Ablation Versus Antiarrhythmic Drugs as First-Line Therapy for Treatment-Naive Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Evidence on the relative safety and efficacy of atrial fibrillation catheter ablation and antiarrhythmic drugs (AADs) as the first-line therapy for patients with treatment-naive atrial fibrillation (AF) remains disputed. Digital databases were queried to identify relevant randomized controlled trials. The incidence of recurrent AF, major adverse cardiovascular events, and its components (all-cause death, nonfatal stroke, and bleeding) were compared using the DerSimonian and Laird method under the random-effects model to calculate pooled unadjusted risk ratio (RR) with 95% confidence intervals (CIs). A total of 6 randomized controlled trials consisting of 1,120 patients (574 ablation and 549 AADs) were included in the final analysis. Over a median follow-up of 1 year, the risk of any AF recurrence (RR 0.54, 95% CI 0.39 to 0.75) was significantly lower in patients receiving ablation than in patients receiving AADs. However, there was similar risk of major adverse cardiovascular events (RR 2.65, 95% CI 0.61 to 11.46), trial-defined composite end point of adverse events (RR 0.71, 95% CI 0.28 to 1.80), stroke (RR 2.42, 95% CI 0.22 to 26.51), all-cause mortality (RR 1.98, 95% CI 0.28 to 13.90), and procedure/medication failure (RR 2.65, 95% CI 0.61 to 11.46) with both therapies. In conclusion, in patients presenting with treatment-naive AF, ablation as a first-line therapy lowers the risk of AF recurrence with no associated increase in major adverse events, stroke, and mortality compared with AADs.

Comparison of very high-power short-duration, high-power short-duration, and low-power long-duration radiofrequency ablation for atrial fibrillation: A systematic review and network meta-analysis.

BACKGROUND: The optimal power and duration settings for radiofrequency (RF) atrial fibrillation (AF) ablation to improve efficacy and safety is unclear. We compared low-power long-duration (LPLD), high-power short-duration (HPSD), and very HPSD (vHPSD) RF settings for AF ablation. METHODS: This network meta-analysis (NMA) was structured according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Observational and randomized studies were included. Eligible studies compared outcomes in AF patients who underwent first-time RF ablation with the following settings: vHPSD (70-90 W, 3-10 s), HPSD (45-60 W, 5-10 s), or LPLD (20-40 W, 20-60 s). RESULTS: Thirty-six studies comprising 10,375 patients were included (33% female). Frequentist NMA showed LPLD tended toward a lower odds of freedom from arrhythmia (FFA) versus HPSD (OR 0.93, 95% CI 0.86-1.00). There was no difference in FFA between vHPSD versus HPSD. Splitwise interval estimates showed a lower odds of FFA in LPLD versus vHPSD on direct (OR 0.78, 95% CI 0.65-0.93) and network estimates (OR 0.85, 95% CI 0.73-0.98). Frequentist NMA showed less total procedural (TP) time with HPSD versus LPLD (generic variance 1.06, 95% CI 0.83 to 1.29) and no difference between HPSD versus vHPSD. CONCLUSION: This NMA shows improved procedural times in HPSD and vHPSD versus LPLD. Although HPSD tended toward improved odds of FFA compared to LPLD, the overall result was not statistically significant. The odds of FFA in LPLD was lower versus vHPSD on direct and network estimates on splitwise interval analysis. Large prospective head-to-head randomized trials are needed to validate HPSD and vHPSD settings.

Mobile electrocardiographic devices and healthcare utilization in post-atrial fibrillation ablation patients.

BACKGROUND: The use of mobile electrocardiogram (mECG) devices is becoming more prevalent. mECG devices allow instant access to recording arrhythmias and enable automatic rhythm interpretation. Providers can remotely evaluate patients and this may reduce in-person healthcare utilization. We sought to evaluate the utility of mECG devices in reducing healthcare utilization among patients who underwent atrial fibrillation (AF) ablation. METHODS: We identified a population of patients with paroxysmal or persistent AF presenting for their first AF ablation. Patients were divided into two groups: KardiaMobile (AliveCor, Mountain View, CA) mECG users and non-KardiaMobile users. Healthcare utilization was compared between the two groups for one year post-ablation. RESULTS: 184 patients were studied (76 KardiaMobile users, 108 non-KardiaMobile users). There was no difference in the number of office visits (p = 0.59), cardiac-specific emergency department visits (p = 0.26), cardiac-specific hospital admissions (p = 0.13), ablations or cardioversions completed (p = 0.24), telephone encounters (p = 0.05), patient electronic health record messages (p = 0.40), or cardiac imaging (transthoracic or transesophageal echocardiograms) tests ordered (p = 0.36). Exposure to the device was associated with a reduction in ambulatory cardiac monitor use (p = 0.04). There was no difference in sinus rhythm maintenance over 12 months by Kaplan-Meier survival analysis (log rank test p = 0.05) between groups. CONCLUSION: Mobile technology is available for heart rhythm monitoring and can give instant feedback to the user. mECG use is associated with a significant reduction in ambulatory cardiac monitor use in the post-ablation period. There was no difference in other AF-related healthcare utilization.

Dyssynchronous Heart Failure: A Clinical Review.

PURPOSE OF THE REVIEW: Dyssynchrony occurs when portions of the cardiac chambers contract in an uncoordinated fashion. Ventricular dyssynchrony primarily impacts the left ventricle and may result in heart failure. This entity is recognized as a major contributor to the development and progression of heart failure. A hallmark of dyssynchronous heart failure (HFd) is left ventricular recovery after dyssynchrony is corrected. This review discusses the current understanding of pathophysiology of HFd and provides clinical examples and current techniques for treatment. RECENT FINDINGS: Data show that HFd responds poorly to medical therapy. Cardiac resynchronization therapy (CRT) in the form of conventional biventricular pacing (BVP) is of proven benefit in HFd, but is limited by a significant non-responder rate. Recently, conduction system pacing (His bundle or left bundle branch area pacing) has also shown promise in correcting HFd. HFd should be recognized as a distinct etiology of heart failure; HFd responds best to CRT.

Pulmonary vein isolation alone versus pulmonary vein isolation with additional extensive ablation for paroxysmal and persistent atrial fibrillation.

Background: The value of additional ablation beyond pulmonary vein isolation for atrial fibrillation (AF) ablation is unclear, especially for persistent AF. It is uncertain whether substrate modification with additional extensive ablation improves outcomes. We reviewed our experience to determine whether pulmonary vein isolation with additional extensive ablation (PVIEA) improves outcomes compared to pulmonary vein isolation alone (PVIA) for AF ablation. Methods: Consecutive cases of patients with PVIA versus PVIEA were compared between September 9, 2013 and December 12, 2020. Procedural data collected include radiofrequency ablation delivery time (RADT) and arrhythmia inducibility. Clinical data collected include sinus rhythm maintenance post-procedure. Results: A total of 235 patients were studied (67 PVIA and 168 PVIEA). RADT was shorter when comparing ablation with PVIA versus PVIEA (32 vs. 40 min; p = .04). More arrhythmias were inducible with PVIEA (p < .01). There was no difference in sinus rhythm maintenance by Kaplan-Meier survival analysis (log-rank test p = .75), after 3 or 12 months between groups overall, and when stratified by AF type (paroxysmal and persistent), left atrial volume, CHA2DS2-VASc score, left ventricular ejection fraction, or catheter ablation setting (high-power short-duration, standard-power standard-duration, temperature-controlled non-contact-force). Conclusion: AF ablation with PVIA or PVIEA produces similar sinus rhythm maintenance overall and when stratified by catheter setting and AF type. PVIA reduced procedure times and less arrhythmias were inducible post-ablation.

Low-voltage area substrate modification for atrial fibrillation ablation: a systematic review and meta-analysis of clinical trials.

AIMS: The value of additional ablation beyond pulmonary vein isolation for atrial fibrillation (AF) ablation is unclear, especially for persistent AF. The optimal target for substrate modification to improve outcomes is uncertain. We investigate the utility of low-voltage area (LVA) substrate modification in patients undergoing catheter ablation for AF. METHODS AND RESULTS: This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the Cochrane risk of bias tool. Only randomized studies were included. AF patients who underwent catheter ablation with voltage-guided substrate modification targeting LVA (LVA group) vs. conventional ablation approaches not targeting LVA (non-LVA group) were compared. Four studies comprising 539 patients were included (36% female). Freedom from arrhythmia (FFA) in patients with persistent AF was greater in the LVA group [risk ratio (RR) 1.30; 95% confidence interval (CI) 1.03-1.64]. There was no difference in FFA in patients with paroxysmal AF between groups (RR 1.30; 95% CI 0.89-1.91). There was no difference in total procedural time (mean difference -17.54 min; 95% CI -64.37 to 29.28 min) or total ablation time (mean difference -36.17 min; 95% CI -93.69 to 21.35 min) in all included patients regardless of AF type between groups. There was no difference in periprocedural complications between groups in all included patients regardless of AF type (RR 0.93; 95% CI 0.22-3.82). CONCLUSION: This meta-analysis demonstrates improved FFA in persistent AF patients who underwent voltage-guided substrate modification targeting LVA.

High-power short-duration versus standard-power standard-duration settings for repeat atrial fibrillation ablation.

INTRODUCTION: High-power short-duration (HPSD) ablation is a novel strategy using contact force-sensing catheters optimized for radiofrequency ablation for atrial fibrillation (AF). No study has directly compared HPSD versus standard-power standard-duration (SPSD) contact force-sensing settings in patients presenting for repeat ablation with AF recurrence after initial ablation. METHODS: We studied consecutive cases of patients with AF undergoing repeat ablation with SPSD or HPSD settings after their initial pulmonary vein isolation (PVI) with temperature controlled non-contact force, SPSD or HPSD settings between 6/23/14 and 3/4/20. Procedural data collected included radiofrequency ablation delivery time (RADT). Clinical data collected include sinus rhythm maintenance post-procedure. RESULTS: A total of 61 patients underwent repeat ablation (36 SPSD, 25 HPSD). A total of 51 patients (83.6%) were found to have pulmonary vein reconnections necessitating repeat isolation, 10 patients (16.4%) had durable PVI and ablation targeted non-PV sources. RADT was shorter when comparing repeat ablation using HPSD compared to SPSD (22 vs 35 min; p = 0.01). There was no difference in sinus rhythm maintenance by Kaplan-Meier survival analysis (log rank test p = 0.87), after 3 or 12-months between groups overall, and when stratified by AF type, left atrial volume index, CHA2DS2-VASc score, or left ventricular ejection fraction. CONCLUSION: We demonstrated that repeat AF ablation with HPSD reduced procedure times with similar sinus rhythm maintenance compared to SPSD in those presenting for repeat ablation.

Comparison of clinical and procedural outcomes between high-power short-duration, standard-power standard-duration, and temperature-controlled noncontact force guided ablation for atrial fibrillation.

INTRODUCTION: High-power short-duration (HPSD) ablation is a novel strategy using contact force-sensing catheters optimized for power-controlled radiofrequency ablation for atrial fibrillation (AF). This study investigates the outcomes of HPSD (50 W delivered for up to 15 s, Lesion Size Index of 5-6) compared to standard-power standard-duration (SPSD) (20-25 W until 400-500 gram seconds, up to 60 s) and temperature-controlled noncontact (TCNC) (20-40 W up to 60 s of ablation) settings. METHODS: We studied consecutive cases of patients with AF undergoing pulmonary vein isolation with TCNC, SPSD, and HPSD between January 7th, 2013 and January 11th, 2019. Procedural data collected include time to isolate the left (LPVT) and right pulmonary veins (RPVT), total ablation time (TAT), and radiofrequency ablation delivery time (RADT). Clinical data collected include sinus rhythm maintenance postprocedure. RESULTS: One hundred and seventy-one patients were studied (44 TCNC, 51 SPSD, 76 HPSD). RADT was shorter when comparing HPSD to SPSD (25 vs. 41 min; p < .01), HPSD to TCNC (25 vs. 76 min; p < .01), and SPSD to TCNC groups (41 vs. 76 min; p < .01). TAT, LPVT, and RPVT were reduced between HPSD versus SPSD, HPSD versus TCNC, and SPSD versus TCNC groups, respectively (p < .01). There was no difference in sinus rhythm maintenance by Kaplan-Meier survival analysis (log rank test p = .12), after 3 or 12 months between groups overall, and when stratified by AF type, left atrial volume, CHA2 DS2 -VASc score, or left ventricular ejection fraction. CONCLUSION: AF ablation with HPSD reduced procedure times with similar sinus rhythm maintenance compared to SPSD and TCNC.

Improved accuracy and confidence with multiple-lead recordings from a single-lead mobile electrocardiographic device.

BACKGROUND: Mobile electrocardiograms (mECGs) utilizing smartphone applications are an emerging technology. Typically, a Lead I rhythm strip is recorded. However, interpretation can be difficult in patients with sinus rhythm and low amplitude P-waves (SR-LAP) or atrial flutter (AFL). We hypothesized that patients could independently obtain multi-lead tracings using a commercial mECG device, and that cardiologists who interpreted the multi-lead tracings would make more accurate diagnoses and have more confidence in their interpretation compared to a single lead only. METHODS: Thirty sets of recordings were obtained from 10 patients with either SR-LAP or AFL that was not apparent on Lead I on a standard ECG. Patients recorded Lead I, Lead II, and Lead V1 tracings using AliveCor's KardiaMobile mECG device. Twenty-nine cardiologists reviewed each patient's Lead I tracing, multi-lead tracings (Leads I, II, V1), and 12-lead ECG. Accuracy was noted and each cardiologist rated their level of confidence in their interpretation. RESULTS: All patients were able to record their own single and multi-lead tracings. Single lead, multi-lead, and the 12-lead ECG yielded 36.4%, 84.3%, and 97.7% agreement with the established diagnosis, respectively (P < .01 for each comparison). Overall mean confidence scores (out of a score of 5) were 2.95, 3.50, and 4.47 for single lead, multi-lead, and the 12-lead ECG, respectively (P < .01 for each comparison). CONCLUSIONS: Patients were able to record their own multi-lead mECG tracings. Compared to a single lead recording, multi-lead mECGs significantly improved cardiologists' diagnostic accuracy and confidence in their interpretation approaching that of a standard 12-lead ECG.

Clinical and Procedural Effects of Transitioning to Contact Force Guided Ablation for Atrial Fibrillation.

BACKGROUND: A major innovation in atrial fibrillation (AF) ablation has been the introduction of contact force (CF) sensing catheters. OBJECTIVE: To evaluate procedural and clinical effects of transitioning to CF-guided AF ablation. METHODS: Consecutive AF ablation patients were studiedduring the period of time of transitioning from a non-CF to CF sensing catheter. Procedural data recorded was total radiofrequency time, time to isolate the left pulmonary veins (LPVs), and time to isolate the right pulmonary veins (RPVs). Clinically, the 3 and 12-month maintenance of sinus rhythm was noted and compared by: paroxysmal vs. persistent AF; CT scan LA volume more or less than 150 cc; CHA2DS2VASC more or less than 2; and LVEF more or less than 55%. Safety data was recorded as well. RESULTS: Total ablation times were shorter (113 vs.146 min, p=0.011)when using the CF catheters compared to non-CF ablations. This was driven by a decrease in both LPV (46 vs.72 min, p<0.001) and RPV time (54 vs. 75 min, p=0.002).The use of CF catheter did not change the overall percentage of patients in sinus rhythm at 3 and 12-months of follow up. However, sinus rhythm was more frequent at 12 months with CF ablation inpatients with an LA volume of more than 150 cc when compared to non-CF ablation (84.6% and 52.4%, p=0.03). There was no difference in outcomes with stratification by CHA2DS2VASC score or LVEF. No significant difference in complications was noted. CONCLUSIONS: For AF ablation, the initial use of CF-sensing technology reduced procedure times with similar overall sinus rhythm maintenance at 3 and 12 months. CF improved 12-month outcomes in patients with an enlarged LA.