Clinical and Biochemical Characteristics of COVID-19-Associated Acute Kidney Injury (COVAKI): A Proof-of-Concept Case-Control Study.

Introduction Acute kidney injury (AKI) develops in 20-70% of patients with COVID-19. AKI is a syndromic diagnosis with multiple causes and outcomes. This cross-sectional study explored different outcomes of AKI in patients admitted with COVID-19. Material and methods It was a cross-sectional and descriptive study carried out in a tertiary care teaching hospital in Western Maharashtra for two months (May to June 2020). We collected clinical and laboratory data of 456 inpatients admitted with COVID-19 over two consecutive months. We excluded patients already on dialysis upon arrival at the hospital. It predominantly consists of patients who developed AKI during their stay in the hospital. Result C-reactive protein (CRP) was elevated in patients with COVID-19 associated with AKI (COVAKI) (78.87) but was statistically significant (p<0.003). Ferritin was elevated significantly (1619.19) in patients with AKI (p<0.0001). Similarly, higher levels of D-dimer (426.35) and lower serum albumin (1.86) were associated with COVAKI (p<0.0001). The average ICU stay was six days for patients with AKI and 0.37 days for patients without AKI. Days on the ventilator were 3.3 days for patients with AKI and 0.11 days for non-AKI patients. Out of a total 12 deaths of COVID-19 patients over these two months, nine had AKI. This made the association statistically significant (p<0.0001). Conclusion The phenotype COVAKI was associated with higher inflammatory markers, prolonged hospital stay, days spent on a ventilator, and higher oxygen requirement translating into higher mortality compared to those without COVAKI. We found low serum albumin without a corresponding proteinuria or liver dysfunction. The development of COVAKI during the hospital stay was associated with the use of glucocorticoids, hydroxychloroquines (HCQs), and heparin.

Mortality Analysis in Geriatric Patients With Acute Kidney Injury Admitted in the Intensive Care Unit: A Single-Center Cross-Sectional Study.

Introduction Acute kidney injury (AKI) is an abrupt reduction in kidney function that causes nitrogenous waste and other waste products to be retained. Methods This cross-sectional study was conducted from February 2015 to January 2016. The study received approval from the Independent Ethics Committee, which included patients over 60 with AKI. The study duration was 12 consecutive months to ascertain the etiology, severity, and hospital outcomes of AKI. Results The common etiologies of AKI included drug-induced (25%), age-related (21.67%), cardiac (13.33%), respiratory (20%), tropical (15%), and pancreatitis (15%) cases. Another predominant etiology observed was obstructive nephropathy (55%), with the highest (37.5%) mortality rate. The distribution of patients based on KDIGO criteria showed no significant difference in mortality percentages among classes (p=0.177). Conservative management without renal replacement therapy was the most common approach to treat AKI, with a 39% mortality rate. Conclusion Among different causes of AKI in the geriatric age group, drug-induced AKI, and obstructive nephropathy were predominantly associated with hospital mortality.

Wearable Ambulatory Accelerometer System for Estimating Arterial Stiffness: A Pilot Study.

Given the gap between the crucial role of measuring arterial stiffness in cardiovascular disease prevention and the lack of a technology for frequent/continuous measurement to assess it without an operator, we have developed a wearable accelerometer-based system. It estimates local stiffness metrics (Ep, ß, and AC) by employing a one-point patient-specific calibration on the features of acceleration plethysmogram (APG) signal. An in-vivo study on 12 subjects was conducted (a) to select suitable ones from the host features on which the calibration could be applied and (b) to assess the feasibility of reliably estimating the stiffness metrics post-exercise when calibrated prior. The acquired APG signals were found to be reliable (SNR > 38 dB) and repeatable (CoV < 10 %). By examining a correlation matrix, it was found that (a-b)/(a"-b") is a potential feature of consideration for calibration against the stiffness. Due to exercise intervention, the local stiffness metrics have physiologically perturbed by a significant amount (p < 0.05), as observed from the reference measurements. Estimated Ep was found to have statistically significant and strong correlation (r = 0.761, p < 0.05) with actual Ep value, whereas statistically significant and moderate correlation were found with estimated ß (r = 0.682, p < 0.05) and estimated AC (r = 0.615, p < 0.05) with their respective actual measures. The system demonstrated its ability to estimate post-exercise stiffness metrics using the baseline calibration, even when subject to significant physiological changes.Clinical Relevance- This study reveals the potential of the developed wearable system to be used for continuous stiffness estimation even in the presence of hemodynamic perturbations.

Zinc finger protein­like 1 is a novel neuroendocrine biomarker for prostate cancer.

Prostate­derived calcitonin (CT) and its receptor induce tumorigenicity and increase metastatic potential of prostate cancer (PC). CT­inducible genes in human prostate were identified by subtraction hybridization. Among these genes, zinc finger protein like 1 (ZFPL1) protein was interesting since it was abundantly expressed in malignant prostates but was almost absent in benign prostates. ZFPL1 expression was upregulated by CT and androgens, and ZFPL1 protein was secreted by prostate tumor cells through exosomal secretion. Serum levels of ZFPL1 in cancer patients were at least 4­fold higher than those in the sera of cancer­free individuals. Cell biology of ZFPL1 suggests its localization in Golgi bodies and exosomes, and its colocalization with chromogranin A and CD44. These results suggested that ZFPL1 is secreted by tumor cells of neuroendocrine (NE)/stem cell phenotype. The knockdown of endogenous ZFPL1 in (PC) cells led to a remarkable decrease in cell proliferation, and invasion while increasing their apoptosis. As expected, the overexpression of ZFPL1 in prostate cells had an opposite effect on these functions. The knockdown of ZFPL1 in PC cells also decreased Akt phosphorylation, suggesting the actions of ZFPL1 may be mediated through the PI3K­Akt pathway. Moreover, the present results revealed that ZFPL1 is released by tumors cells of NE or androgen­independent phenotype and its serum levels are significantly higher in cancer patients, suggesting that it may serve as a blood­based non­invasive biomarker of aggressive PC.

Ripple mapping in ventricular tachycardia substrate mapping and ablation of nonischemic ventricular tachycardia.

INTRODUCTION: Substrate-based ablation for ventricular tachycardia (VT) using Ripple map (RM) is an effective treatment strategy for patients with ischemic cardiomyopathy but has yet to be evaluated in patients with nonischemic cardiomyopathy (NICMO). The aim of this study is to determine the feasibility and effectiveness of an RM-based ablation for NICMO patients. METHODS AND RESULTS: This was a single-center, retrospective study including all NICMO patients undergoing VT ablation at St Vincent Hospital between January 1, 2018 and January 12, 2019. Retrospective RM analysis was performed on those that had a substrate-based ablation to identify the location and number of Ripple channels as well as their proximity to ablation lesions. Thirty-three patients met the inclusion criteria and had a median age of 65 (58, 73.5) with 15.2% of the population being female, and were followed for a median duration of 451 (217.5, 586.5) days. Of these patients, 23 (69.7%) had a substrate-based ablation with a median procedural duration of 196.4 (186.8, 339) min, 1946 (517, 2750) points collected per map, and 277 (141, 554) points were within the scar. Two (8.6%) procedural complications occurred, and 7 (30.4%) patients had VT recurrence during follow-up. RM analysis revealed an average of two Ripple channels and the patients without VT recurrence had ablation performed closer to the Ripple channels: 0 (0, 4.7) versus 14.3 (0, 23.5) cm; p = .02. CONCLUSION: An RM-based substrate ablation can be performed in NICMO patients and ablation within Ripple channels is a predictor of VT freedom.

Rapid detection of isthmus block and rhythm change using local electrogram changes during complex atrial flutter ablation.

AIMS: Multiple re-entry circuits may operate simultaneously in the atria in the form of dual loop re-entry using a common isthmus, or multiple re-entrant loops without a common isthmus. When two or more re-entrant circuits coexist, ablation of an individual isthmus may lead to a seamless transition (without significant changes in surface electrocardiogram, coronary sinus activation or tachycardia cycle length) to a second rhythm, and the isthmus block can go unnoticed. METHODS AND RESULTS: We hypothesize and subsequently illustrate in three patient cases, methods to rapidly identify a transition in the rhythm and isthmus block using local electrogram changes at the ablation site. CONCLUSION: Local activation sequence changes, electrogram timing, and the behaviour of pre-existing double potentials can reveal isthmus block promptly when rhythm transitions occur during ablation of multiloop re-entry tachycardias.

Rhabdomyolysis-Induced Acute Kidney Injury Treated with Medium Cut-Off Membrane: A Case Report.

Acute kidney injury can complicate rhabdomyolysis in 10-40% patients. Myoglobinuria and elevated creatine kinase (CK) form the basis of diagnosis. When associated with azotemia and/or oliguria, intermittent hemodialysis is a treatment option. 31-year-old young man came with lower limb pain after doing 800 sit ups. At the presentation, blood pressure was high, serum creatinine was 15.7mg/dl and creatine kinase(CK)>20000 IU/L. Intermittent dialysis was initiated. He developed posterior reversible encephalopathy syndrome, generalized tonic clonic convulsions and a further rise in CK. He underwent extracorporeal removal of myoglobin with medium cut-off (MCO) membrane. After 3 sessions with MCO membrane, myoglobin and CK levels reduced. He was transitioned to conventional dialysis and discharged in a stable condition with complete renal recovery. Medium cut-off membrane effectively removes circulating myoglobin without significant albumin loss and is cost effective.

Comparative evaluation of post treatment CT scan and clinical parameters in open reduction and closed reduction treatment of condylar fractures.

Background: Mandibular fracture is the second most common fracture of facial bone, next to nasal bone. Twenty-five to forty percent of mandibular fractures involve the condyle. In the literature, there exists no consensus "gold standard" treatment for mandibular condylar fractures, and there is a continuing debate on whether condylar fractures should undergo closed or open reduction. Materials and Method: Twenty patients who had undergone open reduction and closed reduction treatment were included in the study. Clinically maximal interincisal opening, laterotrusive and protrusive movements, pain on mouth opening, malocclusion, chin deviation on mouth opening, facial nerve palsy, hematoma, infected implant, and bite force were evaluated after a minimum of 3 months postoperatively. Also, a postoperative CT is done to evaluate the anatomical position of fragment. Results: On evaluation of clinical parameters, both groups had comparable results. However, none of the patients in open reduction group had deviation of mandible from midline on mouth opening. Also, better anatomical repositioning is obtained in open reduction group. Conclusion: The results of this study suggest that the open reduction method is a better alternative to closed reduction in treatment of mandibular condylar fractures.

Evaluation of the Efficacy of Iso Amyl 2-Cyanoacrylate Glue in Closure of Extraoral Surgical Wound When Compared with Other Non-Absorbable Suture Materials- A Prospective Clinical Study.

Introduction: Appropriate wound closure with appropriate suture material is of prime significance in surgery. Hence, we aim to assess the efficiency of ISO amyl 2-cyanoacrylate glue in closure of extraoral surgical wound when compared with other suture materials like polypropylene (prolene), nylon (ethilon) and silk (mersilk). Materials and Methods: We conducted a prospective clinical observational study in which 60 subjects were divided into two groups: suture group and cyanoacrylate group. They were compared for wound healing complications on days 1, 3, 7, 12, and at 1 month postoperatively with P < 0.05 as significant. Results: We observed that there was no statistically significant difference between the groups for the various parameters of the wound healing for the different time periods except that color acceptability and visibility were significantly superior in the cyanoacrylate group. Conclusion: Iso amyl 2-cyanoacrylate can be used successfully in the suture closure with excellent patient satisfaction and can be considered as an alternative to the routine suture materials.

Diagnostic utility of early premature ventricular complexes in differentiating atrioventricular reentrant and atrioventricular nodal reentrant tachycardias.

BACKGROUND: His-refractory premature ventricular complexes perturbing a supraventricular tachycardia (SVT) establish the presence of an accessory pathway (AP). Earlier premature ventricular complexes (ErPVCs) may perturb SVTs but are considered nondiagnostic. OBJECTIVE: The purpose of this study was to test the hypothesis that an ErPVC will always show a difference >35 ms in its advancement of the next atrial activation during atrioventricular nodal reentrant tachycardia (AVNRT). During atrioventricular reentrant tachycardia (AVRT), a PVC delivered close to the circuit can result in greater advancement of atrial activation due to retrograde conduction via an AP. Thus, an AP response, defined as ErPVC (H1S2) advancing the subsequent atrial activation (A1-A2) more than this minimum difference (A1A2 ≤ H1S2+35 ms), establishes the presence of an AP. METHODS: Sixty-five consecutive patients with SVT were retrospectively evaluated. ErPVCs were defined when the ventricular pacing stimulus was >35 ms ahead of the His during tachycardia. RESULTS: Among the 65 cases, 43 were AVNRT and 22 AVRT. Fourteen AVRT cases had an AP response with a mean H1S2+35 ms of 336 ± 58 ms and A1A2 of 309 ± 51ms. No AVNRT cases had an AP response. The specificity of an AP response to ErPVC in predicting AVRT was 100%. CONCLUSION: An AP response to PVCs (A1A2 ≤ H1S2+35 ms) is 100% specific for the presence of an AP.

Glioblastoma multiforme metastatic to lung in the absence of intracranial recurrence: case report.

We present the case of a 65 year old gentleman who underwent craniotomy and debulking of a left temporal glioblastoma multiforme (GBM). Post-operatively he received chemotherapy and radiotherapy with good response demonstrated on interval MRI scans. At 17 months post-diagnosis and in the absence of clinical or radiological recurrence, he presented with respiratory distress. He was found to have an exudative right-sided pleural effusion, nodular pleural thickening, a hilar mass and associated lymphadenopathy. Percutaneous pleural biopsy revealed metastatic GBM. Systemic GBM metastasis despite good response to oncological treatments and in the absence of intracranial recurrence is exceedingly rare. We review the literature concerning extra-neuraxial GBM metastasis and speculate why this phenomenon is extremely rare.

The Effects of Patient Demographics on Outpatient Endoscopy Utilization in Children With Eosinophilic Esophagitis.

OBJECTIVES: Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus that requires esophagogastroduodenoscopy (EGD) for diagnosis and treatment monitoring. We aimed to identify the frequency of endoscopic monitoring in children with EoE and observe the effect of age, race, socioeconomic factors, and atopy on the rate of endoscopy. METHODS: We queried the Pediatric Health Information System over a 15-year period for ambulatory EGDs in children with EoE. Subjects with at least 1 year of data were included. Age, sex, ethnicity, race, insurance type, median household income, and atopy were collected for each subject. RESULTS: 16,517 subjects were included (mean age 8.5 years). 3211 (19%) of subjects had ≥1 EGD per subject year (EGD/SY). Subjects >13 years old were more likely to have ≥1 EGD/SY compared to children 6-12 years (odds ratio [OR] 2.29, P < 0.001, 95% confidence interval [CI] = 2.06-2.54). Males were more likely to have ≥1 EGD/SY compared to females (OR 1.19, P < 0.001, 95% CI = 1.08-1.31). African-American subjects were 16% less likely than Caucasian subjects to have ≥1 EGD/SY (OR 0.84, P = 0.05, 95% CI = 0.71-1.00). Subjects with allergic rhinitis or anaphylaxis, food allergy, and/or oral allergy syndrome were more likely to have ≥1 EGD/SY (OR 1.67, P < 0.001, 95% CI = 1.47-1.90 and OR 3.65, P < 0.001, 95% CI = 3.25-4.11, respectively). CONCLUSIONS: Nineteen percent of subjects had ≥1 EGD/SY. Older age, male sex, allergic rhinitis, and food allergies were associated with more frequent endoscopic monitoring in children with EoE. Caucasian subjects had more frequent endoscopy than African-American subjects. This study raises awareness about underrecognized variation in the care of children with EoE.

Study of Peripheral Mononuclear Cells and CD34 Levels as a Predictive Marker for Initiating Apheresis in Autologous Stem Cell Transplant.

Background: Autologous HCT in multiple myeloma is done as upfront treatment in newly diagnosed transplant eligible patients after induction chemotherapy. In addition, it is standard for relapsed, aggressive non-Hodgkin lymphoma (NHL) and classical Hodgkin lymphoma (HL), and is curative in ~40% to 45% of patients. Over a decade, many efforts were made to find helpful parameters to predict an optimal time for initiating an efficient peripheral blood stem cell collection so that adequate stem cells are collected.  It has been well accepted that CD34+ cell count in peripheral blood before leukapheresis is the best parameter to predict CD34 cell yield. However, white blood cell count, mononuclear cell count, and other easily obtained parameters are still used to guide the clinical practice of peripheral blood stem cell mobilization and collection.  Materials and Methods: In the present study, we analyzed the correlation between peripheral blood MNC and Apheresis CD34 levels and also between peripheral blood CD34 by flow cytometry and apheresis CD34 levels. Results: We found that there was a statistically insignificant weak correlation between peripheral MNC and apheresis CD34. There was a statistically significant strong correlation between peripheral CD34 and apheresis CD34. Conclusion: The results show that peripheral blood MNC was analogous indicating that no reliable prediction can be done for CD34 cells collected in apheresis while peripheral CD34 by flow cytometry is the strongest predictor for initiating stem cell collection.

Left atrial hypertension and the risk of early incident heart failure after atrial fibrillation ablation.

INTRODUCTION: Elevated left atrial pressure (LAP) during catheter ablation of atrial fibrillation (AF) is associated with an increased risk of AF recurrence, but it is unknown if this correlates with heart failure (HF). The objective of the study was to determine if elevated LAP after AF ablation correlates with HF events. METHODS: Prospective, single-center, cohort study measuring LAP and right atrial pressure (RAP) during AF ablation in 100 patients. The primary endpoint was clinical HF within 30 days of ablation. The secondary outcome was AF-free HF. RESULTS: One hundred patients (63% male, mean age 64.5) were enrolled and 20% had clinical HF within 30 days. Bivariate correlates included mitral valve (MV) disease, persistent AF, class III antiarrhythmics, LAP, and recurrent AF. Multivariate analysis revealed class III antiarrhythmics were protective (odds ratio [OR]: 0.24 [0.1-0.5], p = .04), while MV disease (OR: 8.7 [3.3-23], p = .03) and loop diuretics (OR: 4.8 [2.6-9.1], p = .01) were hazardous. AF-free HF occurred in 9% of patients and correlated with higher LAP and RAP, and chronic kidney disease. CONCLUSION: Patients with HF after AF ablation had higher LAP. MV disease, diuretic use, and class III antiarrhythmics also correlated to HF. These present opportunities to target future interventions to reduce a common complication of AF ablation.

High Frequency (HF10) Spinal Cord Stimulation for Chronic Neuropathic Pain.

BACKGROUND AND INTRODUCTION: Spinal cord stimulation (SCS) is well established treatment. In a prospective randomised controlled trial, novel 10-kHz High-frequency Therapy (HF10 Therapy) was superior to traditional low-frequency SCS for the treatment of chronic back and leg pain. OBJECTIVE: To demonstrate the percutaneous SCS implant technique and discuss the operative nuances. SURGICAL TECHNIQUE/PROCEDURE: During the stage 1 procedure (permanent trial), two percutaneous electrodes were placed in the midline posterior epidural space spanning T8-T10 segments straddling the T9-10 disc space. The electrodes were anchored to the fascia, tunnelled into the supragluteal incision and connected to the extensions, which were tunnelled out for the external trial. RESULTS AND CONCLUSIONS: The patient reported 90% pain reduction at follow-up. Thoracic HF10 SCS is effective modality in managing chronic neuropathic pain.

Avoiding Bladder Catheters During Atrial Fibrillation Ablation.

OBJECTIVES: This study sought to determine if atrial fibrillation (AF) ablation can be performed safely without bladder catheterization. BACKGROUND: Patients undergoing AF ablation often receive bladder catheters. Catheterization is associated with potential complications. The ABCD-AF (Avoiding Bladder Catheters During Atrial Fibrillation) ablation study evaluates the advantages of performing AF ablation without routine catheterization. METHODS: In this single-center, prospective, randomized controlled trial, 80 patients received bladder catheterization (group A), and 80 patients received only as-needed catheterization (group B). The primary endpoint was a composite of cystitis, urethral injury, hematuria, dysuria, or urinary retention. RESULTS: The mean patient age was 63 ± 13 years, and 33% of patients were female. The primary outcome was reached in 45 patients in group A and 11 patients in group B (p < 0.001). Urinary tract infection occurred in 7 patients in group A and 2 patients in group B (p = 0.17). Urinary retention occurred in 12 patients in group A and 5 patients in group B (p = 0.07). Randomization to catheterization carried an odds ratio of 8.1 (95% confidence interval [CI]: 3.7 to 17.5; p < 0.001), and male sex carried an odds ratio of 3.8 (95% CI: 1.7 to 8.6; p = 0.001) for the primary endpoint. On subgroup analysis, randomization to undergo catheterization had no association with the primary outcome in female patients but had an odds ratio of 14.6 (95% CI: 5.6 to 38.1; p < 0.001) in male patients. In multivariable analysis, sex and catheter status remained independently associated with the primary outcome. CONCLUSIONS: Bladder catheterization can be safely avoided in patients undergoing AF ablation and is associated with a significant reduction in adverse outcomes, especially in men.

Predictors of successful ultrasound-guided lead implantation.

BACKGROUND: Technical advances have improved the safety of cardiac implantable electronic device (CIED) insertion, but periprocedural complications persist. Despite ultrasound (US) guidance for vascular access being feasible and exhibiting shorter fluoroscopy times, it is not widely adopted for insertion of CIEDs. Thus, we studied the use of US for CIED insertion to (1) quantify the success rate of venous cannulation, (2) identify predictors of failed cannulation, and (3) quantify the rate of complications using US guidance. METHODS: We studied 166 consecutive patients who underwent US-guided CIED implantation. Anatomic parameters of the axillary vein were measured. The primary outcome was success (group 1) or failure (group 2) to obtain vascular access utilizing US guidance. Secondary outcomes included pneumothorax and hematoma. RESULTS: Successful US-guided cannulation occurred in 154 of 166 patients (93%). No patient had a pneumothorax. Hematoma occurred in 1 of 166 patients (0.01%). Group 2 exhibited higher male proportion at 11 of 12 (92%) compared with 94 of 154 (61%) in group 1 (P = .03), increased vein depth at 3.84 versus 2.85 cm (P = .003), more right-sided implants (P = .03), higher weight at 104.6 versus 85.3 kg (P = .017), higher body mass index at 35.6 versus 29.2 kg/m2 (P = .049), and higher body surface area at 2.24 versus 1.99 m2 (P = .013). Other parameters were statistically nonsignificant. In multivariate analysis, vein depth remained significantly associated with failure. CONCLUSION: Using US guidance for CIED implantation is successful in the vast majority (93%) of patients. Rare cases of unsuccessful cannulation were associated with right-sided implants and increased venous depth.

Calcitonin induces stem cell-like phenotype in prostate cancer cells.

Stem cell-like-cancer cells are key drivers of tumor growth, metastasis, and relapse of cancer following remission. Prostate stem cell-like cancer cells isolated from human prostate cancer (PC) biopsies express CD44+/α2ß1 hi/CD133+ cell surface markers and can self-renew in vitro. Expression of calcitonin (CT) and its receptor (CTR) is frequently elevated in PCs and activation of CT-CTR axis in non-invasive PC cells induces an invasive phenotype. We investigated whether CT-CTR autocrine axis induces stem cell-like phenotype in two PC cell lines. CT-CTR axis in these cell lines was activated by enforced expression of CTR. The cells were then examined for the changes in the expression of CD44 and CD133, collagen adherence, tumorigenic, metastatic and repopulating characteristics. The activation of CT-CTR axis led to a large increase in adherence to collagen and a remarkable increase of CD44 and CD133 in PC-3 and LNCaP cells. This was accompanied by a strong increase in tumorigenic, metastatic and repopulation properties of PC cells. However, the mutation of CTR-C PDZ-binding site in CTR almost abolished CTR-mediated increases in stem cell-like characteristics of PC cells. These results support an important role for CT-CTR axis in the progression of PC from localized cancer to an aggressive form, and a majority of proinvasive CTR actions may be mediated through its interaction with its partner protein at the PDZ-binding site. These results suggest that CT/CTR can serve as a valuable target to prevent the generation of stem-like PC cells.

Single-center experience of the FIRM technique to ablate paroxysmal and persistent atrial fibrillation.

INTRODUCTION: Focal impulse and rotor modulation (FIRM)-guided ablation has had mixed results of published success, and most studies have had a follow-up for a year or less. We aimed to study a consecutive group of patients followed for at least 1.5 years, subgrouped into those with an initial FIRM ablation and those with a previous, failed ablation who now received a FIRM guided one, to evaluate for success in each group and factors that might affect success. METHODS: Of 181 patients, 167 were available for analysis. Group 1 (n = 122) had a first or primary ablation (paroxysmal atrial fibrillation [PAF] 51; persistent atrial fibrillation [PeAF] 71) and group 2 (n = 45) had a redo ablation (PAF 18; PeAF 27). All patients were done under general anesthesia. FIRM mapping was done in the right atrium first and then the left, and only rotors consistently seen on multiple epochs were ablated, using 15 to 30 W. Rotor ablation was discontinued when remapping showed elimination of rotational activity at the site. Wide area catheter ablation was done for pulmonary vein isolation (PVI). Routine follow-up was at 3, 6, and 12 months of the first year, with a Holter monitor at 6 months, and then every 6 months thereafter. Event recorders were given to patients with potential arrhythmic symptoms. RESULTS: Mean follow-up was 16 months. Nearly 40% of patients had obstructive sleep apnea; mean body mass index was 32; and average left atrial size was 39.7 mm and 46.2 mm for PAF and PeAF patients, respectively. Freedom from atrial arrhythmia recurrence was: in group 1 patients, 82.4% for PAF and 67.6% for PeAF patients; in group 2 patients, 83.3% for PAF, but only 40.7% for PeAF patients. Comparing outcomes for the first 10 patients studied to the next 20 or more done by three operators showed no difference, suggesting no learning curve affecting the ablation results. Furthermore, the univariate analysis did not show any demographic factor to have an independent significance for ablation success or failure. Spontaneous termination during rotor ablation occurred in 76.8% of PAF and 27.6% of PeAF patients but did not affect the long-term outcomes for maintenance of sinus rhythm. CONCLUSIONS: FIRM-guided atrial ablation plus PVI in our patient population resulted in good success from a recurrence of atrial arrhythmias in patients undergoing an initial ablation procedure. For those with persistent AF undergoing a second procedure now using FIRM guidance plus PVI, the results are lower. Further research is needed to define better the appropriate population for FIRM-guided ablation and the degree of ablation needed for success in these patients.