The impact of anticoagulation therapy on kidney function in patients with atrial fibrillation and chronic kidney disease.

INTRODUCTION: Atrial fibrillation (AF) and chronic kidney disease (CKD) are closely related. These diseases share common risk factors and are associated with increased risk of thromboembolic events. Choosing the appropriate oral anticoagulant therapy (OAC) in patients with AF and CKD is challenging. Deterioration of renal function is common in patients with AF treated with OACs, although not all OACs affect the kidneys equally. AREAS COVERED: In this review, we aim to summarize the current knowledge of the prevention of thromboembolic events in patients with AF and CKD, focusing on the impact of specific OAC agents on renal function. EXPERT OPINION: Consideration of OAC use is mandatory in patients with AF and CKD who are at increased risk of stroke or systemic embolism. Available evidence suggests that the use of non-vitamin K antagonist oral anticoagulants (NOACs) is associated with slower deterioration of renal function in comparison to Vitamin K antagonists (VKAs). Hence, a NOAC should be used in preference to VKAs in all NOAC-eligible patients with AF and CKD. Regarding patients with end-stage renal dysfunction and those on dialysis or renal replacement therapy, the use of NOAC should be considered in line with locally relevant formal recommendations.

Long-Term Renal Function after Catheter Ablation of Atrial Fibrillation.

Background: Atrial fibrillation (AF) is associated with the development and progression of chronic kidney disease (CKD). This study evaluated the impact of long-term rhythm outcome after catheter ablation (CA) of AF on renal function. Methods and results: The study group included 169 consecutive patients (the mean age was 59.6 ± 10.1 years, 61.5% were males) who underwent their first CA of AF. Renal function was assessed by eGFR (using the CKD-EPI and MDRD formulas), and by creatinine clearance (using the Cockcroft-Gault formula) in each patient before and 5 years after index CA procedure. During the 5-year follow-up after CA, the late recurrence of atrial arrhythmia (LRAA) was documented in 62 patients (36.7%). The mean eGFR, regardless of which formula was used, significantly decreased at 5 years following CA in patients with LRAA (all p < 0.05). In the arrhythmia-free patients, the mean eGFR at 5 years post-CA remained stable (for the CKD-EPI formula: 78.7 ± 17.3 vs. 79.4 ± 17.4, p = 0.555) or even significantly improved (for the MDRD formula: 74.1 ± 17.0 vs. 77.4 ± 19.6, p = 0.029) compared with the baseline. In the multivariable analysis, the independent risk factors for rapid CKD progression (decline in eGFR > 5 mL/min/1.73 m2 per year) were the post-ablation LRAA occurrence (hazard ratio 3.36 [95% CI: 1.25-9.06], p = 0.016), female sex (3.05 [1.13-8.20], p = 0.027), vitamin K antagonists (3.32 [1.28-8.58], p = 0.013), or mineralocorticoid receptor antagonists' use (3.28 [1.13-9.54], p = 0.029) after CA. Conclusions: LRAA after CA is associated with a significant decrease in eGFR, and it is an independent risk factor for rapid CKD progression. Conversely, eGFR in arrhythmia-free patients after CA remained stable or even improved significantly.

Perception of Bar Velocity Loss in Resistance Exercises: Accuracy Across Loads and Velocity Loss Thresholds in the Bench Press.

PURPOSE: Velocity-based training is used to prescribe and monitor resistance training based on velocity outputs measured with tracking devices. When tracking devices are unavailable or impractical to use, perceived velocity loss (PVL) can be used as a substitute, assuming sufficient accuracy. Here, we investigated the accuracy of PVL equal to 20% and 40% relative to the first repetition in the bench-press exercise. METHODS: Following a familiarization session, 26 resistance-trained men performed 4 sets of the bench-press exercise using 4 different loads based on their individual load-velocity relationships (∼40%-90% of 1-repetition maximum [1RM]), completed in a randomized order. Participants verbally reported their PVL at 20% and 40% velocity loss during the sets. PVL accuracy was calculated as the absolute difference between the timing of reporting PVL and the actual repetition number corresponding to 20% and 40% velocity loss measured with a linear encoder. RESULTS: Linear mixed-effects model analysis revealed 4 main findings. First, across all conditions, the absolute average PVL error was 1 repetition. Second, the PVL accuracy was not significantly different between the PVL thresholds (ß = 0.16, P = .267). Third, greater accuracy was observed in loads corresponding to the midportion of the individual load-velocity relationships (∼50%-60% 1RM) compared with lighter (<50% 1RM, ß = 0.89, P < .001) and heavier loads (>60% 1RM, 0.63 ≤ ß ≤ 0.84, all P values < .001). Fourth, PVL accuracy decreased with consecutive repetitions (ß = 0.05, P = .017). CONCLUSIONS: PVL can be implemented as a monitoring and prescription method when velocity-tracking devices are impractical or absent.

Sex-related differences in self-reported treatment burden in patients with atrial fibrillation.

Background: Treatment burden (TB) is defined as the patient's workload of healthcare and its impact on patient functioning and wellbeing. High TB can lead to non-adherence, a higher risk of adverse outcomes and lower quality of life (QoL). We have previously reported a higher TB in patients with atrial fibrillation (AF) vs. those with other chronic conditions. In this analysis, we explored sex-related differences in self-reported TB in AF patients. Materials and methods: A single-center, prospective study included consecutive patients with AF under drug treatment for at least 6 months before enrollment from April to June 2019. Patients were asked to voluntarily and anonymously answer the Treatment Burden Questionnaire (TBQ). All patients signed the written consent for participation. Results: Of 331 patients (mean age 65.4 ± 10.3 years, mean total AF history 6.41 ± 6.62 years), 127 (38.4%) were females. The mean TB was significantly higher in females compared to males (53.7 vs. 42.6 out of 170 points, p < 0.001), and females more frequently reported TB ≥ 59 points than males (37.8% vs. 20.6%, p = 0.001). In females, on multivariable analysis of the highest TB quartile (TB ≥ 59), non-vitamin K Antagonist Oral Anticoagulant (NOAC) use [Odds Ratio (OR) 0.319; 95% Confidence Interval (CI) 0.12-0.83, P = 0.019], while in males, catheter ablation and/or ECV of AF (OR 0.383; 95% CI 0.18-0.81, P = 0.012) were negatively associated with the highest TB quartile. Conclusion: Our study was the first to explore the sex-specific determinants of TB in AF patients. Females had significantly higher TB compared with males. Approximately 2 in 5 females and 1 in 5 males reported TB ≥ 59 points, previously shown to be an unacceptable burden of treatment for patients. Using a NOAC rather than vitamin K antagonist (VKA) in females and a rhythm control strategy in males could decrease TB to acceptable values.

The influence of atrial flutter in automated detection of atrial arrhythmias - are we ready to go into clinical practice?"

OBJECTIVE: To investigate the impact of atrial flutter (Afl) in the atrial arrhythmias classification task. We additionally advocate the use of a subject-based split for future studies in the field in order to avoid within-subject correlation which may lead to over-optimistic inferences. Finally, we demonstrate the effectiveness of the classifiers outside of the initially studied circumstances, by performing an inter-dataset model evaluation of the classifiers in data from different sources. METHODS: ECG signals of two private and three public (two MIT-BIH and Chapman ecgdb) databases were preprocessed and divided into 10s segments which were then subject to feature extraction. The created datasets were divided into a training and test set in two ways, based on a random split and a patient split. Classification was performed using the XGBoost classifier, as well as two benchmark classification models using both data splits. The trained models were then used to make predictions on the test data of the remaining datasets. RESULTS: The XGBoost model yielded the best performance across all datasets compared to the remaining benchmark models, however variability in model performance was seen across datasets, with accuracy ranging from 70.6% to 89.4%, sensitivity ranging from 61.4% to 76.8%, and specificity ranging from 87.3% to 95.5%. When comparing the results between the patient and the random split, no significant difference was seen in the two private datasets and the Chapman dataset, where the number of samples per patient is low. Nonetheless, in the MIT-BIH dataset, where the average number of samples per patient is approximately 1300, a noticeable disparity was identified. The accuracy, sensitivity, and specificity of the random split in this dataset of 93.6%, 86.4%, and 95.9% respectively, were decreased to 88%, 61.4%, and 89.8% in the patient split, with the largest drop being in Afl sensitivity, from 71% to 5.4%. The inter-dataset scores were also significantly lower than their intra-dataset counterparts across all datasets. CONCLUSIONS: CAD systems have great potential in the assistance of physicians in reliable, precise and efficient detection of arrhythmias. However, although compelling research has been done in the field, yielding models with excellent performances on their datasets, we show that these results may be over-optimistic. In our study, we give insight into the difficulty of detection of Afl on several datasets and show the need for a higher representation of Afl in public datasets. Furthermore, we show the necessity of a more structured evaluation of model performance through the use of a patient-based split and inter-dataset testing scheme to avoid the problem of within-subject correlation which may lead to misleadingly high scores. Finally, we stress the need for the creation and use of datasets with a higher number of patients and a more balanced representation of classes if we are to progress in this mission.

Risk factors for late reconnections after circumferential pulmonary vein isolation guided by lesion size index - Data from repeat invasive electrophysiology procedure.

Background: Late reconnections (LR) of pulmonary veins (PVs) after wide antral circumferential ablation (WACA) using point-to-point radiofrequency (RF) ablation are common. Lesion size index (LSI) is a novel marker of lesion quality proposed by Ensite Precision mapping system, expected to improve PV isolation durability. This study aimed to assess the durability of LSI-guided PVI and the risk factors for LR of PVs. Methods: The prospective study included 33 patients with paroxysmal atrial fibrillation (PAF) who underwent (1) the index LSI-guided WACA procedure (with target LSI of 5.5-6.0 for anterior and 5.0-5.5 for posterior WACA segments) and (2) the 3-month protocol-mandated re-mapping procedure in all patients, irrespective of AF recurrence after the index procedure. Ablation parameters reported by Ensite mapping system were collected retrospectively. The inter-lesion distance (ILD) between all adjacent WACA lesions was calculated off-line. Association between index ablation parameters and the LRs of PVs at 3 months was analyzed. Results: The median patient age was 61 (IQR: 53-64) years and 55% of them were males. At index procedure, the first-pass WACA isolation rate was higher for the left PVs than the right PVs (64 vs. 33%, p = 0.014). In addition, a low acute reconnection rates were observed, as follows: in 12.1% of patients, in 6.1% of WACA circles, in 3.8% of WACA segments and in 4.5% of PVs. However, the 3-month remapping study revealed LR of PV in 63.6% of patients, 37.9% of WACA circles, 20.5% of WACA segments and 26.5% of PVs. The LRs were identified mostly along the left anterior WACA segment. Independent risk factors for the LR of WACA were left-sided WACA location (OR 3.216 [95%CI: 1.065-9.716], p = 0.038) and longer ILD (OR 1.256 [95%CI: 1.035-1.523] for each 1-mm increase, p = 0.021). The ILD of > 8.0 mm showed a predictive value for the LR of WACA, with the sensitivity of 84% and specificity of 46%. A single case of cardiac tamponade occurred following the re-mapping invasive procedure. No other complications were encountered. Conclusion: Although the LSI-guided PVI ensures a consistent PVI during the index procedure, LRs of PVs are still common. Besides the LSI, the PVI durability requires an optimal ILD between adjacent lesions, especially along the anterior lateral ridge.

Improvement of Maximal Exercise Performance After Catheter-Ablation of Atrial Fibrillation and Its Prognostic Significance for Long-Term Rhythm Outcome.

Background Rhythm control may improve functional capacity in patients with atrial fibrillation (AF). Long-term exercise tolerance improvement and its prognostic implications following catheter-ablation (CA) of paroxysmal and nonparoxysmal AF are underreported. Methods and Results Consecutive patients underwent cardiopulmonary exercise testing just before and 12 months after their index CA of AF. Follow-up 24-hour Holter recordings were obtained at 6-month intervals post-CA, and any atrial arrhythmia >30 seconds detected after 3 months postprocedure was considered AF recurrence. Of 110 patients (mean age 57.5±10.6 years, 77.2% males) with paroxysmal AF (n=66) or nonparoxysmal AF (n=44), the 12-month exercise tolerance improved significantly in those who maintained sinus rhythm during the first 12 months post-CA (n=96), but not in patients with AF recurrence (n=14). After CA, the 12-month respiratory exchange ratio at maximal workload significantly increased in patients with paroxysmal AF, whereas those with nonparoxysmal AF significantly reduced their heart rate during the 12-month cardiopulmonary exercise testing (all P≤0.001). During the follow-up of 42.8±7.8 months, a total of 29 patients (26.3%) experienced recurrent AF. On multivariate analysis including patients without recurrent AF at 12 months after CA, the extent of work time improvement at follow-up cardiopulmonary exercise testing was independently associated with the rhythm outcome beyond 12 months postprocedure (hazard ratio of 0.936 [95% CI, 0.894-0.979] for each 10 seconds increase in the work time following ablation, P=0.004). Conclusions CA of AF was associated with recovery of exercise intolerance in patients with paroxysmal AF or nonparoxysmal AF. Inability to improve exercise capacity at 12 months post-CA was an independent risk factor for later AF recurrence.

Self-reported treatment burden in patients with atrial fibrillation: quantification, major determinants, and implications for integrated holistic management of the arrhythmia.

AIMS: Treatment burden (TB) refers to self-perceived cumulative work patients do to manage their health. Using validated tools, TB has been documented in several chronic conditions, but not atrial fibrillation (AF). We measured TB and analysed its determinants and impact on quality of life (QoL) in an AF cohort. METHODS AND RESULTS: A single-centre study prospectively included consecutive adult AF patients and non-AF controls managed from 1 April to 21 June 2019, who voluntarily and anonymously answered the TB questionnaire (TBQ) and 5-item EQ-5D QoL questionnaire; TB was calculated as a sum of TBQ points (maximum 170) and expressed as proportion of the maximum value. Of 514 participants, 331 (64.4%) had AF. The mean self-reported TB was 27.6% among AF patients and 24.3% among controls, P = 0.011. The mean TB was significantly higher in patients taking vitamin K antagonists (VKAs) vs. those taking non-VKA antagonist oral anticoagulants (NOAC; 29.5% vs. 24.7%, P = 0.006). The highest item-specific TB was reported for healthcare system organization-related items (e.g. visit appointment), diet, and physical activity modifications. On multivariable analyses, female sex, younger age, and permanent AF were associated with a higher TB, whereas NOACs and electrical AF cardioversion exhibited an inverse association; TB was an independent predictor of decreased QoL (all P < 0.05). CONCLUSION: Our study provided clinically relevant insights into self-perceived TB among AF patients. Approximately one in four patients with AF have a high TB. Specific AF treatments and optimization of healthcare system-required patient activities may reduce the self-perceived TB in AF patients.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome and / or undergoing percutaneous coronary intervention.

The use of triple antithrombotic therapy (TAT) consisting of an oral anticoagulant (OAC), aspirin, and a P2Y12 inhibitor in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and / or undergoing percutaneous coronary intervention (PCI) is associated with a high risk of bleeding. Recently, several randomized clinical trials tested the hypothesis as to whether dual antithrombotic therapy (DAT) regimens (consisting of an OAC and a single antiplatelet drug) may be safer in terms of bleeding events as compared with TAT. They also investigated the role of non-vitamin K antagonist oral anticoagulants (NOACs) as a part of DAT and TAT. The purpose of this review is to provide an overview of available evidence regarding the safety and efficacy of DAT compared with TAT regimens, international guidelines recommendations, knowledge gaps, and unmet needs in the management of patients with AF and ACS and / or undergoing PCI.

Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 1.

Modifiable risk factors, such as cardiometabolic and lifestyle risk factors, considerably contribute to (bi)atrial remodeling, finally resulting in clinical occurrence of atrial fibrillation (AF). Early identification and prompt intervention on these risk factors may delay further progression of atrial arrhythmia substrate and prevent the occurrence of new­onset AF. Moreover, in patients with previous history of recurrent AF, aggressive risk factor management may improve efficacy of other rhythm control strategies, including antiarrhythmic drugs and catheter ablation in sinus rhythm maintenance. Finally, modification of risk factors improves overall health and reduces cardiovascular mortality and morbidity. The first part of this review evaluates the association between AF and the following risk factors: hypertension, diabetes mellitus, physical activity, and cigarette smoking. We systematically discuss the impact of risk factor modification on primary and secondary prevention of AF.

Risk factor modification for the primary and secondary prevention of atrial fibrillation. Part 2.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of death, stroke, and heart failure. Prevalence and incidence of AF are rising due to better overall medical treatment, longer survival, and increasing incidence of cardiometabolic and lifestyle risk factors. Treatment of AF and AF­related complications significantly increases healthcare costs. In addition, the use of conventional rhythm control strategies (including, antiarrhythmic drugs and catheter ablation) is associated with limited efficacy for sinus rhythm maintenance and serious adverse effects. Aggressive cardiometabolic risk factor management may prevent incident as well as recurrent AF, improve overall health, and reduce mortality. Therefore, modifiable risk factor management became one of the 3 treatment pillars in AF management along with anticoagulation as well as conventional rate and rhythm control strategies. The second part of this review systematically discusses the association between AF and potentially modifiable risk factors for AF, such as obesity, obstructive sleep apnea, alcohol consumption, and dyslipidemia. We also provide practical guidelines for the risk factor management with respect to primary and secondary prevention of AF.

A square root pattern of changes in heart rate variability during the first year after circumferential pulmonary vein isolation for paroxysmal atrial fibrillation and their relation with long­term arrhythmia recurrence.

BACKGROUND: An incidental lesion of the parasympathetic ganglia during circumferential pulmonary vein isolation (CPVI) may affect heart rate variability (HRV). AIMS: We studied the pattern of changes in HRV parameters and the relationship between the 1­year HRV change following CPVI and the recurrence of atrial fibrillation (AF). METHODS: A total of 100 consecutive patients undergoing CPVI for paroxysmal AF were enrolled (mean [SD] age, 56 [11.2] years; 61 men). We measured HRV on the day before and after CPVI, and then at 1 month as well as 3, 6, and 12 months after CPVI using 24­hour Holter monitoring. RESULTS: During the median follow­up of 33 months, 38 patients experienced the late recurrence of AF (LRAF). Compared with the pre­CPVI values, HRV was significantly attenuated on day 1 after CPVI in all patients. However, at 3 to 6 months after CPVI, all HRV parameters remained significantly decreased in LRAF­free patients but not in those with LRAF. The multivariate Cox analysis showed that early AF recurrence within the blanking period (hazard ratio [HR], 4.87; 95% CI, 2.44­9.69; P <0.001) and a change in the standard deviation of normal­to­normal intervals (SDNN) observed 3 months after ablation (HR, 0.99; 95% CI, 0.98­1; P = 0.01) were associated with LRAF. The cumulative LRAF freedom after CPVI was greater in patients with an SDNN reduction of more than 25 ms reported 3 months after ablation than in those with a reduction of 25 ms or lower (log­rank P = 0.004). CONCLUSIONS: Sustained parasympathetic denervation during 12 months after CPVI was a marker of successful CPVI, whereas a 3­month post­CPVI SDNN reduction of 25 ms or lower predicted LRAF.

The role of amiodarone in contemporary management of complex cardiac arrhythmias.

Amiodarone is an iodinated benzofuran derivative, a highly lipophilic drug with unpredictable pharmacokinetics. Although originally classified as a class III agent due to its ability to prolong refractoriness in cardiac regions and prevent/terminate re-entry, amiodarone shows antiarrhythmic properties of all four antiarrhythmic drug classes. Amiodarone is a potent coronary and peripheral vasodilator and can be safely used in patients with left ventricular dysfunction after myocardial infarction or those with congestive heart failure or hypertrophic cardiomyopathy. Its use is regularly accompanied with QT and QTc-interval prolongation but rarely with ventricular proarrhythmia. It is the most powerful pharmacological agent for long-term sinus rhythm maintenance in patients with atrial fibrillation. Amiodarone, particularly if co-administered with beta-blockers, reduces the rate of arrhythmic death due to ventricular tachyarrhythmias in patients with heart failure, but its benefit on cardiovascular and overall survival in these patients is uncertain. In addition, amiodarone is an important adjuvant drug for the reduction of shocks in patients with an implantable cardioverter-defibrillator. Over the past 40 years, amiodarone became the most prescribed antiarrhythmic. Nevertheless, the slow onset of its antiarrhythmic action requires a loading dose while the high risk of non-cardiac toxicity and common drug-drug interactions limit its long-term use. Furthermore patients treated with amiodarone require a close supervision by the treating physician. Therefore amiodarone is generally considered a secondary therapeutic option. Long-term treatment with amiodarone should be based on the use of minimal doses for satisfactory arrhythmia outcome and serial screening for thyroid, liver and pulmonary toxicity.

Clinical approach to the patient with Brugada Syndrome: risk stratification and optimal management.

The Brugada Syndrome (BrS) is an inherited cardiac ion channel disorder associated with increased risk of ventricular arrhythmias and mortality. Diagnosis is based on a characteristic electrocardiographic (ECG) pattern of coved type ST-segment elevation >2 mm followed by a negative T-wave in ≥1 of the right precordial leads V1 to V3. Since the first description of BrS, the definition of disease and underlying pathophysiological mechanisms have been significantly improved in recent years. Also, significant progress has been made in the field of genetic testing in these patients. Still, there are several open questions regarding the management and outcome of these patients. There is more information about patients who would need an implantable cardiac defibrillator for the primary prevention of sudden cardiac death (that is, those with spontaneous Type I Brugada ECG pattern and arrhythmia-related syncope), but currently published data concerning asymptomatic patients with Brugada ECG pattern and other less-well defined presentations are conflicting. Whereas the role of cardiac defibrillator in patients with Brugada Syndrome is clear, optimal use of catheter ablation and antiarrhythmic drug therapy needs to be further investigated. In this review, we summarize current evidence and contemporary management of patients with BrS.

Validation of the MB-LATER score for prediction of late recurrence after catheter-ablation of atrial fibrillation.

BACKGROUND: Reliable identification of atrial fibrillation (AF) patients more likely to be AF-free long-term post-single catheter ablation (CA) would facilitate appropriate risk communication to patients. We validated the recently proposed MB-LATER score for prediction of late recurrences of AF (LRAF) post-CA. METHODS: Patients who underwent CA for symptomatic AF refractory to ≥1 antiarrhythmic drugs at the Johns Hopkins Hospital, Baltimore, between March 2003 and December 2015, for whom ≥1-year post-CA follow-up data were available, were enrolled. RESULTS: Of 226 patients (median age 58.5 years [IQR: 52.0-65.0], 163 males [72.1%], 142 [62.8%] with paroxysmal AF), LRAF occurred in 133 patients (58.8%) during a median 2-year follow-up (IQR: 1.1-4.1). The mean MB-LATER score was significantly higher in patients with versus those without LRAF (2.4 ±â€¯1.2 vs. 1.9 ±â€¯1.3, p = 0.002) and showed modest but significant predictive ability for LRAF (AUC: 0.62 [95% CI: 0.54-0.69], p = 0.003). A score cut-off value of >2 showed the best predictive ability for LRAF (70.4% [61.5-77.9]), with modest sensitivity (42.9% [34.3-51.7]) and specificity (74.2% [64.1-82.7]). Kaplan-Meyer survival free from AF was significantly better for patients with a MB-LATER score of ≤2 than for those with a score of >2 (log-rank p = 0.005). CONCLUSION: In our study, the MB-LATER score showed a significant but modest predictive ability for LRAF post-AF ablation. Further prospective validation is needed to better define the potential role of the MB-LATER score in patient selection and treatment decision-making post-AF ablation.

The relationship of early recurrence of atrial fibrillation and the 3-month integrity of the ablation lesion set.

Early recurrence of atrial fibrillation (ERAF) after catheter-ablation (CA) can be a transient phenomenon due to inflammation, or a harbinger of late AF recurrence due to CA lesion (re)conduction. We studied the relationship between ERAF and the 3-month CA lesions integrity. Forty one consecutive AF patients who underwent a pulmonary vein isolation (PVI), roof line (RL) and mitral isthmus line (MIL) CA were enrolled. At 3 months all patients underwent invasive assessment of the lesion set integrity irrespective of ERAF. The PVI, RL and MIL ablation was successful in 100.0%, 95.1% and 82.9% patients, respectively. At the 3-month remapping, a gap in PVI-lesion(s), RL or MIL was identified in 61.0%, 31.7% and 36.6% patients, respectively. Patients with (n = 17, 41.5%) compared to those without ERAF (n = 24) had a significantly higher rate of any PV-reconnection (88.2% vs. 41.7%), the right PV(s)-reconnection (82.5% vs. 29.2%) and the RL gap (52.9% vs. 16.7%), as well as a higher number of reconnected right PVI-segments, all p < 0.05. On multivariate analysis, only the number of reconnected right PVI-segments was associated with ERAF (OR 4.26, p = 0.004). The ERAF following PVI + RL + MIL ablation was significantly related to 3-month PV-reconnections and the presence of RL gaps.

Persistency of left atrial linear lesions after radiofrequency catheter ablation for atrial fibrillation: Data from an invasive follow-up electrophysiology study.

BACKGROUND: Data on the roof line (RL) and mitral isthmus line (MIL) reconnections after atrial fibrillation (AF) catheter ablation (CA) are scarce. OBJECTIVE: We studied the RL and MIL completeness and localization of reconnection sites in consecutive patients after their first-ever AF-CA. METHODS: We prospectively included 41 consecutive AF patients who underwent predefined lesion sets of two circumferential lines (CLs) for ipsilateral pulmonary vein isolation (PVI) combined with a RL and lateral MIL. Three months after CA, all patients underwent invasive follow-up procedure for line persistency evaluation, irrespective of clinical outcome. RESULTS: At the time of index ablation, PVI-CLs, RL, and MIL was completed in 41 (100%), 39 (95%), and 34 (83%) of patients, respectively. At the 3-month follow-up procedure, reconnections of PVI-CLs, RL, and MIL were found in 61% (25/41), 28% (11/39), and 24% (8/34) of patients, respectively. The 3-month reconnections were located commonly in the anterior and posterior PVI-CL segments, and rarely in the right third of RL and in the posterior part of MIL. The 3-month reconnections were rarely seen at the sites of acute reconnections during index procedure (6%, 20%, and 25% of the PVI-CL segments, RL segments, and MIL segments, respectively). CONCLUSIONS: To our knowledge, this is the first study systematically investigating the reconnection of standardized left atrium linear lesions such as RL and MIL after RF-CA for AF in consecutive patients. The RL and MIL 3-month reconnection rates were relatively low (28% and 24%), with poor anatomical concordance between the sites with acute and 3-month reconnections.

Catheter Ablation of Atrial Fibrillation: An Overview for Clinicians.

Catheter ablation (CA) of atrial fibrillation (AF) is currently one of the most commonly performed electrophysiology procedures. Ablation of paroxysmal AF is based on the elimination of triggers by pulmonary vein isolation (PVI), while different strategies for additional AF substrate modification on top of PVI have been proposed for ablation of persistent AF. Nowadays, various technologies for AF ablation are available. The radiofrequency point-by-point ablation navigated by electro-anatomical mapping system and cryo-balloon technology are comparable in terms of the efficacy and safety of the PVI procedure. Long-term success of AF ablation including multiple procedures varies from 50 to 80%. Arrhythmia recurrences commonly occur, mostly due to PV reconnection. The recurrences are particularly common in patients with non-paroxysmal AF, dilated left atrium and the "early recurrence" of AF within the first 2-3 post-procedural months. In addition, this complex procedure can be accompanied by serious complications, such as cardiac tamponade, stroke, atrio-esophageal fistula and PV stenosis. Therefore, CA represents a second-line treatment option after a trial of antiarrhythmic drug(s). Good candidates for the procedure are relatively younger patients with symptomatic and frequent episodes of AF, with no significant structural heart disease and no significant left atrial enlargement. Randomized trials demonstrated the superiority of ablation compared to antiarrhythmic drugs in terms of improving the quality of life and symptoms in AF patients. However, nonrandomized studies reported additional clinical benefits from ablation over drug therapy in selected AF patients, such as the reduction of the mortality and stroke rates and the recovery of tachyarrhythmia-induced cardiomyopathy. Future research should enable the creation of more durable ablative lesions and the selection of the optimal lesion set in each patient according to the degree of atrial remodeling. This could provide better long-term CA success and expand indications for the procedure, especially among the patients with non-paroxysmal AF.