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Journal of Clinical Medicine Jan 2023Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient-provider risk-benefit... (Review)
Review
BACKGROUND
Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with high morbidity and mortality. AF treatment is guided by a patient-provider risk-benefit discussion regarding drug versus ablation or combination. Thermal ablation has a high rate of adverse events compared to pulsed field ablation (PFA). In this systematic review, we aimed to determine the safety and efficacy of PFA.
METHODS
The electronic search for relevant articles in English was completed in PubMed, PubMed Central, Cochrane library, Scopus, and Embase databases till July 2022. The screening was completed via the use of Covidence software. The risk of bias assessment and data extraction from the included studies was performed, and the narrative synthesis was performed accordingly.
RESULTS
A total of six studies were selected for review and 1897 patients receiving PFA were involved in these studies. Our review was focused on pulmonary vein isolation success, major adverse events, and arrhythmia recurrence. Successful pulmonary vein isolation (PVI) was completed in 100% of cases except in two studies. In one of them, six out of seven patients (86%) in the epicardial cohort had successful PVI. In the MANIFEST-PF survey, the acute PVI success rate was 99.9%. The major complications were rare and included pericardial tamponade, vascular complications requiring surgery, and stroke. The atrial arrhythmia recurrence was higher in the thermal group than in the PFA group (39% vs. 11%).
CONCLUSIONS
The success rate of PVI by PFA is high, and major adverse events are low. PFA is found to decrease the recurrence of atrial arrhythmia compared to thermal ablation. Substantial randomized controlled trials (RCTs) are needed to validate the efficacy and safety of PFA over conventional methods.
PubMed: 36675649
DOI: 10.3390/jcm12020719 -
Arquivos Brasileiros de Cardiologia Jul 2022Catheter ablation is a well-established therapy for rhythm control in patients who are refractory or intolerant to anti-arrhythmic drugs (AAD). Less is known about the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Catheter ablation is a well-established therapy for rhythm control in patients who are refractory or intolerant to anti-arrhythmic drugs (AAD). Less is known about the efficacy of catheter ablation compared with AAD as a first-line strategy for rhythm control in atrial fibrillation (AF).
OBJECTIVES
We aimed to perform a systematic review and meta-analysis of catheter ablation vs. AAD in patients naïve to prior rhythm control therapies.
METHODS
PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials that compared catheter ablation to AAD for initial rhythm control in symptomatic AF and reported the outcomes of (1) recurrent atrial tachyarrhythmias (ATs); (2) symptomatic AF; (3) hospitalizations; and (4) symptomatic bradycardia. Heterogeneity was examined with I2statistics. P values of < 0.05 were considered statistically significant.
RESULTS
We included five trials with 994 patients, of whom 502 (50.5%) underwent catheter ablation. Mean follow-up ranged from one to five years. Recurrences of AT (OR 0.36; 95% CI 0.25-0.52; p<0.001) and symptomatic AF (OR 0.32; 95% CI 0.18-0.57; p<0.001), and hospitalizations (OR 0.25; 95% CI 0.15-0.42; p<0.001) were significantly less frequent in patients treated with catheter ablation compared with AAD. Symptomatic bradycardia was not significantly different between groups (OR 0.55; 95% CI 0.18-1.65; p=0.28). Significant pericardial effusions or tamponade occurred in eight of 464 (1.7%) patients in the catheter ablation group.
CONCLUSION
These findings suggest that catheter ablation has superior efficacy to AAD as an initial rhythm control strategy in patients with symptomatic AF.
Topics: Anti-Arrhythmia Agents; Atrial Fibrillation; Catheter Ablation; Heart Atria; Humans; Recurrence; Treatment Outcome
PubMed: 35830118
DOI: 10.36660/abc.20210477 -
Journal of the American College of... Feb 2022Hypertrophic cardiomyopathy (HCM), a relatively common, globally distributed, and often inherited primary cardiac disease, has now transformed into a contemporary highly...
Hypertrophic cardiomyopathy (HCM), a relatively common, globally distributed, and often inherited primary cardiac disease, has now transformed into a contemporary highly treatable condition with effective options that alter natural history along specific personalized adverse pathways at all ages. HCM patients with disease-related complications benefit from: matured risk stratification in which major markers reliably select patients for prophylactic defibrillators and prevention of arrhythmic sudden death; low risk to high benefit surgical myectomy (with percutaneous alcohol ablation a selective alternative) that reverses progressive heart failure caused by outflow obstruction; anticoagulation prophylaxis that prevents atrial fibrillation-related embolic stroke and ablation techniques that decrease the frequency of paroxysmal episodes; and occasionally, heart transplant for end-stage nonobstructive patients. Those innovations have substantially improved outcomes by significantly reducing morbidity and HCM-related mortality to 0.5%/y. Palliative pharmacological strategies with currently available negative inotropic drugs can control symptoms over the short-term in some patients, but generally do not alter long-term clinical course. Notably, a substantial proportion of HCM patients (largely those identified without outflow obstruction) experience a stable/benign course without major interventions. The expert panel has critically appraised all available data and presented management insights and recommendations with concise principles for clinical decision-making.
Topics: Cardiomyopathy, Hypertrophic; Death, Sudden, Cardiac; Humans
PubMed: 35086661
DOI: 10.1016/j.jacc.2021.11.021 -
Heart Rhythm O2 Aug 2022Hybrid Convergent ablation for atrial fibrillation (AF) combines minimally invasive surgical (epicardial) and catheter (endocardial) ablation. The procedural goal is to...
BACKGROUND
Hybrid Convergent ablation for atrial fibrillation (AF) combines minimally invasive surgical (epicardial) and catheter (endocardial) ablation. The procedural goal is to achieve more extensive, enduring ablation of AF substrate around the pulmonary veins, posterior wall, and vestibule of the posterior wall left atrium.
OBJECTIVE
To perform a systematic review and meta-analysis on safety and effectiveness of contemporary Hybrid Convergent procedures.
METHODS
PubMed, Embase, and manual searches identified primary research articles on Hybrid Convergent. Inclusion criteria focused on contemporary practices (epicardial ablation device and lesions). Clinical outcomes at 1 year or later follow-up, patient population, procedural details, and major adverse events (MAE) were recorded.
RESULTS
Of 249 records, 6 studies (5 observational, 1 randomized controlled trial) including 551 patients were included. Endocardial energy sources included radiofrequency and cryoballoon. Hybrid Convergent ablation was mostly performed in patients with drug-refractory persistent and longstanding persistent AF. Mean preprocedural AF duration ranged between 2 and 5.1 years. Most patients (∼92%) underwent Hybrid Convergent in a single hospitalization. At 1 year follow-up or later, 69% (95% confidence interval [CI]: 61%-78%, n = 523) were free from atrial arrhythmias and 50% (95% CI: 42%-58%, n = 343) were free from atrial arrhythmias off antiarrhythmic drugs. Thirty-day MAE rate was 6% (95% CI: 3%-8%, n = 551).
CONCLUSION
Hybrid Convergent ablation is an effective ablation strategy for persistent and longstanding persistent AF. Contemporary procedural approaches and published strategies aim to mitigate complications reported in early experience and address delayed inflammatory effusions.
PubMed: 36097459
DOI: 10.1016/j.hroo.2022.05.006 -
JTCVS Open Sep 2021Both catheter and surgical ablation strategies offer effective treatments of atrial fibrillation (AF). The hybrid (joint surgical and catheter) ablation for AF is an...
BACKGROUND
Both catheter and surgical ablation strategies offer effective treatments of atrial fibrillation (AF). The hybrid (joint surgical and catheter) ablation for AF is an emerging rhythm control strategy. We sought to determine the efficacy and safety of hybrid ablation of AF.
METHODS
Systematic review and meta-analysis interrogating PubMed, EMBASE, and Cochrane databases from January 1, 1991, to November 30, 2017, using the following search terms: "Cox-maze," "mini-maze," "ablation methods (including radiofrequency, cryoablation, cryomaze)," and "surgery." Included studies required ablation procedures to be hybrid and report rhythm follow-up.
RESULTS
We included 925 patients with AF (38% persistent, 51% longstanding persistent) from 22 single-center studies (mean follow-up of 19 months). The surgical lesion set consisted of pulmonary vein isolation (n = 11) or box lesion (n = 11) with variable additional linear ablation. This was followed by sequential (n = 9), staged (n = 9), or combination (n = 4) catheter-based ablation to ensure isolation of pulmonary veins and to facilitate additional ablation or consolidation of surgically ablated lines. Overall, sinus rhythm maintenance was 79.4% (95% confidence interval [CI], 72.4-85.7] and 70.7% (95% CI, 62.2-78.7) with and without antiarrhythmic drugs, respectively at 19 ± 25 (range, 6-128) months. The use of the bipolar AtriCure Synergy system and left atrial appendage exclusion conferred superior rhythm outcome without antiarrhythmic drugs ( ≤ .01). The overall complication rate was 6.5% (95% CI, 3.4-10.2): mortality 0.2% (95% CI, 0-0.9); stroke 0.3% (95% CI, 0-1.1); reoperation for bleeding 1.6% (95% CI, 0.6-3.0); permanent pacing ~0% (95% CI, 0-0.5); conversion to sternotomy 0.3% (95% CI, 0-1.1); atrioesophageal fistula ~0% (95% CI, 0-0.5); and phrenic nerve injury 0.3% (95% CI, 0-1.1).
CONCLUSIONS
Hybrid ablation therapy for AF demonstrates favorable rhythm outcome with acceptable complication rates.
PubMed: 36003726
DOI: 10.1016/j.xjon.2021.07.005 -
Annals of the Academy of Medicine,... Jan 2023Despite promising trials, catheter ablation is still regarded as an adjunct to antiarrhythmic drugs (AADs) in the treatment of paroxysmal atrial fibrillation (PAF). This... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Despite promising trials, catheter ablation is still regarded as an adjunct to antiarrhythmic drugs (AADs) in the treatment of paroxysmal atrial fibrillation (PAF). This study aimed to compare the effectiveness of various ablation therapies and AADs.
METHOD
Randomised controlled trials or propensity score-matched studies comparing atrial tachyarrhythmia recurrence among any combination of ablation modalities or AAD were retrieved. Kaplan-Meier curves and risk tables for this outcome were graphically reconstructed to extract patient-level data. Frequentist network meta-analysis (NMA) using derived hazard ratios (HRs), as well as 2 restricted mean survival time (RMST) NMAs, were conducted. Treatment strategies were ranked using P-scores.
RESULTS
Across 24 studies comparing 6 ablation therapies (5,132 patients), Frequentist NMA-derived HRs of atrial fibrillation recurrence compared to AAD were 0.35 (95% confidence interval [CI]=0.25-0.48) for cryoballoon ablation (CBA), 0.34 (95% CI=0.25-0.47) for radiofrequency ablation (RFA), 0.14 (95% CI=0.07-0.30) for combined CBA and RFA, 0.20 (95% CI=0.10-0.41) for hot-balloon ablation, 0.43 (95% CI=0.15-1.26) for laser-balloon ablation (LBA), and 0.33 (95% CI=0.18-0.62) for pulmonary vein ablation catheter. RMST-based NMAs similarly showed significant benefit of all ablation therapies over AAD. The combination of CBA + RFA showed promising long-term superiority over CBA and RFA, while LBA showed favourable short-term efficacy.
CONCLUSION
The advantage of ablation therapies over AAD in preventing atrial tachyarrhythmia recurrence suggests that ablation should be considered as the first-line treatment for PAF in patients fit for the procedure. The promising nature of several specific therapies warrants further trials to elicit their long-term efficacy and perform a cost-benefit analysis.
Topics: Humans; Anti-Arrhythmia Agents; Atrial Fibrillation; Catheter Ablation; Heart Atria; Network Meta-Analysis; Recurrence; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 36730803
DOI: 10.47102/annals-acadmedsg.2022326 -
Heart, Lung & Circulation May 2018Adenosine can be used to reveal dormant pulmonary vein (PV) conduction after pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). We performed a... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Adenosine can be used to reveal dormant pulmonary vein (PV) conduction after pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). We performed a systematic review and meta-analysis to assess the impact of adenosine administration in patients undergoing PVI for AF.
METHODS
Meta-analysis of 22 studies was performed to assess the rates of freedom from AF in 1) patients with dormant PV conduction versus patients without dormant PV conduction, and 2) patients given routine adenosine post PVI versus patients not given adenosine. Relative-risks (RR) were calculated using random effects modelling.
RESULTS
In 18 studies, 3038 patients received adenosine and freedom from AF in those patients with dormant PV reconnection was significantly lower (62.9%) compared to patients without PV reconnection (67.2%) (RR 0.87; 95% CI: 0.78-0.98). In seven studies with 3049 patients, the freedom from AF was significantly higher in patients who received adenosine (67%) versus those patients who did not receive adenosine (63%) (RR: 1.11; 95% CI: 1.01-1.22).
CONCLUSIONS
The present study showed clear benefits of adenosine testing for freedom from AF recurrence. Adenosine-guided dormant conduction is associated with higher AF recurrence despite further ablation. Future studies should investigate the optimal methodology, including dosage and waiting time between PVI and adenosine administration.
Topics: Adenosine; Atrial Fibrillation; Catheter Ablation; Heart Conduction System; Heart Rate; Humans; Postoperative Period; Vasodilator Agents
PubMed: 28655535
DOI: 10.1016/j.hlc.2017.04.020 -
Pacing and Clinical Electrophysiology :... Oct 2021Cavotricuspid isthmus (CTI) ablation in typical atrial flutter (AFL) restores sinus rhythm in 95% of patients, which may lead to the discontinuation of oral... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Cavotricuspid isthmus (CTI) ablation in typical atrial flutter (AFL) restores sinus rhythm in 95% of patients, which may lead to the discontinuation of oral anticoagulation during follow-up. Therefore, we aimed to systematically review the clinical impact of oral anticoagulation in the incidence of thromboembolic events (TE) after typical AFL ablation.
METHODS
We searched for controlled studies evaluating the impact of anticoagulation in the incidence of TE in patients submitted to AFL ablation in MEDLINE, CENTRAL, PsycINFO database (June/2021). The primary outcome was TE events (ischemic stroke or systemic embolism). A meta-analysis was performed deriving risk ratios (RR) and 95% confidence intervals (CI). Statistical heterogeneity was measured through I metric. The confidence in the evidence was appraised with Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.
RESULTS
Eight observational studies with 4870 patients were included. TE events were not significantly reduced (RR 1.18, 95% CI 0.59-2.36; n = 4870; GRADE very low). A meta-regression showed that for each 10% increase in the prevalence of previous AF in the studied population, anticoagulation reduced TE risk in 32%. There were no significant differences regarding bleeding events (RR 2.16, 95% CI 0.43-10.97, I = 0%; GRADE low), but there was a lower all-cause mortality (RR 0.24, 95% CI 0.17-0.32, GRADE low).
CONCLUSION
The best available evidence lacks robustness and the data did not definitely associate anticoagulation after typical AFL ablation with reduced TE.
Topics: Administration, Oral; Anticoagulants; Atrial Flutter; Catheter Ablation; Humans; Postoperative Complications; Thromboembolism
PubMed: 34409630
DOI: 10.1111/pace.14342 -
Annals of Palliative Medicine Oct 2021This study analyzes and compares the efficacy of using catheter ablation (CA) and traditional drug treatments for atrial fibrillation (AF). Through a systematic review... (Meta-Analysis)
Meta-Analysis
BACKGROUND
This study analyzes and compares the efficacy of using catheter ablation (CA) and traditional drug treatments for atrial fibrillation (AF). Through a systematic review and meta-analysis, it seeks to provide a theoretical basis for using clinical CA for patients with AF.
METHODS
We searched through articles detailing randomly controlled trials (RCTs) that assessed the surgical effect of CA on the treatment of AF. These articles were published before January 31, 2000 in various English databases, including PubMed, Embase, Medline, Ovid, Springer, and Web of Sciences. The Cochrane Handbook for Systematic Reviews of Intervention 5.0.2 was adopted for the bias risk assessment, and Review Manager 5.3 software was used for the meta-analysis of the articles.
RESULTS
A total of 2,098 patients drawn from 13 articles were included in the study. For patients in the experimental group (Exp. group), the meta-analysis showed an increase in the effects of clinical treatment [mean deviation (MD) =3.91; 95% confidence interval (CI), 3.15-4.85; Z=12.36; P<0.00001], an improvement in daily life function (MD =1.45; 95% CI, 1.03-1.87; Z=6.82; P<0.00001), a decrease in body weakness (MD =-2.84; 95% CI, -3.24 to -2.45; Z=14.16; P <0.00001), and an increase in quality of life score (MD =14.15; 95% CI, 7.24-21.05; Z=4.01; P<0.0001). The Exp. group also experienced a reduction in postoperative pain level (MD =-2.5; 95% CI, -3.11 to -1.89; Z=8.04; P<0.00001), reoccurrence of symptomatic AF (OR =0.27; 95% CI, 0.11-0.67; Z=2.82; P=0.005), rehospitalization (MD =0.15; 95% CI, 0.07-0.31; Z=5.11; P<0.00001), other arrhythmia (MD =0.33; 95% CI, 0.18-0.6; Z=3.62; P=0.0003), and pulmonary vein stenosis (PVS) (MD =0.32; 95% CI, 0.14-0.72; Z=2.74; P=0.006). However, in contrast to patients in the control group (Ctrl group), the 'bleeding' mentioned above showed no statistical difference.
DISCUSSION
CA has a good postoperative clinical effect on AF patients, reducing incidences of pain, adverse reactions, and rehospitalization. For this reason, CA is a suitable treatment for AF patients who do not effectively respond to drug therapy.
Topics: Atrial Fibrillation; Catheter Ablation; Humans; Risk Assessment; Treatment Outcome
PubMed: 34763501
DOI: 10.21037/apm-21-2313 -
Frontiers in Cardiovascular Medicine 2023Catheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed... (Review)
Review
INTRODUCTION
Catheter ablation for atrial fibrillation (AF) is the most frequently performed cardiac ablation procedure worldwide. The majority of ablations can now be performed safely with minimal radiation exposure or even without the use of fluoroscopy, thanks to advances in 3-dimensional electroanatomical mapping systems and/or intracardiac echocardiography. The aim of this study was to conduct a meta-analysis to compare the effectiveness of zero fluoroscopy (ZF) versus non-zero fluoroscopy (NZF) strategies for AF ablation procedures.
METHODS
Electronic databases were searched and systematically reviewed for studies comparing procedural parameters and outcomes of ZF vs. NZF approaches in patients undergoing catheter ablation for AF. We used a random-effects model to derive the mean difference (MD) and risk ratios (RR) with a 95% confidence interval (CI).
RESULTS
Our meta-analysis included seven studies comprising 1,593 patients. The ZF approach was found to be feasible in 95.1% of patients. Compared to the NZF approach, the ZF approach significantly reduced procedure time [mean difference (MD): -9.11 min (95% CI: -12.93 to -5.30 min; < 0.01)], fluoroscopy time [MD: -5.21 min (95% CI: -5.51 to -4.91 min; < 0.01)], and fluoroscopy dose [MD: -3.96 mGy (95% CI: -4.27 to -3.64; < 0.01)]. However, there was no significant difference between the two groups in terms of total ablation time [MD: -104.26 s (95% CI: -183.37 to -25.14; = 0.12)]. Furthermore, there was no significant difference in the acute [risk ratio (RR): 1.01, 95% CI: 1.00-1.02; = 0.72] and long-term success rates (RR: 0.96, 95% CI: 0.90-1.03; = 0.56) between the ZF and NZF methods. The complication rate was 2.76% in the entire study population and did not differ between the groups (RR: 0.94, 95% CI: 0.41-2.15; = 0.89).
CONCLUSION
The ZF approach is a feasible method for AF ablation procedures. It significantly reduces procedure time and radiation exposure without compromising the acute and long-term success rates or complication rates.
PubMed: 37396578
DOI: 10.3389/fcvm.2023.1178783