Targeted ablation of specific electrogram patterns in low-voltage areas after pulmonary vein antral isolation in persistent atrial fibrillation: Termination to an organized rhythm reduces atrial fibrillation recurrence

Automatic Echocardiographic Assessment of Left Atrial Function for Prediction of Low-Voltage Areas in Non-Valvular Atrial Fibrillation

Purpose

Left atrial low-voltage areas (LA-LVAs) identified by 3D-electroanatomical mapping are crucial for determining treatment strategies and prognosis in patients with atrial fibrillation (AF). However, convenient and accurate prediction of LA-LVAs remains challenging. This study aimed to assess the viability of utilizing automatically obtained echocardiographic parameters to predict the presence of LA-LVAs in patients with non-valvular atrial fibrillation (NVAF).

Patients and Methods

This retrospective study included 190 NVAF patients who underwent initial catheter ablation. Before ablation, echocardiographic data were obtained, left atrial volume and strain were automatically calculated using advanced software (Dynamic-HeartModel and AutoStrain). Electroanatomic mapping (EAM) was also performed. Results were compared between patients with LA-LVAs ≥5% (LVAs group) and <5% (non-LVAs group).

Results

LA-LVAs were observed in 81 patients (42.6%), with a significantly higher incidence in those with persistent AF than paroxysmal AF (55.6% vs 19.3%, P <0.001). Compared with the non-LVAs group, the LVAs group included significantly older patients, lower left ventricular ejection fraction, higher heart rate, and higher E/e' ratio (P <0.05). The LVAs group exhibited higher left atrial volumemax index (LAVimax) and lower left atrial reservoir strain (LASr) (P <0.001). In multivariate analysis, both LAVimax and LASr emerged as independent indicators of LVAs (OR 0.85; 95% CI 0.80-0.90, P<0.001) and (OR 1.15, 95% CI 1.02-1.29, P =0.021). ROC analysis demonstrated good predictive capacity for LA-LVAs, with an AUC of 0.733 (95% CI 0.650-0.794, P <0.001) for LAVimax and 0.839 (95% CI 0.779-0.898, P <0.001) for LASr.

Conclusion

Automatic assessment of LAVimax and LASr presents a promising non-invasive modality for predicting the presence of LA-LVAs and evaluating significant atrial remodeling in NVAF patients. This approach holds potential for aiding in risk stratification and treatment decision-making, ultimately improving clinical outcomes in patients.

Atrial Fibrillation Termination as a Predictor for Persistent Atrial Fibrillation Ablation: A Systemic Review and Meta-Analysis of Prospective Studies

Background: In this systematic review and meta-analysis, we aimed to validate the predictive role of atrial fibrillation (AF) termination in long-term arrhythmia recurrence. Method: Our search encompassed databases including MEDLINE, EMBASE, PubMed, and the Cochrane Library up to August 1, 2021. Three independent reviewers conducted screening and data extraction. The data included ablation strategy, recurrence mode, AF termination mode, numbers of patients, and recurrence cases in the termination and nontermination groups. The primary endpoint was the recurrence of atrial arrhythmia at long-term follow-up (≥ 12 months). Results: Our analysis included 22 publications, with 11 prospective studies being eligible for further meta-analysis. Among these, 14 studies reported significantly lower rates of arrhythmia recurrence in the AF termination group compared to the nontermination group. Among seven studies involving 1114 patients that examined single procedure outcomes, the pooled estimated effect was RR 0.78 (95% CI 0.68-1.90) with an I 2 value of 57%. Subgroup analysis focusing on termination mode as sinus rhythm yielded a pooled estimated effect of RR 0.74 (95% CI 0.59-0.92) with an I 2 value of 47%. Additionally, analysis of seven studies involving 1433 patients for repeat procedures demonstrated a significant preference for the AF termination group (RR 0.83, 95% CI 0.71-0.97, I 2 = 84%). Subgroup analysis indicated reduced heterogeneity when the termination mode was sinus rhythm (RR 0.68, 95% CI 0.51-0.90, I 2 = 57%). Conclusion: Our study establishes that AF termination serves as an effective predictor for the success of persistent AF ablation procedures. This finding holds potential implications for clinical practice and contributes to our understanding of long-term arrhythmia recurrence in the context of AF termination.

Decreased Noise and Identification of Very Low Voltage Signals Using a Novel Electrophysiology Recording System

Aims

The interpretation of intracardiac electrograms recorded from conventional electrophysiology recording systems is frequently impacted by powerline (50/60 Hz) noise and distortion due to notch filtering. This study compares unipolar electrograms recorded simultaneously from a conventional electrophysiology recording system and one of two 3D mapping systems (control system) with those from a novel system (ECGenius, CathVision ApS) designed to reduce noise without the need for conventional filtering.

Methods

Unipolar electrograms were recorded simultaneously from nine consecutive patients undergoing catheter ablation for AF (five patients), atrioventricular nodal re-entrant tachycardia (three patients), or ventricular tachycardia (one patient) over the course of 1 week in 2020.

Results

The noise spectral power of the novel system (49-51 Hz) was 6.1 ± 6.2 times lower than that of the control system. Saturation artefact following pacing (duration 97 ± 85 ms) occurred in eight control recordings and no novel system recordings (p<0.001). High frequency, low amplitude signals and fractionated electrograms apparent on unfiltered novel system unipolar recordings were not present on control recordings. Control system notch filtering obscured His bundle electrograms observable without such filtering using the novel system and induced electrogram distortion that was not present on novel system recordings. Signal saturation occurred in five of seven control system recordings but none of the novel system recordings.

Conclusion

In this study, novel system recordings exhibited less noise and fewer signal artefacts than the conventional control system and did not require notch filtering that distorted electrograms on control recordings. The novel recording system provided superior electrogram data not apparent with conventional systems.

Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation

BACKGROUND: Clinically effective ablation approaches for patients with persistent atrial fibrillation (AF) are still being debated. So far, ablation targets and strategies beyond pulmonary vein isolation (PVI) have failed to show systematic outcome improvement in randomized controlled clinical trials. METHODS: We conducted a multicenter, randomized trial to determine whether PVI plus individualized substrate ablation of atrial low-voltage myocardium improves outcome in patients with persistent AF. We randomly assigned 324 patients in a 1:1 ratio to receive PVI alone (163 patients; PVI only) or PVI plus substrate modification (161 patients; PVI+SM). The primary study end point was the first recurrence of an atrial arrhythmia longer than 30 seconds after single ablation, with 3 months blanking, using serial 7-day electrocardiogram recordings over 12 months of observation. Patients were also encouraged to receive implantable cardiac monitors. RESULTS: The primary study end point occurred in 75 PVI-only patients (50%) and in 54 PVI+SM patients (35%) (Kaplan–Meier event rate estimates: hazard ratio=0.62, 95% confidence interval [CI]=0.43 to 0.88, log rank P=0.006). Adverse events occurred in three PVI-only patients (1.8%) and in six PVI+SM patients (3.7%) (difference: −1.9 percentage points, 95% CI=−5.5 to 1.7 percentage points). Implant monitoring was used in 242 patients. Among them, 65 PVI-only patients (55%) versus 47 PVI+SM patients (39%) experienced recurrences (difference: 15 percentage points, 95% CI=3 to 28 percentage points). CONCLUSIONS: In this randomized trial, PVI plus individualized ablation of atrial low-voltage myocardium significantly improved outcomes in patients with persistent AF. (ClinicalTrials.gov number, NCT02732626.)

Electrogram fractionation during sinus rhythm occurs in normal voltage atrial tissue in patients with atrial fibrillation

INTRODUCTION

Electrogram (EGM) fractionation is often associated with diseased atrial tissue; however, mechanisms for fractionation occurring above an established threshold of 0.5 mV have never been characterized. We sought to investigate during sinus rhythm (SR) the mechanisms underlying bipolar EGM fractionation with high-density mapping in patients with atrial fibrillation (AF).

METHODS

Forty-five patients undergoing AF ablation (73% paroxysmal, 27% persistent) were mapped at high density (18562 ± 2551 points) during SR (Rhythmia). Only bipolar EGMs with voltages above 0.5 mV were considered for analysis. When fractionation (>40 ms and >4 deflections) was detected, we classified the mechanisms as slow conduction, wave-front collision, or a pivot point. The relationship between EGM duration and amplitude, and tissue anisotropy and slow conduction, was then studied using a computational model.

RESULTS

Of the 45 left atria analyzed, 133 sites of EGM fragmentation were identified with voltages above 0.5 mV. The most frequent mechanism (64%) was slow conduction (velocity 0.45 m/s ± 0.2) with mean EGM voltage of 1.1 ± 0.5 mV and duration of 54.9 ± 9.4 ms. Wavefront collision was the second most frequent (19%), characterized by higher voltage (1.6 ± 0.9 mV) and shorter duration (51.3 ± 11.3 ms). Pivot points (9%) were associated with the highest degree of fractionation with 70.7 ± 6.6 ms and 1.8 ± 1 mV. In 10 sites (8%) fractionation was unexplained. The EGM duration was significantly different among the 3 mechanisms (p = 0.0351).

CONCLUSION

In patients with a history of AF, EGM fractionation can occur at amplitudes > 0.5 mV when in SR in areas often considered not to be diseased tissue. The main mechanism of EGM fractionation is slow conduction, followed by wavefront collision and pivot sites. This article is protected by copyright. All rights reserved.

Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients

Background

The therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients.

Methods

We retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn’t convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA.

Results

After a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation.

Conclusions

LVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.

Atrial substrate characterization in patients with atrial fibrillation and hypertrophic cardiomyopathy: Evidence for an extensive fibrotic disease

INTRODUCTION

Data regarding the left atrial (LA) electroanatomical substrate in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) are missing. In this electroanatomical mapping (EAM) study, we evaluated the extent of LA fibrosis and its impact on catheter ablation outcomes in patients with HCM and AF.

MATERIALS AND METHODS

High-density LA EAM was performed during AF in 28 consecutive patients with obstructive HCM and AF (42.9% displayed paroxysmal AF and 57.1% persistent AF). Propensity score (PS) matching analysis was performed to reduce the impact of potential confounding factors. PS were derived to match patients at a 1:1 ratio. Patients were matched according to age, sex and LA diameter. After PS, 28 non-HCM patients with AF were selected, and served as controls. Two different cut-off values of bipolar signal amplitude were investigated for fibrosis characterization (≤0.25 mV and ≤ 0.4 mV). HCM patients underwent pulmonary vein antral isolation (PVAI) and roof line, while non-HCM patients PVAI only.

RESULTS

After the 3-month blanking period, 10 HCM patients (35.7%) displayed atrial arrhythmia recurrence. HCM patients with arrhythmia recurrence showed significantly greater low voltage areas defined as either bipolar voltage ≤0.25 mV (22.5 ± 10% vs. 5.5 ± 6.4%, p = 0.001) or ≤ 0.4 mV (32 ± 13.9% vs. 5.9 ± 5.1%, p < 0.001). The presence of low voltage areas ≤0.4 mV greater than 14.1% of the total LA area also predicted arrhythmia recurrence with excellent sensitivity (100%) and specificity (100%). Univariate analysis revealed that the extent of LA fibrosis was the only predictor of AF recurrence. After PS matching with non-HCM patients, patients with HCM exhibited wider fibrotic regions ≤0.25 mV compared to non-HCM patients (p = 0.016).

CONCLUSIONS

High-density EAM reveals extensive LA fibrotic disease in patients with HCM, an event with certain implications in catheter ablation outcomes.

Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms: A randomized controlled trial

INTRODUCTION

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI.

METHODS

We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs.

RESULTS

The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329).

CONCLUSION

Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%.

Characterization of cardiac electrogram signals in atrial arrhythmias

Despite significant advancements in 3D cardiac mapping systems utilized in daily electrophysiology practices, the characterization of atrial substrate remains crucial for the comprehension of supraventricular arrhythmias. During mapping, intracardiac electrograms (EGM) provide specific information that the cardiac electrophysiologist is required to rapidly interpret during the course of a procedure in order to perform an effective ablation. In this review, EGM characteristics collected during sinus rhythm (SR) in patients with paroxysmal atrial fibrillation (pAF) are analyzed, focusing on amplitude, duration and fractionation. Additionally, EGMs recorded during atrial fibrillation (AF), including complex fractionated atrial EGMs (CFAE), may also provide precious information. A complete understanding of their significance remains lacking, and as such, we aimed to further explore the role of CFAE in strategies for ablation of persistent AF. Considering focal atrial tachycardias (AT), current cardiac mapping systems provide excellent tools that can guide the operator to the site of earliest activation. However, only careful analysis of the EGM, distinguishing low amplitude high frequency signals, can reliably identify the absolute best site for RF. Evaluating macro-reentrant atrial tachycardia circuits, specific EGM signatures correspond to particular electrophysiological phenomena: the careful recognition of these EGM patterns may in fact reveal the best site of ablation. In the near future, mathematical models, integrating patient-specific data, such as cardiac geometry and electrical conduction properties, may further characterize the substrate and predict future (potential) reentrant circuits.

Safety of catheter ablation of atrial fibrillation without pre- or peri-procedural imaging for the detection of left atrial thrombus in the era of uninterrupted anticoagulation

BACKGROUND

The need for pre- or peri-procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus.

PATIENTS AND METHODS

Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days.

RESULTS

A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2-VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30-day post-discharged period.

CONCLUSIONS

Catheter ablation can be safely performed in low-risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.

Simple hematological predictors of AF recurrence in patients undergoing atrial fibrillation ablation

BACKGOUND

Red cell distribution width (RDW) and neutrophil-to-lymphocyte ratio (NLR) are simple hematologic indices that have been used to predict adverse outcomes in different clinical settings. The aim of our study is to determine whether RDW and NLR can predict atrial fibrillation (AF) recurrence in patients undergoing AF ablation.

METHODS

Consecutive patients, without known hematological disorders, who underwent AF catheter ablation between January 2014 and April 2017 were enrolled into this study. Blood samples were taken one day before and five hours after the ablation procedure.

RESULTS

A total of 346 patients (224 males (65%), mean age: 59 ± 11 years old) were included. After a mean follow up of 26.2 ± 12.1 months, 80 (23.1%) patients experienced late AF recurrence (defined as any recurrence after the blanking period of three months), while 97 (28%) patients experienced early AF recurrence during the blanking period. Univariate analysis showed that early arrhythmia recurrence, type of AF and NLR after the procedure were significantly associated with late AF recurrence, while early arrhythmia recurrence and NLR remained significant in multivariate analysis. RDW was not associated with late AF recurrence. None of the parameters above predicted early arrhythmia recurrence.

CONCLUSIONS

Simple and inexpensive hematological indices such as NLR should be evaluated for their ability to predict AF recurrence in patients undergoing catheter ablation in larger prospective studies.

Atrial Fibrosis: Translational Considerations for the Management of AF Patients

Fibrosis plays a fundamental role in the initiation and maintenance of AF, mainly due to enhanced automaticity and anisotropy-related re-entry. The identification and quantification of atrial fibrosis is achieved either preprocedurally by late gadolinium enhancement MRI or intraprocedurally using electroanatomic voltage mapping. The presence and extent of left atrial fibrosis among AF patients may influence relevant decision making regarding the need for anticoagulation, the adoption of rate versus rhythm control and mainly the type of ablation strategy that will be followed during interventional treatment. Several types of individualised substrate modifications targeting atrial fibrotic areas have been proposed, although their impact on patient outcome needs to be further investigated in adequately powered prospective randomised controlled clinical trials.