Effect of epicardial fat volume on outcomes after left atrial posterior wall isolation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation

Extended Period Outcomes of Posterior Box Isolation in 4 Randomized Atrial Fibrillation Catheter Ablation Trials

BACKGROUND

Catheter-based electrical posterior box isolation (POBI) and circumferential pulmonary vein isolation (CPVI) do not improve the rhythmic outcomes of atrial fibrillation catheter ablation in previous studies with 12 to 24 months of follow-up.

OBJECTIVES

The authors analyzed the long-term rhythm outcomes of our 4 previously conducted randomized controlled trials comparing CPVI alone vs CPVI plus additional POBI using the intention-to-treat principle.

METHODS

The authors analyzed 575 AF patients included in our 4 previous randomized controlled trials. We compared clinical recurrence defined as recurrent atrial arrhythmia after the index procedure. In patients who underwent a repeat procedure because of recurrence after the index procedure, the mechanism of recurrence was analyzed.

RESULTS

After a median follow-up of 48 months, there were no significant differences in the clinical recurrence or major adverse cardiac events between the CPVI alone and CPVI plus POBI groups. The procedure time was significantly longer, and the atrial tachycardia recurrence rate was higher in the CPVI plus POBI group. In the patients who experienced clinical recurrence, there were no significant differences in the rates of cardioversion or need for repeat procedures between the groups. In patients who underwent a repeat procedure because of recurrence after the index procedure (n = 64), the pulmonary vein reconnection rate did not differ, but re-entrant atrial tachycardia was more common in the CPVI plus POBI group, while extrapulmonary vein triggers were more common in the CPVI alone group.

CONCLUSIONS

The addition of POBI to CPVI did not improve the long-term rhythm outcomes in patients undergoing atrial fibrillation catheter ablation. (The Evaluation for Prognostic Factors After Catheter Ablation of Atrial Fibrillation, NCT02138695; Evaluation of Proper Radiofrequency Catheter Ablation Strategy for the Patients Who Were Changed to Paroxysmal Atrial Fibrillation From Persistent Atrial Fibrillation, NCT02176616; Comparison of Circumferential Pulmonary Vein Isolation Alone Versus Linear Ablation in Addition to Circumferential Pulmonary Vein Isolation for Catheter Ablation in Persistent Atrial Fibrillation: Prospective Randomized Controlled Trial, NCT02721121; Comparison of Circumferential Pulmonary Vein Isolation and Complex Pulmonary Vein Isolation Additional Linear Ablation for Recurred Atrial Fibrillation After Previous Catheter Ablation: Prospective Randomized Trial [RILI Trial]; NCT02747498.

Atrial Fibrillation in Heart Failure: Novel Insights, Challenges, and Treatment Opportunities

PURPOSE OF REVIEW

Atrial fibrillation and heart failure frequently co-exist. This review discusses the comorbidity of atrial fibrillation and heart failure, the bi-directional link between them, and the recent advances in the management of these co-existing diseases.

RECENT FINDINGS

Catheter ablation received a class 1 A recommendation for patients with AF and HF, after overwhelming evidence in heart failure with reduced ejection fraction and end-stage heart failure, while clinical trials are still lacking in patients with preserved ejection. Guideline-medical therapy of heart failure decreases the incidence of atrial fibrillation and the progression of atrial myopathy. Based on the current evidence, management of patients with both HF and AF should be include early optimization of comorbidity control, guideline-medical therapy for heart failure, and rhythm control preferentially through catheter ablation in properly selected patients.