Time to –30°C as a predictor of acute success during cryoablation in patients with atrial fibrillation

Background: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter that could assist pulmonary vein isolation. The aim of this study is to assess freezing rate (time to reach –30°C ([TT-30C]) as an early predictor of acute pulmonary vein isolation using the CB. Methods: Biophysical data from CB freeze applications within a multicenter, nation-wide CB ablation registry were gathered. Successful application (SA), was defined as achieving durable intraprocedural vein isolation with time to isolation in under 60 s (SA-TTI<60) as achieving durable vein isolation in under 60 s. Logistic regressions were performed and predictive models were built for the data set. Results: 12,488 CB applications from 1,733 atrial fibrillation (AF) ablation procedures were included within 27 centers from a Spanish CB AF ablation registry. SA was achieved in 6,349 of 9,178 (69.2%) total freeze applications, and SA-TTI<60 was obtained in 2,673 of 4,784 (55.9%) freezes and electrogram monitoring was present. TT-30C was shorter in the SA group (33.4 ± 9.2 vs 39.3 ± 12.1 s; p < 0.001) and SA-TTI<60 group (31.8 ± 7.6 vs. 38.5 ± 11.5 s; p < 0.001). Also, a 10 s increase in TT-30C was associated with a 41% reduction in the odds for an SA (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.56–0.63) and a 57% reduction in the odds for achieving SA-TTI<60 (OR 0.43; 95% CI 0.39–0.49), when corrected for electrogram visualization, vein position, and application order. Conclusions: Time to reach –30°C is an early predictor of the quality of a CB application and can be used to guide the ablation procedure even in the absence of electrogram monitoring.

Comparison of Radiofrequency Catheter Ablation of Drivers versus Circunferencial Pulmonary Vein Isolation in Patients with Atrial Fibrillation. A Noninferiority Randomized Clinical Trial

BACKGROUND Empiric circumferential pulmonary vein isolation (CPVI) has become the therapy of choice for drugrefractory atrial fibrillation (AF). Although results are suboptimal, it is unknown whether mechanistically-based strategies targeting AF drivers are superior. OBJECTIVES This study sought to determine the efficacy and safety of localized high-frequency source ablation (HFSA) compared with CPVI in patients with drug-refractory AF. METHODS This prospective, multicenter, single-blinded study of 232 patients (age 53 10 years, 186 males) randomized those with paroxysmal AF (n ¼ 115) to CPVI or HFSA-only (noninferiority design) and those with persistent AF (n ¼ 117) to CPVI or a combined ablation approach (CPVI þ HFSA, superiority design). The primary endpoint was freedom from AF at 6 months post-first ablation procedure. Secondary endpoints included freedom from atrial tachyarrhythmias (AT) at 6 and 12 months, periprocedural complications, overall adverse events, and quality of life. RESULTS In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months after a single procedure but, after redo procedures, was noninferior to CPVI at 12 months for freedom from AF and AF/AT. Serious adverse events were significantly reduced in the HFSA group versus CPVI patients (p ¼ 0.02). In persistent AF, there were no significant differences between treatment groups for primary and secondary endpoints, but CPVI þ HFSA trended toward more serious adverse events. CONCLUSIONS In paroxysmal AF, HFSA failed to achieve noninferiority at 6 months but was noninferior to CPVI at 1 year in achieving freedom of AF/AT and a lower incidence of severe adverse events. In persistent AF, CPVI þ HFSA offered no incremental value. (Radiofrequency Ablation of Drivers of Atrial Fibrillation [RADAR-AF]; NCT00674401) (J Am Coll Cardiol 2014;64:2455–67).This study was funded by the Centro Nacional de Investigaciones Cardiovasculares and by an unrestricted research grant from St. Jude Medical. Dr. Atienza has received research grants from St. Jude Medical; and is on the advisory board of Medtronic, Inc. Dr. Jalife is on the scientific advisory board of Topera, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.Martínez Alzamora, MN.; Atienza, F.; Almendral, J.; Ormaetxe, JM.; Moya, Á.; Martínez-Alday, JD.; Hernández-Madrid, A.... (2014). Comparison of Radiofrequency Catheter Ablation of Drivers versus Circunferencial Pulmonary Vein Isolation in Patients with Atrial Fibrillation. A Noninferiority Randomized Clinical Trial. Journal of the American College of Cardiology. 64(23):2455-2467. doi:10.1016/j.jacc.2014.09.053S24552467642

Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation A Report From the GARFIELD-AF Registry

IMPORTANCE Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes

Outcomes in Newly Diagnosed Atrial Fibrillation and History of Acute Coronary Syndromes: Insights from GARFIELD-AF

BACKGROUND: Many patients with atrial fibrillation have concomitant coronary artery disease with or without acute coronary syndromes and are in need of additional antithrombotic therapy. There are few data on the long-term clinical outcome of atrial fibrillation patients with a history of acute coronary syndrome. This is a 2-year study of atrial fibrillation patients with or without a history of acute coronary syndromes