Róbert Pap

Introduction: Restoration and maintenance of sinus rhythm (SR) before pulmonary vein isolation (PVI) by antiarrhythmic drug (AAD) therapy can lead to a better outcome in persistent atrial fibrillation (AF). It is unknown, however if pharmacologic conversion by amiodarone loading itself, compared to the need for additional electrical cardioversion (ECV), predicts a better outcome of PVI. Furthermore, it remains controversial whether subsequent AF episodes occurring while on amiodarone before PVI, have any predictive value. Our aim was to assess whether amiodarone response before the procedure shows predictive value in patients with persistent AF undergoing PVI. Methods and Results: We retrospectively collected data from consecutive patients with persistent AF who underwent PVI between 2013 and 2023, and who received temporary amiodarone therapy, with or without ECV to restore and maintain sinus rhythm before the intervention. A total of 353 patients (30% female, mean age: 63.76 ± 9.27 years) were included. Conversion to sinus rhythm was achieved solely by amiodarone therapy (AmioConv) in 96 patients (27%), while 257 patients (73%) required additional ECV as well. There were no differences between the two groups in terms of comorbidities, CHADS‐VASc score (2.46 ± 1.43 vs. 2.26 ± 1.48, p = 0.27), or echocardiographic parameters, but the AmioConv group had a shorter history of AF (2.22 ± 2.96 years vs. 3.74 ± 4.64 years, p < 0.01). During a mean follow‐up of 3.48 ± 2.32 years after PVI, patients in the AmioConv group less frequently experienced AF recurrences (41% vs. 56%, p = 0.016) and had significantly longer mean recurrence‐free survival (5.21 ± 0.54 vs. 3.6 ± 0.35 years, p < 0.01), compared to the ECV group. The lack of pharmacologic conversion by amiodarone therapy (need for ECV) was found to be the only independent predictor of post PVI recurrences (adjusted HR 1.86, 95% CI 1.21–2.85, p < 0.01). On the contrary, breakthrough episodes of AF during amiodarone therapy, before ablation, were not predictive (adjusted HR 0.87, 95% CI 0.57–1.32, p = 0.51). Conclusion: In patients with persistent atrial fibrillation the outcome after PVI is predicted by pharmacologic conversion during amiodarone loading, but not the reoccurrence of the arrhythmia during continued pre‐ablation AAD therapy.

Background: Better outcome has been suggested for repeat procedures after atrial fibrillation (AF) ablation, when recurrence presented as organized atrial tachycardia (OAT) compared to recurrent AF. However, this contradicts the finding of more advanced atrial remodeling in patients with OAT recurrence and may be related to iatrogenesis by substrate modification during the index procedure. Therefore, we examined the prognostic significance of the type of recurrent arrhythmia after pulmonary vein isolation (PVI) without additional substrate modification. Methods: We included 185 patients (88 female, 64 ± 9 years) undergoing repeat ablation after index PVI for recurrent OAT (24%) or AF (76%). The recurrence rate, arrhythmia‐free survival time, and the type of further recurrences were recorded. Results: There was no difference in the rate and mean time of arrhythmia‐free survival between patients with OAT versus AF recurrence after the first (49% vs. 52%, p = .72 and 51.08 ± 6.66 vs. 53.37 ± 4.75 months, p = .54, respectively) and last (60% vs. 58%, p = .80 and 63.2 ± 7.04 vs. 61.2 ± 5.32 months, p = .23, respectively) redo procedure. AF occurred in the majority of subsequently recurring patients in both groups. No significant difference was found in the outcome of redo procedures between patients with typical flutter and atypical OAT, but a higher rate of successful rhythm control was observed in those with paroxysmal, as compared to persistent AF recurrence. Conclusion: After a PVI‐only index procedure, recurrent OAT is not associated with a better outcome of redo procedures compared to recurrent AF. After repeat ablations, both groups experience AF as the dominant further recurrence.

Background: An atrioventricular defibrillator system with a floating atrial dipole (VDD ICD) can provide atrial sensing by a single lead. Our aim was to compare the arrhythmia detection efficacy of VDD ICDs with conventional single- (VVI) and dual-chamber (DDD) defibrillators. Methods: Data from consecutive patients undergoing ICD implantation were retrospectively analyzed. The primary endpoint was the incidence of device-detected, new-onset atrial arrhythmias, while secondary endpoints were sensing parameters, complication rates, incidence of appropriate/inappropriate ICD therapy, arrhythmic/heart failure-related hospitalizations, and all-cause mortality. Results: A total of 256 patients (mean age 64 ± 12 years, male 75%, primary prophylaxis 28%, mean follow-up 3.7 ± 2.4 years) were included (VVI: 93, VDD: 94, DDD: 69). Atrial arrhythmia episodes were detected more frequently by VDD systems compared to VVI ICDs (aHR 7.087; 95% CI 2.371–21.183; p < 0.001), and at a rate similar to that of DDD ICDs (aHR 1.781; 95% CI 0.737–4.301; p = 0.200). The rate of inappropriate shocks was not different among the three ICD systems. Conclusion: VDD devices revealed an advantage in atrial arrhythmia detection compared to VVI ICDs and were non-inferior to DDD systems. Their main indication may be closer monitoring in high-risk patients with atrial arrhythmias to help therapy optimization and not the improvement of tachycardia discrimination.

Introduction: Routine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized‐trial data.Methods: Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi‐random allocation to either US‐guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US‐guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation).Results: Of the 457 patients 199 were allocated to the US‐guided puncture group, while the conventional, palpation‐based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p < .0001), including both major (4.26% vs. 1.01%, p = .038) and minor (7.36% vs. 1.01%, p = .001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US‐guided puncture group (5.04% vs. 1.01%, p = .032).Conclusion: The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi‐randomized comparison strongly supports adapting routine use of US for AF ablation procedures.

Introduction Failure to isolate ipsilateral pulmonary veins (PV) "en bloc" by wide-area circumferential ablation (WACA) may necessitate ablation at the intervenous carina. It is unknown how this scenario impacts rates of atrial fibrillation (AF) recurrence. Methods A standard random-effect meta-analysis of randomized or observational studies were performed, where the outcome of first-time AF ablation was reported in patients with "en bloc" isolation of PVs by WACA as compared with those in whom ablation at the intervenous carina was needed after WACA to achieve complete isolation. Results A total of five single-center, observational studies (N = 1185) and one, multi-center randomized trial (N = 234) were enrolled. PV isolation could be achieved by WACA "en bloc" in 902/1419 (63.6%) cases. The rest required additional ablation at one or both of the left and right intervenous carinas to achieve isolation. The follow-up time after ablation ranged from 1 to 2 years in the included trials. The incidence of AF recurrence proved to be significantly lower in patients with successful "en bloc" isolation compared to those requiring carina ablation(s) to achieve complete bilateral PV isolation (MH-OR 1.89, 95% CI 1.42-2.53, p < .01) Conclusion This present meta-analysis demonstrates a lower arrhythmia recurrence rate in patients with bilateral "en bloc" isolation, as compared to those who needed additional carina ablation for complete PVI. Therefore, it is imperative that every effort be made to isolate ipsilateral PVs "en bloc" during PVI.

Background: The two most common postoperative atrial flutter (AFL) circuits after right atriotomy are the cavotricuspid isthmus (CTI) dependent and the lateral, peri‐incisional. We investigated whether radiofrequency ablation (RFA) of both circuits results in more favorable long‐term outcomes.Methods: Single‐center retrospective cohort study of consecutive patients who underwent RFA of AFL after open‐heart surgery. The effect of surgery type and RFA strategy on AFL recurrence was evaluated.Results: One hundred and forty‐two patients (mean age 64.5 ± 12.7 years, 65.% male) were enrolled. Patients with right atrial (RA) flutter (n = 124) were divided into two groups based on the index RFA procedure: only one RA circuit was ablated (Group 1, n = 84, 67.7%) or both the CTI and the peri‐incisional circuit ablated (Group 2, n = 40, 32.3%). The previous open‐heart surgery was categorized based on the extension of the RA incision: limited (Type A) or extended (Type B) atriotomy. After a mean follow‐up of 36 ± 28 months, flutter recurrence was not different among patients with limited RA atriotomy (25% vs. 22% in Groups 1A and 2A, respectively, p = 1.0). However, after type B surgery, ablation of both AFL circuits was associated with a reduced recurrence rate (63% vs. 26% in Groups 1B and 2B, respectively, p = .002).Conclusions: In patients with postoperative RA flutter after extended right atriotomy, ablation of both the CTI and the peri‐incisional isthmus significantly reduces the AFL recurrence rate. Prophylactic ablation of both isthmi, even if not proven to support reentry, is reasonable in this population.

A case is presented where the emergence of inferior, pathologic Q-waves aids in the differential diagnosis.