Distribution of antral lesions with the novel size-adjustable cryoballoon for pulmonary vein isolation and the differences based on left atrial remodeling.

INTRODUCTION: The novel cryoballoon with 28 mm or 31 mm adjustable diameters, aims to achieve a wide antral pulmonary vein isolation (PVI). However, the distribution of antral lesions and their variations based on left atrial (LA) remodeling require further clarification. METHODS: We evaluated 22 patients (67 [59.5-74.8] years, 19 males) who underwent PVI of atrial fibrillation (AF) (13 paroxysmal AF [PAF] and 9 non-PAF) using size-adjustable cryoballoons. LA electro-anatomical mapping was performed post-PVI with three-dimensional mapping systems. We assessed the shapes of the LA and pulmonary veins (PVs) and the distribution of isolated areas (IAs), comparing the results between PAF and non-PAF patients. RESULTS: In the left PVs (LPVs), the distance between the PV orifice and IA edge (PVos-IA) was larger on the roof and posterior segments (~15 mm) but relatively smaller on the anterior segment near the PV ridge (<10 mm). For the right PVs (RPVs), it was more extensive in the posterior segment (10-15 mm). Comparing PAF and non-PAF, there were no significant differences in the PVos-IA except for the right posterior-carina segment, antrum IA (LPVs: 5.9 ± 1.6 vs. 5.8 ± 0.8 cm², p = .81; RPVs: 4.8 ± 2.3 vs. 4.8 ± 1.2 cm², p = .81), distances between the right and left IAs on the LA posterior wall (LAPW), and un-isolated LAPW area (9.0 ± 4.9 vs. 9.9 ± 2.5 cm², p = .62). No individual PVIs were observed in either group. Two patients exhibited overlapping IAs on the roof, and one patient who underwent 31 mm balloon applications for all PVs exhibited an LAPW isolation. CONCLUSION: The size-adjustable cryoballoon achieved a wide antral PVI even in non-PAF patients.

Comparison of three different approaches to very high-power short-duration ablation using the QDOT-MICRO catheter.

BACKGROUND/OBJECTIVES: The QDOT-MICRO™ catheter allows very high-power and short-duration (vHPSD) ablation. This study aimed to investigate lesion characteristics using different ablation settings. METHODS: Radiofrequency applications (90 W/4 s, temperature-control mode with 55°C or 60°C target) were performed in excised porcine myocardium using three different approaches: single (SA), double nonrepetitive (DNRA), and double repetitive applications (DRA). Applications were performed with an interval of 1 min for DNRA, and without interval for DRA. RESULTS: A total of 480 lesions were analyzed. Lesion depth and volume were largest for DRA followed by DNRA and SA regardless of catheter direction (depth: 3.8 vs. 3.3 vs. 2.6 mm, p < .001 for all comparisons; volume: 176.6 vs. 145.1 vs. 97.0 mm3 , p < .001 for all comparisons). Surface area was significantly larger for DRA than for SA (45.1 vs. 38.3 mm2 , p < .001) and larger for DNRA than for SA (44.5 vs. 38.3 mm2 , p < .001), but was similar between DRA and DNRA (45.1 vs. 44.5 mm2 , p = .54). Steam-pops more frequently occurred for DRA than for SA (15.6% vs. 4.4%, p = .004) and DNRA (15.6% vs. 6.9%, p = .061), but the incidence was similar between SA and DNRA (4.4% vs. 6.9%, p = 1). Although surface area and lesion volume were larger in lesions with steam-pops than without steam-pops (46.5 vs. 38.1 mm2 , p = .018 and 128.3 vs. 96.8 mm3 , p = .068, respectively), lesions were not deeper (pop(+): 2.5 mm vs. pop(-): 2.6 mm, p = .75). CONCLUSIONS: DNRA produces larger lesions than SA without increasing the risk of steam-pops. DRA produces the largest lesions among the three groups, but with an increased risk of steam-pops. Even with steam-pops, lesions do not become deeper in vHPSD ablation.

Impact of filter configurations on bipolar EGMs: An optimal filter setting for identifying VT substrates.

BACKGROUND: The impact of filtering on bipolar electrograms (EGMs) has not been systematically examined. We tried to clarify the optimal filter configuration for ventricular tachycardia (VT) ablation. METHODS: Fifteen patients with VT were included. Eight different filter configurations were prospectively created for the distal bipoles of the ablation catheter: 1.0-250, 10-250, 100-250, 30-50, 30-100, 30-250, 30-500, and 30-1000 Hz. Pre-ablation stable EGMs with good contact (contact force > 10 g) were analyzed. Baseline fluctuation, baseline noise, bipolar peak-to-peak voltage, and presence of local abnormal ventricular activity (LAVA) were compared between different filter configurations. RESULTS: In total, 2276 EGMs with multiple bipolar configurations in 246 sites in scar and border areas were analyzed. Baseline fluctuation was only observed in the high-pass filter of (HPF) ≤ 10 Hz (p < .001). Noise level was lowest at 30-50 Hz (0.018 [0.012-0.029] mV), increased as the low-pass filter (LPF) extended, and was highest at 30-1000 Hz (0.047 [0.041-0.061] mV) (p < .001). Conversely, the HPF did not affect the noise level at ≤30 Hz. As the HPF extended to 100 Hz, bipolar voltages significantly decreased (p < .001), but were not affected when the LPF was extended to ≥100 Hz. LAVAs were most frequently detected at 30-250 Hz (207/246; 84.2%) and 30-500 Hz (208/246; 84.6%), followed by 30-1000 Hz (205/246; 83.3%), but frequently missed at LPF ≤ 100 Hz or HPF ≤ 10 Hz (p < .001). A 50-Hz notch-filter reduced the bipolar voltage by 43.9% and LAVA-detection by 34.5% (p < .0001). CONCLUSION: Bipolar EGMs are strongly affected by filter settings in scar/border areas. In all, 30-250 or 30-500 Hz may be the best configuration, minimizing the baseline fluctuation, baseline noise, and detecting LAVAs. Not applying the 50-Hz notch filter may be beneficial to avoid missing VT substrate.

Comparison of lesion characteristics using temperature-flow-controlled versus conventional power-controlled ablation with fixed ablation index.

INTRODUCTION: The QDOT-MicroTM catheter is a novel irrigated contact force (CF) sensing catheter which benefits from thermocouples for temperature monitoring, allowing temperature-flow-controlled (TFC) ablation. We compared lesion metrics at fixed ablation index (AI) value during TFC-ablation and conventional power-controlled (PC)-ablation. METHODS: A total of 480 RF-applications were performed on ex-vivo swine myocardium with predefined AI targets (400/550) or until steam-pop occurred, using the QDOT-MicroTM (TFC-ablation) and Thermocool SmartTouch SFTM (PC-ablation). RESULTS: Both TFC-ablation and PC-ablation produced similar lesions in volume (218 ± 116 vs. 212 ± 107 mm3 , p = .65); however, lesions using TFC-ablation were larger in surface area (41.3 ± 8.8 vs. 34.8 ± 8.0 mm2 , p < .001) and shallower in depth (4.0 ± 1.0 vs. 4.2 ± 1.1 mm, p = .044). Average power tended to be lower in TFC-alation (34.2 ± 8.6 vs. 36.9 ± 9.2, p = .005) compared to PC-ablation due to automatic regulation of temperature and irrigation-flow. Although steam-pops were less frequent in TFC-ablation (24% vs. 15%, p = .021), they were particularly observed in low-CF (10 g) and high-power ablation (50 W) in both PC-ablation (n = 24/240, 10.0%) and TFC-ablation (n = 23/240, 9.6%). Multivariate analysis revealed that high-power, low-CF, long application time, perpendicular catheter orientation, and PC-ablation were risk factors for steam-pops. Furthermore, activation of automatic regulation of temperature and irrigation-flow was independently associated with high-CF and long application time while ablation power had no significant relationship. CONCLUSIONS: With a fixed target AI, TFC-ablation reduced the risk of steam-pops, producing similar lesions in volume, but with different metrics in this ex-vivo study. However, lower CF and higher power in fixed-AI ablation may increase the risk of steam-pops.

Impact of baseline pool impedance on lesion metrics and steam pops in catheter ablation.

INTRODUCTION: Little is known about the impact of blood-pool local impedance (LI) on lesion characteristics and the incidence of steam pops. METHODS: Radiofrequency applications at a range of powers (30, 40, and 50 W), contact forces (CF) (5, 15, and 25 g), and durations (15, 30, 45, and 120 s) using perpendicular/parallel catheter orientation were performed in 40 excised porcine preparations, using a catheter capable of monitoring LI (StablePoint©, Boston Scientific). To simulate the variability in blood-pool impedance, the saline-pool LI was modulated by calibrating saline concentrations. Lesion characteristics were compared under three values of saline-pool LI: 120, 160, and 200 Ω. RESULTS: Of 648 lesions created, steam pops occurred in 175 (27.0%). When power, CF, time, and catheter orientation were adjusted, ablation at a saline-pool impedance of 160 or 200 Ω more than doubled the risk of steam pops compared with a saline-pool impedance of 120 Ω (Odds ratio = 2.31; p = .0002). Lesions in a saline-pool impedance of 120 Ω were significantly larger in surface area (50 [38-62], 45 [34-56], and 41 [34-60] mm2 for 120, 160, and 200 Ω, p < .05), but shallower in depth (4.0 [3-5], 4.4 [3.2-5.3], and 4.5 [3.8-5.5] mmfor 120, 160, and 200 Ω, respectively, p < .05) compared with the other two settings. The correlation between the absolute LI-drop and lesion size weakened as the saline-pool LI became higher (e.g., 120 Ω group (r2 = .30, r2 = .18, and r2 = .16, respectively for 120, 160, and 200 Ω), but the usage of %LI-drop (= absolute LI-drop/initial LI) instead of absolute LI-drop may minimize this effect. CONCLUSIONS: In an experimental model, baseline saline-pool impedance significantly affects the lesion metrics and the risk of steam pops.

Transcoronary mapping with an over-the-wire multielectrode catheter in scar-related ventricular tachycardia patients.

AIMS: The usefulness of coronary venous system mapping has been reported for assessing intramural and epicardial substrates in patients with scar-related ventricular tachycardia (VT). However, there has been little data on mapping from coronary arteries. We investigated the safety and utility of mapping from coronary arteries with a novel over-the-wire multielectrode catheter in scar-related VT patients. METHODS AND RESULTS: Ten consecutive scar-related VT patients with non-ischaemic cardiomyopathy who underwent mapping from a coronary artery were analysed. Six patients underwent simultaneous coronary venous mapping. High-density maps were created by combining the left ventricular endocardium and coronary vessels. Substrate maps were created during the baseline rhythm with 2438 points (IQR 2136-3490 points), including 329 (IQR 59-508 points) in coronary arteries. Abnormal bipolar electrograms were successfully recorded within coronary arteries close to the endocardial substrate in seven patients. During VT, isthmus components were recorded within the coronary vessels in three patients with no discernible isthmus components on endocardial mapping. The ablation terminated the VT from an endocardial site opposite the earliest site in the coronary arteries in five patients. CONCLUSION: The transcoronary mapping with an over-the-wire multielectrode catheter can safely record abnormal bipolar electrograms within coronary arteries. Additional mapping data from the coronary vessels have the potential to assess three-dimensional ventricular substrates and circuit structures in scar-related VT patients.

Detailed analysis of tachycardia cycle length aids diagnosis of the mechanism and location of atrial tachycardias.

AIMS: Although the mechanism of an atrial tachycardia (AT) can usually be elucidated using modern high-resolution mapping systems, it would be helpful if the AT mechanism and circuit could be predicted before initiating mapping. OBJECTIVE: We examined if the information gathered from the cycle length (CL) of the tachycardia can help predict the AT-mechanism and its localization. METHODS: One hundred and thirty-eight activation maps of ATs including eight focal-ATs, 94 macroreentrant-ATs, and 36 localized-ATs in 95 patients were retrospectively reviewed. Maximal CL (MCL) and minimal CL (mCL) over a minute period were measured via a decapolar catheter in the coronary sinus. CL-variation and beat-by-beat CL-alternation were examined. Additionally, the CL-respiration correlation was analysed by the RhythmiaTM system. : Both MCL and mCL were significantly shorter in macroreentrant-ATs [MCL = 288 (253-348) ms, P = 0.0001; mCL = 283 (243-341) ms, P = 0.0012], and also shorter in localized-ATs [MCL = 314 (261-349) ms, P = 0.0016; mCL = 295 (248-340) ms, P = 0.0047] compared to focal-ATs [MCL = 506 (421-555) ms, mCL = 427 (347-508) ms]. An absolute CL-variation (MCL-mCL) < 24 ms significantly differentiated re-entrant ATs from focal-ATs with a sensitivity = 96.9%, specificity = 100%, positive predictive value (PPV) = 100%, and negative predictive value (NPV) = 66.7%. The beat-by-beat CL-alternation was observed in 10/138 (7.2%), all of which showed the re-entrant mechanism, meaning that beat-by-beat CL-alternation was the strong sign of re-entrant mechanism (PPV = 100%). Although the CL-respiration correlation was observed in 28/138 (20.3%) of ATs, this was predominantly in right-atrium (RA)-ATs (24/41, 85.7%), rather than left atrium (LA)-ATs (4/97, 4.1%). A positive CL-respiration correlation highly predicted RA-ATs (PPV = 85.7%), and negative CL-respiration correlation probably suggested LA-ATs (NPV = 84.5%). CONCLUSION: Detailed analysis of the tachycardia CL helps predict the AT-mechanism and the active AT chamber before an initial mapping.

Peri-procedural anticoagulation in patients with end-stage kidney disease undergoing atrial fibrillation ablation: results from the multicentre end-stage kidney disease-atrial fibrillation ablation registry.

AIMS: The optimal anticoagulation regimen in patients with end-stage kidney disease (ESKD) undergoing atrial fibrillation (AF) catheter ablation is unknown. We sought to describe the real-world practice of peri-procedural anticoagulation management in patients with ESKD undergoing AF ablation. METHODS AND RESULTS: Patients with ESKD on haemodialysis undergoing catheter ablation for AF in 12 referral centres in Japan were included. The international normalized ratio (INR) before and 1 and 3 months after ablation was collected. Peri-procedural major haemorrhagic events as defined by the International Society on Thrombosis and Haemostasis, as well as thromboembolic events, were adjudicated. A total of 347 procedures in 307 patients (67 ±9 years, 40% female) were included. Overall, INR values were grossly subtherapeutic [1.58 (interquartile range: 1.20-2.00) before ablation, 1.54 (1.22-2.02) at 1 month, and 1.22 (1.01-1.71) at 3 months]. Thirty-five patients (10%) suffered major complications, the majority of which was major bleeding (19 patients; 5.4%), including 11 cardiac tamponade (3.2%). There were two peri-procedural deaths (0.6%), both related to bleeding events. A pre-procedural INR value of 2.0 or higher was the only independent predictor of major bleeding [odds ratio, 3.3 (1.2-8.7), P = 0.018]. No cerebral or systemic thromboembolism occurred. CONCLUSION: Despite most patients with ESKD undergoing AF ablation showing undertreatment with warfarin, major bleeding events are common while thromboembolic events are rare.

Superiority of the Combination of Input and Output Parameters to the Single Parameter for Lesion Size Estimation.

BACKGROUND: For lesion size prediction, each input parameter, including ablation energy (AE), and output parameter, such as impedance, is individually used. We hypothesize that using both parameters simultaneously may be more optimal.Methods and Results: Radiofrequency applications at a range of power (30-50 W), contact force (10 g and 20 g), duration (10-60 s), and catheter orientation with normal saline (NS)- or half-normal saline (HNS)-irrigation were performed in excised porcine hearts. The correlations, with lesion size of AE, absolute impedance drop (∆Imp-drop), relative impedance drop (%Imp-drop), and AE*%Imp-drop were examined. Lesion size was analyzed in 283 of 288 lesions (NS-irrigation, n=142; HNS-irrigation, n=141) without steam pops. AE*%Imp-drop consistently showed the strongest correlations with lesion maximum depth (NS-irrigation, ρ=0.91; HNS-irrigation, ρ=0.94), surface area (NS-irrigation, ρ=0.87; HNS-irrigation, ρ=0.86), and volume (NS-irrigation, ρ=0.94; HNS-irrigation, ρ=0.94) compared with the other parameters. Moreover, compared with AE alone, AE*%Imp-drop significantly improved the strength of correlation with lesion maximum depth (AE vs. AE*%Imp-drop, ρ=0.83 vs. 0.91, P<0.01), surface area (ρ=0.73 vs. 0.87, P<0.01), and volume (ρ=0.84 vs. 0.94, P<0.01) with NS-irrigation. This tendency was also observed with HNS-irrigation. Parallel catheter orientation showed a better correlation with lesion depth and volume using ∆Imp-drop, %Imp-drop, and AE*%Imp-drop than perpendicular orientation. CONCLUSIONS: The combination of input and output parameters is more optimal than each single parameter for lesion prediction.

Demonstration of the discrepancy between AT-wave morphology on 12-lead ECG and AT mechanism in scar-related AT.

The 12-lead electrocardiogram (ECG) is a fundamental modality to help determine the mechanism and the localization of atrial tachycardias (ATs). Although macroreentrant ATs and focal ATs typically show F-waves and discrete P-waves respectively on the 12-lead ECG, this is not universally the case in scar-related ATs.1, We present three cases clearly showing the discrepancy between the AT morphology on the 12-lead ECG and the AT-mechanism.

Safety verification of a novel irrigation catheter with flexible tip of laser-cut kerfs and contact force sensor.

BACKGROUND AND AIMS: The safety evaluation of TactiFlex, a novel contact-force sensing catheter with a flexible 4-mm tip irrigated through laser-cut kerfs, has been ongoing. This study aimed to verify the safety of this type of catheter. METHODS: Study 1: Radiofrequency (RF) applications at a range of powers (30-50 W), contact forces (10-20 g), and durations (10-60 s) using perpendicular/parallel catheter orientation with half-normal (HNS) or normal saline irrigation were compared between TactiFlex (4-mm tip) and TactiCath (3.5-mm tip) with temperature-controlled mode in excised porcine hearts. Study 2: The relation between RF applications using TactiFlex and the incidence of steam-pops in the real clinical cases were examined. RESULTS: Study-1: 576 RF lesions were examined. TactiFlex demonstrated a significantly lower risk of steam-pops (5[1.7%] vs. 59[20.5%], p < .0001). Compared to 3.5-mm-tip catheter (TactiCath), 4-mm-tip catheter (TactiFlex) produced smaller lesion volume at perpendicular (193[98-554]mm3 vs. 263[139-436]mm3 , p < .0001), but relatively similar lesion volume at parallel contact (243[105-443]mm3 vs. 278[180-440]mm3 , p = .06). HNS-irrigation tended to increase the lesion volume in both catheters and to increase the incidence of steam-pops with TactiCath, but not with TactiFlex. The cut-off value of %impedance-drop ( = absolute impedance-drop/initial impedance) of 20% predicted steam-pops with a sensitivity = 100% and specificity = 89.6% in TactiFlex. Study-2: 5496 RF applications in 84 patients (51AFs/8ATs/3AVNRTs/4AVRTs/17PVCs/4VTs) using TactiFlex were analyzed. Four steam-pops (0.07%) in three patients with pericardial effusion were observed (%impedance-drop = 24%/26%/29%/35%, respectively). The cut-off value of %impedance-drop = 20%, derived from ex-vivo study, showed sensitivity = 100% and specificity = 90.1% in detecting steam-pops. CONCLUSION: TactiFlex reduced the risk of steam-pops than TactiCath. %impedance-drop ≤ 20% may be reasonable for safely use with a sufficient safety margin. For 4-mm-tip catheter, parallel-contact may be recommended for larger lesion creation.

Usefulness of the over-the-wire microelectrodes catheter in treatment of ventricular arrhythmia arising from the left ventricular summit.

BACKGROUND: This study was aimed to investigate the efficacy of the over-the-wire (OTW) microelectrodes catheter in coronary venous system (CVS) mapping and treatment of outflow tract ventricular arrhythmia (OTVA) arising from the vicinity of the left ventricular summit (LVS). METHODS: Consecutive 62 patients with idiopathic OTVA in whom the OTW microelectrodes catheter was routinely used for CVS mapping were analyzed. CVS mapping was performed for both main trunk (from great cardiac vein to anterior interventricular vein) and branches including the annular branch or septal branch. RESULTS: The earliest activation site (EAS) was within the CVS in 21 patients. Among them, the EAS was within the main trunk of the CVS in seven (33%) and within the branch of the CVS in 14 (67%) patients. Radiofrequency catheter ablation was started at an anatomically adjacent site to the EAS, which eliminated OTVA in 16 (76%) patients　(the endocardial LVOT in 10 and the aortic sinus of Valsalva in six patients). For the remaining five patients with unsuccessful catheter ablation at an anatomically adjacent site, targeted OTVA was eliminated by catheter ablation at the EAS within the CVS in two patients and by chemical ablation with ethanol injection in one patient, resulting in the overall success rate of 90% (19/21). CONCLUSION: The OTW microelectrodes-guided ablation of OTVA from the vicinity of the LVS was effective. In maximizing the efficacy of ablation, CVS branch mapping is important since the earliest activation was commonly recorded not in the main trunk but within the branch of the CVS.

Endocardial contact mapping of the left atrial appendage in persistent atrial fibrillation.

INTRODUCTION: Isolation of the left atrial appendage (LAA) is often performed in persistent atrial fibrillation (AF). Propagation patterns in the LAA during AF remain to be elucidated. We sought to characterize propagation patterns in the LAA during AF in persistent AF. METHODS: Persistent AF patients undergoing catheter ablation were studied. Pulmonary vein isolation (PVI) was performed during continuous AF. If AF was not terminated by PVI, bi-atrial mapping was performed using a multi-electrode catheter during AF. Maps were collected at each site for 30 seconds and analyzed offline with a novel software, CARTOFINDER. This software made automatic determinations of whether activation was focal or rotational. The left atrium (LA) was divided into five regions, of which the LAA was one, and the right atrium (RA) into three. RESULTS: Eighty patients were studied (62 ± 10 years, 65 males). On average, 9.6 ± 2.2 and 4.1 ± 1.2 maps were created in the LA and RA, respectively. The LAA was mapped in 70 patients, resulting in 85 maps. In the LAA, activation was identified as focal more often than rotational (64 [91%] vs 10 [14%] patients, P < .001), seven patients displayed both. The number of focal activation events was greatest in the LAA (28.5 events/30 seconds [interquartile range, 15-54]) of the eight atrial regions. During focal activation, sites designated as earliest activation frequently covered a wide area, rather than being localized to a discrete site (5.4 ± 3.1 electrodes). CONCLUSIONS: The results of this study suggest that focal activation is a major mechanism underlying the arrhythmogenicity of the LAA in persistent AF.

Pulmonary vein narrowing after visually guided laser balloon ablation: Occurrence and clinical correlates.

INTRODUCTION: There are limited data focusing on pulmonary vein (PV) narrowing following ablation using a visually guided laser balloon (VGLB). We sought to assess the frequency and predictors of PV narrowing after VGLB ablation. METHODS AND RESULTS: Patients with paroxysmal atrial fibrillation treated with VGLB were screened. Study participants underwent contrast-enhanced computed tomography (CT) scanning before and 6 months after the procedure. We defined 25% to 49%, 50% to 74%, and 75% to 100% reduction in PV cross-sectional area as mild, moderate, and severe narrowing, respectively. Of 146 PVs in 38 patients analyzed, severe narrowing developed in two right superior and one right inferior PV. Moderate or severe narrowing occurred in 40 veins (27% of all PVs, 50% of the right superior, 22% of the right inferior, 21% of the left superior, and 14% of the left inferior PV). In PVs with moderate-severe narrowing, the baseline orifice area was significantly larger (4.1 [interquartile range, 3.2-4.8] vs 2.5 [1.9-3.3] cm2 , P < .0001), the narrowest region of stenosis was significantly more distal into the vessel (1.9 [0.7-2.9] vs 0 [0-1.7] mm from the orifice, P = .0006) and the total amount of energy delivered per vein was significantly greater (5190 ± 970 vs 4626 ± 1573 J, P = .018) than in PVs with mild or no significant narrowing. The baseline orifice area independently predicted moderate-severe narrowing in multivariate analysis (odds ratio, 1.8 [1.3-2.5] per 1 cm2 increase, P = .0003). No patient exhibited any signs or symptoms of PV stenosis. CONCLUSIONS: Baseline PV orifice area, ablating distally inside the veins, and total amount of laser energy are associated with PV narrowing after VGLB ablation.

Clinical outcome of pulmonary vein isolation alone ablation strategy using VISITAG SURPOINT in nonparoxysmal atrial fibrillation.

BACKGROUND: Recent studies have shown the improvement in long-term effectiveness with standardized pulmonary vein isolation (PVI) aimed at creating durable and contiguous lesions with VISITAG SURPOINT (VS) in paroxysmal atrial fibrillation (PAF). OBJECTIVE: We aimed to assess efficacy of PVI alone strategy using VS in non-PAF patients and evaluate factors associated with corresponding clinical outcomes. METHODS: Consecutive patients who underwent PVI for persistent/long-standing persistent AF between May 2017 to July 2019 were studied retrospectively. PVI was performed with 30-50 W guided by VS (posterior target: 400-500, anterior target: 500). Left atrial voltage maps were created during atrial pacing after PVI. RESULTS: A total of 140 patients (119 males, age 62 ± 10 years, long-standing persistent AF: 35) were included and followed for median of 454 days. No adverse events were reported in any patients during periprocedural and follow-up period of up to 28 months. Kaplan-Meier analysis estimated that freedom from atrial tachycardia or AF (AT/AF) without antiarrhythmics at 1-year was 70%. Radiofrequency delivery with higher power was associated with increased first-pass isolation rate, but not with freedom from AT/AF. In multivariate analysis, long-standing persistent AF and % low-voltage zone (%LVZ) were independent predictors of clinical outcome. The best cut-off value of %LVZ for predicting AT/AF recurrence was 3.24%. Freedom from AT/AF was 88% in patients with persistent AF and %LVZ < 3.24%, while 27% in those with long-standing persistent AF and %LVZ ≥ 3.24%. CONCLUSIONS: PVI alone using VS was associated with excellent 1-year success in patients with persistent AF and %LVZ < 3.24%, but was insufficient in those with long-standing persistent AF and/or %LVZ ≥ 3.24%.

Occurrence of Focal Atrial Tachycardia During the Ablation Procedure Is Associated With Arrhythmia Recurrence After Termination of Persistent Atrial Fibrillation.

INTRODUCTION: Catheter ablation can terminate persistent atrial fibrillation (AF). However, atrial tachycardia (AT) often arises after termination of AF. METHODS AND RESULTS: Of 215 patients who underwent index stepwise ablation for persistent AF, 141 (66%) patients (64 ± 9 years) in whom AF terminated during the ablation procedure were studied. If AF converted into AT, ablation for AT was subsequently performed. ATs were categorized as focal or macroreentrant AT. We assessed whether type of AT occurring after conversion of AF during the ablation procedure was associated with freedom from atrial tachyarrhythmia (AF or AT) during follow-up. Sinus rhythm was directly restored from AF in 37 patients, while 34, 37, and 33 patients had focal AT alone, a mix of focal and macroreentrant AT, and macroreentrant AT alone after termination of AF, respectively. Arrhythmia-free survival rates at 1 year after the index procedure were 30%, 34%, 61%, and 59% in the patients with focal AT alone, a mix of focal AT and macroreentrant AT, macroreentrant AT alone, and direct restoration of sinus rhythm, respectively (P = 0.004). Type of AT occurring during the index procedure was associated with type of recurrent AT (P = 0.03), but the origin of focal AT occurring during the index ablation differed from that of the recurrent AT in 85% of patients. CONCLUSION: In patients who had AF termination by ablation, occurrence of focal AT during the ablation procedure was associated with worse clinical outcome than occurrence of macroreentrant AT, likely due to ATs arising from other foci during follow-up.

Usefulness of Lipoprotein(a) for Predicting Clinical Outcomes After Endovascular Therapy for Aortoiliac Atherosclerotic Lesions.

PURPOSE: To evaluate the usefulness of serum lipoprotein(a) as a biomarker of clinical outcomes after endovascular therapy (EVT) for atherosclerotic aortoiliac lesions. METHODS: Serum lipoprotein(a) concentrations were measured at admission in 189 consecutive patients (median age 72 years; 160 men) with peripheral artery disease who underwent EVT for aortoiliac occlusive disease. The patients were dichotomized into 2 groups based on serum lipoprotein(a) levels ≤40 mg/dL (LOW; n=135) or >40 mg/dL (HIGH; n=54). After EVT, the incidences of major adverse limb events (MALE) were analyzed. Predictors of MALE were sought with a Cox proportional hazards analysis; results are presented as the hazard ratio (HR) and 95% confidence interval. RESULTS: At the median follow-up of 33 months (interquartile range 11, 54), MALE occurred in 44 (23.3%) patients. The MALE-free survival estimate was significantly lower in patients in the HIGH group (55.6% vs 85.2%, p<0.001). Independent predictors of MALE after EVT were hemodialysis (HR 2.23, 95% CI 1.04 to 4.78, p=0.039) and high lipoprotein(a) levels (HR 2.80, 95% CI 1.44 to 5.45, p=0.003). CONCLUSION: High lipoprotein(a) levels were associated with a higher incidence of MALE after EVT for patients with aortoiliac lesions.

Management Reality of Female Patients with COPD: A Multicenter Cross-Sectional CAP Study in Japan.

Background: Reports from Europe and North America suggest that female chronic obstructive pulmonary disease (COPD) patients have a higher symptom burden and mortality than male patients. However, little is known about the management reality of female patients with COPD in Japan. Patients and Methods: We compared the clinical characteristics of female COPD patients with those of male using the cohort of the COPD Assessment in Practice study, which is a cross-sectional multicenter observational study. Results: Of the 1168 patients, 133 (11.4%) were female. A history of never smoking was higher in females than males (p<0.01). Although there was no difference in age or forced expiratory volume in one second (FEV1) % predicted between the groups, modified medical research council dyspnea scale (mMRC) and number of frequent exacerbators were higher in females (mMRC≥2: p<0.01; number of exacerbations≥2: p=0.011). The mean forced vital capacity and FEV1 values in females were lower than those in males (p<0.0001 and p<0.0001, respectively). Females were more likely to use long-term oxygen therapy and inhaled corticosteroids than males (p=0.016 and p<0.01, respectively). The prevalence of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, D (ABCD GOLD 2017 classification), and E (ABE GOLD 2023 classification) was higher in females than in males. Conclusion: The disease burden of female patients with COPD is higher than that of male patients in Japan, suggesting the importance of interventions considering female-dominant features such as lower absolute FVC and FEV1, respiratory failure, and asthma-like conditions.

Effect of reference electrode on intracardiac electrograms: Close indifferent electrode vs Wilson central terminal.

BACKGROUND: Unipolar electrograms (uni-EGMs) are an essential part of intracardiac mapping. Although Wilson central terminal (WCT) is conventionally used as a reference for signals, avoidance of contamination by far-field and nonphysiologic signals is challenging. OBJECTIVE: The aim of the study was to explore the impact of an intracardiac indifferent reference electrode close to the recording electrodes, in lieu of WCT, on electrograms. METHODS: Sinus node activation was mapped in patients undergoing catheter ablation by a multielectrode array with a close indifferent electrode (CIE) embedded in the distal end of the catheter shaft. An equal number of points was sequentially acquired at each site with use of CIE as a reference first and subsequently with WCT. Uni-EGMs, bipolar EGMs, and the earliest activation area (defined as the area activated in the first 10 ms of the beat) were compared between CIE- and WCT-based activation maps. RESULTS: Seventeen patients (61 ± 18 years; 76% male) were studied. Uni-EGM voltages acquired with CIE were significantly larger than (n = 11) or comparable to (n = 4) those acquired with WCT. When points from the entire cohort were analyzed altogether, unipolar voltages and their maximum negative dV/dT and bipolar voltages recorded with CIE were significantly larger than those recorded with WCT (2.36 [1.42-3.79] mV vs 1.96 [1.25-3.03] mV, P < .0001; 0.40 [0.18-0.77] mV/s vs 0.35 [0.15-0.71] mV/s, P < .0001; and 1.46 [0.66-2.81] mV vs 1.33 [0.54-2.64] mV, P < .0001, respectively). The earliest activation area was significantly smaller in CIE-based activation maps than in WCT-based ones (0.3 [0.7-1.4] cm2 vs 0.6 [1.0-1.8] cm2, P = .01). CONCLUSION: CIE-based maps were associated with an approximately 20% increase in unipolar voltage and may highlight the origin of a focal activation more clearly than WCT-based ones.