, were gathered for all patients. Echocardiography was employed to measure the maximum EAT thickness near the apex of the heart on the anterior right ventricular wall and near the base of the right ventricle for each participant. Pd values were computed for each patient based on standard 12-lead synchronous electrocardiogram (ECG). The study involved comparing the disparity in EAT thickness between the two specified sites across the three groups. Additionally, correlation analyses were performed to assess the relationship between EAT thickness at the two sites and Pd. Regression analysis was applied to explore potential risk factors for atrial fibrillation. The diagnostic value of EAT at each site in predicting atrial fibrillation was evaluated using Receiver Operating Characteristic curve (ROC) analysis. Results: EAT thickness of the anterior wall near the apex of the heart and near the base of the right ventricle were significantly positively correlated with Pd (p < 0.05), EAT thickness near the base and left atrial diameter were independent risk factors for atrial fibrillation (OR = 13.673, 95% CI 2.819~66.316, p = 0.001; OR = 2.294, 95% CI 1.020~5.156, p = 0.045). ROC analysis showed that the area under the curve of EAT thickness near the heart base was 0.723, and the best threshold for predicting the occurrence of AF was 1.05 cm. Conclusions: The echocardiography-measured epicardial adipose tissue thickness, particularly in proximity to the heart base, exhibits a significant correlation with Pd. Notably, EAT thickness near the heart base demonstrates superior predictive capability for atrial fibrillation compared to thickness near the apex.

The value of phenylalanine in predicting atrial fibrillation risk in chronic heart failure.

Backgrounds: Atrial fibrillation (AF) is a common complication of chronic heart failure (HF). Serum phenylalanine (Phe) levels are related to inflammation disorder. It is meaningful to study the circulating Phe with AF occurrence in HF. Methods: The cross-sectional study recruited 300 patients (78.0% male; mean age, 65 ± 13 years) with HF (left ventricular ejection fraction of ≤50%, containing 70 AF patients) and 100 normal controls. Serum Phe value was measured by liquid chromatography-tandem mass spectrometry. Logistic regression analysis was conducted to measure the association between Phe and AF risk in HF. The association between Phe and high-sensitivity C-reactive protein (hsCRP) was assessed by simple correlation analysis. In the prospective study, the 274 HF subjects (76.6% male; mean age, 65 ± 13 years) were followed up for a mean year (10.99 ± 3.00 months). Results: Serum Phe levels increased across the control, the HF without AF, and the HF with AF groups (77.60 ± 8.67 umol/L vs. 95.24 ± 28.58 umol/L vs. 102.90 ± 30.43 umol/L, ANOVA P < 0.001). Serum Phe value was the independent risk factor for predicting AF in HF [odds ratio (OR), 1.640; 95% CI: 1.150-2.339; P = 0.006]. Phe levels were correlated positively with hsCRP value in HF patients with AF (r = 0.577, P < 0.001). The elevated Phe levels were associated with a higher risk of HF endpoint events in HF patients with AF (log-rank P = 0.005). Conclusions: In HF with AF subjects, elevated Phe value confers an increased risk for prediction AF and was more related to poor HF endpoint events. Phe can be a valuable index of AF in HF.

Sepsis-Induced Coagulopathy Score is Associated with an Increased Risk of New-Onset Atrial Fibrillation in Septic Patients: A Two-Centered Retrospective Study.

Purpose: New-onset atrial fibrillation (NOAF) and sepsis-induced coagulopathy (SIC) are severe complications in septic patients. However, the relationship between NOAF and SIC score has not been clearly defined. This study aims to investigate the association between SIC score and NOAF, as well as their effect on mortality in sepsis. Patients and Methods: This study was a two-center retrospective analysis. Medical data were collected from patients diagnosed with sepsis. The patients were divided into NOAF and non-NOAF groups, and the SIC score was calculated for each group. Univariable and multivariable logistic regression analyses were performed to explore the relationship between the SIC score and NOAF, as well as their effects on mortality. The Kaplan-Meier curve was used to assess the survival rate. Results: A total of 2,280 septic patients were included, with 132 (5.7%) suffering from NOAF. Multivariable logistic regression analyses indicated that age, gender, the Acute Physiology and Chronic Health Evaluation II score (APACHE II), heart rate, renal failure, stroke, chronic obstructive pulmonary disease (COPD), and the SIC score were independent risk factors for NOAF in sepsis. Moreover, NOAF was associated with an increased risk of in-hospital mortality, 28-day mortality, and 90-day mortality. These results were consistent across subgroup analyses. Conclusion: The SIC score was an independent risk factor for NOAF in septic patients, and NOAF was an independent risk factor for predicting mortality.

Cardiac Arrhythmias and Their Management: An In-Depth Review of Current Practices and Emerging Therapies.

Cardiac arrhythmias encompass a range of conditions characterized by abnormal heart rhythms, affecting millions globally and significantly contributing to morbidity and mortality. This review provides a comprehensive analysis of the current practices and emerging therapies in managing cardiac arrhythmias, covering their definition, classification, epidemiology, and the critical importance of effective management. It explores the pathophysiology underlying various arrhythmias, including the mechanisms of arrhythmogenesis, such as re-entry, automaticity, and triggered activity. The review details the latest diagnostic tools, including ECG, Holter monitoring, and electrophysiological studies, and discusses the clinical presentation of different arrhythmias, from supraventricular to ventricular types and bradyarrhythmias. We examine current pharmacological and non-pharmacological treatment strategies, such as antiarrhythmic drugs, catheter ablation, and device therapy, highlighting their efficacy and limitations. Furthermore, the review delves into emerging therapies, including advanced catheter ablation techniques, novel antiarrhythmic agents, gene therapy, and innovative device technologies like leadless pacemakers and subcutaneous implantable cardioverter-defibrillators (ICDs). Special considerations for managing arrhythmias in diverse populations, including pediatrics, the elderly, and pregnant women, are discussed. Additionally, the review explores future directions in arrhythmia management, emphasizing personalized medicine, artificial intelligence applications, and the integration of advanced technologies in diagnosis and treatment. By synthesizing current knowledge and prospects, this review aims to enhance understanding and promote advancements in the field, ultimately improving patient outcomes with cardiac arrhythmias.

Unmasking the Intricate Association Between Takotsubo Syndrome, Atrial Fibrillation, and Diabetes Mellitus: A Case Report and Literature Review.

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction without obstructive coronary artery disease, often mimicking acute coronary syndrome. Its association with diabetes mellitus and arrhythmias, such as atrial fibrillation (AF), suggests potential shared pathophysiological mechanisms. We report the case of a 76-year-old woman with diabetes who developed sudden, severe chest pain and palpitations after cataract surgery. Initial EKG showed ST-segment elevation, and laboratory tests revealed elevated high-sensitivity troponin, inflammatory markers, and diabetic ketoacidosis (DKA). Despite acute coronary syndrome symptoms, coronary angiography showed no significant obstruction. Transthoracic echocardiography revealed left ventricular apical akinesia and a moderately reduced ejection fraction. A cardiac MRI a month later demonstrated complete recovery of left ventricular function and spontaneous resolution of AF tachycardia. This case highlights a rare presentation of TTS in a diabetic patient with AF and DKA. The spontaneous resolution of AF and recovery of left ventricular function underscore the complex interplay between these conditions. Further research is needed to explore the mechanisms linking TTS with diabetes and AF to improve clinical management and outcomes.

Assessment of the relational strength between triggers detected in physiological signals and the occurrence of atrial fibrillation episodes.

OBJECTIVE: Despite the growing interest in understanding the role of triggers in paroxysmal atrial fibrillation (AF), solutions beyond questionnaires to identify a broader range of triggers remain lacking. This study aims to investigate the relation between triggers detected in wearable-based physiological signals and the occurrence of AF episodes. Methods: Week-long physiological signals were collected during everyday activities from 35 patients with paroxysmal AF, employing an ECG patch attached to the chest and a photoplethysmogram (PPG)-based wrist-worn device. The signals acquired by the patch were used for detecting triggers of physical exertion, psychophysiological stress, lying on the left side, and sleep disturbances, as well as to annotate AF episodes. To assess the relation between detected triggers and the occurrence of AF episodes, a measure of relational strength is employed accounting for pre- and post-trigger AF burden. The utility of ECG- and PPG-based AF detectors in determining AF burden and assessing the relational strength is also analyzed. Results: Physical exertion emerged as the trigger associated with the largest increase in relational strength for the largest number of patients (p< 0.01). On the other hand, no significant difference was observed for psychophysiological stress and sleep disorders. When AF episodes are captured using AF detectors, the relational strength exhibits a moderate correlation with the relational strength of the annotated AF, withr= 0.66 for ECG-based AF detection andr= 0.62 for PPG-based AF detection. Conclusions: The findings indicate a patient-specific increase in relational strength for all four types of triggers. Significance: The proposed approach has the potential to facilitate the implementation of longitudinal studies and can serve as a less biased alternative to questionnaire-based AF trigger detection.

Exploring SCN5A Variants Associated with Atrial Fibrillation in Atrial Cardiomyocytes Derived from hiPSCs: A Characterization Study.

BACKGROUND: Atrial fibrillation (AF) poses a major risk for heart failure, myocardial infarction, and stroke. Several studies have linked SCN5A variants to AF, but their precise mechanistic contribution remains unclear. Human induced pluripotent stem cells (hiPSCs) provide a promising platform for modeling SCN5A-linked AF variants and their functional alterations. OBJECTIVE: The purpose of this study was to assess the electrophysiological impact of three AF-linked SCN5A variants, K1493R, M1875T and N1986K identified in three unrelated individuals. METHODS: CRISPR-Cas9 was used to generate a new hiPSC line in which NaV1.5 was knocked-out. Following differentiation into specific atrial cardiomyocyte by using retinoic acid, the adult WT and SCN5A variants were introduced into the NaV1.5 KO line through transfection. Subsequent analysis including molecular biology, optical mapping, and electrophysiology were performed. RESULTS: The absence of NaV1.5 channels altered the expression of key cardiac genes. NaV1.5 KO hiPSC-aCMs displayed slower conduction velocities, altered action potential (AP) parameters, and impaired calcium transient propagation. The transfection of the WT channel restored sodium current density and AP characteristics. Among the AF variants, one induced a loss-of-function (N1986K) while the other two induced a gain-of-function in NaV1.5 channel activity. Cellular excitability alterations, and early afterdepolarizations were observed in AF variants. CONCLUSION: Our findings suggest that distinct alterations in NaV1.5 channel properties may trigger atrial hyperexcitability and arrhythmogenic activity in AF. Our KO model offers an innovative approach for investigating SCN5A variants in a human cardiac environment.

Causal association between epilepsy and its DNA methylation profile and atrial fibrillation.

BACKGROUND: The "epileptic heart" concept is emerging, but the causal relationship between epilepsy and atrial fibrillation (AF) remains unclarified. OBJECTIVE: This study explores the genetic correlations and bidirectional causality between various epilepsy phenotypes and AF. METHODS: Genome-wide association study (GWAS) statistics for 10 epilepsy subtypes (29,944 cases, 52,538 controls) and AF (60,620 cases, 970,216 controls) were sourced from the International League Against Epilepsy (ILAE) and HGRI-EBI Catalog-GWAS, respectively. Linkage disequilibrium score regression (LDSC) and genome-wide Mendelian Randomization (MR) evaluated genetic correlations and bidirectional causal relationships. Epilepsy-related DNA methylation data (N= ∼800) from EWAS catalog were analyzed to identify causal CpG sites influencing AF risk through epigenetic MR. RESULTS: LDSC revealed significant genetic correlations between four epilepsy subtypes and AF (rg from 0.116 to 0.241). Forward MR suggested a significant causal effect of focal epilepsy with hippocampal sclerosis (FE with HS) on AF risk (IVW and MR-PRESSO: OR = 1.046, P ≤ 0.004), with results robust against heterogeneity, horizontal pleiotropy, and outliers. Epigenetic MR indicated that lower methylation at cg06222062 (OR = 0.994, P = 3.16E-04) mapped to PLA2G5 and cg08461451 mapped to SPPL2B gene (OR = 0.954, P = 1.19E-03), and higher cg10541930 in the C10orf143 promoter (OR = 1.043, P = 4.18E-22) increases AF risk. Sensitivity analyses affirmed no pleiotropic bias. CONCLUSION: FE with HS significantly increases AF risk, highlighting the natural neural-cardiac connection and the need for cardiac monitoring in epilepsy patients. Specific methylated CpG sites may serve as biomarkers and preventive targets for AF susceptibility.

Animal Experimental Study of Bioabsorbable Left Atrial Appendage Occluder.

Left atrial appendage (LAA) closure can prevent stroke in high-risk patients with atrial fibrillation.A bioabsorbable LAA occluder made of degradable polymer materials, such as polydioxanone (PDO) and poly-L-lactic acid (PLA), and nitinol wire was used. Occluders were successfully implanted in 18 Chinese rural dogs, 2 of which died within 48 hours after operation due to pericardial tamponade and hemorrhage, respectively. Follow-up observation was performed after transcatheter LAA closure. New tissue was found on the surface of the occluder 2 months after operation. No adjacent structures such as the mitral valve and the left superior pulmonary vein were affected by the occluder discs. Hematoxylin and eosin (HE) staining was performed at 3 months after operation, which showed intact intimal structure on the occluder surface, and unabsorbed PDO and PLA were observed. Scanning electron microscopy showed irregular arrangement of endothelial cells. New endothelial tissue was observed to completely cover the occluder at 6 months after operation. Most PDOs were replaced by fibrous connective tissue, and scanning electron microscopy showed regularly arranged endothelial cells. Pathological examination at 12 months showed only a small remnant of PDO. The gross specimens of the liver, spleen, and kidneys and pathological examination did not indicate thromboembolism.The bioabsorbable LAA occluder made of PDO, PLA, and nitinol wire was safe and effective for the occlusion of LAA in dogs. The surface of the occluder was endothelialized half a year after operation. The absorbable materials of the occluder were degraded after 1 year.

Comparison of inflammatory markers for the prediction of atrial fibrillation recurrence following cryoablation.

Aim: The aim of this study is to investigate the value of inflammatory markers for atrial fibrillation (AF) recurrence prediction after cryo-balloon ablation (CA).Materials & methods: The study included 399 patients divided into two groups by AF recurrence after CA. Inflammatory markers including uric acid/albumin ratio (UAR), systemic immune inflammation index (SIII) and CRP/albumin ratio (CAR) were evaluated.Results: UAR, SIII, and CAR were independently associated with the risk of recurrence in AF patients following CA. In ROC curve analysis, CAR had a greater area under curve (AUC:0.73) value than either SIII (AUC:0.68) or UAR (AUC:0.64).Conclusion: Our study results indicate that CAR compared with SIII and UAR had a greater predictive value than others inflammatory markers in predicting AF recurrence post-CA.

[Box: see text].

Direct-to-catheter ablation versus second line catheter ablation for persistent atrial fibrillation: Effect on arrhythmia recurrence, AF burden, early left atrium remodeling and quality of life.

BACKGROUND: Catheter ablation has obtained class 1 indication in ablation of young, healthy patients with symptomatic paroxysmal atrial fibrillation (AF). Anti-arrhythmic drugs (AADs) remain first-line therapy before ablating persistent AF (PersAF). We sought to evaluate the efficacy of a direct-to-catheter ablation approach against catheter ablation post AADs in PersAF. METHODS: In this DECAAF II subanalysis, patients were stratified into two subgroups: 'Direct-to-catheter' group comprising patients who had not received AADs prior to ablation, and'second-line ablation' group, comprising patients who had been on any AAD therapy at any time before ablation. Patients were followed over 18 months. The primary outcome was AF recurrence. Secondary outcomes included AF burden, quality of life (QoL) that assessed by the AFSS and SF-36 scores, and changes in the left atrial volume index (LAVI) assessed by LGE-MRI scans. RESULTS: The analysis included 815 patients, with 279 classified as'direct-to-catheter' group and 536 classified as'Second-line ablation' group. The primary outcome was similar between both groups (44.8% vs 44.4%, p > 0.05), as was AF burden (20% vs 16%, p > 0.05). Early remodeling, reflected by LAVI reduction, was similar between the groups (9.1 [1.6-18.0] in the second-line ablation group and 9.5 [2.5-19.7] in the direct-to-catheter group, p > 0.05). QoL pre/post ablation was also similar (p > 0.05). On multivariate analysis, history of AAD was not predictive of AF recurrence(p > 0.05). CONCLUSION: Prior AAD therapy demonstrated minimal impact on atrial remodeling and QoL improvement, in addition to limited benefit on AF recurrence and burden post-ablation in patients with PersAF. Additional studies are warranted to explore the efficacy of catheter ablation as a first-line therapy in PersAF.

Application Value and Safety Analysis of Warfarin, Rivaroxaban, and Dabigatran Ester in Elderly Patients With Atrial Fibrillation.

BACKGROUND: This study aimed to evaluate the application value and safety of Warfarin, Rivaroxaban, and Dabigatran in elderly patients with atrial fibrillation. METHODS: A total of 180 elderly patients with atrial fibrillation admitted to our hospital were retrospectively analyzed. According to their anticoagulant treatment regimen, patients were divided into three groups: Warfarin (57 cases), Rivaroxaban (61 cases), and Dabigatran (62 cases). General demographic information was collected, and coagulation function indicators-including fibrinogen (FIB), thrombin time (PT), activated partial thrombin time (APTT), and D-dimer (D-D)-as well as liver function indexes-including total bilirubin (TbiL), alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alanine transferase (ALT)-were compared before and after 4 weeks of treatment. RESULTS: There were no significant differences in demographic characteristics such as gender, age, body mass index, or disease course among the three groups. The total effective rate in the Warfarin group (84.21%) was significantly lower than in the Rivaroxaban (98.36%) and Dabigatran (96.77%) groups (p < 0.05). However, there was no significant difference in the total effective rate between the Rivaroxaban and Dabigatran groups (p > 0.05). Additionally, no significant differences were found in the effects of the three drugs on coagulation function, liver function, or the incidence of bleeding (p = 0.052). CONCLUSION: Warfarin, Rivaroxaban, and Dabigatran can effectively prevent thrombosis in elderly patients with atrial fibrillation, with Rivaroxaban and Dabigatran showing superior effectiveness. All three drugs demonstrated similar low rates of bleeding events and had no significant impact on coagulation and liver function.

Incidence, outcomes, and predictors of new heart failure in syrian conflict-affected population following hospitalization for atrial fibrillation: A retrospective cohort study.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia worldwide. Data regarding readmission for new congestive heart failure (CHF) following index admission for AF in the developing world are poorly described. OBJECTIVES: The study aimed to assess the rate, predictors, and outcomes of 120-day CHF readmission after index admission for AF in Syria. METHODS: This retrospective cohort study collected all adult patients without known CHF who had an index admission with AF to Latakia's tertiary center between June 2021-December 2023. Data were taken from patients' medical notes. The primary outcome included readmission with incident CHF within 120 of index discharge, and secondary outcomes included predictors and outcomes of these CHF readmissions. RESULTS: A total of 660 patients were included in the final analysis, of which 69 (11.7%) were readmitted with new CHF within 120 days of index discharge. Readmitted patients had higher median age (58 vs 70 years, p < .001). Factors that independently increased 120-day CHF incidence were age ≥60 years (HR: 9.8, 95% CI: 4.8-23.6, p < .001), diabetes mellitus (DM) (HR:2.9, 95% CI:1.7-4.9, p < .001), valvular heart disease (VHD) (HR:1.7, 95% CI:1.04-2.78, p = .047), and hypertension (HR:2.5, 95% CI:1.5-4, p < .001). Inpatient mortality occurred in six readmitted patients (9%). LVEF <40% (HR:6.7, 95% CI: 24.31, p = .01) and DM (HR:7.2, 95% CI: 1.9-33, p = .004) were independently associated with inpatient mortality. CONCLUSION: Hospitalization for new CHF was common in Syrian patients discharged with AF. The clinical predictors of incident CHF emphasize the importance of integrated management of lifestyle risk factors and common comorbidities in AF patients to optimize outcomes in resource-depleted communities.

Short- and long-term outcomes in thoracoscopic versus hybrid thoracoscopic ablation in patients with atrial fibrillation: a systematic review and reconstructed individual patient data meta-analysis.

BACKGROUND AND AIMS: Both isolated thoracoscopic and hybrid thoracoscopic atrial fibrillation (AF) ablation techniques have demonstrated favorable outcomes in the management of patients with (long-standing) persistent AF, as compared to catheter ablation. However, it is currently unknown whether there is a difference in short- and long-term outcomes when comparing these two minimally invasive surgical AF ablation procedures. Therefore, a systematic review and meta-analysis were performed to investigate these two techniques, with a specific emphasis on long-term freedom from atrial tachyarrhythmias (ATA). METHODS: A systematic search through PubMed, EMBASE, and the Cochrane Library databases was performed. All studies reporting on short-term outcomes were included in the meta-analysis. A pooled analysis of long-term freedom from ATA was performed based on Kaplan-Meier (KM) curve-derived individual patient data (IPD). Reconstructed individual time-to-event data were analyzed in a multivariable Cox frailty model with adjustments for age, sex, type of AF, duration of AF history, and study variable (frailty term in the frailty Cox model). RESULTS: In total, 53 studies were included in the meta-analysis, encompassing 4950 patients. There were no differences in major short-term outcomes (mortality or stroke) between isolated thoracoscopic and hybrid thoracoscopic ablation. A total of 18 studies reported KM curves for long-term freedom from ATA, comprising 2038 patients. Adjusted analysis revealed that hybrid ablation was significantly associated with greater freedom from ATA (Adjusted Hazard Ratio [aHR]=0.59, 95%CI: 0.43-0.83, p<0.001) compared to isolated thoracoscopic ablation. Additionally, older age (aHR=1.07, 95%CI: 1.03-1.12, p=0.002) and a higher percentage of male patients (aHR=1.02, 95% CI: 1.01-1.03, p<0.001) were significantly associated with lower long-term freedom from ATA recurrence. CONCLUSION: Hybrid thoracoscopic AF-ablation is associated with a greater long-term freedom from ATA when compared to isolated thoracoscopic ablation, without differences in complications.

Catheter ablation for atrial fibrillation in patients with prior left atrial appendage occlusion device.

BACKGROUND: The safety and efficacy of CA for AF and left-sided atrial arrhythmias (AA) in patients with left atrial appendage occlusion (LAAO) devices are lacking. METHODS: This is a single-center retrospective registry that included all patients with prior LAAO who underwent catheter ablation for AF or left-sided atrial arrhythmia from January 2020-January 2023. The primary outcomes were procedure-related complications, device-related complications, AA recurrence, and stroke. RESULTS: A total of 30 patients with prior LAAO were included in the analysis (mean age 75.1 ± 7.1 years old, 50% male, mean CHA2DS2-VASc score 4 ± 1.6, 46.7% paroxysmal AF, 73.3% had prior AF ablation, mean time to ablation 475 ± 365 days). 93.3% (n = 28) and 6.6% (n = 2) patients had ablation for AF (46.7% paroxysmal, 36.7% persistent, 10% long-standing persistent) and left-sided atrial tachycardia, respectively. 16.7% (n = 5) patients underwent ablation along the left atrial appendage ostium, and 3.3% (n = 1) underwent Vein of Marshall alcohol ablation. There were 3 (10%) peri-procedural complications (1 access hematoma and two pericardial effusions requiring intervention-none related to left atrial appendage ostium or alcohol ablation). During the mean follow-up of 440 ± 379 days, 40% (n = 12) patients had AA recurrence (91.6% AF, 8.3% atrial tachycardia), of which five patients needed repeat ablation, and two patients were readmitted for heart failure. There was no stroke or any device-related complications, including new peri-device leaks or device-related thrombosis in patients who had follow-up imaging studies (n = 11, 36.7%). CONCLUSION: Catheter ablation for AF (including VoM alcohol ablation) in patients with prior LAAO devices is feasible and safe with favorable outcomes.

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

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

Efficacy and safety of atrial fibrillation ablation in patients with aged 80 years or older.

Atrial fibrillation (AF) is the most common cardiac arrhythmia observed in the elderly. Its prevalence rises with age, particularly in individuals over 80 years old. While catheter ablation has emerged as a first line therapy for the patients with symptomatic AF, evidence on its application in elderly patients remains controversial. This study aimed to assess safety and efficacy outcomes of AF ablation in patients aged ≥ 80 years. Consecutive 1327 patients who underwent a first pulmonary vein isolation (PVI) for AF were retrospectively analyzed. Patients aged ≥ 80 years (elderly group, n = 107) were compared with patients aged < 80 years (younger group, n = 1220). At 1-year follow-up, there was no significant difference in AF free rate between the elderly and the younger group (72.0% vs. 73.9%, P = 0.786). Regarding major complications, the elderly patients had a greater incidence of periprocedural stroke (1.9% vs. 0.1%, P = 0.018). The rates of cardiac tamponade, phrenic palsy, and vascular complications were not significantly different between the 2 groups. PVI for AF is effective in patients aged ≥ 80 years with a similar success rate, but periprocedural stoke risk was higher compared to the younger population.