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Long-term Outcome of Pulmonary Vein Isolation Versus Amiodarone Therapy in Patients with Coexistent Persistent AF and Congestive Heart Failure.

ABSTRACT: Although pharmacological rhythm control of AF in patients with heart failure with reduced ejection fraction (HFrEF) does not seem to provide any benefit over rate control, catheter ablation of AF has been shown to improve clinical outcomes. These results can be explained with higher success rates of catheter ablation in restoring and maintaining sinus rhythm compared with antiarrhythmic drugs. In addition, pharmacotherapy is not void of side-effects, which are thought to offset its potential antiarrhythmic benefits. Therefore, efforts should be made towards optimisation of ablation techniques for AF in patients with HFrEF.

SUBMITTER: Faggioni M

PROVIDER: S-EPMC7199124 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Long-term Outcome of Pulmonary Vein Isolation Versus Amiodarone Therapy in Patients with Coexistent Persistent AF and Congestive Heart Failure.

Faggioni Michela M Della Rocca Domenico G DG Mohanty Sanghamitra S Trivedi Chintan C Canpolat Ugur U Gianni Carola C Al-Ahmad Amin A Horton Rodney R Gallinghouse Gerald Joseph GJ Burkhardt John David JD Natale Andrea A

Cardiac failure review 20200301

Although pharmacological rhythm control of AF in patients with heart failure with reduced ejection fraction (HFrEF) does not seem to provide any benefit over rate control, catheter ablation of AF has been shown to improve clinical outcomes. These results can be explained with higher success rates of catheter ablation in restoring and maintaining sinus rhythm compared with antiarrhythmic drugs. In addition, pharmacotherapy is not void of side-effects, which are thought to offset its potential ant ...[more]

PMID: 32377383

Similar Datasets

Ablation guided by STAR-mapping in addition to pulmonary vein isolation is superior to pulmonary vein isolation alone or in combination with CFAE/linear ablation for persistent AF.

Project description:IntroductionThe optimal ablation approach for persistent atrial fibrillation (AF) remains unclear.Methods and resultsObjective was to compare the long-term rates of freedom from AF/AT in patients that underwent STAR mapping guided ablation against outcomes of patients undergoing conventional ablation procedures. Patients undergoing ablation for persistent AF as part of the Stochastic Trajectory Analysis of Ranked signals (STAR) mapping study were included. Outcomes following 'pulmonary vein isolation (PVI) plus STAR mapping guided ablation (STAR mapping cohort) were compared to patients undergoing PVI alone ablation during the same time period and also a propensity-matched cohort undergoing PVI plus the addition of complex fractionated electrogram (CFAE) and/or linear ablation ("conventional ablation"). Rates of procedural AF termination and freedom from AF/AT during follow-up were compared. Sixty-five patients were included in both the STAR cohort and propensity matched conventional ablation cohort. AF termination rates were significantly higher in the STAR cohort (51/65, 78.5%) than conventional ablation cohort (10/65, 15.4%) and PVI alone ablation cohort (13/50, 26.0%; STAR cohort vs. other 2 cohorts both p < .001). There was no significant difference in procedure time between the three cohorts. During ≥20 months follow-up a lower proportion of patients had AF/AT recurrence in the STAR cohort (20.0%) compared with the conventional ablation cohort (50.8%) or the PVI alone ablation cohort (50.0%; both p < .05 compared to STAR cohort).ConclusionsOutcomes of PVI plus STAR mapping guided ablation was superior to PVI alone or in combination with linear/CFAE ablation. A multicenter randomized controlled trial is planned to confirm these findings.

| S-EPMC8607469 | biostudies-literature

ECGI targeted ablation for persistent AF not responding to pulmonary vein isolation: Results of a two-staged strategy (TARGET AF2).

Project description:BackgroundMechanisms sustaining persistent atrial fibrillation (AF) remain unclear.ObjectivesThe study sought to evaluate both the clinical outcomes and response to ablation of potential drivers in patients with recurrent persistent AF recurrence following pulmonary vein isolation (PVI).MethodsA total of 100 patients with persistent AF of <2 years' duration underwent cryoballoon PVI (ECGI phenotyping of persistent AF based on driver burden and distribution to predict response to pulmonary vein isolation). Patients with documented recurrence of atrial arrhythmia within 12 months were recruited and underwent repeat PVI (if needed) followed by ablation of potential drivers (PDs) identified by electrocardiographic imaging (ECGI). PDs were defined as rotational activity >1.5 revolutions or focal activations. Cycle lengths were measured pre- and postablation. The primary outcome was freedom from atrial arrhythmia off antiarrhythmic drugs at 1 year as per guidelines.ResultsOf 37 patients recruited, 26 had recurrent AF and underwent ECGI-guided ablation of PDs. An average of 6.4 ± 2.7 PDs were targeted per patient. The mean ablation time targeting PDs was 15.5 ± 6.9 minutes. An ablation response occurred in 20 patients (AF termination in 6, cycle length prolongation ≥10% in 14). At 1 year, 14 (54%) of 26 patients were free from arrhythmia, and 12 (46%) of 26 were off antiarrhythmic drugs. Considering the 96 patients who completed follow-up out of the original cohort of 100 patients undergoing cryoablation in this staged strategy, freedom from arrhythmia at 1 year following the last procedure was 72 (75%) of 96, or 70 (73%) of 96 off antiarrhythmic drugs.ConclusionsIn patients with recurrent AF despite PVI, ECGI-guided ablation caused an acute response in a majority with reasonable long-term outcomes.

| S-EPMC10626178 | biostudies-literature

AF Ablation Guided by Spatiotemporal Electrogram Dispersion Without Pulmonary Vein Isolation: A Wholly Patient-Tailored Approach.

Project description:BACKGROUND:The use of intracardiac electrograms to guide atrial fibrillation (AF) ablation has yielded conflicting results. OBJECTIVES:The authors evaluated the usefulness of spatiotemporal dispersion, a visually recognizable electric footprint of AF drivers, for the ablation of all forms of AF. METHODS:The authors prospectively enrolled 105 patients admitted for AF ablation. AF was sequentially mapped in both atria with a 20-pole PentaRay catheter. The authors tagged and ablated only regions displaying electrogram dispersion during AF. Results were compared to a validation set in which a conventional ablation approach was used (pulmonary vein isolation/stepwise approach). To establish the mechanism underlying spatiotemporal dispersion of AF electrograms, the authors conducted realistic numerical simulations of AF drivers in a 2-dimensional model and optical mapping of ovine atrial scar-related AF. RESULTS:Ablation at dispersion areas terminated AF in 95% of the 105 patients. After ablation of 17 ± 10% of the left atrial surface and 18 months of follow-up, the atrial arrhythmia recurrence rate was 15% after 1.4 ± 0.5 procedures per patient versus 41% in the validation set after 1.5 ± 0.5 procedures per patient (arrhythmia free-survival: 85% vs. 59%; log-rank p < 0.001). Compared with the validation set, radiofrequency times (49 ± 21 min vs. 85 ± 34.5 min; p = 0.001) and procedure times (168 ± 42 min vs. 230 ± 67 min; p < 0.0001) were shorter. In simulations and optical mapping experiments, virtual PentaRay recordings demonstrated that electrogram dispersion is mostly recorded in the vicinity of a driver. CONCLUSIONS:The clustering of intracardiac electrograms exhibiting spatiotemporal dispersion is indicative of AF drivers. Their ablation allows for a nonextensive and patient-tailored approach to AF ablation. (Substrate Ablation Guided by High Density Mapping in Atrial Fibrillation [SUBSTRATE HD]; NCT02093949).

| S-EPMC5568427 | biostudies-literature

Baseline left atrial low-voltage area predicts recurrence after pulmonary vein isolation: WAVE-MAP AF results.

Project description:AimsElectro-anatomical mapping may be critical to identify atrial fibrillation (AF) subjects who require substrate modification beyond pulmonary vein isolation (PVI). The objective was to determine correlations between pre-ablation mapping characteristics and 12-month outcomes after a single PVI-only catheter ablation of AF.Methods and resultsThis study enrolled paroxysmal AF (PAF), early persistent AF (PsAF; 7 days-3 months), and non-early PsAF (>3-12 months) subjects undergoing de novo PVI-only radiofrequency catheter ablation. Sinus rhythm (SR) and AF voltage maps were created with the Advisor HD Grid™ Mapping Catheter, Sensor Enabled™ for each subject, and the presence of low-voltage area (LVA) (low-voltage cutoffs: 0.1-1.5 mV) was investigated. Follow-up visits were at 3, 6, and 12 months, with a 24-h Holter monitor at 12 months. A Cox proportional hazards model identified associations between mapping data and 12-month recurrence after a single PVI procedure. The study enrolled 300 subjects (113 PAF, 86 early PsAF, and 101 non-early PsAF) at 18 centres. At 12 months, 75.5% of subjects were free from AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence. Univariate analysis found that arrhythmia recurrence did not correlate with AF diagnosis, but LVA was significantly correlated. Low-voltage area (<0.5 mV) >28% of the left atrium in SR [hazard ratio (HR): 4.82, 95% confidence interval (CI): 2.08-11.18; P = 0.0003] and >72% in AF (HR: 5.66, 95% CI: 2.34-13.69; P = 0.0001) was associated with a higher risk of AF/AFL/AT recurrence at 12 months.ConclusionLarger extension of LVA was associated with an increased risk of arrhythmia recurrence. These subjects may benefit from substrate modification beyond PVI.

| S-EPMC10410193 | biostudies-literature

Reduction of myocardial necrosis using "CLOSE" protocol during pulmonary vein isolation-Preliminary results from ACTIVE-AF trial.

Project description:BackgroundNew protocols of pulmonary veins isolation (PVI) result in easier and more efficient procedure performance. Ablation index (AI) is the novel tool which helps to achieve transmural lesions during catheter ablation. However, benefit of this protocol in the reduction of myocardial injury is still not known.PurposeThe aim of the study was to compare myocardial injury during catheter ablation using standard and AI protocol.MethodsTo the analysis we included 24 patients with paroxysmal atrial fibrillation, who underwent radiofrequency catheter PVI using CARTO system (Biosense Webster, Inc). In all patients cardiac troponin I (cTnI) levels were assessed before and 24 hours after the procedure. In 12 patients PVI was performed using continuous applications (dragging technique) and in 12 patients during PVI ablation AI protocol was implemented. To unify analyzed groups, we excluded patients with additional ablation lines (including line separating ipsilateral pulmonary veins).ResultsIn analyzed group mean age was 59.3 ± 7.7 years and 18 (75%) patients were male. There were no differences in the clinical characteristic between both subgroups. Trend in shorter total x-ray time was observed in AI group compared with dragging group (8.6 ± 5.4 vs. 5.3 ± 3.2 min.; P = .093) with no differences in total procedure time (146.3 ± 28.9 vs. 153.2 ± 37.1 min.; P = .616). Twenty-four hours after the PVI procedure cTnI levels were significantly lower in AI group than in dragging group (1.984 ± 0.644 vs. 3.369 ± 1.818 ng/mL; P = .026), with no difference in mean baseline cTnI levels (0.004 ± 0.006 vs. 0.015 ± 0.032 ng/mL; P = .304).ConclusionPresented study revealed that compared with standard, continuous applications, AI protocol implementation results in reduction of myocardial injury during catheter PVI in patients with paroxysmal atrial fibrillation.

| S-EPMC7733585 | biostudies-literature

Echocardiographic diagnosis of atrial cardiomyopathy allows outcome prediction following pulmonary vein isolation.

Project description:BackgroundRelevant atrial cardiomyopathy (ACM), defined as a left atrial (LA) low-voltage area ≥ 2 cm2 at 0.5 mV threshold on endocardial contact mapping, is associated with new-onset atrial fibrillation (AF), higher arrhythmia recurrence rates after pulmonary vein isolation (PVI), and an increased risk of stroke. The current study aimed to assess two non-invasive echocardiographic parameters, LA emptying fraction (EF) and LA longitudinal strain (LAS, during reservoir (LASr), conduit (LAScd) and contraction phase (LASct)) for the diagnosis of ACM and prediction of arrhythmia outcome after PVI.MethodsWe prospectively enrolled 60 consecutive, ablation-naive patients (age 66 ± 9 years, 80% males) with persistent AF. In 30 patients (derivation cohort), LA-EF and LAS cut-off values for the presence of relevant ACM (high-density endocardial contact mapping in sinus rhythm prior to PVI at 3000 ± 1249 sites) were established in sinus rhythm and tested in a validation cohort (n = 30). Arrhythmia recurrence within 12 months was documented using 72-h Holter electrocardiograms.ResultsAn LA-EF of < 34% predicted ACM with an area under the curve (AUC) of 0.846 (sensitivity 69.2%, specificity 76.5%) similar to a LASr < 23.5% (AUC 0.878, sensitivity 92.3%, specificity 82.4%). In the validation cohort, these cut-offs established the correct diagnosis of ACM in 76% of patients (positive predictive values 87%/93% and negative predictive values 73%/75%, respectively). Arrhythmia recurrence in the entire cohort was significantly more frequent in patients with LA-EF < 34% and LASr < 23.5% (56% vs. 29% and 55% vs. 26%, both p < 0.05).ConclusionThe echocardiographic parameters LA-EF and LAS allow accurate, non-invasive diagnosis of ACM and prediction of arrhythmia recurrence after PVI.

| S-EPMC8563528 | biostudies-literature

Using computed tomogram atrial myocardial thickness maps in high‐power short‐duration radiofrequency pulmonary vein isolation: UTMOST AF

Project description: Not available

| S-EPMC10995596 | biostudies-literature

Personalized pulmonary vein antrum isolation guided by left atrial wall thickness for persistent atrial fibrillation.

Project description:AimsPulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF.Methods and resultsConsecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50-67), fluoroscopy time was 43 s (IQR 20-71), and radiofrequency (RF) time was 16.5 min (IQR 14.3-18.4). The median AI tailored to the local LAWT was 387 (IQR 360-410) for the anterior wall and 335 (IQR 300-375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up.ConclusionIn this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

| S-EPMC10228614 | biostudies-literature

Prevention of cerebral thromboembolism by oral anticoagulation with dabigatran after pulmonary vein isolation for atrial fibrillation: the ODIn-AF trial.

Project description:Background and objectivesLong-term oral anticoagulation (OAC) following successful catheter ablation of atrial fibrillation (AF) remains controversial. Prospective data are missing. The ODIn-AF study aimed to evaluate the effect of OAC on the incidence of silent cerebral embolic events and clinically relevant cardioembolic events in patients at intermediate to high risk for embolic events, free from AF after pulmonary vein isolation (PVI).MethodsThis prospective, randomized, multicenter, open-label, blinded endpoint interventional trial enrolled patients who were scheduled for PVI to treat paroxysmal or persistent AF. Six months after PVI, AF-free patients were randomized to receive either continued OAC with dabigatran or no OAC. The primary endpoint was the incidence of new silent micro- and macro-embolic lesions detected on brain MRI at 12 months of follow-up compared to baseline. Safety analysis included bleedings, clinically evident cardioembolic, and serious adverse events (SAE).ResultsBetween 2015 and 2021, 200 patients were randomized into 2 study arms (on OAC: n = 99, off OAC: n = 101). There was no significant difference in the occurrence of new cerebral microlesions between the on OAC and off OAC arm [2 (2%) versus 0 (0%); P = 0.1517] after 12 months. MRI showed no new macro-embolic lesion, no clinical apparent strokes were present in both groups. SAE were more frequent in the OAC arm [on OAC n = 34 (31.8%), off OAC n = 18 (19.4%); P = 0.0460]; bleedings did not differ.ConclusionDiscontinuation of OAC after successful PVI was not found to be associated with an elevated risk of cerebral embolic events compared with continued OAC after a follow-up of 12 months.

| S-EPMC11269394 | biostudies-literature

Impact of atrial fibrillation phenotype and left atrial volume on outcome after pulmonary vein isolation.

Project description:AimsPulmonary vein isolation (PVI) is increasingly performed in patients with atrial fibrillation (AF). Both AF phenotype and left atrial (LA) volume have been shown to influence ablation outcome. The inter-relationship of the two is incompletely understood. We aimed to investigate the impact of AF phenotype vs. LA volume on outcome after PVI.Methods and resultsIn a retrospective analysis of a prospective registry of patients undergoing a first PVI, the association of AF phenotype and LA volume index (LAVI) was assessed as well as their impact on AF recurrence during follow-up. Overall, 476 patients were enrolled (median age 63 years, 29% females, 65.8% paroxysmal AF). Obesity, hypertension, chronic kidney disease, and heart failure were all significantly more frequent in persistent AF. After 1 year, single-procedure, freedom from arrhythmia recurrence was 61.5%. Patients with paroxysmal AF had better outcomes compared with patients with persistent AF (65.6 vs. 52.7%, P = 0.003), as had patients with no/mild vs. moderate/severe LA dilation (LAVI <42 mL/m2 67.1% vs. LAVI ≥42 mL/m2 53%, P < 0.001). The combination of both parameters refined prediction of 1-year recurrence (P < 0.001). After adjustment for additional clinical risk factors in multivariable Cox proportional hazard analysis, both AF phenotype and LAVI ≥42 mL/m2 contributed significantly towards the prediction of 1-year recurrence.ConclusionAtrial fibrillation phenotype and LA volume are independent predictors of outcome after PVI. Persistent AF with no/mild LA dilation has a similar risk of recurrence as paroxysmal AF with a moderate/severe LA dilation and should be given similar priority for ablation.

| S-EPMC11004789 | biostudies-literature

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