Stroke event rates in anticoagulated patients with paroxysmal atrial fibrillation

Aims. To test the hypothesis that stroke and systemic embolic events (SEE) in the stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) III and V trials are different between paroxysmal and persistent atrial fibrillation (AF). Methods. Data analysis from two cohorts of patients enroled in the prospective SPORTIF III and V clinical trials (n = 7329); 836 subjects (11.4%) with paroxysmal AF [mean age 70.1 years (SD = 9.5)] were compared with 6493 subjects with persistent AF for this ancillary study. Results. The annual event rates for stroke/SEE are 1.73% for persistent AF and 0.93% for paroxysmal AF. In a multivariate analysis, after adjusting for stroke risk factors, gender and aspirin usage, the differences remained statistically significant with a higher hazard ratio (HR) for stroke/SEE in persistent AF [vs. paroxysmal AF, HR 1.87, 95% confidence interval (CI) 1.04–3.36; P = 0.037]. In ‘high risk’ patients (with ≥2 stroke risk factors) annual event rates for stroke/SEE were 2.08% for persistent AF and 1.27% for paroxysmal AF (adjusted HR = 1.68, 95% CI 0.91–3.1, P = 0.098). Elderly patients had annual event rates for stroke/SEE of 2.38% for persistent AF and 1.13% for paroxysmal AF (adjusted HR = 2.27, 95% CI 0.92–5.59, P = 0.075). Vitamin K antagonist (VKA)‐naïve paroxysmal AF patients had a 1.89%/year stroke/SEE rate, compared with 0.61% for previous VKA takers (HR = 0.33, 95% CI 0.11–1.01, P = 0.052). Conclusion. In this large clinical trial cohort of anticoagulated AF patients, those with paroxysmal AF had stroke rates which were lower than for patients with persistent AF, although both groups had broadly similar stroke risk factors. Subjects with paroxysmal AF at ‘high risk’ had stroke/SEE rates that were not significantly different to persistent AF subjects.     

Interatrial Mechanical Dyssynchrony Worsened Atrial Mechanical Function in Sinus Node Disease With or Without Paroxysmal Atrial Fibrillation

Introduction: Atrial electromechanical dysfunction might contribute to the development of atrial fibrillation (AF) in patients with sinus node disease (SND). The aim of this study was to investigate the prevalence and impact of atrial mechanical dyssynchrony on atrial function in SND patients with or without paroxysmal AF. Methods: We performed echocardiographic examination with tissue Doppler imaging in 30 SND patients with (n = 11) or without (n = 19) paroxysmal AF who received dual‐chamber pacemakers. Tissue Doppler indexes included atrial contraction velocities (Va) and timing events (Ta) were measured at midleft atrial (LA) and right atrial (RA) wall. Intraatrial synchronicity was defined by the standard deviation and maximum time delay of Ta among 6 segments of LA (septal/lateral/inferior/anterior/posterior/anterospetal). Interatrial synchronicity was defined by time delay between Ta from RA and LA free wall. Results: There were no differences in age, P‐wave duration, left ventricular ejection fraction, LA volume, and ejection fraction between with or without AF. Patients with paroxysmal AF had lower mitral inflow A velocity (70 ± 19 vs 91 ± 17 cm/s, P = 0.005), LA active empting fraction (24 ± 14 vs 36 ± 13%, P = 0.027), mean Va of LA (2.6 ± 0.9 vs 3.4 ± 0.9 cm/s, P = 0.028), and greater interatrial synchronicity (33 ± 25 vs 12 ± 19 ms, P = 0.022) than those without AF. Furthermore, a lower mitral inflow A velocity (Odd ratio [OR]= 1.12, 95% Confidence interval [CI] 1.01–1.24, P = 0.025) and prolonged interatrial dyssynchrony (OR = 1.08, 95% CI 1.01–1.16, P = 0.020) were independent predictors for the presence of AF in SND patients. Conclusion: SND patients with paroxysmal AF had reduced regional and global active LA mechanical contraction and increased interatrial dyssychrony as compared with those without AF. These findings suggest that abnormal atrial electromechanical properties are associated with AF in SND patients.     

High-density mapping of atrial fibrillation in humans: relationship between high-frequency activation and electrogram fractionation

Introduction: Sites of complex fractionated atrial electrograms (CFAE) and dominant frequency (DF) have been implicated in maintaining atrial fibrillation (AF); however, their relationship is poorly understood. Methods and Results: Twenty patients underwent biatrial high‐density contact mapping (507 ± 150 points/patient) during AF. CFAE were characterized using software to quantify electrogram complexity (CFE‐mean). Spectral analysis determined the frequency with greatest power and sites of high DF with a frequency gradient. CFE‐mean was higher (less fractionated) for right compared with left atria (P < 0.001) and in paroxysmal compared with persistent AF (P < 0.001). DF was lower for right compared with left atria (P = 0.02) and in paroxysmal compared with persistent AF (P < 0.001). There was significant regional variation in DF in paroxysmal (P < 0.001) but not persistent AF. Highest DF points clustered together with 5.2 ± 1.7 clusters/patient. Correlation between CFE‐mean and DF was poor on a point‐by‐point basis (r =?0.17, P < 0.001), but moderate on an individual basis (r =?0.50, P = 0.03). Exploration of their spatial relationship demonstrated CFAE areas in close proximity (median 5 mm, IQR 2–10) to high DF sites; within 10 mm in 80% and 10–20 mm in 10%. Simultaneous activation mapping at these sites further supports this observation. Conclusion: Greater fractionation and higher DF are seen in persistent AF and left atria during AF. Preferential areas of high DF are observed in paroxysmal but not persistent AF. CFAE and DF correlate within an individual but not point‐by‐point. Exploration of their spatial relationship demonstrates CFAE in areas adjacent to high DF, and this is supported by activation mapping at these sites.     

Efficacy of cardiac autonomic denervation for atrial fibrillation: a meta-analysis

Cardiac Autonomic Denervation and AF. Introduction : Adjunctive complex fractionated atrial electrograms (CFAE) ablation or ganglionated plexi (GP) ablation have been proposed as new strategies to increase the elimination of AF, but the difference between CFAE/GP ablation and pulmonary vein isolation (PVI), as well as the combined effect of CFAE/GP plus PVI ablation were unclear. This meta‐analysis was designed to determine whether adjunctive cardiac autonomic denervation (CAD) was effective for the elimination of AF, and whether CAD alone was superior to PVI in AF patients. Methods: A systemic literature search in MEDLINE, EMBASE, and Cochrane Controlled Trials Register (CCRT) was performed and controlled trials comparing the effect of PVI plus CFAE/GP ablation with PVI, as well as CFAE/GP ablation with PVI were collected. Results : A total of 15 trials including 1,147 patients with AF were qualified for this meta‐analysis. CAD plus PVI significantly increased the freedom from AF/ATs (OR 1.85, 95% CI: 1.33–2.59, P = 0.29). Subgroup analysis showed that additional CAD increased the ratio of sinus rhythm maintenance in both paroxysmal AF (OR 1.69; 95% CI: 1.09–2.62, P = 0.41) and nonparoxysmal AF (OR 2.11, 95% CI: 1.14–3.90, P = 0.14). Besides, when compared respectively, adjunctive CAD was not superior to PVI (OR 0.31; 95% CI: 0.11–0.86, P = 0.002). Conclusion : This study suggested that CAD plus PVI significantly increase the freedom from recurrence of AF both in paroxysmal and nonparoxysmal patients. However, when compared alone, the benefit of CAD was not superior to PVI. (J Cardiovasc Electrophysiol, Vol. 23, pp. 592–600, June 2012)     

Time to Cardioversion of Recurrent Atrial Arrhythmias After Catheter Ablation of Atrial Fibrillation and Long‐Term Clinical Outcome

Introduction: It is unclear whether early restoration of sinus rhythm in patients with persistent atrial arrhythmias after catheter ablation of atrial fibrillation (AF) facilitates reverse atrial remodeling and promotes long‐term maintenance of sinus rhythm. The purpose of this study was to determine the relationship between the time to restoration of sinus rhythm after a recurrence of an atrial arrhythmia and long‐term maintenance of sinus rhythm after radiofrequency catheter ablation of AF. Methods and Results: Radiofrequency catheter ablation was performed in 384 consecutive patients (age 60 ± 9 years) for paroxysmal (215 patients) or persistent AF (169 patients). Transthoracic cardioversion was performed in all 93 patients (24%) who presented with a persistent atrial arrhythmia: AF (n = 74) or atrial flutter (n = 19) at a mean of 51 ± 53 days from the recurrence of atrial arrhythmia and 88 ± 72 days from the ablation procedure. At a mean of 16 ± 10 months after the ablation procedure, 25 of 93 patients (27%) who underwent cardioversion were in sinus rhythm without antiarrhythmic therapy. Among the 46 patients who underwent cardioversion at ≤30 days after the recurrence, 23 (50%) were in sinus rhythm without antiarrhythmic therapy. On multivariate analysis of clinical variables, time to cardioversion within 30 days after the onset of atrial arrhythmia was the only independent predictor of maintenance of sinus rhythm in the absence of antiarrhythmic drug therapy after a single ablation procedure (OR 22.5; 95% CI 4.87–103.88, P < 0.001). Conclusion: Freedom from AF/flutter is achieved in approximately 50% of patients who undergo cardioversion within 30 days of a persistent atrial arrhythmia after catheter ablation of AF.     

Prevalence and predictors of complications of radiofrequency catheter ablation for atrial fibrillation

Complications of Atrial Fibrillation Ablation. Introduction: Up to 6% of patients experience complications after radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The purpose of this study is to determine the prevalence and predictors of periprocedural complications after RFA for AF. Methods and Results: The subjects were 1,295 consecutive patients (age = 60 ± 10 years) who underwent RFA (n = 1,642) for paroxysmal (53%) or persistent AF (47%) from January 2007 to January 2010. A complication occurred in 57 patients (3.5%); a vascular access complication in 31 (1.9%); pericardial tamponade in 20 (1.2%); a thromboembolic event in 4 (0.2%); deep venous thrombosis in 1 (<0.01%); and pulmonary vein stenosis in 1 patient (<0.01%). There were no procedure‐related deaths. On multivariate analysis, female gender (OR = 2.27; ±95% CI: 1.31–2.57, P < 0.01) and procedures performed in July or August (OR = 2.10; ±95% CI: 1.16–3.80, P = 0.01) were independent predictors of any complication. For vascular complications, treatment with clopidogrel (OR = 4.40; ±95% CI: 1.43–13.53, P = 0.01), female gender (OR = 3.65; ±95% CI: 1.72–7.75, P < 0.01) and performing RFA in July or August (OR = 2.71; ±95% CI: 1.25–5.87, P = 0.01) were independent predictors. The only predictor of cardiac tamponade was prior RFA (OR = 3.32; ±95% CI: 0.95–11.61; P < 0.05). Conclusion: Prevalence of perioperative complications for RFA of AF is 3.5% and vascular access complications constitute the majority. The need for clopidogrel therapy should be carefully considered prior to RFA. At teaching institutions close supervision should be exercised during vascular access early in the year. Improvements in ablation technology and elimination of the need for repeat procedures may decrease the risk of pericardial tamponade . (J Cardiovasc Electrophysiol, Vol. 22, pp. 626‐631, June 2011)     

Efficacy of adjuvant anterior left atrial ablation during intracardiac echocardiography-guided pulmonary vein antrum isolation for atrial fibrillation

Background: Recent data have shown that the septum and anterior left atrial (LA) wall may contain “rotor” sites required for AF maintenance. However, whether adding ablation of such sites to standard ICE‐guided PVAI improves outcome is not well known. Objective: To determine if adjuvant anterior LA ablation during PVAI improves the cure rate of paroxysmal and permanent AF. Methods: One hundred AF patients (60 paroxysmal, 40 persistent/permanent) undergoing first‐time PVAI were enrolled over three months to receive adjuvant anterior LA ablation (Group I). These patients were compared with 100 randomly selected, matched first‐time PVAI controls from the preceding three months who did not receive adjuvant ablation (Group II). All 200 patients underwent ICE‐guided PVAI during which all four PV antra and SVC were isolated. In group I, a decapolar lasso catheter was used to map the septum and anterior LA wall during AF (induced or spontaneous) for continuous high‐frequency, fractionated electrograms (CFAE). Sites where CFAE were identified were ablated until the local EGM was eliminated. A complete anterior line of block was not a requisite endpoint. Patients were followed up for 12 months. Recurrence was assessed post‐PVAI by symptoms, clinic visits, and Holter at 3, 6, and 12 months. Patients also wore rhythm transmitters for the first 3 months. Recurrence was any AF/AFL >1 min occurring >2 months post‐PVAI. Results: Patients (age 56 ± 11 years, 37% female, EF 53%± 11%) did not differ in baseline characteristics between group I and II by design. Group I patients had longer procedure time (188 ± 45 min vs 162 ± 37 min) and RF duration (57 ± 12 min vs 44 ± 20 min) than group II (P < 0.05 for both). Overall recurrence occurred in 15/100 (15%) in group I and 20/100 (20%) in group II (P = 0.054). Success rates did not differ for paroxysmal patients between group I and II (87% vs 85%, respectively). However, for persistent/permanent patients, group I had a higher success rate compared with group II (82% vs 72%, P = 0.047). Conclusions: Adjuvant anterior LA ablation does not appear to impact procedural outcome in patients with paroxysmal AF but may offer benefit to patients with persistent/permanent AF.     

Image‐Integration of Intraprocedural Rotational Angiography‐Based 3D Reconstructions of Left Atrium and Pulmonary Veins into Electroanatomical Mapping: Accuracy of a Novel Modality in Atrial Fibrillation Ablation

DynaCT Cardiac Integration into Electroanatomical Mapping. Introduction: Exact visualization of complex left atrial (LA) anatomy is crucial for safety and success rates when performing catheter ablation of atrial fibrillation (AF). The aim of our study was to validate the accuracy of integrating rotational angiography‐based 3‐dimensional (3D) reconstructions of LA and pulmonary vein (PV) anatomy into an electroanatomical mapping (EAM) system. Methods and Results: In 38 patients (62 ± 8 years, 25 females) undergoing catheter ablation of paroxysmal (n = 19) or persistent (n = 19) AF, intraprocedural rotational angiography of LA and PVs was performed. The subsequent 3D reconstruction and segmentation of LA and PVs was transferred to the EAM system and registered to the EAM. The distances of all EAM points to corresponding points on the LA syngo® DynaCT Cardiac surface were calculated. Segmentation of LA with clear visualization of adjacent structures was possible in all patients. Also, the integrated segmentation of the LA was used to guide the encirclement of ipsilateral veins, which resulted in PV isolation in all patients. Integration into the 3D mapping system was achieved with a distance error of 2.2 ± 0.4 mm when compared with the EAM surface. Subgroups with paroxysmal and persistent AF showed distance errors of 2.3 ± 0.3 mm and 2.1 ± 0.4 mm, respectively (P = n.s.). Conclusion: Intraprocedural registration of LA and PV anatomy by contrast enhanced rotational angiography was feasible and accurate. There were no differences between patients with paroxysmal or persistent AF. Therefore, integration of rotational angiography‐based reconstructions into 3D EAM systems might be helpful to guide catheter ablation for AF. (J Cardiovasc Electrophysiol, Vol. 21, pp. 278–283, March 2010)     

Psychopathology and symptoms of atrial fibrillation: implications for therapy

Psychopathology and Symptoms of Atrial Fibrillation. Introduction: Current guidelines recommend that the choice of AF management strategy be guided by the symptomatic status of the patient when in AF. However, little is known regarding what drives AF symptoms. Several limited studies suggest that psychological distress may be linked with AF symptom severity. Methods: A total of 300 patients with documented AF completed a questionnaire assessing general health and well‐being, including a comprehensive psychological assessment as well as disease‐specific measures of AF symptom severity. AF burden was determined by 1‐week continuous looping monitor in a subset of patients. Analysis of covariance was used to determine the association between individual measures of depression, anxiety, and somatization disorder symptom severity with measures of general health status and AF‐specific symptom severity, adjusting for important confounders. Results: Patients with worsened severity of depression, anxiety, or somatization disorder symptoms had an associated increase in the severity of symptoms attributed to AF regardless of AF severity scale used (P < 0.0001 for each measure of psychological distress). This association persisted after adjusting for important confounders. Increasing severity of depression and anxiety symptoms were also associated with increased visits to medical care for AF management. Conclusions: Our study demonstrates the consequence of psychological distress on AF‐specific symptom severity and healthcare resource utilization. Psychological well‐being may strongly influence symptom severity and healthcare utilization. An assessment of psychological distress may be an important adjunct to standard AF management that warrants further study, particularly if symptom relief is the primary goal. (J Cardiovasc Electrophysiol, Vol. 23, pp. 473‐478, May 2012)     

High washout rate of iodine-123-metaiodobenzylguanidine imaging predicts the outcome of catheter ablation of atrial fibrillation

¹²³ I‐MIBG and Ablation for Atrial Fibrillation. Introduction: Excessive sympathetic nervous activity may contribute to atrial fibrillation (AF) recurrences after ablation, but its precise role remains controversial. The goals of this study were to assess the effects of AF on the iodine‐123‐metaiodobenzylguanidine (¹²³I‐MIBG) findings and to elucidate its impact on the procedural outcome in patients undergoing a first‐time catheter ablation to treat AF. Methods and Results: This study included 88 consecutive patients with paroxysmal (n = 48) or persistent (n = 40) AF who underwent radiofrequency catheter ablation and ¹²³I‐MIBG scintigraphy. Five days after the ablation of AF, ¹²³I‐MIBG scintigraphy was performed during sinus rhythm. Anterior planar imaging was obtained at 15 minutes and 180 minutes and the washout rate of the ¹²³I‐MIBG was calculated. The ¹²³I‐MIBG scintigraphy demonstrated an enhanced adrenergic nervous function (high washout rate) and decreased adrenergic nervous distribution (low heart to mediastinum ratios) in patients with both paroxysmal and persistent AF. During a mean follow‐up period of 13.5 ± 2.2 months after the ablation, 25 (28%) patients had AF recurrences. The univariate predictors of an AF recurrence were the duration of the AF history, left atrial dimension, and washout rate of the ¹²³I‐MIBG. Only the ¹²³I‐MIBG washout rate was a multivariate predictor of an AF recurrence (hazard ratio: 1.6, 95% confidence interval: 1.004–1.125, P = 0.037). Conclusions: Excessive sympathetic nervous activation may be one of the mechanisms of AF recurrences. The evaluation of the cardiac nerve activity using ¹²³I‐MIBG scintigraphy shortly after the AF ablation may be a promising tool to predict the patient's outcome. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1297‐1304, December 2011)     

Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in the elderly

Introduction: The number of elderly patients with atrial fibrillation (AF) is increasing rapidly, and the safety and efficacy of catheter ablation in this demographic group has not been established. Methods: Over a 7‐year period we studied 1,165 consecutive patients undergoing 1,506 AF ablation procedures using a consistent ablation protocol that included proximal ostial pulmonary vein (PV) isolation and focal ablation of non‐PV AF triggers. Outcome was analyzed for three distinct age groups: <65 years (group 1; n = 948 patients), 65–74 years (group 2; n = 185 patients), and ≥75 years (group 3; n = 32 patients) based on the age at the initial procedure. Results: There was no significant difference in AF control (89% in group 1, 84% in group 2, and 86% in group 3, P = NS) during a mean follow‐up of 27 months. Major complication rates were also comparable (1.6% in group 1, 1.7% in group 2, 2.9% in group 3, P = NS) between the three groups. There was no difference in the left atrial size, percentage with left ventricular ejection fraction <50%, or percentage with paroxysmal versus more persistent forms of atrial fibrillation. However, older patients were more likely to be women (20% in group 1, 34% in group 2, and 56% in group 3, P < 0.001) and have hypertension and/or structural heart disease (56% in group 1 vs 68% in group 2 vs 88% in group 3; P < 0.001). There was a strong trend demonstrating that older patients were less likely to undergo repeat ablation (26% vs 27% vs 9%) to achieve AF control and more likely to remain on antiarrhythmic drugs (20% vs 29% vs 37%; P < 0.05). Conclusions: Elderly patients with AF undergoing catheter ablation therapy are represented by a higher proportion of women and have a higher incidence of hypertension/structural heart disease. To achieve a similar level of AF control, there appears to be no increased risk from the ablation procedure, but elderly patients are more likely to remain on antiarrhythmic drugs.     

Long-term outcome of catheter ablation in patients with atrial fibrillation originating from the superior vena cava

Long‐Term Outcome of SVC AF Ablation. Introduction: Data of the long‐term clinical outcome after superior vena cava (SVC) isolation are limited. We aimed to evaluate the long‐term outcome in patients with atrial fibrillation (AF) who had triggers originating from the SVC and received catheter ablation of AF. Methods and Results: The study consisted of 68 patients (age 56 ± 12 years old, 32 males) who underwent the ablation procedure for drug‐refractory, symptomatic paroxysmal AF originating from the SVC since 1999. Group 1 consisted of 37 patients with AF initiated from the SVC only, and group 2 consisted of 31 patients with both SVC and pulmonary vein (PV) triggers. During a follow‐up period of 88 ± 50 months, the AF recurrence rate was 35.3% after a single procedure. The freedom‐from‐AF rates were 85.3% at 1 year and 73.3% at 5 years. In the baseline study, group 2 had larger left atrium (38 ± 4 mm vs 36 ± 5 mm, P = 0.04), left ventricle (50 ± 5 mm vs 46 ± 5 mm, P = 0.003), and PV diameters. Kaplan–Meier survival analysis showed a higher AF recurrence rate in group 2 compared to that in group 1 (P = 0.012). The independent predictor of an AF recurrence was a larger SVC diameter (P = 0.02, HR 1.4, 95% CI 1.1–1.8). Conclusion: Among the patients with paroxysmal AF originating from the SVC, 73% remained free of AF for 5 years after a single catheter ablation procedure. Superior vena cava isolation without PV isolation is an acceptable therapeutic strategy in those patients with AF originating from the SVC only. The SVC diameter was an independent predictor of AF recurrence. (J Cardiovasc Electrophysiol, Vol. 23, pp. 955‐961, September 2012)     

Automatic 3D mapping of complex fractionated atrial electrograms (CFAE) in patients with paroxysmal and persistent atrial fibrillation

Background: Complex fractionated atrial electrograms (CFAE) are a possible target for atrial fibrillation (AF) ablation and can be visualized in three‐dimensional (3D) mapping systems with specialized software. Objective: To use the new CFAE software of CartoXP® (Biosense Webster, Diamond Bar, CA, USA) for analysis of spatial distribution of CFAE in paroxysmal and persistent AF. Methods: We included 16 consecutive patients (6 females; mean 59.3 years) with AF (6 paroxysmal and 10 persistent) undergoing AF ablation. Carto maps of left atrium (LA) were reconstructed. Using the new CFAE software, the degree of local electrogram fractionation was displayed color‐coded on the map surface. LA was divided into four regions: anterior wall, inferior wall, septum, and pulmonary veins (PV). The relationship among regions with CFAE visualized and CFAE ablation regions (persistent AF only) was analyzed retrospectively. Results: In paroxysmal and persistent AF, CFAE were observed in all four LA regions. In paroxysmal AF, the density of CFAE around the PV was significantly higher than in other regions (P < 0.05) and higher than in persistent AF (P < 0.05). In persistent AF, CFAE were evenly distributed all over the LA. Of 40 effective ablation sites with significant AF cycle length prolongation, 33 (82.5%) were judged retrospectively by CFAE map as CFAE sites. Conclusion: CFAE software can visualize the spatial distribution of CFAE in AF. CFAE in persistent AF were observed in more regions of LA compared to paroxysmal AF in which CFAE concentrated on the PV. Automatically detected CFAE match well with ablation sites targeted by operators.     

Prevalence and predictors of worsened left ventricular diastolic dysfunction after catheter ablation of atrial fibrillation

Background

The interactions between atrial fibrillation (AF) and left ventricular diastolic dysfunction (LVDD) are complex and not well defined. Despite the high prevalence of LVDD in the AF population, therapies for LVDD remain limited. Previous studies have suggested that restoration of sinus rhythm with catheter ablation has a positive effect on LVDD, but the prevalence and predictors for worsened LVDD are unknown.

Methods

70 consecutive patients included in prospective AF catheter ablation registry (61 ± 10 years, 66% male) with paroxysmal (n = 40) or persistent AF (n = 30) were examined by transthoracic echocardiography, before and 12 months after ablation. LVDD was classified according to current guidelines. Rhythm outcome of the ablation was verified by serial 7-day Holter ECG.

Results

LVDD was present in 27 patients (38%) at baseline and in 33 patients (47%) at 12 months follow-up (p = .327). An improvement of LVDD was observed in 13 patients (19%), an aggravation was found in 19 (27%), while it was unchanged in the remaining 38 patients (54%). In uni- and multivariable regression analysis, total ablation time (OR 1.611 per 10 min ablation time, 95% CI 1.088 – 2.386, p = .017) was associated with LVDD progression, while neither baseline characteristics nor rhythm during follow-up influenced LVDD alterations. There was no association between echocardiographic deterioration and symptoms.

Conclusions

Catheter ablation of AF can worsen LVDD in a substantial proportion of patients with more aggressive ablation leading to aggravation of LVDD. While there are no apparent negative short-term effects, long-term consequences need to be determined.     

Long‐Term Results of Transcatheter Atrial Fibrillation Ablation in Patients with Impaired Left Ventricular Systolic Function

AF Ablation and Impaired Left Ventricular Function. Introduction: Long‐term outcome of AF ablation in patients with impaired LVEF is unknown. The aim of this study is to evaluate sinus rhythm (SR) maintenance, clinical status, and echocardiographic parameters over a long‐term period following atrial fibrillation (AF) transcatheter ablation in patients with left ventricular ejection fraction (LVEF) <50%. Methods and Results: A total of 196 patients (87.2% males, age 60.5 ± 10.2 years) with LVEF <50% underwent radiofrequency transcatheter ablation for paroxysmal (22.4%) or persistent (77.6%) AF. Patients were followed up for 46.2 (16.4–63.5) months regarding AF recurrences, functional class, and echocardiographic parameters. All patients underwent pulmonary vein isolation, while 167 (85.2%) required additional atrial lesions. Eleven (5.6%) patients suffered procedural complications. During follow‐up, 58 (29.6%) patients required repeated ablations. At the follow‐up end, 15 (7.7%) patients died, while 74 (37.8%) documented at least one episode of AF, atrial flutter, or atrial ectopic tachycardia. Eighty‐three (47.2%) patients maintained antiarrhythmic drugs. During follow‐up, NYHA class improved by at least one class more frequently among patients maintaining SR compared to those experiencing relapses (70.6% vs 47.9%, P = 0.003). LVEF showed a broader relative increase in patients maintaining SR (32.7% vs 21.4%; P = 0.047) and mitral regurgitation grading significantly decreased (P <0.001) only within these patients. At multivariable analysis SR maintenance emerged as an independent predictor (odds ratio 4.26, 95% CI 1.69–10.74, P = 0.002) of long‐term clinical improvement (reduction in NYHA class ≥1 and relative increase in LVEF ≥10%). Conclusions: Although not substantially worse than in patients with preserved LVEF, AF ablation in patients with impaired LVEF is affected by high long‐term recurrence rate. Among these patients SR maintenance is associated with greater clinical improvement. (J Cardiovasc Electrophysiol, Vol. 24, pp. 24‐32, January 2013)     

Preprocedural predictors of atrial fibrillation recurrence following pulmonary vein antrum isolation in patients with paroxysmal atrial fibrillation: long-term follow-up results

Predictors of Recurrence after AF Ablation. Introduction: The objective of this study was to identify the simple preprocedural parameters of atrial fibrillation (AF) recurrence following single ablation procedure in patients with paroxysmal AF during long‐term follow‐up period. Methods and Results: Consecutive 474 patients (61 ± 10 years; 364 males, left atrial (LA) diameter 37.6 ± 5.1 mm) with drug‐refractory paroxysmal AF who underwent AF ablation were analyzed. Pulmonary vein antrum isolation (PVAI), cavotricuspid isthmus line creation with bidirectional conduction block, and elimination of all non‐PV triggers of AF were performed in all patients. With a mean follow‐up of 30 ± 13 months after single procedure, 318 patients (67.1%) were in sinus rhythm without any antiarrhythmic drugs. Multivariate analysis using Cox's proportional hazards model, including the age, gender, duration of AF, body mass index, LA size, left ventricular ejection fraction, and presence of hypertension and structural heart disease as variables, demonstrated that LA size was an independent predictor of AF recurrences after PVAI with a 7.2% increase in the probability for every 1 mm increase in LA diameter (P = 0.0007). When the patients were categorized into 3 groups according to the LA diameter, the patients with moderate (40–50 mm) and severe dilatation (>50 mm) had a 1.30‐fold (P = 0.0131) and 2.14‐fold (P = 0.0057) increase, respectively, in the probability of recurrent AF as compared with the patients with normal LA diameter (≤40 mm). Conclusion : In the long‐term follow‐up period, LA size was the best preprocedural predictor of AF recurrence following single ablation procedure in the patients with paroxysmal AF, even in the patients with a relatively small LA. (J Cardiovasc Electrophysiol, Vol. 22, pp. 621‐625, June 2011)     

Incidence of asymptomatic cerebral microthromboembolism after atrial fibrillation ablation guided by complex fractionated atrial electrogram

Cerebral Microthromboembolism After CFAE Ablation . Background: The incidence of cerebral thromboembolism after pulmonary vein isolation (PVI) ranges from 2% to 14%. This study investigated the incidence of cerebral thromboembolism after complex fractionated atrial electrogram (CFAE) ablation with or without PVI. Methods: One hundred consecutive atrial fibrillation (AF) patients (50 paroxysmal and 50 persistent, including 10 longstanding) who underwent CFAE ablation combined with (n = 41, PVI+CFAE group) or without (n = 59, CFAE group) PVI were studied. Coronary angiography (CAG) was conducted with AF ablation in 5 cases in which coronary artery stenosis was suspected on 3D‐computed tomography. PVI was performed before CFAE ablation without circular catheter during AF. After termination of AF, additional ablation was performed to complete PVI with a circular catheter. All patients underwent cerebral magnetic resonance imaging (MRI) including diffusion‐weighted MRI and T2‐weighted MRI the day after ablation. Results: New thromboembolism was detected in 7.0%, and there was no significant difference between the 2 strategies (7.3% in PVI+CFAE group, 6.8% in CFAE group). CHADS2 score (1.6 ± 1.0 vs 0.8 ± 0.9, P < 0.05), left atrial volume (LAV; 83.8 ± 27.1 vs 67.8 ± 21.8, P < 0.05), and left ventricular ejection fraction (LVEF, 53.1 ± 9.2 vs 65.1 ± 9.7, P < 0.01) were significantly different when comparing patients with or without thromboembolism. In multivariate analysis, LVEF (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.84–0.99; P < 0.05) and concomitant CAG (OR 18.82; 95% CI, 1.77–200.00; P < 0.05) were important predictors of new cerebral thromboembolism. Conclusions: The incidence of cerebral microthromboembolism after CFAE ablation was not greater than previous reports in PVI. Cautious management is required during AF ablation, especially in the patients with low LVEF. (J Cardiovasc Electrophysiol, Vol. 23, pp. 567–573, June 2012)     

Predictors of early recurrence and delayed cure after segmental pulmonary vein isolation for paroxysmal atrial fibrillation without structural heart disease

Background Early recurrence of atrial fibrillation (ERAF) and delayed cure are commonly observed after atrial fibrillation (AF) ablation. The purpose of this study was to determine the predictors of ERAF and delayed cure after a single pulmonary vein isolation (PVI) performed in paroxysmal AF patients without structural heart disease.Methods and results In 108 consecutive patients (93 men, 15 women; mean age 51 ± 8 years) with paroxysmal AF and no structural heart disease, segmental PVI guided by a Lasso catheter was performed. Forty-one percent (44/108) AF patients had ERAF after a single PVI. Univariate analysis revealed that left atrial diameter (p = 0.004), age (p = 0.024) and P-wave dispersion (p = 0.045) were significantly related to ERAF. Logistic regression analysis revealed that left atrial enlargement was the only independent predictor of ERAF (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.04–1.30, p = 0.006). Delayed cure occurred in 32% (14/44) patients with ERAF. P-wave dispersion (p = 0.001), left atrial diameter (p = 0.008) were significantly related to delayed cure. P-wave dispersion was the only independent predictive factor of delayed cure (OR 0.91; 95% CI 0.85–0.97, p = 0.004).Conclusions Elderly patients with left atrial enlargement and a high dispersion of P wave are susceptible to ERAF after a single PVI. Left atrial enlargement is the only independent predictor of ERAF. Among patients with ERAF, those with less P-wave dispersion and less left atrial diameter have a higher probability of delayed cure. P-wave dispersion can independently predict delayed cure.This study was supported by National Natural Science Foundation of China. (NSFC No.30470704). There is not any potential conflict of interest.     

Thromboembolic events during the perioperative period in patients undergoing permanent pacemaker implantation

Background:

Thromboembolism (TE) is one of the most serious complications after pacemaker implantation. It has been demonstrated that several patient characteristics and different pacing modes are related to an increased risk of TE events during long‐term follow‐up.

Hypothesis:

We propose that TE events occurring during the perioperative period of pacemaker implantation may be associated with certain clinical characteristics.

Methods:

The potential risk factors of TE events were analyzed in 406 consecutive patients who underwent pacemaker implantation.

Results:

We identified TE events in 11 patients (2.7%) within 7 days after pacemaker implantation. Four of the 11 (36.4%) patients died of complications of TE. Univariate analysis revealed that an age of >75 years (4.56 odds ratio [OR], P = 0.031), hypertension (3.59 OR, P = 0.028), diabetes (8.89 OR, P < 0.001), coronary heart disease (4.8 OR, P = 0.005), atrial fibrillation (AF) (5.68 OR, P = 0.006), persistent AF (10.36 OR, P < 0.001), and a history of stroke or transient ischemic attack (5.62 OR, P = 0.002) were associated with an increased risk of TE events. Multivariate logistic analysis showed that persistent AF (9.8 OR, P < 0.001) was independently associated with TE. The incidence of perioperative TE was not significantly different between patients with single‐ and dual‐chamber pacemakers.

Conclusions:

We found TE events during the perioperative period in patients undergoing pacemaker implantation were not uncommon. Because persistent AF during the perioperative period was the only independent risk factor for perioperative TE, appropriate anticoagulation therapy may be necessary in those patients. © 2012 Wiley Periodicals, Inc. J. Liu, MD, is co‐first author. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Effect of catheter ablation on progression of paroxysmal atrial fibrillation

Ablation and Progression of Atrial Fibrillation. Objective: The objective was to determine the effect of radiofrequency catheter ablation (RFA) on progression of paroxysmal atrial fibrillation (AF). Background: Progression to persistent AF may occur in up to 50% of patients with paroxysmal AF receiving pharmacological therapy. Hypertension, age, prior transient ischemic event, chronic obstructive pulmonary disease, and heart failure (HATCH score) have been identified as independent risk factors for progression of AF. Methods: RFA was performed in 504 patients (mean age: 58 ± 10 years) to eliminate paroxysmal AF. A repeat RFA procedure was performed in 193 patients (38%). Clinical variables predictive of outcome and their relation to progression of AF after RFA were assessed using multivariate analysis. Results: At a mean follow‐up of 27 ± 12 months after RFA, 434/504 patients (86%) were in sinus rhythm; 49/504 patients (9.5%) continued to have paroxysmal AF; and 14 (3%) were in atrial flutter. Among the 504 patients, 7 (1.5%) progressed to persistent AF. In patients with recurrent AF after RFA, paroxysmal AF progressed to persistent AF in 7/56 (13%, P < 0.001). The progression rate of AF was 0.6% per year after RFA (P < 0.001 compared to 9% per year reported in pharmacologically treated patients). Age >75 years, duration of AF >10 years and diabetes were independent predictors of progression to persistent AF. The HATCH score was not significantly different between patients with paroxysmal AF who did and did not progress to persistent AF (0.7 ± 0.8 vs 1.0 ± 0.5, P = 0.3). Conclusions: Compared to a historical control group of pharmacologically treated patients with paroxysmal AF, RFA appears to reduce the rate of progression of paroxysmal AF to persistent AF. Age, duration of AF, and diabetes are independent risk factors for progression to persistent AF after RFA. (J Cardiovasc Electrophysiol, Vol. 23, pp. 9‐14, January 2012)