Efficacy and feasibility of cryoballoon ablation for atrial fibrillation in patients with heart failure: A large-scale multicenter study.

INTRODUCTION: Data are limited regarding outcomes of cryoballoon ablation for atrial fibrillation (AF) in patients with heart failure (HF). This large-scale multicenter study aimed to evaluate the prognosis of patients with HF after cryoballoon ablation for AF. METHODS: Among 3655 patients undergoing cryoballoon ablation at 17 institutions, 549 patients (15%) (391 with paroxysmal AF and 158 with persistent AF) diagnosed with HF preoperatively were analyzed. Clinical endpoints were recurrence, mortality, and HF hospitalization after ablation. RESULTS: Most patients had a preserved left ventricular ejection fraction (LVEF) ≥ 50%. During a mean follow-up period of 25.7 months, recurrence, all-cause death, and HF hospitalization occurred in 29%, 4.0%, and 4.8%, respectively. Cardiac function on echocardiography and B-type natriuretic peptide (BNP) levels significantly improved postoperatively, and the effect was more pronounced in the nonrecurrence group. Major complications occurred in 33 patients (6.0%), but most complications were phrenic nerve palsy (3.6%). Although death and HF hospitalization occurred more frequently in patients with LVEF ≤ 40% (n = 73) and New York Heart Association (NYHA) class III-IV (n = 19) than other subgroups, the BNP levels, and LVEF significantly improved after ablation in all LVEF and NYHA class subgroups. High BNP levels, NHYA class, CHADS2 score, and structural heart disease, but not postablation recurrence, independently predicted death, and HF hospitalization on multivariate analysis. The patients with tachycardia-induced cardiomyopathy had better recovery of BNP levels and LVEF after ablation than those with structural heart disease. CONCLUSIONS: Cryoballoon ablation for AF in HF patients is feasible and leads to significantly improved cardiac function.

Echocardiographic Assessment of Cardiac Structural and Functional Abnormalities in Patients With End-Stage Renal Disease Receiving Chronic Hemodialysis.

BACKGROUND: The aim of this study was to assess the echocardiographic characteristics of chronic hemodialysis (HD) patients with end-stage renal disease (ESRD) in a multicenter prospective cohort study.Methods and Results:Three hundred and fifteen patients with ESRD (67.9±10.6 years, 47.6% male) on chronic HD for ≥1 year were examined on transthoracic echocardiography, including Doppler-derived aortic valve area (AVA) measurement. Only 11.5% and 3.4% of all patients had normal left ventricular (LV) geometry and normal LV filling pattern, respectively. The majority of patients had aortic and mitral valvular calcification, and approximately 50% of all 315 patients had aortic valve narrowing with AVA <2.0 cm2. Patients were divided into 3 groups according to AVA index tertile: group 1, highest tertile; group 2, middle tertile; and group 3, lowest tertile. Group 3 was older, had a greater cardiothoracic ratio on chest X-ray, higher plasma brain natriuretic peptide and total LV afterload, and lower stroke volume index than the other 2 groups. Age and intact parathyroid hormone (PTH) level were independently associated with low AVA index. CONCLUSIONS: Patients with ESRD on chronic HD have a high prevalence of cardiac structural and functional abnormalities including calcified aortic sclerosis. High age and PTH were associated with aortic valve narrowing in these patients.

Predictors of chronic pulmonary vein reconnections after contact force-guided ablation: importance of completing electrical isolation with circumferential lines and creating sufficient ablation lesion densities.

PURPOSE: We aimed to identify the predictors of chronic pulmonary vein reconnections (CPVRs) after contact force (CF)-guided circumferential PV isolation (CPVI) of atrial fibrillation (AF). METHODS: Forty-nine consecutive patients undergoing second ablation procedures for recurrent AF after CF-guided ablation were retrospectively studied. The CPVI was performed by point-by-point ablation with a target CF of 15-20 g. The incidence of CPVRs was evaluated along the right- and left-sided anterior and posterior CPVI regions (Ant-RPVs, Post-RPVs, Ant-LPVs, and Post-LPVs). RESULTS: CPVRs were observed in 30.6, 22.4, 20.4, and 32.7 % of patients along the Ant-RPVs, Post-RPVs, Ant-LPVs, and Post-LPVs, respectively (P = 0.436). In the multivariate logistic analyses, completing a left atrium-PV conduction block with touch-up ablation inside the initially estimated CPVI lines (Ant-RPVs, Post-RPVs, Ant-LPVs, Post-LPVs; odds ratio [OR] 5.747, 15.000, 207.619, 7.940; P = 0.032, 0.004, 0.034, 0.021) and region length (Post-LPVs; OR 3.183, P = 0.027) were positive predictors of CPVRs, while the mean CF (Ant-RPVs; OR 0.861, P = 0.045) and number of radiofrequency applications per unit length (Ant-LPVs, Post-LPVs; OR 0.038, 0.122; P = 0.034, 0.029) were negative predictors. At optimal cutoffs of 5.8 cm for the region length, 14.2 g for the mean CF, and 1.97/cm (Ant-LPVs) and 2.01/cm (Post-LPVs) for the radiofrequency application density, the sensitivity and specificity were 93.8 and 63.6 %, 60.0 and 76.5 %, 90.0 and 64.1 %, and 75.0 and 63.6 %, respectively. CONCLUSIONS: Completing PVI with circumferential lines without touch-up ablation and creating a sufficient density of radiofrequency ablation lesions on the lines with a sufficient CF may be necessary to prevent CPVRs after a CF-guided CPVI.

Silent Cerebral Ischemic Lesions After Catheter Ablation of Atrial Fibrillation in Patients on 5 Types of Periprocedural Oral Anticoagulation　- Predictors of Diffusion-Weighted Imaging-Positive Lesions and Follow-up Magnetic Resonance Imaging.

BACKGROUND: The aim of this study was to identify the predictors of silent cerebral ischemic lesions (SCIL) after catheter ablation of atrial fibrillation (AF) and to determine whether SCIL develop into cerebral infarcts in patients with 5 types of oral anticoagulants (OAC). METHODS AND RESULTS: We retrospectively studied 286 consecutive patients (median, 67 years; 208 male; paroxysmal/persistent/long-standing persistent AF [LSP-AF], 147/90/49) who received periprocedural OAC and underwent MRI after the procedure. Warfarin (n=46) was continued, while dabigatran (n=47), rivaroxaban (n=89), apixaban (n=87), and edoxaban (n=17) were discontinued on the day of the procedure. I.v. heparin was infused to maintain an activated clotting time of 300-350 s during the procedure. Fifty-eight SCIL in 40 patients (14.0%) were identified on diffusion-weighted MRI. On multivariate logistic analysis, LSP-AF and dabigatran use were significant positive predictors of SCIL (OR, 2.912 and 2.287; P=0.006 and 0.042, respectively). Among 34 patients with 49 SCIL undergoing follow-up MRI, 45 (91.8%) of the lesions disappeared and 4 lesions developed into chronic cerebral infarcts. The SCIL with development into infarcts had a larger lesion diameter than those without (median, 6.55 mm vs. 4.2 mm; P=0.002). CONCLUSIONS: LSP-AF and dabigatran use were independent risk factors for post-ablation SCIL in patients with uninterrupted warfarin and interrupted non-vitamin K antagonist OAC, but the majority of SCIL disappeared.

Clinical features of patients with left atrial thrombus undergoing anticoagulant therapy.

PURPOSE: Left atrial (LA) thrombus was sometimes found by transesophageal echocardiography (TEE) in non-valvular atrial fibrillation (AF), even in the setting of continuous warfarin therapy. A D-dimer cutoff level of 0.50 µg/mL appears to be a useful marker to rule out venous vein thrombosis. This study analyzed the clinical features of patients with LA thrombi who received anticoagulant therapy and whether the D-dimer test is useful to exclude LA thrombus. METHODS: Two hundred twenty-five consecutive patients with AF (149 with paroxysmal and 76 with persistent) were enrolled. All patients received continuous warfarin therapy with the prothrombin time-international normalized ratio (PT-INR) between 1.6 and 3.0 for more than 3 months and TEE was performed. RESULTS: LA thrombi were present in 23 and absent in 202 patients. Age, gender, and PT-INR (1.96 ± 0.59 vs. 1.98 ± 0.53) were not different between the two groups. Persistent AF (65 vs. 30%; p < 0.005), LA diameter (44 ± 5 vs. 40 ± 7 mm; p < 0.005), ejection fraction (57 ± 13 vs. 65 ± 9%; p < 0.005), brain natriuretic peptide levels (203 ± 209 vs. 105 ± 166 pg/mL; p < 0.05), D-dimer (0.55 ± 0.70 vs. 0.16 ± 0.20 µg/mL; p < 0.001), LA appendage flow velocity (33 ± 15 vs. 54 ± 19 cm/s; p < 0.001), CHADS(2) scores (2 ± 1 vs. 1 ± 1; p < 0.005), and CHA(2)DS(2)-VASc scores (3 ± 2 vs. 2 ± 1; p < 0.005) were significantly different in both groups. Although multivariate analysis showed that D-dimer and LA appendage flow velocity were significant independent predictors of LA thrombus, D-dimer levels below 0.5 µg/mL were found in 19 of 23 patients with LA thrombi. CONCLUSION: D-dimer levels below 0.5 µg/mL is not enough to rule out LA thrombus in AF patients with well-controlled anticoagulation.

Efficacy of linear block at the left atrial roof in atrial fibrillation.

BACKGROUND: After extensive encircling of ipsilateral pulmonary vein isolation (EEPVI) for atrial fibrillation (AF), we sometimes observe AF recurrence, or the occurrence of atrial tachycardia originating from the left atrium. This study examined the efficacy of additional linear ablation at the left atrial (LA) roof in combination with EEPVI to prevent arrhythmia recurrences. METHODS: This study included 104 patients with drug-refractory AF (75 with paroxysmal, 29 with persistent). The patients in Group A (n=70) underwent EEPVI treatment alone, and the patients in Group B (n=34) underwent linear ablation at the LA roof in addition to EEPVI treatment. At 1, 3, 6, and 12 months after ablation, patients underwent clinical review and 24-h ambulatory electrocardiogram monitoring to identify asymptomatic arrhythmias. Follow-up included daily trans-telephonic event monitoring, transmitted irrespective of the patient's symptoms. RESULTS: At 12 months, 57% of Group A and 79% of Group B were free of arrhythmias (p<0.05). Cox regression analysis demonstrated that among the variables of age, sex, duration of AF, types of AF (paroxysmal or persistent), LA size, ejection fraction, existence of hypertension, ischemic heart disease, valvular heart disease, history of stroke, and the ablation technique, only the ablation technique of the linear block at the LA roof was the independent predictor of arrhythmia-free recovery after ablation. CONCLUSIONS: EEPVI in combination with the linear ablation at the LA roof is associated with an improved clinical outcome compared with EEPVI alone.