471 Arrhythmia-free survival in early-persistent atrial fibrillation patients undergoing radiofrequency catheter ablation

Abstract Aims Despite advances in success rate of paroxysmal atrial fibrillation (PAF) ablation, outcomes of radiofrequency catheter ablation (RFCA) in patients with persistent AF are highly variable. Early persistent AF (EPsAF) is defined as AF that is sustained beyond 7 days but is less than 3 months in duration. Arrhythmia-free survival data after RFCA in this specific population are still limited. We sought to report the outcomes of RFCA in the subgroup of patients with EPsAF, compared to those with PAF and with 'late' persistent AF (LPsAF) lasting between 3 and 12 months. Methods and results Data from 1143 consecutive AF patients receiving their first RFCA were prospectively collected. Patients with EPsAF (n = 190) were compared with PAF (n = 531) and LPsAF (n = 422) patients. All patients received pulmonary vein antrum isolation + posterior wall and sustained non-pulmonary vein (PV) trigger ablation. Non-sustained non-PV triggers were ablated based on operator discretion. Non-PV triggers were defined as sites of firing leading to sustained (>30 s) or non-sustained arrhythmias (<30 s, including premature atrial contractions ≥10 beats/min) with earliest activation outside the PVs. Mean age of the population was 64 ± 11 years. Female patients were more in PAF group (39%) compared to EPsAF (26%) and LPsAF (28%) (P < 0.001). There was no difference in other clinical characteristics among populations. Non-PV triggers were detected more in EPsAF [127 (66.8%)], and LPsAF [296 (70.1%)] patients compared to PAF [185 (34.8%)] (P < 0.001).One-year arrhythmia-free survival rate after a single procedure was 75.0% (398), 74.2% (141), and 64.5% (272) in PAF, EPsAF, and LPsAF, respectively. Success rate was significantly higher in PAF {[HR: 0.67 (0.53, 0.84), P = 0.001] and EPsAF [HR: 0.67 (0.49, 0.93)], P = 0.015} compared to LPsAF. Conclusions In patients with EPsAF, RFCA may result in significantly better freedom from atrial arrhythmias, compared to LPsAF. In this cohort, ablation might be reasonable as first line approach to improve outcomes and prevent AF progression

Long-term Outcome of Pulmonary Vein Isolation Versus Amiodarone Therapy in Patients with Coexistent Persistent AF and Congestive Heart Failure

Although pharmacological rhythm control of AF in patients with heart failure with reduced ejection fraction (HFrEF) does not seem to provide any benefit over rate control, catheter ablation of AF has been shown to improve clinical outcomes. These results can be explained with higher success rates of catheter ablation in restoring and maintaining sinus rhythm compared with antiarrhythmic drugs. In addition, pharmacotherapy is not void of side-effects, which are thought to offset its potential antiarrhythmic benefits. Therefore, efforts should be made towards optimisation of ablation techniques for AF in patients with HFrEF

Environmental Law

Perhaps following broader legal trends, the Eleventh Circuit\u27s environmental law decisions in this survey period suggest a rise in the importance of state law, both as it might impact enforcement of federal environmental programs and as a source of independent environmental remedies. As an example of the former, the court narrowed the extent to which the absence of a state-level program to implement the federal Clean Water Act\u27s permit requirement shields a member of the regulated community from the obligation to obtain a permit. As an example of the latter, the court affirmed an award of $4,350,000 in punitive damages on a common-law nuisance theory in a case in which the actual damages totaled only$47,000 and the administrative penalties under the stateenforced clean water regulations totaled only $10,000. As with earlier environmental law survey articles, this Article will not review basic statutory schemes unless the Eleventh Circuit has not previously interpreted the statute in question. For readers seeking background on the law, a brief overview of those statutes can be found in earlier survey articles

Synthesis of Nitrogen-Substituted Methylenecyclopropanes by Strain-Driven Overman Rearrangement of Cyclopropenylmethyl Trichloroacetimidates

Nitrogen-substituted methylenecyclopropanes have been prepared by a strain-driven Overman rearrangement of cyclopropenylmethyl trichloroacetimidates. The reaction proceeds at room temperature and without the need of a transition-metal catalyst. Furthermore, it has been shown that C-3-substituted cyclopropenylmethyl trichloroacetimidates undergo a hydrolytic ring-opening reaction to form allenylcarbinols