Predictors of pulmonary vein non-reconnection in the second procedure after ablation index-guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome.

INTRODUCTION: Although first-pass isolation (FPI) of the pulmonary vein (PV) has been suggested as a marker for PV isolation (PVI) durability, it has not been confirmed. Non-PV atrial fibrillation (AF) triggers were the main target in patients without PV reconnection in the second ablation procedure, but the outcome was unclear. We aimed to validate FPI as a marker of PVI durability and evaluate the outcome after the second procedure in patients without PV reconnection by comparing it to those with reconnection. METHODS: Among the 2087 patients undergoing the first ablation index-guided radiofrequency AF ablation, 309 with atrial tachyarrhythmias (ATs) recurrence and undergoing the second procedure were studied. Clinical characteristics and outcomes were compared between the patients without PV reconnection (PV non-reconnection group, n = 142) and with reconnection (PV reconnection group, n = 167). RESULTS: FPI in both PV sides in the first ablation procedure was significantly more frequent in the PV non-reconnection group (77.5%) than in the PV reconnection group (45.5%) (p < .001). Multivariate logistic regression analysis revealed that FPI (odds ratio, 3.71 [95% confidence interval, 2.23-6.19], p < .001) was the only predictor of PV non-reconnection. Radiofrequency applications for non-PV AF triggers were more frequently performed in the PV non-reconnection group (40.8% vs. 24.6%, respectively, p < .001). Kaplan-Meier analysis revealed that AT recurrence-free rate was significantly lower in the PV non-reconnection group (1-year recurrence-free rate, 62.7% vs. 75.4%, respectively; p = .01 by log-rank test). CONCLUSION: FPI was the only independent predictor of PV non-reconnection. Despite aggressive ablation for non-PV triggers, AT recurrence was more frequent in patients with PV non-reconnection.

Posterior wall thickness of the confluent inferior pulmonary veins measured by left atrial intracardiac echocardiography: implications for catheter ablation.

BACKGROUND: Confluent inferior pulmonary veins (CIPV) is a rare anatomical variant. There is few evidence in the literature regarding anatomic landmarks consideration to guide radiofrequency application in avoiding complications in the esophagus in CIPV cases. METHODS: Of 986 consecutive patients undergoing atrial fibrillation (AF) ablation from July 2020 to June 2022, seven (0.7%) had CIPV with a common trunk connecting to the LA diagnosed by 3-dimensional contrast-enhanced computed tomography. Using intracardiac echocardiography (ICE) performed from the left atrium (LA), we measured the posterior wall thickness (PWT) of the CIPV adjacent to the esophagus and compared the measurement with the LA posterior wall thickness (LAPWT) at the left inferior PV level of 25 controls without CIPV. For ablation in CIPV patients, each superior PV was individually isolated, and box isolation of CIPV without ablating the CIPV posterior wall was added (tri-circle ablation technique). RESULTS: The CIPV PWT was 0.7 ± 0.1 mm, while non-CIPV LAPWT was 2.0 ± 0.4 mm (P < 0.001). In the CIPV group, upper and lower portions of the CIPV were both apart from the esophagus (mean distances, 6.7 ± 3.4 mm and 7.9 ± 2.7 mm, respectively). Individual superior PV isolation and box CIPV isolation resulted in complete isolation of all PVs, with no complications. All CIPV patients except one remained AF recurrence-free for 376 ± 52 days. CONCLUSIONS: Although CIPV frequency is low, CIPV PWT is very thin and special care is needed during ablation. A "tri-circle" ablation strategy avoids ablating in the thinnest portion of the posterior wall. Further studies are warranted to assess the safety.

Safety and efficacy of ablation index-guided atrial fibrillation ablation in octogenarians.

BACKGROUND: Limited data on the efficacy and safety of atrial fibrillation (AF) ablation using an ablation index (AI) for octogenarians is available. We aimed to compare the efficacy and safety of AI-guided AF ablation between AF patients aged ≥80 years (Group 1) and <80 (Group 2). HYPOTHESIS: We hypothesized that AI-guided AF ablation could complete the procedure with comparable efficiency and safety in patients aged ≥80 years and <80. METHODS: We retrospectively reviewed 2087 AF patients undergoing their first AI-guided AF ablation in our hospital. We compared the atrial tachyarrhythmia (AT) recurrence and procedure-related complication rate between Group 1 (n = 193) and Group 2 (n = 1894). RESULTS: The mean age was 83.0 (interquartile range [IQR] 81.0, 84.0) years in Group 1 and 67.0 (IQR 60.0, 72.0) in Group 2. AF type was significantly different between the two groups: Of Group 1 patients, 120 (62.2%) had paroxysmal AF, 61 (31.6%) persistent AF, and 12 (6.2%) long-standing persistent AF, while of Group 2 patients, 1016 (53.6%) paroxysmal AF, 582 (30.7%) persistent AF, and 296 (15.6%) long-standing persistent AF (p = .001). Unadjusted AT recurrence-free survival curves showed similar AT recurrence-free survival between the two groups (p = .67 by log-rank test). After the adjustment for AF type, the survival curve was similar between them (hazard ratio, 1.24; 95% CI [0.92-1.65]; p = .15, Group 1 vs. Group 2). The rate of procedure-related complications was similar between the two groups (3.1% vs. 3.0%, respectively, p = .83). CONCLUSION: Catheter ablation guided by AI achieved similar AT recurrence and complication rates between elderly AF patients aged ≥80 years and patients <80 years.