Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial

Impact of radiofrequency versus cryoballoon ablation on left atrial calcification after atrial fibrillation ablation: A propensity score-matched comparison

INTRODUCTION

Left atrial calcification (LAC) following atrial fibrillation (AF) ablation is associated with major adverse cardiovascular events, with prior reports focusing on radiofrequency catheter ablation (RFCA) rather than cryoballoon ablation (CBA). The aim of this study was to investigate the frequency of LAC and stiff LA physiology (SLAP) in patients undergoing CBA as the initial therapy for AF, compared with those undergoing RFCA, using a propensity score-matched (PSM) population.

METHODS

We conducted a retrospective cohort study involving 2680 consecutive patients who underwent AF ablation with RFCA or CBA. Patients with rheumatic valve disease or mitral valve replacement, those undergoing dialysis, and those without postoperative computed tomography (CT) imaging were excluded. CT images acquired ≥1 year after the initial procedure were used to evaluate the LAC.

RESULTS

In total, 473 eligible patients were identified. PSM created 125 pairs. After a median follow-up of 4.7 years, 9 (4 %) of 250 patients presented with LAC. Those who underwent CBA had a significantly lower incidence of LAC and SLAP compared to those who underwent RFCA (LAC: 1 % vs. 6 %, P = 0.03; SLAP: 1 % vs. 9 %, P = 0.005). Right ventricular systolic pressure significantly increased in the RFCA group (pre-ablation: 23 ± 8 vs. post-ablation: 26 ± 8, P = 0.01), but remained unchanged in the CBA group (pre-ablation: 23 ± 7 vs. post-ablation: 23 ± 8, P = 0.88).

CONCLUSIONS

The use of CBA as the initial ablation seems to have clinical benefits in preventing LAC and SLAP compared to RFCA.

Association between Surrogate Insulin Resistance markers and Post-Ablation Atrial Fibrillation Recurrence: A Systematic Review and Meta-Analysis

BACKGROUND

Atrial fibrillation (AF) is the most common persistent arrhythmia and demonstrates a notable recurrence rate after ablation. Previous studies suggested that surrogate markers of insulin resistance could predict post-ablation AF recurrence.

OBJECTIVE

This systematic review and meta-analysis aims to assess studies examining the relationship between surrogate insulin resistance markers and the recurrence of AF following ablation.

METHODS

We searched PubMed, Web of Science, Embase, and Scopus for observational studies published from inception to August 2024. We incorporated studies that assessed the relationship between surrogate insulin resistance markers and the occurrence of post-ablation AF in patients with either paroxysmal or persistent AF. The random effects model was employed for meta-analysis. The Newcastle-Ottawa Scale was used to evaluate risk of bias and the leave-one-out method was applied for sensitivity analysis (PROSPERO: CRD42024584526).

RESULTS

Nine studies involving 7,729 participants met the inclusion criteria. Significant associations with AF recurrence were observed for the TyG index (HR = 1.29, 95% CI [1.15, 1.44], I2 = 44%), HOMA-IR (HR = 1.27, 95% CI [1.14, 1.42], I2 = 0%), and METS-IR (HR = 1.04, 95% CI [1.03, 1.05], I2 = 0%). However, the Triglyceride/HDL ratio did not demonstrate a statistically significant association with AF recurrence (HR = 1.09, 95% CI [0.96, 1.24], I2 = 86%).

CONCLUSION

Surrogate markers of insulin resistance can be valuable predictors for assessing the risk of AF recurrence in patients who have undergone catheter ablation, potentially aiding in preventive strategies. Nevertheless, further prospective studies are required to validate our findings.

Procedural and Clinical Outcomes of High-Frequency Low-Tidal Volume Ventilation Plus Rapid-Atrial Pacing in Paroxysmal Atrial Fibrillation Ablation

BACKGROUND

High-frequency low-tidal-volume (HFLTV) ventilation is a safe and cost-effective strategy that improves catheter stability, first-pass pulmonary vein isolation, and freedom from all-atrial arrhythmias during radiofrequency catheter ablation (RFCA) of paroxysmal and persistent atrial fibrillation (AF). However, the incremental value of adding rapid-atrial pacing (RAP) to HFLTV-ventilation has not yet been determined.

OBJECTIVE

To evaluate the effect of HFLTV-ventilation plus RAP during RFCA of paroxysmal AF on procedural and long-term clinical outcomes compared to HFLTV-ventilation alone.

METHODS

Patients from the REAL-AF prospective multicenter registry, who underwent RFCA of paroxysmal AF using either HFLTV + RAP (500-600 msec) or HFLTV ventilation alone from April 2020 to February 2023 were included. The primary outcome was freedom from all-atrial arrhythmias at 12-month follow-up. Secondary outcomes included procedural characteristics, long-term clinical outcomes, and procedure-related complications.

RESULTS

A total of 545 patients were included in the analysis (HFLTV + RAP = 327 vs. HFLTV = 218). There were no significant differences in baseline characteristics between the groups. No differences were observed in procedural (HFLTV + RAP 74 [57-98] vs. HFLTV 66 [53-85.75] min, p = 0.617) and RF (HFLTV + RAP 15.15 [11.22-21.22] vs. HFLTV 13.99 [11.04-17.13] min, p = 0.620) times. Both groups showed a similar freedom from all-atrial arrhythmias at 12-month follow-up (HFLTV + RAP 82.68% vs. HFLTV 86.52%, HR = 1.43, 95% CI [0.94-2.16], p = 0.093). There were no significant differences in freedom from AF-related symptoms (HFLTV + RAP 91.4% vs. HFLTV 93.1%, p = 0.476) or AF-related hospitalizations (HFLTV + RAP 98.5% vs. HFLTV 97.2%, p = 0.320). Procedure-related complications were low in both groups (HFLTV + RAP 0.6% vs. HFLTV 0%, p = 0.247).

CONCLUSION

In patients undergoing RFCA for paroxysmal AF, adding RAP to HFLTV-ventilation was not associated with improved procedural and long-term clinical outcomes.

Pulsed Field or Cryoballoon Ablation for Paroxysmal Atrial Fibrillation

BACKGROUND

Pulmonary-vein isolation is an effective treatment for paroxysmal atrial fibrillation. Pulsed field ablation (PFA) is a nonthermal ablation method with few adverse effects beyond the myocardium. Data are lacking on outcomes after PFA as compared with cryoballoon ablation as assessed with continuous rhythm monitoring.

METHODS

In this randomized noninferiority trial in Switzerland, we randomly assigned patients with symptomatic paroxysmal atrial fibrillation in a 1:1 ratio to undergo PFA or cryoablation. All the patients received an implantable cardiac monitor to detect atrial tachyarrhythmias. The primary end point was the first recurrence of an atrial tachyarrhythmia between day 91 and day 365 after ablation. We assessed noninferiority using a margin of 20 percentage points for the difference in the cumulative incidence of recurrence. The safety end point was a composite of procedure-related complications.

RESULTS

A total of 105 patients were assigned to undergo PFA, and 105 were assigned to undergo cryoablation. A recurrence of atrial tachyarrhythmia was observed between day 91 and day 365 in 39 patients in the PFA group and in 53 patients in the cryoablation group (Kaplan-Meier cumulative incidence, 37.1% and 50.7%, respectively; between-group difference, -13.6 percentage points; 95% confidence interval, -26.9 to -0.3; P<0.001 for noninferiority, P = 0.046 for superiority). The safety end point occurred in 1 patient (1.0%) with PFA and in 2 patients (1.9%) with cryoablation.

CONCLUSIONS

Among patients with symptomatic paroxysmal atrial fibrillation, PFA was noninferior to cryoballoon ablation with respect to the incidence of a first recurrence of atrial tachyarrhythmia, as assessed by continuous rhythm monitoring. (Funded by Inselspital and others; SINGLE SHOT CHAMPION ClinicalTrials.gov number, NCT05534581.).

Pulsed field ablation for atrial fibrillation

INTRODUCTION

Atrial fibrillation is the most common sustained arrhythmia, associated with substantial morbidity and a reduced quality of life. The current standard of care, transcatheter pulmonary vein isolation using thermal ablation techniques, provides symptom relief but carries a risk of collateral tissue damage. In recent years, pulsed field ablation, a nonthermal technique based on irreversible electroporation, has emerged as a promising alternative to conventional thermal ablation methods.

AREAS COVERED

This review provides an overview of pulsed field ablation, a novel nonthermal ablation technique. We briefly explain its biophysical principles and general technical aspects, describe currently available technologies, and summarize findings from clinical studies. Additionally, we discuss its safety profile, unresolved issues, and limitations, while also exploring future perspectives.

EXPERT OPINION

Pulsed field ablation offers distinct advantages over traditional thermal ablation methods, such as shorter procedure times and a favorable safety profile due to precise tissue targeting. Future improvements in ablation device design, energy delivery settings, integration with mapping systems, workflow efficiency, ablation protocols, and patient selection criteria are expected to further enhance clinical outcomes.

Radiofrequency or cryoablation or medical therapy for paroxysmal atrial fibrillation: An indirect comparison of effectiveness

Background

Paroxysmal atrial fibrillation (PAF) is commonly treated with pharmacological therapies, but these may be insufficient for symptom control. Radiofrequency and cryoballoon ablation have emerged as alternative strategies. This study aimed to compare the efficacy of cryoballoon ablation, radiofrequency ablation, and anti-arrhythmic drugs as initial therapies for symptomatic PAF based on randomized trial data.

Methods

Data were extracted from randomized trials, and individual patient data were reconstructed from Kaplan-Meier curves using artificial intelligence techniques. Time-to-event analysis was performed to evaluate arrhythmia recurrence, with hazard ratios (HRs) as the primary measure of efficacy. A heterogeneity analysis was conducted to assess variability between studies.

Results

Five randomized trials were included in the analysis. Significant between-trial heterogeneity was observed. Both cryoballoon ablation (HR 0.48; 95% CI: 0.36-0.63; p < .001) and radiofrequency ablation (HR 0.54; 95% CI: 0.37-0.80; p = .002) demonstrated superior efficacy compared to anti-arrhythmic drug therapy in reducing arrhythmia recurrence.

Conclusions

Cryoballoon and radiofrequency ablation are more effective than anti-arrhythmic drugs for initial therapy in symptomatic PAF. These findings support the use of ablation techniques as preferred interventions in this patient population.

A conductive polymer restores connexin43 expression through the suppression of mitogen-activated protein kinases to improve intercellular communication and alleviate atrial fibrillation

Conductive biomaterials have shown promising results for correcting pathological cardiac electrical signaling. However, their mechanisms of operation are still largely unclear. One reason behind disrupted cardiac intercellular communication, though, is lowered expression of the gap junction protein connexin43 (Cx43), which may be alleviated by conductive biomaterials. In this study, we aimed to test this hypothesis, using the self-doping conductive biomaterial poly-3-amino-4-methoxybenzoic acid-gelatin (PAMB-G). An in vitro model was established, in which cardiomyocytes (CMs) were treated with anisomycin, while the in vivo model involved anisomycin-treated mice subjected to electrical pacing to induce atrial fibrillation (AF). Cx43 expression, Ca2+ transient propagation, and CM electrical conduction in vitro, as well as the in vivo effects of PAMB-G on AF, were evaluated; additionally, the underlying molecular mechanisms were identified. We found that anisomycin, at different concentrations, down-regulated Cx43; this was counteracted by PAMB-G, which restored proper Cx43 expression, coupled with improved Ca2+ signal and electrical conduction. Cx43 restoration was due to PAMB-G suppressing anisomycin-induced activation of MAPKs P38 and JNK, which are involved in phosphorylating Cx43 for degradation. Similar observations were also found in vivo, where a PAMB-G patch acted against anisomycin-induced Cx43 downregulation and impaired atrial cell communication, subsequently alleviating pacing-induced AF. Therefore, PAMB-G suppresses MAPKs, in turn upregulating Cx43, leading to improved electrical signal transduction. As a result, modulating the MAPK-Cx43 pathway, such as with PAMB-G, could serve as a potential therapeutic strategy for cardiac arrhythmia. STATEMENT OF SIGNIFICANCE: Disruption of atrial intercellular gap junction channels, comprised of connexins, leads to atrial fibrillation (AF), the most prevalent arrhythmia, with poor clinical outcomes. Current AF treatments are associated with adverse effects, and only focus on managing symptoms, thereby necessitating innovative treatment strategies. One such strategy is conductive biomaterials, which show promising results for correcting pathological cardiac electrical signaling. We synthesized a self-doping conductive biomaterial, poly-3-amino-4-methoxybenzoic acid-gelatin (PAMB-G), and found that it counteracts against anisomycin-induced connexin43 (Cx43) downregulation, subsequently improving cardiac electrical conduction and alleviating pacing-induced AF. This is owed to PAMB-G suppressing anisomycin-associated activation of mitogen-activated kinases P38 and JNK, which are involved in phosphorylating Cx43 for degradation. Therefore, PAMB-G modulation of MAPK-Cx43 pathway could aid in cardiac arrhythmia treatment.

The Role of Cardiac Magnetic Resonance in Characterizing Atrial Cardiomyopathy and Guiding Substrate Ablation in Atrial Fibrillation: A Narrative Review

Cardiac magnetic resonance imaging (MRI) is increasingly recognized as a promising tool for tissue characterization in atrial fibrillation (AF), providing detailed insights into anatomy, fibrosis, and scarring. While MRI cannot directly guide ablation lesions, its ability to identify arrhythmogenic substrates could improve patient stratification and procedural planning. Despite these theoretical advantages, the clinical utility of MRI in guiding substrate-based ablation strategies remains a matter of debate. Methods: Our review evaluates the current evidence supporting the integration of MRI into the workflow of AF ablation. Specifically, we examine findings from randomized trials and prospective studies that have investigated the predictive value of MRI-derived fibrosis quantification for procedural outcomes and arrhythmia recurrence. We aim to assess whether MRI can enhance the personalization of ablation strategies and predict treatment success. Challenges such as variability in imaging protocols, lack of standardization in fibrosis quantification, and limited large-scale validation are also addressed. This review provides a comprehensive overview of the current status and potential of MRI in the evolving field of AF ablation.

Catheter Ablation of Atrial Fibrillation: Technique and Future Perspectives

Atrial fibrillation is the most common sustained cardiac arrhythmia with a significant impact on quality of life in terms of symptoms and reduction of functional status. Also, it is associated with an increased risk of mortality, stroke, and peripheral embolism. Catheter ablation for atrial fibrillation has become a well-established treatment, improving arrhythmia outcomes without increasing the risk of serious adverse events compared to antiarrhythmic drug therapy. The field has undergone significant advancements in recent years, yet pulmonary vein isolation continues to be the cornerstone of any atrial fibrillation ablation procedure. The purpose of this review is to provide an overview of the current techniques, emerging technologies, and future directions.

Atrial fibrillation burden in clinical practice, research, and technology development: a clinical consensus statement of the European Society of Cardiology Council on Stroke and the European Heart Rhythm Association

Atrial fibrillation (AF) is one of the most common cardiac diseases and a complicating comorbidity for multiple associated diseases. Many clinical decisions regarding AF are currently based on the binary recognition of AF being present or absent with the categorical appraisal of AF as continued or intermittent. Assessment of AF in clinical trials is largely limited to the time to (first) detection of an AF episode. Substantial evidence shows, however, that the quantitative characteristic of intermittent AF has a relevant impact on symptoms, onset, and progression of AF and AF-related outcomes, including mortality. Atrial fibrillation burden is increasingly recognized as a suitable quantitative measure of intermittent AF that provides an estimate of risk attributable to AF, the efficacy of antiarrhythmic treatment, and the need for oral anticoagulation. However, the diversity of assessment methods and the lack of a consistent definition of AF burden prevent a wider clinical applicability and validation of actionable thresholds of AF burden. To facilitate progress in this field, the AF burden Consensus Group, an international and multidisciplinary collaboration, proposes a unified definition of AF burden. Based on current evidence and using a modified Delphi technique, consensus statements were attained on the four main areas describing AF burden: Defining the characteristics of AF burden, the recording principles, the clinical relevance in major clinical conditions, and implementation as an outcome in the clinic and in clinical trials. According to this consensus, AF burden is defined as the proportion of time spent in AF expressed as a percentage of the recording time, undertaken during a specified monitoring duration. A pivotal requirement for validity and comparability of AF burden assessment is a continuous or near-continuous duration of monitoring that needs to be reported together with the AF burden assessment. This proposed unified definition of AF burden applies independent of comorbidities and outcomes. However, the disease-specific actionable thresholds of AF burden need to be defined according to the targeted clinical outcomes in specific populations. The duration of the longest episode of uninterrupted AF expressed as a time duration should also be reported when appropriate. A unified definition of AF burden will allow for comparability of clinical study data to expand evidence and to establish actionable thresholds of AF burden in various clinical conditions. This proposed definition of AF burden will support risk evaluation and clinical treatment decisions in AF-related disease. It will further promote the development of clinical trials studying the clinical relevance of intermittent AF. A unified approach on AF burden will finally inform the technology development of heart rhythm monitoring towards validated technology to meet clinical needs.

Safety and feasibility of cardiac electrophysiology procedures in ambulatory surgery centers

BACKGROUND

Despite their improved safety, by and large, cardiac electrophysiology procedures including catheter ablation (CA), are presently performed in hospital outpatient departments.

OBJECTIVE

This large multicenter study investigated the safety and outcomes associated with various cardiac electrophysiology procedures performed at 6 ambulatory surgery centers (ASCs), primarily during the coronavirus disease 2019 pandemic under the Center for Medicare and Medicaid Services Hospitals Without Walls program.

METHODS

We retrospectively analyzed the outcomes from consecutive electrophysiology procedures performed in ASCs with same-day discharge, including transesophageal echocardiography, cardioversion, cardiac implantable electronic device (CIED) implantation, electrophysiology studies, and CA for atrial fibrillation (AF), atrial flutter (AFL)/supraventricular tachycardia, ventricular premature complexes (VPCs), and atrioventricular node.

RESULTS

Altogether, 4037 procedures were performed, including 779 transesophageal echocardiography/cardioversion procedures (19.3%), 1453 CIED implantation procedures (36.0%), 26 electrophysiology studies (0.6%), and 1779 CA procedures (44.1%) for AF (75.4%), AFL/supraventricular tachycardia (18.8%), VPC (4.7%), and atrioventricular node (1.1%). Overall, 80.2% of CA procedures were for left-sided atrial arrhythmias (AF/atypical AFL) requiring transseptal catheterization. Left-sided VPC ablation procedures (42.2%) were performed using a transseptal/retrograde approach. Adverse event rates were low, but comparable between CIED implantation and CA (0.76% vs 0.73%; P = .93), as were the incidences of urgent/unplanned postprocedure hospitalization (0.48% vs 0.45%; P = .89), respectively. Moreover, the adverse event rates in ASCs vs hospital outpatient departments did not differ for CIED (0.76% vs 0.65%; P = .71) or CA (0.73% vs 0.80%; P = .79).

CONCLUSION

The results from this large multicenter study suggest that ASCs represent a safe and effective setting to perform a variety of cardiac electrophysiology procedures including CA. These findings bear important implications for healthcare delivery and policy.

The Influence of Risk Factor Modification on Atrial Fibrillation Outcomes and Their Impact on the Success of Catheter Ablation

The global prevalence of atrial fibrillation (AF) is growing with a significant increase in AF burden. The pathophysiology of AF is complex and exhibits a strong relationship with modifiable lifestyle AF risk factors, such as physical inactivity, smoking, obesity, and alcohol consumption, as well as co-morbidities, such as hypertension, diabetes mellitus, and cardiovascular disease. Current evidence suggests that cardiac rehabilitation and lifestyle risk factor modification can potentially lower the overall AF burden. Additionally, AF ablation can be an effective treatment for a rhythm control strategy, but reducing AF recurrences post-catheter ablation is paramount. Thus, addressing these modifiable lifestyle risk factors and co-morbidities is critical, as the recent 2024 European Society of Cardiology AF guidance update highlights. A comprehensive approach to treating these risk factors is essential, especially given the rising prevalence of AF. This article provides a state-of-the-art update on the evidence of addressing AF-related risk factors and co-morbidities, particularly in patients undergoing AF ablation.

A Bayesian Interpretation of CABANA and Other Randomized Controlled Trials for Catheter Ablation in Patients With Atrial Fibrillation

BACKGROUND

Catheter ablation improves symptoms and quality of life in atrial fibrillation patients, but its effect on adverse cardiovascular outcomes and mortality remains uncertain. Bayesian analysis of randomized controlled trials offers a deeper understanding of treatment effects beyond conventional p-value thresholds.

METHODS

We conducted a post hoc Bayesian reanalysis of CABANA and four similar trials to estimate catheter ablation's effect on cardiovascular and survival outcomes. Using publicly available, trial-level data, we fitted ordinal Bayesian regression models to assess the impact of catheter ablation on the primary composite outcome-comprising all-cause mortality, stroke with disability, serious bleeding, and cardiac arrest-as well as mortality alone. We considered two sets of prior distributions: (1) a noninformative prior, where all effect sizes are equally probable and inference is primarily based on trial data, and (2) a treatment effect distribution derived from four trials using a random effects model.

RESULTS

In this analysis, refined probability distributions for treatment effects were obtained by integrating data from CABANA with diverse priors through Bayes' theorem, offering a novel, nuanced probabilistic understanding of the potential impact of ablation compared with medical therapy on cardiovascular outcomes and all-cause mortality. In contrast to CABANA's original frequentist estimates, which were inconclusive, Bayesian analyses indicated probabilities of 82.6% and 81.1% that ablation is superior in reducing adverse cardiovascular outcomes and mortality, respectively. Incorporating results from four other similar trials increased the probability of improved effects on mortality to 86.0%.

CONCLUSIONS

Bayesian analysis augmented the interpretation of previously inconclusive findings, suggesting a clinically relevant probability of benefit from catheter ablation compared to medical therapy in a broad population with atrial fibrillation.

Long-term outcomes of cryoballoon versus robotic magnetic navigation guided radiofrequency ablation in patients with persistent atrial fibrillation

This study aimed to evaluate the long-term efficacy and clinical outcomes of catheter ablation performed with cryoballoon (CRYO) in comparison with robotic magnetic navigation (RMN) in patients with persistent atrial fibrillation (PersAF). A total of 200 patients with symptomatic PersAF were prospectively enrolled and non-randomly assigned (1:1) to the CRYO or RMN guided-ablation group undergoing pulmonary vein isolation (PVI) and additional linear ablation if necessary and then followed up over 5 years. The primary endpoint was freedom from atrial tachyarrhythmias (ATs) recurrence following a 3-month blanking period after the initial procedure. The secondary endpoints consisted of all-cause and cardiovascular rehospitalizations, rates of electrical cardioversion (EC) and re-do ablation, new-onset neurological event, major bleeding event and the difference in CHA2DS2-VASc score at 5-year compared with baseline. After a median follow-up period of 60 months, 184 patients (93 in RMN, 91 in CRYO) completed the follow-up. Freedom from recurrent ATs was achieved in 44 out of 93 patients in the RMN group and 37 out of 91 patients in the CRYO group (47.3% vs. 40.7%, P = 0.32). There were no significant differences in the risk of all-cause and cardiovascular rehospitalizations, rates of EC and re-do ablation, new-onset neurological event, and major bleeding event at 5 years. Anticoagulation (OAC) discontinuation was relatively common after ablation, since 48.4% of patients with a CHA2DS2-VASc score ≥ 2 were not on OAC therapy. CRYO is comparable to RMN-guided ablation with respect to long-term freedom from ATs in patients with PersAF. Discontinuation of OAC after ablation is not rare even in patients at risk of stroke for continued OAC therapy.

Predicting outcomes in persistent atrial fibrillation: the impact of surface ECG f-wave amplitude following pulmonary vein isolation

BACKGROUND

Fibrillatory wave amplitude (fWA) on 12-lead ECG predicts the outcome of ablation in atrial fibrillation (AF). We hypothesized that changes in fWA following wide circumferential isolation of pulmonary veins (WPVI) in persistent AF (peAF) is a better predictor of ablation outcome compared to baseline fWA.

METHODS

Eighty-nine patients (sustained peAF 7 ± 7 months) underwent a first-time WPVI. Sixty-second ECG signals devoid of QRST waves were recorded at baseline and at the end of the WPVI (endWPVI). fWA for each ECG lead and mean fWA (meanfWA) across the 12-lead ECG were computed. Patients with recurrence after the index WPVI underwent a redo to ensure complete PVI. The primary endpoint was long-term AF freedom OFF antiarrhythmics drugs (AADs) after one or two WPVI (SUCCESS group). The FAILURE group was defined as AF recurrence post-redo.

RESULTS

Over a mean follow-up of 35 ± 10 months, freedom from AF OFF AADs was achieved in 61% (SUCCESS group), while 29% had AF recurrence after redo WPVI (FAILURE group). The SUCCESS group showed significantly higher fWA values in ECG leads V1, V4, and V5 at baseline (p < 0.05), as well as in leads III, aVL, aVF, and V4, and in meanfWA at endWPVI (p < 0.05) compared to the FAILURE group. A baseline mean fWA ≥ 0.044 mV or a decrease in mean fWA ≤ 11% following WPVI predicted long-term sinus rhythm restoration with a sensitivity of 81% and a specificity of 69% (p < 0.05).

CONCLUSION

Low fWA values and a significant reduction in fWA following WPVI are associated with a high risk of AF recurrence in patients with peAF.

The relationship between the 3D electroanatomical mapping parameters of the left atrial posterior wall and the recurrence of paroxysmal atrial fibrillation

Background

Pulmonary vein isolation (PVI) remains the cornerstone of catheter ablation in paroxysmal atrial fibrillation (PAF). However, the recurrence of AF after PVI needs further investigation. The left atrial posterior wall (LAPW) is embryologically related to the pulmonary vein and plays an important role in the initiation and maintenance of AF. This study aims to explore the relationship between the 3D electroanatomical mapping parameters of the LAPW and recurrence in patients with PAF.

Methods

A retrospective analysis was conducted on patients with PAF who underwent PVI. Both clinical and procedural characteristics from the enrolled subjects were collected before PVI. 3D electroanatomical mapping anatomical and electrical parameters were measured and calculated in the CARTO system. Intergroup comparisons and multivariate logistic regression analysis were performed to demonstrate the relationship between the parameters of LAPW and AF recurrence. A combined prediction model for AF recurrence was constructed in this study.

Results

A total of 120 patients were included in the final analysis. Among procedural characteristics, compared with Group 1 (no recurrence), there was a significantly larger posterior wall surface area (PWSA) (p = 0.013) and a percentage of very low-voltage area (PVLVA) (p < 0.001) in Group 2 (recurrence). Further analysis revealed that there was a significant difference between the two groups in terms of the distribution of VLVA (p = 0.026). Subsequently, in a multivariate logistic regression analysis, both PWSA and PVLVA were found to be independent risk factors for AF recurrence [odds ratio (OR): 1.457, 95% confidence interval (CI): 1.037-2.049, p = 0.030; OR: 1.059, 95% CI: 1.013-1.107, p = 0.012, respectively]. Finally, a prediction model that combined the PWSA with the PVLVA for AF recurrence was constructed to draw the receiver operating characteristic curve. The area under the curve of this model was 0.900 (0.827-0.973) (p < 0.001). The result, evaluated by using the Hosmer-Lemeshow goodness-of-fit test, showed that χ2 = 4.643 (p = 0.796).

Conclusions

This study demonstrates that both PWSA and PVLVA were independent risk factors for AF recurrence. Moreover, we proposed a model that combined the PWSA with the PVLVA to predict the recurrence of AF, which may provide an approach for screening patients with PAF who may require attention for the LAPW.

In-hospital safety of cryoballoon and radiofrequency ablation in patients with atrial fibrillation-German nationwide analysis of more than 300,000 procedures

BACKGROUND

Pulmonary vein isolation can be performed by radiofrequency (RF) or cryoballoon (CB) ablation. Guidelines do not favor one technique, and knowledge about complication rates is limited.

OBJECTIVE

We aimed to report the procedural safety of RF and CB ablation using data from a German nationwide real-world registry.

METHODS

By use of health records, all left atrial catheter ablation procedures with RF or CB ablation in Germany from 2013 to 2021 were analyzed. After adjustment for confounders, safety performance end points were compared.

RESULTS

From 2013 to 2021, RF ablation was performed in 184,616 patients and CB ablation in 118,984 patients with increasing trends in patient numbers and performing centers for both procedures. Patients with RF ablation had slightly more comorbidities. In-hospital mortality (RF, 0.08%; CB, 0.06%) and other investigated complications were rare. After adjustment for patient baseline characteristics, the risk of in-hospital mortality, serious bleeding, stroke, intracerebral bleeding, and acute kidney injury did not differ. The risk of pericardiocentesis (relative risk, 0.50; 95% confidence interval, 0.46-0.55; P < .001), vascular complication (0.36; 0.33-0.39; P < .001), and ventilation >48 hours (0.81; 0.66-0.99; P = .042) was significantly lower for CB ablation. Pericardiocentesis risk negatively correlated with annual procedure numbers per center with a faster learning curve for CB ablation (both P < .01).

CONCLUSION

RF and CB ablation had low overall procedural complication rates, with CB ablation showing a 50% reduced risk of pericardiocentesis. Centers with higher volume provided a better in-hospital safety with a faster learning curve for CB ablation.

The Role of Early Risk Factor Modification and Ablation in Atrial Fibrillation Substrate Remodeling Prevention

Atrial fibrillation (AF) is the most common sustained arrhythmia, contributing to significant morbidity and healthcare burden worldwide. This review evaluates the role of early risk factor modification and timely catheter ablation in preventing AF progression and improving patient outcomes. A comprehensive literature search was conducted using PubMed, MEDLINE, and Google Scholar, focusing on studies published after the ESC 2020 guidelines for the diagnosis and management of AF up to the release of the updated ESC 2024 guidelines for the management of AF. Keywords included "atrial fibrillation", "catheter ablation", "risk factor management", and "psychological stress". Relevant clinical trials, randomized controlled trials, systematic reviews, and meta-analyses were included, with particular emphasis on novel studies contributing to the ESC 2024 updated recommendations. Traditional risk factors such as obesity, hypertension, diabetes, sleep apnea, alcohol consumption, and physical exertion are well established in AF progression. Early evidence also suggests a role for psychological stress and mood disorders, including depression and post-traumatic stress disorder (PTSD), in increasing AF susceptibility. Psychological stress and mood disorders are linked to AF primarily through behavioral changes such as poor medication adherence, unhealthy lifestyle choices, and increased substance use. Recent guidelines recommend early catheter ablation in selected patients to reduce AF burden, prevent atrial remodeling, and improve quality of life, particularly in those resistant to antiarrhythmic drugs or individuals with AF-induced cardiomyopathy. Furthermore, we highlight the importance of a patient-centered, multidisciplinary approach, integrating electrophysiologists, cardiologists, and primary care providers with structured risk factor interventions and shared decision-making. Despite these advances, gaps remain in defining optimal timing, patient selection, and long-term benefits of catheter ablation in persistent AF, necessitating the need for further research. By integrating early intervention, personalized treatment strategies, and collaborative care models, we may usher in a paradigm shift in AF management, improving long-term cardiovascular outcomes and patient quality of life.

[European Society of Cardiology (ESC) guidelines on atrial fibrillation 2024 : What is new and what is important?]

The 2024 guidelines of the European Society of Cardiology (ESC) on atrial fibrillation (AF) present current and comprehensive recommendations for the diagnosis, prevention and treatment of AF. They are based on the AF-CARE treatment pathway, which includes modification of cardiovascular risk factors, stroke prevention, symptom management and continuous re-evaluation. Accordingly, all patients with newly diagnosed AF should undergo transthoracic echocardiography. Sodium-glucose cotransporter 2 (SGLT2) inhibitors are recommended for the treatment of heart failure across all clinical and echocardiographic levels of left ventricular ejection fraction (LVEF). The CHA2DS2-VASc score has been simplified to the CHA2DS2-VA score for the risk assessment of thromboembolism. For rate or rhythm control pharmacotherapy with beta-blockers, digitalis, amiodarone and flecainide are still the most important drugs. Pulmonary vein isolation is now also recommended as a first-line treatment for paroxysmal AF. Re-evaluation of risk factors and treatment of comorbidities is also emphasized. Overall the guidelines represent a further development and update based on recent studies. They remain practical and provide clear and detailed recommendations for action that are globally recognized in the clinical practice.

High-frequency low-tidal volume ventilation improves procedural and long-term clinical outcomes in persistent atrial fibrillation ablation: Prospective multicenter registry

BACKGROUND

High-frequency, low-tidal volume (HFLTV) ventilation increases the efficacy and efficiency of radiofrequency catheter ablation (RFCA) of paroxysmal atrial fibrillation. Whether those benefits can be extrapolated to RFCA of persistent atrial fibrillation (PeAF) is undetermined.

OBJECTIVE

The purpose of this study was to evaluate whether using HFLTV ventilation during RFCA in patients with PeAF is associated with improved procedural and long-term clinical outcomes compared to standard ventilation (SV).

METHODS

In this prospective multicenter registry (REAL-AF), patients who had undergone pulmonary vein isolation (PVI) + posterior wall isolation (PWI) for PeAF using either HFLTV ventilation or SV were included. The primary efficacy outcome was freedom from all-atrial arrhythmias at 12 months. Secondary outcomes included procedural and long-term clinical outcomes and complications.

RESULTS

A total of 210 patients were included (HFLTV=95 vs. SV=115) in the analysis. There were no differences in baseline characteristics between the groups. Procedural time (80 [66-103.5] minutes vs 110 [85-141] minutes; P <.001), total radiofrequency (RF) time (18.73 [13.93-26.53] minutes vs 26.15 [20.30-35.25] minutes; P <.001), and pulmonary vein RF time (11.35 [8.78-16.69] minutes vs 18 [13.74-24.14] minutes; P <.001) were significantly shorter using HFLTV ventilation compared with SV. Freedom from all-atrial arrhythmias was significantly higher with HFLTV ventilation compared with SV (82.1% vs 68.7%; hazard ratio 0.41; 95% confidence interval [0.21-0.82]; P = .012), indicating a 43% relative risk reduction and a 13.4% absolute risk reduction in all-atrial arrhythmia recurrence. There was no difference in long-term procedure-related complications between the groups (HFLTV 1.1% vs SV 0%, P = .270).

CONCLUSION

In patients undergoing RFCA with PVI + PWI for PeAF, the use of HFLTV ventilation was associated with higher freedom from all-atrial arrhythmias at 12-month follow-up, with significantly shorter procedural and RF times compared to SV, while reporting a similar safety profile.

Atrial Fibrillation: A Review

Importance

In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.

Observations

Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

Conclusions and Relevance

AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

Coronary artery injury in pulsed field ablation

PURPOSE OF REVIEW

Although pulsed field ablation (PFA) has emerged as an innovative nonthermal catheter ablation modality, recent reports raise concerns about its potential impact on nearby coronary arteries. This review provides a comprehensive overview of the current understanding and future directions regarding the effects of PFA on or near coronary arteries.

RECENT FINDINGS

Clinical studies have demonstrated the risks of acute transient vasospasm after delivery of PFA, especially with ablation of structures in proximity to the coronary arteries, such as the cavotricuspid and mitral isthmuses. The clinical incidence has been reported to be approximately 0.14%, according to the largest multicenter registry. Nitroglycerin pretreatment has been demonstrated to mitigate vasospastic events. However, early preclinical models indicate that chronic neointimal hyperplasia, tunica media fibrosis and mild coronary artery narrowing may occur, suggesting long-term coronary injury after delivering PFA near coronary arteries.

SUMMARY

Despite reducing collateral tissue damage compared with thermal methods, PFA near coronary arteries may require careful procedural planning and proactive use of nitroglycerin to reduce coronary vasospasm. Further research is essential to elucidate the mechanisms underlying PFA-induced coronary spasm, optimize catheter design and placement, and assess the long-term coronary health implications.

lncRNA-056298 Regulates GAP43 and Promotes Cardiac Intrinsic Autonomic Nerve Remodelling in a Canine Model of Atrial Fibrillation Induction after Ganglionated Plexus Ablation

BACKGROUND

Cardiac intrinsic autonomic nerve remodelling has been reported to play an important role in the recurrence of atrial fibrillation after radiofrequency ablation, which significantly affects the long-term efficacy of this procedure. lncRNAs have been shown to interact in the pathological processes underlying heart diseases. However, the roles and mechanisms of lncRNAs in cardiac intrinsic autonomic nerve remodelling during atrial fibrillation reduction after ganglionated plexus ablation remain unknown.

OBJECTIVE

The aim of this study was to investigate the mechanism by which lncRNA- 056298 modulates GAP43 to affect cardiac intrinsic autonomic nerve remodelling and facilitate the induction of atrial fibrillation after ganglionated plexus ablation.

METHODS

A canine model of right atrial ganglionated plexus ablation was established. The atrial electrophysiological characteristics and neural markers were detected before and after 6 months of ganglionated plexus ablation. High-throughput sequencing was used to screen differentially expressed lncRNAs in target atrial tissues, and lncRNA- 056298 was selected to further explore its effects and mechanisms on cardiac intrinsic autonomic nerve remodelling.

RESULTS

The induction rate of atrial fibrillation increased in dogs after ganglionated plexus ablation. Overexpression of lncRNA-056298 by lentivirus can shorten the atrial effective refractory period and increase the induction of atrial fibrillation. lncRNA- 056298 promoted cardiac intrinsic autonomic nerve remodelling via endogenous competition with cfa-miR-185 to induce transcription of its target gene GAP43, thereby affecting the induction of atrial fibrillation.

CONCLUSION

lncRNA-056298 regulates GAP43 by sponging miR-185, which affects cardiac intrinsic autonomic nerve remodelling and mediates atrial fibrillation induction after ganglionated plexus ablation.

Maintenance of Sinus Rhythm Is Associated With Lower Incidence of Stroke in Patients With Drug-Refractory Atrial Fibrillation

BACKGROUND AND OBJECTIVES

Recent studies have demonstrated that early rhythm control for first-line treatment of atrial fibrillation (AF) improved cardiovascular outcomes. However, there is limited data regarding the long-term outcome of patients who failed antiarrhythmic drugs and who refuse radiofrequency catheter ablation (RFCA).

METHODS

Patients with AF who were refractory to antiarrhythmic drugs and had refused further rhythm control attempts via RFCA were retrospectively identified and propensity-score (PS) matched with those who had been treated with RFCA. The primary outcome of interest was all-cause mortality or ischemic stroke.

RESULTS

A total of 169 patients who refused rhythm control with RFCA and PS matched 169 patients who had been treated with RFCA were included for analysis. During a mean follow-up of 4.3 (2.3;6.9) years, maintenance of sinus rhythm was more achieved in RFCA group (7 [4.1%] in Refuse group vs. 133 [78.7%] in RFCA group, p < 0.001). The incidence of ischemic stroke was significantly higher in patients who refused RFCA compared with patients who underwent RFCA (2.96 per 100 person-years in the Refused group vs. 0.74 per 100 person-years in the RFCA group, log-rank p < 0.001), but all-cause mortality was not significantly different (log-rank p = 0.8). Refusal of attempted rhythm control via RFCA was an independent risk factor for ischemic stroke on multivariate Cox analysis (hazard ratio [HR] 3.2; 95% confidence interval [CI] 1.2-8.53, p = 0.02).

CONCLUSION

In patients with antiarrhythmic drug-refractory AF, the risk of stroke was significantly higher in patients who refused rhythm control via RFCA compared with that of those treated with RFCA.

Usefulness of empiric superior vena cava isolation in paroxysmal atrial fibrillation ablation: a meta-analysis of randomized clinical trials

BACKGROUND

The long-term success rate of pulmonary vein isolation (PVI) is suboptimal due to the presence of non-pulmonary vein (PV) foci that can trigger atrial fibrillation (AF) in up to 11%. Among non-PV triggers, the superior vena cava (SVC) is a major site of origin of ectopic beats initiating AF.

OBJECTIVE

To compare data from randomized controlled trials (RCTs) assessing PVI + empiric SVC isolation (SVCI) versus PVI alone in terms of AF recurrence, procedure-related complications, and fluoroscopic and procedural times.

METHODS

A search of online scientific libraries (from inception to April 1, 2024) was performed. Four RCTs were considered eligible for the meta-analysis totaling 600 patients of whom 287 receiving PVI + SVCI and 313 receiving PVI alone.

RESULTS

In the overall population, SVCI + PVI was associated with a non-significant reduction of AF recurrence at follow-up (0.66 [0.43;1.00], p = 0.05, I2 0%). In patients with paroxysmal AF (PAF), a significant reduction of AF recurrence was related to SVCI + PVI (11.7%) as compared to PVI alone (19.9%) (0.54 [0.32;0.92], p = 0.02, I2 0%). No statistical differences were found among the groups in terms of fluoroscopic (3.31 [- 0.8;7.41], p = 0.11, I2 = 91%), procedural times (5.69 [- 9.78;21.16], p = 0.47, I2 = 81%), and complications (1.06 [0.33;3.44], p = 0.92, I2 = 0%).

CONCLUSION

The addition of SVCI to PVI in patients in PAF is associated with a significant lower rate of AF recurrence at follow-up, without increasing complication rates and procedural and fluoroscopy times.

A novel focal lattice-tip catheter toggling between pulsed field energy and radiofrequency for atrial arrhythmia ablation: Results from a real-world, multicenter registry

BACKGROUND

A novel focal lattice-tip catheter allowing the delivery of either pulsed field (PF) or radiofrequency (RF) energy has recently received regulatory approval. The technology features a proprietary 3-dimensional electroanatomic mapping system.

OBJECTIVE

We describe the first real-world and multicenter experience.

METHODS

Consecutive AF patients undergoing first-time or redo atrial tachyarrhythmia ablation with the Affera system were prospectively enrolled at 3 different centers. PF was the only energy source allowed when ablating the posterior left atrium; anterior applications were performed with either RF (PF/RF strategy) or PF (PF/PF strategy) on the basis of the operator's preference. The primary efficacy end point included acute electrical isolation of pulmonary veins and posterior wall or bidirectional block in case of linear lesions.

RESULTS

The study included 130 patients (mean age, 67 ± 10 years; 63.8% [n = 83] male; 61.5% [n = 80] nonparoxysmal AF; 55.4% first-time AF ablation). First-time pulmonary vein isolation was performed in 72 patients: RF/PF in 13 (18.1%) patients and PF/PF in the remaining 59 (81.9%); first-pass isolation for pulmonary vein and posterior wall was achieved in 100% of cases. A total of 289 ablation lines were performed (roof line, 91 patients; inferior line, 83 patients; anterior mitral line, 32 patients; posterior mitral line, 45 patients; cavotricuspid isthmus line, 38 patients). First-pass isolation and primary efficacy end point were 96.2% (roof line, 100%; inferior line, 100%; anterior mitral line, 96.9%; posterior mitral line, 84.4%; cavotricuspid isthmus, 92.1%) and 100%, respectively. We had 2 (1.5%) major complications: 1 ST-segment elevation at the inferolateral leads requiring intracoronary administration of nitrate and 1 complete atrioventricular block.

CONCLUSION

Catheter ablation with a novel 9-mm lattice-tip catheter confirmed high efficacy and safety in a real-world scenario.

Long-term outcomes of catheter ablation compared with medical therapy in atrial fibrillation

BACKGROUND

The long-term effects of catheter ablation (CA) compared with medical therapy on cardiovascular outcomes for atrial fibrillation (AF) remain undetermined.

OBJECTIVE

Using a population-based cohort, we sought to determine what the association between CA and medical therapy was on these outcomes.

METHODS

By use of Alberta administrative data, patients with AF as the primary diagnosis during hospitalization, emergency department visit, or physician visit were included between October 1, 2008, and March 31, 2018. Based on therapy received, patients were assigned to categories of CA, rate control, or rhythm control with medication. The association of treatment with the primary composite outcome of all-cause death, hospitalization for heart failure, or stroke was examined after adjustment for age, sex, comorbidities, and baseline medications.

RESULTS

Of 39,966 treated AF patients, 2077 (5.2%), 29,467 (73.7%), and 8422 (21.1%) were treated with CA, rate control, and rhythm control with medication, respectively. Patients in the CA group had a lower incidence of the primary outcome (4.0/100 person-years) compared with the rate control group (8.7/100 person-years) or the rhythm control with medication group (6.8/100 person-years) during a median follow-up of 6.3 years. In multivariable analysis, compared with CA, both rate control (hazard ratio, 1.28; 95% confidence interval, 1.09-1.50) and rhythm control with medication (hazard ratio, 1.21; 95% confidence interval, 1.03-1.43) were associated with a higher risk of the primary outcome.

CONCLUSION

In this cohort study, patients who received CA demonstrated a reduction in the risk of long-term adverse cardiovascular outcomes compared with medical therapy in patients with AF, providing some data to indicate the effects of CA in the long-term.

Spotlight on the 2024 ESC/EACTS management of atrial fibrillation guidelines: 10 novel key aspects

Atrial fibrillation (AF) remains the most common cardiac arrhythmia worldwide and is associated with significant morbidity and mortality. The European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) have recently released the 2024 guidelines for the management of AF. This review highlights 10 novel aspects of the ESC/EACTS 2024 Guidelines. The AF-CARE framework is introduced, a structural approach that aims to improve patient care and outcomes, comprising of four pillars: [C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, and [E] Evaluation and dynamic reassessment. Additionally, graphical patient pathways are provided to enhance clinical application. A significant shift is the new emphasis on comorbidity and risk factor control to reduce AF recurrence and progression. Individualized assessment of risk is suggested to guide the initiation of oral anticoagulation to prevent thromboembolism. New guidance is provided for anticoagulation in patients with trigger-induced and device-detected sub-clinical AF, ischaemic stroke despite anticoagulation, and the indications for percutaneous/surgical left atrial appendage exclusion. AF ablation is a first-line rhythm control option for suitable patients with paroxysmal AF, and in specific patients, rhythm control can improve prognosis. The AF duration threshold for early cardioversion was reduced from 48 to 24 h, and a wait-and-see approach for spontaneous conversion is advised to promote patient safety. Lastly, strong emphasis is given to optimize the implementation of AF guidelines in daily practice using a patient-centred, multidisciplinary and shared-care approach, with the simultaneous launch of a patient version of the guideline.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Lesion monitoring parameters as predictors of atrial arrhythmia recurrence after catheter ablation in persistent AF: A DECAAF II sub-analysis

BACKGROUND

The formation of transmural lesions is necessary for the ablation of persistent atrial fibrillation (prAF). Ablation index (AI) and generator impedance drop (ID) predict lesion size but their correlation with long-term outcomes in prAF is not known. Furthermore, we proposed a new parameter, efficacy ratio (ER) calculated as ID/AI, to gain indirect insight into the role of factors affecting ID but not considered by AI.

METHODS

We included ablations performed during the DECAAF II trial if they had uploaded lesion-by-lesion summary data and were performed with radiofrequency catheters on the CARTO system. Average patient-level parameters were calculated from all generated Vizitags.

RESULTS

A total of 427 ablations met inclusion criteria and 166 utilized AI. Analyzed as continuous variables, ID and ER predicted long-term arrhythmia-free survival but not AI. The ideal cut-off for ID was ID ≥ 10.4 ohms and had a C-index of 0.55. It predicted reduced risk of arrhythmia: hazard ratio 0.56 [0.36-0.88], p = .013 (arrhythmia-free survival of 67% vs. 52%). Similarly, an ER of 1.7 ohms/100AI had a C-index of 0.58 and predicted reduced arrhythmia recurrence: HR 0.39 [0.22-0.69], p = .001. ER < 1.7 ohms/100AI was related to just 32% arrhythmia-free survival. ER improved prognostication as compared to ID alone and identified a subset of low ID patients with even worse outcomes.

CONCLUSION

Average ID was predictive of improved outcomes following ablation of prAF. The ratio of ID/AI (ER) was postulated as a measure to summarize the overall impact of factors not considered in the AI formula and provided improved prognostication.

Discordant Treatment Goals for Patients With Atrial Fibrillation and Clinical Trials Metrics

BACKGROUND

Most clinical trials define successful atrial fibrillation (AF) treatment as no AF episodes longer than 30 seconds. Yet, there has been minimal study of how patients define successful treatment and whether their perspectives align with trial outcomes.

OBJECTIVES

Survey patients with AF to identify: 1) what aspect of AF is most important to address (frequency, duration, or severity of AF episodes); 2) what AF burden would be considered acceptable to consider treatment successful; and 3) to establish patient preferences for successful treatment thresholds for a validated patient-reported outcome (PRO) score.

METHODS

We surveyed patients receiving active care for AF at a single tertiary care center modeled after the Toronto AF Severity Scale (AFSS). The survey consisted of current and "successful treatment" AF frequency, burden, and symptom domains; and baseline socioeconomic information.

RESULTS

Of 7,000 invitations, 852 individuals completed the survey (12% response) with a mean age of 65 ± 13 years, 36.5% were female, and they had a mean CHA2DS2-VAsc score of 2.9 ± 1.9. Overall, 114 (13%) selected a decrease in AF episode duration as their top treatment priority, 505 (59%) episode frequency, and 230 (27%) episode severity. Overall, 207 (24%) patients would only consider a treatment successful if they never had AF again, whereas 645 (76%) patients considered success to be fewer AF episodes. A total of 341 (40%) patients would only consider a treatment successful if AF episodes lasted less than a few minutes, whereas 509 (60%) patients would accept AF episodes lasting >30 minutes. An AFSS symptom score ≤5 was considered a good outcome by 80% of respondents.

CONCLUSIONS

Patients prioritize decreased AF frequency over improvements in severity or duration, and an AFSS ≤5 would be a reasonable outcome of AF treatment. Most patients would consider treatment successful if they had more than 1 AF episode lasting longer than 30 seconds. Future clinical trial design should consider patients' perspectives when designing outcomes.

Effect of catheter ablation versus medical therapy on mental health and quality of life in patients with atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The association between atrial fibrillation (AF) and mental health is well-documented, but the relative benefits of catheter ablation versus medical therapy on mental health and quality of life are not clearly understood. This study assesses the impact of these interventions on AF patients' mental health and quality of life.

METHODS

Through a systematic review of PubMed, Scopus, and Cochrane databases, randomized controlled trials (RCTs) comparing catheter ablation to medical therapy for AF were analyzed. The study focused on a range of outcomes, particularly mental health and quality of life, measured by tools including the SF-36 mental component, HADS, SF-36 physical component, and AFEQT scores, among others. Analyses were stratified by AF type (paroxysmal versus persistent) and synthesized using random or fixed-effects models to calculate mean differences (MDs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs).

RESULTS

From 24 RCTs totaling 6,353 patients (51.4% receiving catheter ablation, 71.1% male, average age 59), catheter ablation was found to significantly improve mental health (SMD 0.34; 95% CI 0.05-0.63; p = 0.02) and quality of life as indicated by PCS SF-36 (MD 2.64; 95% CI 1.06-4.26; p < 0.01) and AFEQT scores (MD 6.24; 95% CI 4.43-8.05; p < 0.01), with no significant difference in outcomes between AF subtypes.

CONCLUSION

Catheter ablation offers significant improvements in mental health and quality of life over medical therapy for AF patients, demonstrating its efficacy across different types of AF.

Quantifying the frequency modulation in electrograms during simulated atrial fibrillation in 2D domains

Atrial fibrillation (AF) affects millions of people in the world, causing increased morbidity and mortality. Treatment involves antiarrhythmic drugs and catheter ablation, showing high success for paroxysmal AF but challenges for persistent AF. Experimental evidence suggests reentrant waves and rotors contribute to AF substrates. Ablation procedures rely on electroanatomical maps and electrogram (EGM) signals; however, current methods used in clinical practice lack consideration for time-frequency varying EGM components. The fractional Fourier transform (FrFT) can be adopted to capture time-varying frequency components, thereby enhancing the comprehension of arrhythmogenic substrates during AF for improved ablation strategies. To this end, a FrFT-based algorithm is developed to characterize non-stationary components in EGM signals from simulated AF episodes. The proposed algorithm comprises a pre-processing step to enhance the coarser features of the EGM waveform, a windowing process for dynamic assessment of the EGM, and a FrFT order optimization stage that seeks compact signal representations in fractional Fourier domains. The resulting order is related to the rate of frequency change in the signal, making it a useful indicator for frequency-modulated components. The FrFT-based algorithm is implemented on EGM signals from AF simulations in 2D domains representing a region of the atrial tissue. Consequently, the computed optimum FrFT orders are used to build maps that are spatially correlated to the underlying propagation dynamics of the simulated AF episode. The results evince that the extreme values in the optimum orders map pinpoint the localization of fibrillatory mechanisms, generating EGM activation waveforms with varying frequency content over time.

Validation Strategy for Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation in Long-Term Maintaining Sinus Rhythm: A Randomized Controlled Study

Background: Data comparing the outcomes of loose versus rigorous validation strategies for pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (PAF) are limited. We aimed to prospectively assess the effectiveness of loose versus rigorous validation for PVI in patients with PAF with a maintained sinus rhythm. Methods: Patients (n = 117) with PAF were randomized to receive either loose validation (n = 59) or rigorous validation (n = 58) after PVI. The presence of dormant conduction in loose validation was assessed only by adenosine administration followed by isoproterenol infusion. The complete absence of pulmonary vein (PV) potentials in rigorous validation was confirmed by the combination of the Lasso catheter with isoproterenol plus adenosine. Dormant conduction, revealed by validation after PVI, was ablated until all reconnections were eliminated. Results: The procedure time in the rigorous validation group was greater than that in the loose validation group (161.3 ± 52.7 min vs. 142.5 ± 37.6 min, p=0.03, respectively). After successful PVI, the detection of dormant PV reconnections in the rigorous validation group was significantly greater than that in the loose validation group (69.0% vs. 37.3%, p=0.001). However, after reisolation of the sites of dormant PV conduction, the postablation recurrence rates in 1.3 years were similar between the groups (79.2% vs. 83.6%, p=0.67). Conclusion: Rigorous validation can reveal dormant conduction in more than two-thirds of patients with PAF undergoing PVI. However, rigorous validation and additional ablation of the resulting connections do not improve long-term outcomes when a protocol that includes electrophysiological confirmation and pharmacological validation is used.

Catheter-based ablation to improve outcomes in patients with atrial fibrillation and heart failure with preserved ejection fraction: Rationale and design of the CABA-HFPEF-DZHK27 trial

AIMS

Atrial fibrillation (AF) is common in heart failure (HF) and negatively impacts outcomes. The role of ablation-based rhythm control in patients with AF and HF with preserved (HFpEF) or mildly reduced ejection fraction (HFmrEF) is not known. The CABA-HFPEF-DZHK27 (CAtheter-Based Ablation of atrial fibrillation compared to conventional treatment in patients with Heart Failure with Preserved Ejection Fraction) trial will determine whether early catheter ablation for AF can prevent adverse cardiovascular outcomes in patients with HFpEF or HFmrEF.

METHODS

CABA-HFPEF-DZHK27 (NCT05508256) is an investigator-initiated, prospective, randomized, open, interventional multicentre strategy trial with blinded outcome assessment. Approximately 1548 patients with paroxysmal or persistent AF diagnosed within 24 months prior to enrolment and HFpEF or HFmrEF will be randomized to early catheter ablation within 4 weeks after randomization or to usual care. All patients receive anticoagulation, rate control, and HF management according to current guideline recommendations. Usual care can include rhythm control in symptomatic patients. Patients will be followed until the end of the trial for the primary outcome, a composite of cardiovascular death, stroke, and total unplanned hospitalizations for HF or acute coronary syndrome. The safety outcome comprises complications of catheter ablation and death. The trial is powered for a rate ratio of 0.75 (two-sided alpha = 0.05, 1-beta = 0.8).

CONCLUSION

CABA-HFPEF-DZHK27 will define the role of systematic and early catheter ablation in patients with AF and HFpEF or HFmrEF.

Pulsed Field Ablation of Atrial Fibrillation: A Novel Technology for Safer and Faster Ablation

Atrial fibrillation (AF), the most common arrhythmia, is associated with increased morbidity, mortality, and healthcare costs. Evidence indicates that rhythm control offers superior cardiovascular outcomes compared to rate control, especially when initiated early after the diagnosis of AF. Catheter ablation remains the single best therapy for AF; however, it is not free from severe complications and only a small percentage of AF patients in the Western world ultimately receive ablation. Ensuring that AF ablation is safe, effective, and efficient is essential to make it accessible to all patients. With the limitations of traditional thermal ablative energies, pulsed field ablation (PFA) has emerged as a novel non-thermal energy source. PFA targets irreversible electroporation of cardiomyocytes to achieve cell death without damaging adjacent structures. Through its capability to create rapid, selective lesions in myocytes, PFA presents a promising alternative, offering enhanced safety, reduced procedural times, and comparable, if not superior, efficacy to thermal energies. The surge of new evidence makes it challenging to stay updated and understand the possibilities and challenges of PFA. This review aims to summarize the most significant advantages of PFA and how this has translated to the clinical arena, where four different catheters have received CE-market approval for AF ablation. Further research is needed to explore whether adding new ablation targets, previously avoided due to risks associated with thermal energies, to pulmonary vein isolation can improve the efficacy of AF ablation. It also remains to see whether a class effect exists or if different PFA technologies can yield distinct clinical outcomes given that the optimization of PFA parameters has largely been empirical.

Catheter ablation for atrial fibrillation in patients with prior left atrial appendage occlusion device

BACKGROUND

The safety and efficacy of CA for AF and left-sided atrial arrhythmias (AA) in patients with left atrial appendage occlusion (LAAO) devices are lacking.

METHODS

This is a single-center retrospective registry that included all patients with prior LAAO who underwent catheter ablation for AF or left-sided atrial arrhythmia from January 2020-January 2023. The primary outcomes were procedure-related complications, device-related complications, AA recurrence, and stroke.

RESULTS

A total of 30 patients with prior LAAO were included in the analysis (mean age 75.1 ± 7.1 years old, 50% male, mean CHA2DS2-VASc score 4 ± 1.6, 46.7% paroxysmal AF, 73.3% had prior AF ablation, mean time to ablation 475 ± 365 days). 93.3% (n = 28) and 6.6% (n = 2) patients had ablation for AF (46.7% paroxysmal, 36.7% persistent, 10% long-standing persistent) and left-sided atrial tachycardia, respectively. 16.7% (n = 5) patients underwent ablation along the left atrial appendage ostium, and 3.3% (n = 1) underwent Vein of Marshall alcohol ablation. There were 3 (10%) peri-procedural complications (1 access hematoma and two pericardial effusions requiring intervention-none related to left atrial appendage ostium or alcohol ablation). During the mean follow-up of 440 ± 379 days, 40% (n = 12) patients had AA recurrence (91.6% AF, 8.3% atrial tachycardia), of which five patients needed repeat ablation, and two patients were readmitted for heart failure. There was no stroke or any device-related complications, including new peri-device leaks or device-related thrombosis in patients who had follow-up imaging studies (n = 11, 36.7%).

CONCLUSION

Catheter ablation for AF (including VoM alcohol ablation) in patients with prior LAAO devices is feasible and safe with favorable outcomes.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Mechanistic Insights From Trials of Atrial Fibrillation Ablation: Charting a Course for the Future

Success rates for catheter ablation of atrial fibrillation (AF), particularly persistent AF, remain suboptimal. Pulmonary vein isolation has been the cornerstone for catheter ablation of AF for over a decade. While successful for most patients, pulmonary vein isolation alone is still insufficient for a substantial minority. Frustratingly, multiple clinical trials testing a diverse array of additional ablation approaches have led to mixed results, with no current strategy that improves AF outcomes beyond pulmonary vein isolation in all patients. Nevertheless, this large collection of data could be used to extract important insights regarding AF mechanisms and the diversity of the AF syndrome. Mechanistically, the general model for arrhythmogenesis prompts the need for tools to individually assess triggers, drivers, and substrates in individual patients. A key goal is to identify those who will not respond to pulmonary vein isolation, with novel approaches to phenotyping that may include mapping to identify alternative drivers or critical substrates. This, in turn, can allow for the implementation of phenotype-based, targeted approaches that may categorize patients into groups who would or would not be likely to respond to catheter ablation, pharmacological therapy, and risk factor modification programs. One major goal is to predict individuals in whom additional empirical ablation, while feasible, may be futile or lead to atrial scarring or proarrhythmia. This work attempts to integrate key lessons from successful and failed trials of catheter ablation, as well as models of AF, to suggest future paradigms for AF treatment.

Incidence of All-Cause, Cardiovascular, and Atrial Fibrillation-Related Hospitalizations: Focus on Antiarrhythmic Drugs

Background

Atrial fibrillation (AF) is associated with an increased risk of hospital admission, but few data on reasons for hospitalization and on the role of anti-arrhythmic drugs are available.

Objectives

The purpose of this study was to investigate the incidence rate and factors associated with all-cause, cardiovascular, and AF-related hospitalizations.

Methods

Prospective ongoing ATHERO-AF (Atherosclerosis in Atrial Fibrillation) cohort study enrolling AF patients on oral anticoagulants. Primary end points were all-cause, cardiovascular, and AF-related hospitalization, the latter defined as AF recurrences for paroxysmal AF and high-rate symptomatic AF episodes for persistent/permanent AF patients.

Results

2,782 patients were included (43.5% female; mean age was 74.6 ± 9.1 years). During a mean follow-up of 31 ± 26.8 months, 1,205 (12.1%/year) all-cause, 533 cardiac (5.7%/year), and 180 (2.0%/year) AF-related hospitalizations occurred. Predictors of AF-related hospitalizations were the use of flecainide/propafenone in both paroxysmal and persistent/permanent AF patients (HR: 1.861; 95% CI: 1.116 to 3.101 and 1.947; 95% CI: 1.069 to 3.548, respectively). Amiodarone (HR: 3.012; 95% CI: 1.835-4.943), verapamil/diltiazem (HR: 2.067; 95% CI: 1.117-3.825), and cancer (HR: 1.802; 95% CI: 1.057-3.070) but not beta-blockers and digoxin were associated with an increased risk of AF-related hospitalizations in persistent/permanent AF patients.

Conclusions

Elderly AF patients frequently undergo hospitalizations for both cardiovascular and noncardiovascular causes. The use of anti-arrhythmic drugs was associated with an increased risk of AF-related hospitalization suggesting a scarce effect of these drugs in preventing AF episodes. Therefore, their use should be carefully considered and reserved for symptomatic patients with frequent AF recurrences.

Adjunctive left atrial posterior wall isolation for atrial fibrillation: An updated systematic review and meta-analysis

OBJECTIVE

Posterior left atrial wall isolation (PWI) plus traditional pulmonary vein isolation (PVI) has been proposed as a promising intervention to decrease atrial fibrillation (AF) recurrence. We aim to investigate the efficacy and safety of adding PWI to the traditional PVI in patients with AF.

METHODS

A systematic review and meta-analysis was conducted using synthesizing randomized controlled trials (RCTs) retrieved by systematically searching PubMed, Web of Science, SCOPUS, EMBASE, and Cochrane through June 14, 2023. We used Stata version 17 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023446227).

RESULTS

We included 11 RCTs with a total number of 1534 patients. Combined ablation with PWI + PVI was not associated with any significant difference over PVI only regarding the recurrence of clinical AF (RR: 0.86 with 95% CI [0.70-1.06]), all atrial arrhythmia (RR: 0.93 with 95% CI [0.82-1.07]), nonatrial fibrillation arrhythmia (RR: 1.22 with 95% CI [0.97-1.53]), early AF (RR: 0.89 with 95% CI [0.62-1.27]), and antiarrhythmic drugs at discharge (RR: 0.83 with 95% CI [0.67-1.04]). However, it was associated with increased total ablation duration (minutes) (MD: 12.58 with 95% CI [6.80-18.37]) and total procedure duration (minutes) (MD: 16.77 with 95% CI [9.63-23.91]), without any significant difference regarding adverse events (RR: 1.05 with 95% CI [0.63-1.74]).

CONCLUSION

While the pooled data from PWI + PVI using point-by-point radiofrequency did not suggest a benefit in the recurrence of various atrial arrhythmias compared to PVI alone, PWI+PVI using direct posterior wall ablation, especially with cryoballoon, demonstrated a significant reduction in recurrence of AF/atrial arrhythmias. Also, PWI + PVI significantly increased the ablation and total procedure durations.

Pulmonary vein isolation using pulsed field ablation vs. high-power short-duration radiofrequency ablation in paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up (PRIORI study)

AIMS

Pulsed field ablation (PFA) is a novel, non-thermal, cardiac tissue-selective ablation modality. To date, radiofrequency (RF)-guided high-power short-duration (HPSD) ablation represents the gold standard besides cryo-ablation for pulmonary vein isolation (PVI). This single-centre, retrospective study investigated the efficacy of PFA-PVI vs. HPSD-RF PVI in terms of single-procedure arrhythmia-free outcome and safety in a real-world setting.

METHODS AND RESULTS

Consecutive, paroxysmal atrial fibrillation (AF) patients who underwent PVI using PFA or HPSD-RF were enrolled. In group PFA, PVI was performed using a pentaspline PFA catheter. The ablation procedure in group HPSD-RF was performed with RF energy (45 W, ablation index). A total of 410 patients (group PFA, 201; group HPSD-RF, 209) were included. There was no difference between both groups regarding age, gender, and CHA2DS2-VASc score. The procedure time was significantly shorter in group PFA [61 (44-103) vs. 125 (105-143) min; P < 0.001]; fluoroscopy time and dose area product were significantly higher in group PFA [16 (13-20) vs. 4 (2-5) min; P < 0.01 and 412 (270-739) vs. 129 (58-265) μGym2; P < 0.01]. The overall complication rates were 2.9% in group PFA and 6.2% in group HPSD (P = 0.158). There was one fatal stroke in the PFA group. The 1-year Kaplan-Meier estimated freedom from any atrial tachyarrhythmia was 85% with PFA and 79% with HPSD-RF (log-rank P = 0.160). In 56 repeat ablation procedures, the PV reconnection rate was 30% after PFA and 38% after HPSD-RF (P = 0.372).

CONCLUSION

Both PFA and HPSD-RF were highly efficient and effective in achieving PVI in paroxysmal AF patients. The arrhythmia-free survival is comparable. The PV reconnection rate was not different.

PolarX vs Arctic Front for Cryoballoon Ablation of Paroxysmal AF: The Randomized COMPARE CRYO Study

BACKGROUND

Pulmonary vein isolation is an effective treatment for atrial fibrillation (AF). Cryoballoon ablation using the Arctic Front cryoballoon (Medtronic) was found to be superior to antiarrhythmic drug treatment. Recently, a novel cryoballoon system was introduced (PolarX, Boston Scientific).

OBJECTIVES

The purpose of this study was to compare the efficacy and safety of the 2 cryoballoons in a randomized controlled trial.

METHODS

Patients with symptomatic paroxysmal AF were enrolled in 2 centers and randomized 1:1 to pulmonary vein isolation using the PolarX or the Arctic Front cryoballoon. All patients received an implantable cardiac monitor. The primary endpoint was first recurrence of atrial tachyarrhythmia (AF, atrial flutter, or atrial tachycardia [AT]) between days 91 and 365. Procedural safety was assessed by a composite of tamponade, phrenic nerve palsy lasting >24 hours, vascular complications, stroke/transient ischemic attack, atrioesophageal fistula or death up to 30 days.

RESULTS

A total of 201 patients were enrolled. At 1 year, recurrence of atrial tachyarrhythmia had occurred in 41 of 99 patients (41.6%) assigned to the PolarX group and in 48 of 102 patients (47.1%) assigned to the Arctic Front group (HR: 0.85 [95% CI: 0.56-1.30]; P = 0.03 for noninferiority; P = 0.46 for superiority). The safety endpoint occurred in 5 patients (5%) in the PolarX group (n = 5 phrenic nerve palsies lasting >24 hours), whereas no safety endpoints occurred in the Arctic Front group (P = 0.03).

CONCLUSIONS

In this randomized controlled trial using implantable cardiac monitors for continuous rhythm monitoring, the novel PolarX cryoballoon was noninferior compared with the Arctic Front cryoballoon regarding efficacy. However, the PolarX balloon resulted in significantly more phrenic nerve palsies. (Comparison of PolarX and the Arctic Front Cryoballoons for PVI in Patients With Symptomatic Paroxysmal AF [COMPARE-CRYO]; NCT04704986).

Benefits of early rhythm control of atrial fibrillation

In contrast to current guidelines and earlier trials, recent studies demonstrated superiority of rhythm- over rate-control and challenged the strategy of "rate versus rhythm" therapy in patients with atrial fibrillation. These newer studies have started to shift the use of rhythm-control therapy from the symptom-driven therapy of current guidelines to a risk-reducing strategy aimed at restoring and maintaining sinus rhythm. This review discusses recent data and presents an overview on the current discourse: The concept of early rhythm control seems attractive. Patients with rhythm control may undergo less atrial remodeling compared to those with rate control. In addition, in EAST-AFNET 4 an outcome-reducing effect of rhythm control was achieved by delivering therapy with relatively few complications early after the initial AF diagnosis. Successful rhythm control therapy and most likely reduced AF burden, estimated by the presence of sinus rhythm at 12 months after randomization, explained most of the reduction in cardiovascular outcomes achieved by rhythm control. However, it is too early to call for early rhythm control for all AF patients. Rhythm control may raise concerns regarding the generalizability of trial results in routine practice involving important questions on the definition of "early" and "successful", and the relevant issue of antiarrhythmic drugs versus catheter ablation. Further information is required to select patients who will benefit from an early ablative or non-ablative rhythm management.

Antiarrhythmic drug therapy and catheter ablation in patients with paroxysmal or persistent atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Catheter ablation and antiarrhythmic drug therapy are utilized for rhythm control in atrial fibrillation (AF), but their comparative effectiveness, especially with contemporary treatment modalities, remains undefined. We conducted a systematic review and meta-analysis contrasting current ablation techniques against antiarrhythmic medications for AF.

METHODS

We searched PubMed, SCOPUS, Cochrane CENTRAL, and Web of Science until November 2023 for randomized trials comparing AF catheter ablation with antiarrhythmics, against antiarrhythmic drug therapy alone, reporting outcomes for > 6 months. Four investigators extracted data and appraised risk of bias (ROB) with ROB 2 tool. Meta-analyses estimated pooled efficacy and safety outcomes using R software.

RESULTS

Twelve trials (n = 3977) met the inclusion criteria. Catheter ablation was associated with lower AF recurrence (relative risk (RR) = 0.44, 95%CI (0.33, 0.59), P ˂ 0.0001) and hospitalizations (RR = 0.44, 95%CI (0.23, 0.82), P = 0.009) than antiarrhythmic medications. Catheter ablation also improved the physical quality of life component score (assessed by a 36-item Short Form survey) by 7.61 points (95%CI -0.70-15.92, P = 0.07); but, due to high heterogeneity, it was not statistically significant. Ablation was significantly associated with higher procedural-related complications [RR = 15.70, 95%CI (4.53, 54.38), P < 0.0001] and cardiac tamponade [RR = 9.22, 95%CI (2.16, 39.40), P = 0.0027]. All-cause mortality was similar between the two groups.

CONCLUSIONS

For symptomatic AF, upfront catheter ablation reduces arrhythmia and hospitalizations better than continued medical therapy alone, albeit with moderately more adverse events. Careful patient selection and risk-benefit assessment are warranted regarding the timing of ablation.

New Perspectives in The Management of Paroxysmal Atrial Fibrillation: Dual AntiArrhythmic Medications

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice projected to affect 12.1 million individuals by the year 2030. Patients who are diagnosed with AF have an increased risk of morbidity and mortality. Although catheter ablation is a class I treatment recommendation in patients with symptomatic paroxysmal AF, antiarrhythmic medications (AAM) continue to be the mainstay of treatment in limited resource settings not offering ablation procedures. Currently, the most used AAMs are those which block either the sodium or potassium channels. We hypothesized that the use of selective dual AAM (sodium and potassium channel blockers) (DAAM) improves the chance of maintaining sinus rhythm and decreases the need for catheter ablation when compared with single AAM (SAAM). This retrospective observational study was conducted in 150 patients with paroxysmal AF over 5 years at Richmond University Medical Center in Staten Island, New York. The following data were collected: age, sex, comorbidities, electrocardiogram findings, ejection fraction by echocardiography, classes of AAM, duration, and response to treatments. The primary endpoint included the absence of symptoms and maintenance of sinus rhythm. The secondary endpoint included the requirement of electrical cardioversion or catheter ablation. A total of 86 patients met the inclusion criteria in our analysis. The average age of the patients was 71.06 years (SD = 7.66). About 45 patients were given DAAM of either amiodarone + flecainide or dronedarone + flecainide and were treated for an average of 15.4 months, followed by catheter ablation, if needed. Also, 41 patients received a SAAM followed by catheter ablation, if needed. A Mann-Whitney test indicated that electrical cardioversion and catheter ablation were greater for the SAAM group (Md = 1) than for the DAAM group (Md = 0) (U = 294.00, P value <0.001; U = 507.00, P value <0.001, respectively). No pro-arrhythmic side effects or death were encountered in either group. Treatment of paroxysmal AF with DAAM is effective compared with SAAM and is less likely to need catheter ablation or electrical cardioversion. Well-designed prospective studies are needed to further explore the use of DAAM in the management of paroxysmal AF and its clinical impact in limited resource settings.

Chinese guidelines for the diagnosis and management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.