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Circulation. Arrhythmia and... Jul 2023The cryoballoon (CB) represents the gold standard single-shot device for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Single-shot pulsed...
BACKGROUND
The cryoballoon (CB) represents the gold standard single-shot device for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Single-shot pulsed field PVI ablation (nonthermal, cardiac tissue selective) has recently entered the arena. We sought to compare procedural data and long-term outcome of both techniques.
METHODS
Consecutive AF patients who underwent pulsed field ablation (PFA) and CB-based PVI were enrolled. CB PVI was performed using the second-generation 28-mm CB; PFA was performed using a 31/35-mm pentaspline catheter. Success was defined as freedom from atrial tachyarrhythmia after a 3-month blanking period.
RESULTS
Four hundred patients were included (56.5% men; 60.8% paroxysmal AF; age 70 [interquartile range, 59-77] years), 200 in each group (CB and PFA), and baseline characteristics did not differ. Acute PVI was achieved in 100% of PFA and in 98% (196/200) of CB patients (=0.123; 4 touch-up ablations). Median procedure time was significantly shorter in PFA (34.5 [29-40] minutes) versus CB (50 [45-60] minutes; <0.001), fluoroscopy time was similar. Overall procedural complications were 6.5% in CB and 3.0% in PFA (=0.1), driven by a higher rate of phrenic nerve palsies using CB. The 1-year success rates in paroxysmal AF (CB, 83.1%; PFA, 80.3%; =0.724) and persistent AF (CB, 71%; PFA, 66.8%; =0.629) were similar for both techniques.
CONCLUSIONS
PFA compared with CB PVI shows a similar procedural efficacy but is associated with shorter procedure time and no phrenic nerve palsies. Importantly, 12-month clinical success rates are favorable but not different between both groups.
Topics: Male; Humans; Aged; Female; Atrial Fibrillation; Follow-Up Studies; Treatment Outcome; Pulmonary Veins; Cryosurgery; Paralysis; Catheter Ablation; Recurrence
PubMed: 37254781
DOI: 10.1161/CIRCEP.123.011920 -
Human Molecular Genetics Jul 2023FOXJ1 is expressed in ciliated cells of the airways, testis, oviduct, central nervous system and the embryonic left-right organizer. Ablation or targeted mutation of...
FOXJ1 is expressed in ciliated cells of the airways, testis, oviduct, central nervous system and the embryonic left-right organizer. Ablation or targeted mutation of Foxj1 in mice, zebrafish and frogs results in loss of ciliary motility and/or reduced length and number of motile cilia, affecting the establishment of the left-right axis. In humans, heterozygous pathogenic variants in FOXJ1 cause ciliopathy leading to situs inversus, obstructive hydrocephalus and chronic airway disease. Here, we report a novel truncating FOXJ1 variant (c.784_799dup; p.Glu267Glyfs*12) identified by clinical exome sequencing from a patient with isolated congenital heart defects (CHD) which included atrial and ventricular septal defects, double outlet right ventricle (DORV) and transposition of the great arteries. Functional experiments show that FOXJ1 c.784_799dup; p.Glu267Glyfs*12, unlike FOXJ1, fails to induce ectopic cilia in frog epidermis in vivo or to activate the ADGB promoter, a downstream target of FOXJ1 in cilia, in transactivation assays in vitro. Variant analysis of patients with heterotaxy or heterotaxy-related CHD indicates that pathogenic variants in FOXJ1 are an infrequent cause of heterotaxy. Finally, we characterize embryonic-stage CHD in Foxj1 loss-of-function mice, demonstrating randomized heart looping. Abnormal heart looping includes reversed looping (dextrocardia), ventral looping and no looping/single ventricle hearts. Complex CHDs revealed by histological analysis include atrioventricular septal defects, DORV, single ventricle defects as well as abnormal position of the great arteries. These results indicate that pathogenic variants in FOXJ1 can cause isolated CHD.
Topics: Humans; Male; Forkhead Transcription Factors; Heart Atria; Heart Defects, Congenital; Heart Septal Defects; Heterotaxy Syndrome; Transposition of Great Vessels
PubMed: 37158461
DOI: 10.1093/hmg/ddad065 -
Journal of Clinical Medicine Dec 2023Catheter ablation to perform pulmonary vein isolation (PVI) is established as a mainstay in rhythm control of atrial fibrillation (AF). The aim of this review is to... (Review)
Review
Catheter ablation to perform pulmonary vein isolation (PVI) is established as a mainstay in rhythm control of atrial fibrillation (AF). The aim of this review is to provide an overview of current practice and future perspectives in AF ablation. The main clinical benefit of AF ablation is the reduction of arrhythmia-related symptoms and improvement of quality of life. Catheter ablation of AF is recommended, in general, as a second-line therapy for patients with symptomatic paroxysmal or persistent AF, who have failed or are intolerant to pharmacological therapy. In selected patients with heart failure and reduced left-ventricular fraction, catheter ablation was proven to reduce all-cause mortality. Also, optimal management of comorbidities can reduce AF recurrence after AF ablation; therefore, multimodal risk assessment and therapy are mandatory. To date, the primary ablation tool in widespread use is still single-tip catheter radiofrequency (RF) based ablation. Additionally, balloon-based pulmonary vein isolation (PVI) has gained prominence, especially due to its user-friendly nature and established safety and efficacy profile. So far, the cryoballoon (CB) is the most studied single-shot device. CB-based PVI is characterized by high efficiency, convincing success rates, and a beneficial safety profile. Recently, CB-PVI as a first-line therapy for AF was shown to be superior to pharmacological treatment in terms of efficacy and was shown to reduce progression from paroxysmal to persistent AF. In this context, CB-based PVI gains more and more importance as a first-line treatment choice. Non-thermal energy sources, namely pulsed-field ablation (PFA), have garnered attention due to their cardioselectivity. Although initially applied via a basket-like ablation tool, recent developments allow for point-by-point ablation, particularly with the advent of a novel lattice tip catheter.
PubMed: 38137626
DOI: 10.3390/jcm12247556 -
European Cardiology 2023AF is a chronic and progressive heart rhythm disorder characterised by exacerbations and remissions. Contemporary guidelines recommend antiarrhythmic drugs (AADs) as the... (Review)
Review
AF is a chronic and progressive heart rhythm disorder characterised by exacerbations and remissions. Contemporary guidelines recommend antiarrhythmic drugs (AADs) as the initial therapy for the maintenance of sinus rhythm. However, these medications have modest efficacy and are associated with significant adverse effects. Several recent trials have evaluated catheter ablation as an initial therapy for AF, demonstrating that cryoballoon catheter ablation significantly improves arrhythmia outcomes (e.g. atrial tachyarrhythmia recurrence and arrhythmia burden), produces clinically meaningful improvements in patient-reported outcomes (e.g. symptoms and quality of life), and significantly decreases healthcare resource usage (e.g. hospitalisation), without increasing the risk of serious adverse events. Moreover, in contrast to antiarrhythmic drugs, catheter ablation appears to be disease-modifying, significantly reducing the progression of disease. These findings are relevant to patients, providers, and healthcare systems, helping inform the initial choice of rhythm-control therapy in patients with treatment-naïve AF.
PubMed: 37546183
DOI: 10.15420/ecr.2023.04 -
JACC. Asia Oct 2023
PubMed: 38095002
DOI: 10.1016/j.jacasi.2023.08.005 -
Frontiers in Cardiovascular Medicine 2023For many years, guidelines have suggested thermal ablation for the treatment of atrial fibrillation. Thermal ablation involves the destruction of tissue, leading to... (Review)
Review
For many years, guidelines have suggested thermal ablation for the treatment of atrial fibrillation. Thermal ablation involves the destruction of tissue, leading to multiple complications. This ablation technique has been tried and tested, however, newer techniques are being investigated in order to avoid these complications. Pulsed field ablation, a nonthermal method of tissue ablation, is being explored as a more safe and efficient way to treat atrial fibrillation. This mini review aims to highlight the mechanisms of pulsed field ablation, its history and evolution, previous studies showing its efficacy, its major challenges and pitfalls, and future advancements to overcome these challenges. This method of ablation could potentially revolutionize the treatment of atrial fibrillation and prevent recurrences, thereby making it easier for the physicians and patients involved.
PubMed: 37937293
DOI: 10.3389/fcvm.2023.1235317 -
Frontiers in Cardiovascular Medicine 2023
PubMed: 37829690
DOI: 10.3389/fcvm.2023.1280925 -
JACC. Clinical Electrophysiology Jul 2023Although catheter ablation (CA) is successful for the treatment of paroxysmal atrial fibrillation (AF), results are less satisfactory in persistent AF. Hybrid ablation... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Although catheter ablation (CA) is successful for the treatment of paroxysmal atrial fibrillation (AF), results are less satisfactory in persistent AF. Hybrid ablation (HA) results in better outcomes in patients with persistent atrial fibrillation (persAF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure.
OBJECTIVES
The purpose of this study was to compare the effectiveness and safety of HA with CA in a prospective, superiority, unblinded, randomized controlled trial.
METHODS
Forty-one ablation-naive patients with (long-standing)-persAF were randomized to HA (n = 19) or CA (n = 22) and received pulmonary vein isolation, posterior left atrial wall isolation and, if needed, a cavotricuspid isthmus ablation. The primary efficacy endpoint was freedom from any atrial tachyarrhythmia >5 minutes off antiarrhythmic drugs after 12 months. The primary and secondary safety endpoints included major and minor complications and the total number of serious adverse events.
RESULTS
After 12 months, the freedom of atrial tachyarrhythmias off antiarrhythmic drugs was higher in the HA group compared with the CA group (89% vs 41%, P = 0.002). There was 1 pericarditis requiring pericardiocentesis and 1 femoral arteriovenous-fistula in the HA group. In the CA arm, 1 bleeding from the femoral artery occurred. There were no deaths, strokes, need for pacemaker implantation, or conversions to sternotomy, and the number of (serious) adverse events was comparable between groups (21% vs 14%, P = 0.685).
CONCLUSIONS
Hybrid AF ablation is an efficacious and safe procedure and results in better outcomes than catheter ablation for the treatment of patients with persistent AF. (Hybrid Versus Catheter Ablation in Persistent AF [HARTCAP-AF]; NCT02441738).
Topics: Humans; Atrial Fibrillation; Treatment Outcome; Prospective Studies; Anti-Arrhythmia Agents; Catheter Ablation
PubMed: 36752455
DOI: 10.1016/j.jacep.2022.12.011 -
Journal of Arrhythmia Oct 2023A 72-year-old man was treated for recurrent atrial tachycardia (AT) and underwent ablation. The AT was diagnosed as bi-AT based on the activation map and the postpacing...
A 72-year-old man was treated for recurrent atrial tachycardia (AT) and underwent ablation. The AT was diagnosed as bi-AT based on the activation map and the postpacing interval. Another AT appeared and was diagnosed as bi-AT by the same method. Surprisingly, the circuits of both ATs were perfectly matched and rotated in opposite directions. The left atrial anteroseptal wall was ablated during the AT. The AT was immediately stopped and was no longer induced.
PubMed: 37799785
DOI: 10.1002/joa3.12919 -
Europace : European Pacing,... Dec 2023Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have worse clinical outcomes than those with sinus rhythm (SR). We aim...
AIMS
Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have worse clinical outcomes than those with sinus rhythm (SR). We aim to investigate whether maintaining SR in patients with HFpEF through a strategy such as AF ablation would improve outcomes.
METHODS AND RESULTS
This is a cohort study that analysed 1034 patients (median age 69 [63-76] years, 46.2% [478/1034] female) with HFpEF and AF. Of these, 392 patients who underwent first-time AF ablation were assigned to the ablation group, and the remaining 642 patients, who received only medical therapy, were assigned to the no ablation group. The primary endpoint was a composite of all-cause death or rehospitalization for worsening heart failure. After a median follow-up of 39 months, the cumulative incidence of the primary endpoint was significantly lower in the ablation group compared to the no ablation group (adjusted hazard ratio [HR], 0.55 [95% CI, 0.37-0.82], P = 0.003) in the propensity score-matched model. Secondary endpoint analysis showed that the benefit of AF ablation was mainly driven by a reduction in rehospitalization for worsening heart failure (adjusted HR, 0.52 [95% CI, 0.34-0.80], P = 0.003). Patients in the ablation group showed a 33% relative decrease in atrial tachycardia/AF recurrence compared to the no ablation group (adjusted HR, 0.67 [95% CI, 0.54-0.84], P < 0.001).
CONCLUSION
Among patients with HFpEF and AF, the strategy of AF ablation to maintain SR was associated with a lower risk of the composite outcome of all-cause death or rehospitalization for worsening heart failure.
Topics: Humans; Female; Aged; Atrial Fibrillation; Cohort Studies; Stroke Volume; Heart Failure; Risk Factors
PubMed: 38099508
DOI: 10.1093/europace/euad363