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Schematic drawing showing catheter ablation of atrial fibrillation using either RF energy or cryoballoon AF ablation. A: Shows a typical wide area lesion set created using RF energy. Ablation lesions are delivered in a figure of eight pattern around the left and right PV veins. Also shown is a linear cavotricuspid isthmus lesion created for ablation of typical atrial flutter in a patient with a prior history of typical atrial flutter or inducible isthmus-dependent typical atrial flutter at the time of ablation. A multielectrode circular mapping catheter is positioned in the left inferior PV. B: Shows an ablation procedure using the cryoballoon system. Ablation lesions have been created surrounding the right PVs, and the cryoballoon ablation catheter is positioned in the left superior PV. A through the lumen multielectrode circular mapping catheter is positioned in the left superior PV. Illustration: Tim Phelps ? 2017 Johns Hopkins University, AAM.
Contexts in source publication
Context 1
... energy sources and tools are available in some parts of the world and/or are in various stages of development and/or clinical investigation. Shown in Figure 9 are schematic drawings of AF ablation using point-by-point RF energy ( Figure 9A) and AF abla- tion using the cryoballoon (CB) system ( Figure 9B). ...
Context 2
... energy sources and tools are available in some parts of the world and/or are in various stages of development and/or clinical investigation. Shown in Figure 9 are schematic drawings of AF ablation using point-by-point RF energy ( Figure 9A) and AF abla- tion using the cryoballoon (CB) system ( Figure 9B). ...
Context 3
... energy sources and tools are available in some parts of the world and/or are in various stages of development and/or clinical investigation. Shown in Figure 9 are schematic drawings of AF ablation using point-by-point RF energy ( Figure 9A) and AF abla- tion using the cryoballoon (CB) system ( Figure 9B). ...
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Citations
... The endpoint was defined as the freedom from AF, AFL, or AT recurrence for 30 seconds. The detailed description of the process was in accordance with the expert consensus 22 . ...
8)Acknowledgements We would like to thank Yuwei Li, Pengfei Zhao and Junhuan Li for their help in imaging analysis. We thank all the volunteers who took part in this study. Abstract Objectives：Fat radiomic profile (FRP) was a promising imaging biomarker for identifying increased cardiac risk. We hypothesize FRP can be extended to fat regions around pulmonary veins (PV), left atrium (LA) and left atrial appendage (LAA) to investigate their usefulness in identifying atrial fibrillation (AF) and the risk of AF recurrence. Methods: We analyzed 300 individuals and grouped patients according to the occurrence and types of AF. We used receiver operating characteristic (ROC) and survival curves analyses to evaluate the value of imaging biomarkers, including fat attenuation index (FAI) and FRP, in distinguishing AF from sinus rhythm and predicting post-ablation recurrence. Results: FRPs from AF-relevant fat regions showed significant performance in distinguishing AF and non-AF with higher AUC values than FAI (peri-PV: FRP = 0.961 vs. FAI = 0.579, peri-LA: FRP = 0.923 vs. FAI = 0.575, peri-LAA: FRP = 0.900 vs. FAI = 0.665). FRPs from peri-PV, peri-LA, and peri-LAA were able to differentiate persistent and paroxysmal AF with an AUC values of 0.804, 0.819 and 0.694. FRP from these regions improved AF recurrence prediction with an AUC of 0.929, 0.732 and 0.794. Patients with FRP cutoff values of ≥ 0.16, 0.38, 0.26 had a 7.22, 5.15, and 4.25-fold higher risk of post-procedure recurrence respectively. Conclusion: FRP demonstrated potential in identifying AF, distinguishing AF types, and predicting AF recurrence risk after ablation. FRP from peri-PV fat depot exhibited a strong Downloaded from https://academic.oup.com/bjr/advance-article/doi/10.1093/bjr/tqad046/7471998 by guest on 23 December 2023 3 correlation with AF. Therefore, evaluating epicardial fat using FRP was a promising approach to enhance AF clinical management. Advances in knowledge: The role of epicardial adipose tissue (EAT) in atrial fibrillation (AF) had been confirmed, we focused on the relationship between EAT around pulmonary arteries and left atrial appendage in AF which was still unknown. Meanwhile, we used the fat radiomic profile (FRP) to excavate more information of EAT in AF.
... The detailed description of the process was in accordance with the expert consensus. 22 Fat definition on CCTA ...
Objectives
Fat radiomic profile (FRP) was a promising imaging biomarker for identifying increased cardiac risk. We hypothesize FRP can be extended to fat regions around pulmonary veins (PV), left atrium (LA), and left atrial appendage (LAA) to investigate their usefulness in identifying atrial fibrillation (AF) and the risk of AF recurrence.
Methods
We analysed 300 individuals and grouped patients according to the occurrence and types of AF. We used receiver operating characteristic and survival curves analyses to evaluate the value of imaging biomarkers, including fat attenuation index (FAI) and FRP, in distinguishing AF from sinus rhythm and predicting post-ablation recurrence.
Results
FRPs from AF-relevant fat regions showed significant performance in distinguishing AF and non-AF with higher AUC values than FAI (peri-PV: FRP = 0.961 vs FAI = 0.579, peri-LA: FRP = 0.923 vs FAI = 0.575, peri-LAA: FRP = 0.900 vs FAI = 0.665). FRPs from peri-PV, peri-LA, and peri-LAA were able to differentiate persistent and paroxysmal AF with AUC values of 0.804, 0.819, and 0.694. FRP from these regions improved AF recurrence prediction with an AUC of 0.929, 0.732, and 0.794. Patients with FRP cut-off values of ≥0.16, 0.38, and 0.26 had a 7.22-, 5.15-, and 4.25-fold higher risk of post-procedure recurrence, respectively.
Conclusions
FRP demonstrated potential in identifying AF, distinguishing AF types, and predicting AF recurrence risk after ablation. FRP from peri-PV fat depot exhibited a strong correlation with AF. Therefore, evaluating epicardial fat using FRP was a promising approach to enhance AF clinical management.
Advances in knowledge
The role of epicardial adipose tissue (EAT) in AF had been confirmed, we focussed on the relationship between EAT around pulmonary arteries and LAA in AF which was still unknown. Meanwhile, we used the FRP to excavate more information of EAT in AF.
... In the consensus statement on catheter and surgical ablation of AF, PV stenosis is defined as a reduction in PV diameter and classified as mild (<50% diameter reduction), moderate (50-70% diameter reduction), and severe (>70% diameter reduction). 15 We classified mild stenosis as a diameter reduction of 30-50% and moderate and severe stenosis according to the consensus statement. ...
Background: Adverse atrial remodeling, including epicardial adipose tissue (EAT) deposition in the left atrium (LA), is implicated in atrial fibrillation (AF). Radiofrequency hotballoon (RHB) ablation can produce wide planar lesions because the balloon is highly compliant; however, chronic effects of RHB ablation on structural remodeling remain unknown. This clinical-experimental investigation characterized chronic effects of RHB ablation on EAT in persistent AF (PsAF).
Methods and Results: The clinical study involved 91 patients (obese, n=30; non-obese, n=61) undergoing RHB ablation for PsAF. LA-EAT was assessed from computed tomography images obtained before ablation and 6 months later. Tissue effects of RHB ablation were explored in a chronic swine model. RHB ablation significantly reduced LA volume (mean [±SD] 177.7±29.7 vs. 138.4±29.6 mL; P<0.001) and LA-EAT volume (median [interquartile range] 22.0 [12.4–33.3] vs. 16.5 [7.9–25.8] mL; P<0.001). The reduction in EAT was significantly greater in the pulmonary vein (PV) antrum than in other LA regions (37.9% vs. 15.8%; P<0.001). The percentage reduction in PV antrum EAT was equivalent between obese and non-obese patients, as was the postablation success rate (73% vs. 70%; P=0.77). RHB ablation produced transmural lesions reaching the pigs’ epicardial fat region.
Conclusions: RHB-based planar-transmural lesions altered the structurally remodeled LA, including EAT. Further studies are needed to determine whether factors other than PV isolation contribute to the clinical success of RHB ablation.
... This study conforms to the principles of the Declaration of Helsinki. Details of the patient population and definitions of paroxysmal AF (PAF), persistent AF (PeAF), and long-standing persistent AF (LS-PeAF) 21 were described in the Supplementary data online, Appendix. Eight autopsy cases were histologically analysed to compare the extent of fibrosis at the RA septum with that at various left atrium (LA) locations. ...
Background and aims:
This study aimed to histologically validate atrial structural remodelling associated with atrial fibrillation.
Methods and results:
Patients undergoing atrial fibrillation ablation and endomyocardial atrial biopsy were included (n = 230; 67 ± 12 years old; 69 women). Electroanatomic mapping was performed during right atrial pacing. Voltage at the biopsy site (Vbiopsy), global left atrial voltage (VGLA), and the proportion of points with fractionated electrograms defined as ≥5 deflections in each electrogram (%Fractionated EGM) were evaluated. SCZtotal was calculated as the total width of slow conduction zones, defined as regions with a conduction velocity of <30 cm/s. Histological factors potentially associated with electroanatomic characteristics were evaluated using multiple linear regression analyses. Ultrastructural features and immune cell infiltration were evaluated by electron microscopy and immunohistochemical staining in 33 and 60 patients, respectively. Fibrosis, intercellular space, myofibrillar loss, and myocardial nuclear density were significantly associated with Vbiopsy (P = .014, P < .001, P < .001, and P = .002, respectively) and VGLA (P = .010, P < .001, P = .001, and P < .001, respectively). The intercellular space was associated with the %Fractionated EGM (P = .001). Fibrosis, intercellular space, and myofibrillar loss were associated with SCZtotal (P = .028, P < .001, and P = .015, respectively). Electron microscopy confirmed plasma components and immature collagen fibrils in the increased intercellular space and myofilament lysis in cardiomyocytes, depending on myofibrillar loss. Among the histological factors, the severity of myofibrillar loss was associated with an increase in macrophage infiltration.
Conclusion:
Histological correlates of atrial structural remodelling were fibrosis, increased intercellular space, myofibrillar loss, and decreased nuclear density. Each histological component was defined using electron microscopy and immunohistochemistry studies.
... 6,7 AF is a progressive disease and can be clinically categorized as early AF (paroxysmal AF) or advanced AF (persistent or long-standing persistent AF). 8,9 Progression from early AF to advanced AF is associated with increased morbidity and worse clinical outcomes. 10 Prior observational evidence has suggested that patients with AF treated with medical therapy have more rapid rates of AF progression versus those treated with RFCA, 11 and the recent ATTEST (Atrial Fibrillation Progression Trial, https://www.clinicaltrials.gov; ...
Background:
Radiofrequency catheter ablation (RFCA) is an established treatment for atrial fibrillation (AF) refractory to antiarrhythmic drugs. The economic value of RFCA in delaying disease progression has not been quantified.
Methods:
An individual-level, state-transition health economic model estimated the impact of delayed AF progression using RFCA versus antiarrhythmic drug treatment for a hypothetical sample of patients with paroxysmal AF. The model incorporated the lifetime risk of progression from paroxysmal AF to persistent AF, informed by data from the ATTEST (Atrial Fibrillation Progression Trial). The incremental effect of RFCA on disease progression was modeled over a 5-year duration. Annual crossover rates were also included for patients in the antiarrhythmic drug group to mirror clinical practice. Estimates of discounted costs and quality-adjusted life years asssociated with health care utilization, clinical outcomes, and complications were projected over patients' lifetimes.
Results:
From the payer's perspective, RFCA was superior to antiarrhythmic drug treatment with an estimated mean net monetary benefit per patient of $8516 ($148-$16 681), driven by reduced health care utilization, cost, and improved quality-adjusted life years. RFCA reduced mean (95% CI) per-patient costs by $73 (-$2700 to $2200), increased mean quality-adjusted life years by 0.084 (0.0-0.17) and decreased the mean number of cardiovascular-related health care encounters by 24%.
Conclusions:
RFCA is a dominant (less costly and more effective) treatment strategy for patients with AF, especially those with early AF for whom RFCA could delay progression to advanced AF. Increased utilization of RFCA-particularly among patients earlier in their disease progression-may provide clinical and economic benefits.
... Paroxysmal AF was described as AF that ended unexpectedly or was cardioverted within 7 days, persistent AF was described as AF that continued for more than 7 days and was treated with medications or direct current cardioversion, long-lasting persistent AF was described as AF that continued more than one year, and permanent AF was described as AF that was unsuccessful or indicated for rhythm reversal methods, such as ablation and cardioversion [10]. Non-paroxysmal AF was composed of persistent AF, long-lasting persistent AF, and permanent AF. ...
Introduction:
N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been demonstrated as a valuable risk marker for mortality and morbidity of cardiovascular disease. Recurrence after atrial fibrillation (AF) radiofrequency catheter ablation remains common.
Aim:
We investigated the predictive value of the pre-procedural level of NT-proBNP to differentiate high-risk patients for post-ablation AF recurrence.
Material and methods:
326 individuals with nonvalvular AF and preserved systolic function after enduring an initial radiofrequency catheter ablation (RFCA) between March 2018 and December 2019 were categorized into a recurrent group and a non-AF recurrent group. The serum NT-proBNP levels were examined before the ablation procedure. The researchers used multivariate logistic regression to find the determinants of AF recurrence.
Results:
During a 14-month (interquartile range (IQR): 12-16) median follow-up, AF recurred in 84 (25.8%) patients. Patients in the recurrence group had considerably greater pre-ablation NT-proBNP levels (389.4 vs. 141.7 pg/ml, p < 0.001 in non-paroxysmal AF and 348.0 vs. 99.4 pg/ml, p < 0.001 in paroxysmal AF) as well as a greater left atrium (40 vs. 36 mm, p = 0.01 in non-paroxysmal AF and 38 vs. 36 mm, p = 0.01 in paroxysmal AF) than the non-AF recurrence group. A cut-off value of NT-proBNP ≥ 168.05 pg/ml identified AF recurrence with a sensitivity of 78.6% and specificity of 53.7% (area under ROC curve 0.68, 95% confidence interval (CI) 0.62-0.74, p < 0.001). Kaplan-Meier examination revealed that the elevated NT-proBNP (≥ 168.05 pg/ml) group presented a considerably shorter period without an occurrence compared to the low-NT-proBNP group (18.4 vs. 22.2 months, log-rank p = 0.001). Multivariate cox regression investigation showed that a level of NT-proBNP ≥ 168.05 pg/ml (hazard ratio (HR): 2.89, 95% CI: 1.71-4.903, p < 0.001) was a reliable predictor of AF recurrence after RFCA.
Conclusions:
A high pre-ablation NT-proBNP level was associated with AF recurrence, and it was also discovered to be a prognostic factor of recurrence of AF following RFCA.
... While VLRAF may have been underdetected due to intermittent rhythm monitoring, the rates of routine ambulatory rhythm monitoring at our institution increased over the two study periods. Furthermore, at a minimum, post-ablation rhythm monitoring was performed according to Heart Rhythm Society recommendations, and there were no differences in the rates of prolonged ambulatory rhythm monitoring between patients who did, and did not, have VLRAF [22]. ...
Background
To date, few risk models have been validated to predict recurrent atrial fibrillation (AF) >1 year after ablation. The SCALE-CryoAF score was previously derived to predict very late return of AF (VLRAF) >1 year following cryoballoon ablation (CBA), with strong predictive ability. In this study, we aim to validate the SCALE-CryoAF score for VLRAF after CBA in a novel patient cohort.
Methods
Retrospective analysis of a prospectively maintained single-center database was performed. Inclusion criteria were pulmonary vein isolation using CBA 2017-2020. Exclusion criteria included prior ablation, <1-year follow-up, lack of pre-CBA echocardiogram, additional ablation lesion sets, and documented AF recurrence 90–365 days post-CBA. The area under the curve (AUC) of SCALE-CryoAF was compared to the derivation value and other established risk models.
Results
Among 469 CBA performed, 241 (61% male, 62.8 ±11.7 years old) cases were included in analysis. There were 37 (15.4%) patients who developed VLRAF. Patients with VLRAF had a higher SCALE-CryoAF score (VLRAF 5.4 ± 2.7; no VLRAF 3.1 ± 2.9; p<0.001). SCALE-CryoAF was linearly associated with VLRAF (y=14.35x-11.72, R²=0.99), and a score > 5 had a 32.7% risk of VLRAF. The SCALE-CryoAF risk model predicted VLRAF with an AUC of 0.74, which was similar to the derivation value (AUCderivation: 0.73) and statistically superior to MB-LATER, CHA2DS2-VASc, and CHADS2 scores.
Conclusions
The current analysis validates the ability of SCALE-CryoAF to predict VLRAF after CBA in a novel patient cohort. Patients with a high SCALE-CryoAF score should be monitored closely for recurrent AF >1 year following CBA.
Graphical abstract
... 2,7 Current guidelines, thus, recommend therapeutic oral anticoagulation with VKAs/DOACS for ≥3 weeks before any rhythm control attempt. 1,2,[11][12][13] If that is unfeasible, for urgency or practical reasons, preprocedural screening for LA thrombus with transoesophageal echocardiography (TOE) may be performed. 2,13 However, the preprocedural anticoagulation period suggested in the guidelines was arbitrarily based on the assumed time needed for endothelialization or resolution of pre-existing AF thrombus. ...
... Durable and safe isolation of all PVs remains difficult [1] despite technical improvements including introduction of cryoballoon single shot devices [2], irrigated radiofrequency catheters, and contact force sensing ablation catheters [3]. In addition, unintended damage to other atrial or extracardiac structures can cause rare but severe complications, such as phrenic nerve palsy [4], PV stenosis [5], or atrio-esophageal fistula. ...
Purpose
Pulsed-field ablation (PFA) is a new energy source to achieve pulmonary vein isolation (PVI) by targeted electroporation of cardiomyocytes. Experimental and controlled clinical trial data suggest good efficacy of PFA-based PVI. We aimed to assess efficacy, safety and follow-up of PFA-based PVI in an early adopter routine care setting.
Methods
Consecutive patients with symptomatic paroxysmal or persistent atrial fibrillation (AF) underwent PVI using the Farawave® PFA ablation catheter in conjunction with three-dimensional mapping at two German high-volume ablation centers. PVI was achieved by applying 8 PFA applications in each PV.
Results
A total of 138 patients undergoing a first PVI (67 ± 12 years, 66% male, 62% persistent AF) were treated. PVI was achieved in all patients by deploying 4563 applications in 546 PVs (8.4 ± 1.0/PV). Disappearance of PV signals after the first application was demonstrated in 544/546 PVs (99.6%). More than eight PFA applications were performed in 29/546 PVs (6%) following adapted catheter positioning or due to reconnection as assessed during remapping. Mean procedure time was 78 ± 22 min including pre- and post PVI high-density voltage mapping. PFA catheter LA dwell-time was 23 ± 9 min. Total fluoroscopy time and dose area product were 16 ± 7 min and 505 [275;747] cGy*cm ² . One pericardial tamponade (0.7%), one transient ST-elevation (0.7%) and three groin complications (2.2%) occurred. 1-year follow-up showed freedom of arrhythmia in 90% in patients with paroxysmal AF ( n = 47) and 60% in patients with persistent AF ( n = 82, p = 0.015).
Conclusions
PFA-based PVI is acutely highly effective and associated with a beneficial safety and low recurrence rate.
Graphical abstract
... Lower rates of concomitant surgical ablation have been reported with non-mitral valve surgeries, despite published evidence suggesting that they have similar safety and effectiveness to concomitant ablation with mitral valve surgeries. 38,39 Standalone Surgical Ablation Not all patients who have AF are candidates for or are in need of a primary cardiac surgery procedure, such as coronary artery bypass grafting or valve repair. Long-term outcomes of standalone Cox maze procedures performed via sternotomy or right thoracotomy have been reported. ...
The burden of AF is increasing in prevalence and healthcare resource usage in the UK and worldwide. It can result in impaired quality of life for affected patients, as well as increased risk of stroke, heart failure and mortality. A holistic, integrated approach to AF management is recommended, which may include a focus on reducing risk factors and on medical management with anticoagulation and anti-arrhythmic drugs. There are also various ablation strategies that may be considered when anti-arrhythmic drugs fail to alleviate symptoms and reduce AF burden. These ablation techniques range from standalone percutaneous endocardial catheter ablation to open surgical ablation procedures concomitant with cardiac surgery. More recently, hybrid ablation that combines aspects of both surgical and electrophysiologically targeted ablation has been described. This article reviews the evolution of ablation strategies, beginning with the origin of the Cox maze IV procedure and continuing to the recent hybrid convergent approach, and provides a summary of the associated outcomes.
