2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary.

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Outcome of Total Pulmonary Vein Isolation in Patients with Persistent Atrial Fibrillation

Background: Although the efficacy of pulmonary vein (PV) isolation for paroxysmal atrial fibrillation (AF) has been well-established, its effect on persistent AF has not been sufficiently established to date. Methods and Results: In 68 consecutive patients (mean age, 52 ± 10 years) with paroxysmal (45) and persistent (23) AF, isolation of all four PVs was performed and the subsequent clinical outcome was evaluated. In total, 268/272 PVs (99%) were completely isolated from the left atrium by radiofrequency applications. During a mean follow-up period of 11 months, 84% of patients with paroxysmal AF and 57% of patients with persistent AF were free from symptomatic AF without any antiarrhythmic drug (AAD) therapy (p = 0.04). In the remaining recurrent AF patients, no significant difference between the paroxysmal and persistent AF was observed as long as they took AADs which had been ineffective at baseline (freedom from AF; 98% and 96%, respectively, p = NS). Repeat procedure performed in the 12 recurrent patients (paroxysmal AF 6, persistent AF 6) allowed 11 (92%) of them to become free from AF recurrence without AADs. Conclusion: Electrical isolation of PV by standard catheter technique is equally and highly effective for both paroxysmal and persistent AF patients, when all four PVs were isolated

When Should We Decide to Perform a Repeat Pulmonary Vein Isolation Procedure in Patients with Atrial Fibrillation?

Background: It is sometimes difficult to differentiate the transient appearance of atrial fibrillation (AF) after pulmonary vein (PV) isolation from a true recurrence of AF. We attempted to differentiate them by analyzing the time course after the procedure. Methods and Results: 79 patients who underwent PV isolation were divided into two groups (successful: N = 60 and unsuccessful: N = 19) according to the final outcome. Antiarrhythmic drugs were used either temporarily or continuously to treat re-appearance of AF after the procedure. The transient appearance of AF in the successful group gradually faded, while true AF recurrence in the unsuccessful group consistently increased in line with the follow-up (F/U) period. The appearance of AF after 3 months predicted a subsequent failure of the procedure with a positive/negative predictive value of 87/90%, respectively. Conclusion: Since the transient appearance of AF decreased and the true recurrence of AF increased in line with the F/U period, we should therefore wait at least 3 months before judging the outcome of PV isolation

Common Trunk of the Inferior Pulmonary Veins in a Patient with Paroxysmal Atrial Fibrillation

Herein we report a case of a patient presenting with paroxysmal atrial fibrillation (PAF) in whom the pulmonary veins (PVs) had a common inferior trunk and PV isolation at the common inferior trunk was successfully performed to prevent recurrence of PAR A 58-year-old man with drug-resistant PAF was referred to undergo curative treatment at our institution. A three-dimensional image of the PVs re-constructed by contrast-enhanced multi-detector computed tomography before the operation revealed a common inferior trunk of the PVs (24mm diameter). Segmental ostial PV isolation with the guidance of a circular mapping catheter was performed for both superior PVs and the common inferior PV trunk. All three PV ostia were successfully isolated from the LA, and the patient has been free from PAF thereafter for 18 months. Preprocedural multi-detector computed tomography or magnetic resonance imaging to evaluate the anatomy of PVs (the number, size, and shape) is thus considered to be useful for performing safe and smooth catheter ablation in patients with PA

Nationwide survey of catheter ablation for atrial fibrillation: The Japanese catheter ablation registry of atrial fibrillation (J-CARAF)–A report on periprocedural oral anticoagulants

Background: Catheter ablation has become an established therapy for the treatment of atrial fibrillation (AF). To obtain a perspective on the current status of this therapy in Japan, the Japanese Heart Rhythm Society (JHRS) conducted a nationwide survey, the Japanese Catheter Ablation Registry of Atrial Fibrillation (J-CARAF). In this study, we focused on whether periprocedural use of novel oral anticoagulants (NOACs) was related with excessive thromboembolic or bleeding complications. Methods: Using an online questionnaire, JHRS requested electrophysiology centers in Japan to register the data of patients who underwent AF ablations in September 2011, March 2012, and September 2012. We compared the clinical profiles and ablation data, including the incidence of complications among patients in whom warfarin, a NOAC or neither was used as a periprocedural anticoagulant. Results: A total of 179 centers submitted data relating to 3373 patients (62.2±10.6 years). Paroxysmal atrial fibrillation (PAF) was observed in 64.4% of patients. Warfarin, as a periprocedural oral anticoagulant, was used by 53.6% (1808/3373) of patients. A NOAC was given to 541 subjects (dabigatran: 504 [16.1%], rivaroxaban: 37 [1.1%]). In the remaining 1024 patients (30.4%), no periprocedural oral anticoagulants (OACs) were used. The proportion of PAF in warfarin-treated patients (61.1%) was significantly lower than that in NOAC-treated patients (70.1%, p<0.01) or in patients not treated with an OAC (67.4%, p<0.01). Patients treated with uninterrupted warfarin therapy were associated with significantly higher CHA2DS2-VASc scores. A total of 158 complications occurred in 151 subjects (4.5%). The incidence of complications in NOAC-treated patients (14/541 [2.6%]) was lower than that in patients receiving uninterrupted warfarin therapy (4.8%, p<0.05). The incidence of pericardial effusion in NOAC-treated patients (0.7%) was lower than in warfarin-treated patients (2.6%, p<0.05). The difference in the periprocedural anticoagulant strategy was not related to the frequency of other bleeding events. Cerebral infarction occurred in one patient from each patient group. Conclusions: Our results suggest that NOACs are safe for use as substitutes for warfarin without causing excessive increases in the rates of thromboembolic or bleeding complications

Unidirectional block on the mitral isthmus during radiofrequency application for perimitral atrial tachycardia

We present the case of a patient who developed regular, narrow QRS tachycardia after ablation for long-standing persistent atrial fibrillation. During the electrophysiological study, this tachycardia was diagnosed as macroreentrant atrial tachycardia circulating around the mitral annulus. Catheter ablation was performed to treat the tachycardia by targeting the linear region between the annulus and the left inferior pulmonary vein. Although linear radiofrequency application along the mitral isthmus (MI) line resulted in the termination of this tachycardia, a unidirectional conduction block was observed through the MI. Bidirectional conduction block was subsequently achieved by delivering supplemental radiofrequency energies at the gap on the MI