Catheter Ablation – ABC CARDIOL

ABCHF

Case Report

Wolff–Parkinson–White Syndrome in a Heart Transplant Recipient

Adir Schreiber Junior et al. Lucas Simonetto Faganello Ana Paula Arbo Magalhães Kaleb Pinto Spannemberger … Eduardo Caberlon Leandro Ioschpe Zimerman Mauricio Pimentel

Abstract

A 44-year-old woman underwent heart transplantation due to refractory angina and advanced heart failure. During the postoperative period, she developed episodes of supraventricular tachycardia and intermittent ventricular pre-excitation on the electrocardiogram. After an initial period of pharmacological management, she underwent successful radiofrequency ablation of a left posteroseptal accessory pathway. A review of the literature regarding Wolff–Parkinson–White syndrome in heart transplant recipients is also presented.

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ABC

Review Article

Impact of Catheter Ablation on LVEF in Patients with Atrial Fibrillation and Heart Failure with Reduced Ejection Fraction: A Systematic Review

Antonio Maria Zacarias Araújo Monteiro et al. Maria Giovanna da Cruz Tocantins Jéssica Batista Souza Renan de Jesus da Silva Albuquerque … João Vitor Ferreira de Oliveira Roni Oliveira Pinheiro Ster Marques de Lima Silva

Abstract

Atrial fibrillation (AF) is a condition that frequently affects patients with heart failure with reduced ejection fraction (HFrEF) and is associated with worsening left ventricular ejection fraction (LVEF) and unfavorable clinical outcomes. Catheter ablation has been proposed as a strategy to restore sinus rhythm; however, its effects on LVEF remain heterogeneous in the literature. To evaluate the impact of catheter ablation, compared with medical therapy, on LVEF in patients with AF and HFrEF. A systematic review of randomized clinical trials was conducted in accordance with the PRISMA guidelines. The primary outcome was improvement in LVEF, while secondary outcomes included cardiovascular mortality, all-cause mortality, and hospitalizations due to heart failure. Other exploratory outcomes were also considered. The included randomized clinical trials demonstrated improvement in LVEF among patients undergoing catheter ablation compared with those receiving medical therapy. In the CAMERA-MRI study, an absolute increase of 18.3% in LVEF was observed after six months. In the CASTLE-AF trial, catheter ablation was also associated with a lower incidence of cardiovascular mortality and heart failure hospitalizations. In the absence of a meta-analysis, no quantitative synthesis of the effects was performed. The available evidence from individual randomized trials suggests that catheter ablation may be associated with improvement in LVEF and more favorable clinical outcomes in patients with AF and HFrEF. However, given the lack of quantitative synthesis, these findings should be interpreted with caution.

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ABC

Research Letter

Reversibility of Heart Failure after Catheter Ablation in Patients with Ventricular Pre-Excitation-Induced Cardiomyopathy

Samuel Santos Boa Morte et al. Luiz Pereira de Magalhães Jussara de Oliveira Pinheiro Duarte Alex Teixeira Guabiru … Adimeia Souza Santos Eduardo Faria Soares de Magalhães Roque Aras

Introduction

Ventricular pre-excitation is characterized by the presence of an atrioventricular accessory pathway, predisposing patients to cardiac arrhythmias that may lead to syncope, palpitations, or sudden death. Although rare, a possible complication is the development of heart failure (HF), referred to as pre-excitation–induced cardiomyopathy. It has been suggested that the eccentric ventricular activation caused by the accessory pathway leads to mechanical ventricular dyssynchrony, resulting in structural alterations and ventricular dysfunction. Case reports have described improvement of HF after catheter ablation of the accessory pathway. It is important to alert the medical community to this rare entity, which should be considered in patients with ventricular pre-excitation and reduced ejection fraction, as it represents a potentially reversible cause of HF following ablation.

[…]

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IJCS

Original Article

Long-Term Clinical Outcomes of Catheter Ablation in Hypertrophic Cardiomyopathy and Atrial Fibrillation: A Systematic Review and Meta-Analysis

Acácio Fernandes Cardoso et al. Fernanda Cristina Poscai Ribeiro Luiz Claudio Behrmann Martins Glaucylara Reis Geovanini … Cynthia Aparecida da Silva Rocha Nemer Luiz Pichara Áleff Mascarenhas da Silva

Abstract

Background:

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of atrial fibrillation (AF). However, the benefits of catheter ablation (CA) for reducing adverse clinical outcomes in this population are not well established.

Objective:

To assess the long-term impact of CA on clinical outcomes in patients with HCM and AF through a systematic review and meta-analysis.

Methods:

Controlled studies of patients with HCM and AF undergoing CA were identified through PubMed/MEDLINE, Embase, LILACS, and Cochrane. Meta-analysis employed a random-effects model in R Studio, version 4.3.2, with p < 0.05 considered significant.

Results:

Four retrospective cohort studies met inclusion criteria, all with long follow-up period (5.52 ± 0.91 years). Arrhythmia-free survival after multiple CA ranged from 36.3% to 82%. Combined event analysis (mortality, stroke, and heart failure) yielded odds ratio 0.22 (95% confidence interval 0.08 to 0.60; p < 0.05; I² = 64%). In individual analysis, only heart failure hospitalizations were significantly lower in the CA group (odds ratio 0.32; 95% confidence interval 0.13 to 0.82; p = 0.01).

Conclusions:

This study suggests that CA may improve clinical outcomes in patients with HCM and AF, particularly by improving heart failure hospitalizations. Studies with greater methodological rigor are needed to prove this hypothesis, since only four studies were included in this systematic review.

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ABC

Original Article

Brazilian Registry of Pulsed Field Catheter Ablation for the Treatment of Patients with Atrial Fibrillation

Bruna Miers May et al. Nilson Araujo Junior Silvia Helena Cardoso Boghossian Jacob Atie … Washington A. Maciel Carina Abigail Hardy Alexander Romeno Janner Dal Forno Eduardo B. Saad Claudio Munhoz Angelo Amato Vincenzo de Paola Mauricio Scanavacca Andre Zimerman José Tarcísio Medeiros de Vasconcelos André d’Avila

Abstract

Background:

Pulsed field ablation (PFA), a new catheter-based, non-thermal ablation technique, enhances the safety and efficacy of catheter ablation of atrial fibrillation (AF) compared to conventional thermal methods. While widely adopted in Europe and the United States, its application in Brazil is recent and remains undocumented.

Objective:

This study reports the initial multicenter Brazilian experience with the pulse field ablation to treat patients with AF, emphasizing its rapid adoption and short learning curve.

Methods:

A retrospective analysis of 394 consecutive procedures, performed by 60 operators across multiple Brazilian centers, was conducted. Data encompassed patient demographics, procedural metrics, imaging modalities, and ablation outcomes. A sub-analysis compared high-volume operators (n=139 procedures) with others (n=255). All statistical tests were two-tailed, with a p-value threshold of <0.05 for statistical significance.

Results:

Paroxysmal AF was predominant (62%), with pulmonary vein isolation (PVI) only as the primary lesion set in 54%. General anesthesia was near-universal (98%), and no major complications occurred. High-volume centers had significantly shorter procedure and ablation times (82 ± 27 vs. 131 ± 76 minutes; p<0.001 and 33 ± 14 vs. 50 ± 33 minutes; p<0.001, respectively), alongside fewer additional lesions after remapping (7% vs. 30%; p<0.001), suggesting a rapid learning curve.

Conclusion:

Pulsed field ablation demonstrates high acute efficacy, safety, and ease of adoption in Brazil, with a notably short learning curve, as evidenced by the efficiency of high-volume operators. Long-term outcome studies are warranted.

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ABC

Letter to the Editor

Predictors of Atrial Arrhythmia Recurrence after Catheter Ablation: Socioeconomic Impact in Low to Middle-Income Countries

Marwan Shawki et al. Thalys Sampaio Rodrigues Levindo Jose Garcia Quarto

To the Editor,

We read with great interest the article by Ternes et al., recently published in the Arquivos Brasileiros de Cardiologia, with its accompanying insightful editorial.^, This multicentre prospective cohort study of consecutive patients across three centres in Brazil provided valuable insights into the predictors of atrial arrhythmia recurrence following first-time catheter ablation. It highlighted its clinical setting in a middle-income country and reported outcomes similar to those in high-income countries. However, the results must be interpreted cautiously, and some points merit further discussion.

[…]

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ABC

Original Article

Pulsed Field Ablation Versus Very High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis

Asad Iqbal et al. Wellgner Fernandes Oliveira Amador Martin Cevallos-Cueva Maaz Ahmad … Juan Alejandro Pinilla Alarcón Radamés Vieira Diniz

Abstract

Background

Pulmonary vein isolation (PVI) is a cornerstone treatment for atrial fibrillation (AF). Pulsed-field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency (RF) ablation are emerging technologies, but their comparative efficacy and safety remain unclear.

Objectives

To assess the efficacy and safety of PFA compared to vHPSD RF ablation for AF.

Methods

A systematic search of PubMed, Embase, Web of Science, and Cochrane databases identified studies comparing PFA and vHPSD ablation. Outcomes included PVI success, skin-to-skin procedure time, fluoroscopy time, freedom from atrial arrhythmias, and complications such as cardiac tamponade, stroke, and vascular access events. Continuous outcomes were analyzed using mean differences (MD), while binary outcomes were assessed with risk ratios (RR) and 95% confidence intervals (CI). A significance threshold of p < 0.05 was considered for statistical analyses. This study is registered in PROSPERO (CRD42024619301).

Results

Four observational studies with 605 patients were included, of whom 315 (52%) underwent PFA. PFA and vHPSD achieved similar PVI success (RR 1.00; 95% CI 0.99–1.01; p = 1). PFA reduced procedure time (MD -30.07 min; 95% CI -31.41 to -28.74; p<0.01) but increased fluoroscopy time (MD 6.87 min; 95% CI 3.66–10.08; p<0.01). Freedom from atrial arrhythmias was comparable (RR 1.03; 95% CI 0.94–1.14; p=0.5). Complication rates, including cardiac tamponade, stroke, and vascular access issues, showed no significant differences between groups.

Conclusion

PFA significantly shortens procedure time but requires longer fluoroscopy compared to vHPSD. Both techniques exhibit comparable efficacy for PVI and arrhythmia freedom, with similar safety profiles.

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ABC

Letter to the Editor

How to Improve Clinical Outcomes in Women with Atrial Fibrillation

Naoya Kataoka et al. Teruhiko Imamura

To the editor

Anticoagulation is a standard therapeutic approach for patients with atrial fibrillation (AF), requiring careful consideration of the balance between antithrombotic efficacy and the risk of hemorrhagic complications. The authors examined the rate of anticoagulant prescriptions among patients admitted to the emergency department with symptomatic AF, revealing a higher prevalence of non-prescription in women compared to men. This observation raises several important concerns.

[…]

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ABC

Original Article

Brazilian Multicenter Registry of Alcohol Septal Ablation for Patients with Symptomatic Hypertrophic Obstructive Cardiomyopathy – BRASA Registry

Pedro Jallad et al. Marilia Soliani Pedro Henrique Almeida Marins Fábio Fernandes … Edmundo Arteaga-Fernandez Vagner Madrini Pedro Lemos Neto Charles Mady Felix Ramires Alexandre A. Abizaid Fábio Sândoli de Brito Jr Henrique Barbosa Ribeiro

Abstract

Background

Alcohol septal ablation (ASA) is an alternative to surgical myectomy for patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) and significant left ventricular (LV) outflow tract (LVOT) obstruction. Although widely studied worldwide, data on ASA outcomes in Brazil are still limited.

Objective

To assess the safety and effectiveness of ASA in symptomatic HOCM patients receiving optimal medical therapy using current techniques across multiple centers in Brazil.

Methods

Patients with HOCM and angina (classified by the Canadian Cardiovascular Society [CCS]) or dyspnea (classified by the New York Heart Association [NYHA]) class >II who did not respond to optimal medical treatment were included. The primary efficacy endpoint was defined as a reduction of more than 50% in the maximum resting LVOT gradient, with a final gradient <50 mmHg. Patients were classified as responders or nonresponders. A p-value <0.05 was considered statistically significant.

Results

A total of 41 patients (median age 66.4 years; 73% female) underwent ASA. At baseline, 93.2% were in NYHA class III/IV or CCS class III/IV. The mean LV ejection fraction (LVEF) was 66.4%, and the mean LVOT gradient was 88.4 mmHg. After 12 months, 92.8% had improved to NYHA class I/II or CCS class I/II (p<0.01). The mean LVOT gradient dropped from 88.4 mmHg to 27.0 mmHg (p=0.003), and interventricular septum (IVS) thickness decreased from 19.3 mm to 14.7 mm (p=0.048). Responders had lower baseline gradients (73.4 vs 112.6 mmHg, p=0.04) and fewer hospitalizations (21.1% vs 82.4%, p=0.04). Complete atrioventricular block occurred in 16.7% of patients, and 4.8% required pacemakers. No deaths were reported during a median follow-up of 394 days. At the last in-person evaluation, 78.4% were in functional class I/II.

Conclusions

ASA is a safe, effective option for relieving symptoms in selected HOCM patients. It reduces LVOT gradient and septal thickness. Patients with higher baseline gradients were less likely to respond to the procedure.

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ABCIC

Review Article

My Approach to Intracardiac Echocardiography During Atrial Fibrillation Ablation

Simone Nascimento dos Santos et al. Benhur Davi Henz Maria Eduarda Leite da Silva Luiz Roberto Leite da Silva

Abstract

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and is associated with serious complications such as stroke and heart failure. The prevalence of AF is increasing significantly due to population aging and related comorbidities. In addition, advances in technology — particularly the detection of AF through wearable devices such as smartwatches — have enabled earlier diagnosis. Intracardiac echocardiography (ICE) is a valuable imaging modality in electrophysiology and hemodynamic labs and is well-supported by the literature.^– Since the early studies conducted at the Mayo Clinic,^, ICE has rapidly become an indispensable tool for assessing cardiac anatomy. ICE enables real-time visualization of catheter positioning, tissue contact, its relationship to arrhythmogenic substrates and ablation targets, lesion formation, and procedural complications. Several recent studies have demonstrated the benefits of ICE in complex ablations, including reduced procedure times and complication rates, such as lower risks of cardiac tamponade and mortality, along with higher success rates (Central Illustration).^– ICE-guided procedures are increasingly used in clinical practice across a variety of settings. They are considered feasible, safe, and associated with decreased fluoroscopy exposure — or even complete fluoroless procedures, as implemented by several groups in Brazil and worldwide.^,– This article provides a step-by-step “My Approach to” guide on how to perform ICE during AF ablation.

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ABC

Editorial

Atrioesophageal Fistula After Catheter Ablation of Atrial Fibrillation: Can We Really Prevent It?

Luiz Eduardo Montenegro Camanho

Catheter ablation of atrial fibrillation (AF) is a widely used and established procedure in clinical practice. Several randomized studies have demonstrated the superiority of this method in patients with paroxysmal/persistent AF who are symptomatic and refractory to antiarrhythmic therapy, with a strong positive impact on quality of life and in reducing the clinical recurrence of this arrhythmia, regardless of the type of energy used.^– The primary objective of the procedure is the electrical isolation of the pulmonary veins, associated or not with more extensive lesions, particularly of the posterior wall.

The main complications related to the procedure, such as death, per-procedure thromboembolic event, atrioesophageal fistula (AEF), cardiac tamponade, severe pulmonary vein stenosis, and permanent phrenic nerve palsy are, in reality, infrequent complications (0.02 to 1.3%). A recent publication demonstrated a decrease in these complications in recent years (2018-2022) when compared to the previous five years (3.8 versus 5.3%).

[…]

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ABC

Editorial

High-Power Short Duration or Pulsed Field Ablation: What is the Best Choice for AF Ablation?

José Carlos Pachon-M et al. Enrique I. Pachon-M Tasso J. Lobo Tomas G. Santillana-P Carlos Thiene C. Pachon

Conclusion

Both methods highlight the advancements in AF ablation techniques, focusing on improving procedural efficiency and safety. The HPSD meta-analysis demonstrates that high-power, short-duration radiofrequency ablation reduces AF recurrence and procedural times while minimizing complications like esophageal injury. On the other hand, the PFA meta-analysis shows that pulsed field ablation offers shorter procedural times compared to traditional thermal ablation, with no significant difference in complications or AF recurrence. Finally, a highly relevant issue that has not been adequately considered in these studies is the extent of vagal denervation resulting from these techniques. It is well established that a greater degree of vagal denervation, including the potential incorporation of cardioneuroablation^, is strongly associated with a significant reduction in long-term recurrence rates.

[…]

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ABC

Viewpoint

Treating Patients with Heart Failure with Reduced Ejection Fraction (HFrEF) and Atrial Fibrillation: We Need to Talk About the Fifth Pillar

Mauricio Pimentel et al. Lucas Simonetto Faganello Ana Paula Arbo Magalhães Eduardo Caberlon Leandro Ioschpe Zimerman

Heart failure with reduced ejection fraction (HFrEF) is a complex clinical syndrome characterized by symptoms of dyspnea and worsening functional capacity resulting from reduced cardiac output in patients with left ventricular ejection fraction (LVEF) ≤40%. HFrEF represents an important public health problem, being one of the main causes of hospital admission, with high morbidity and mortality rates. Based on large randomized clinical trials, the standard treatment for patients with HFrEF until the late 1990s consisted of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs). After about two decades, a new era in the treatment of HFrEF began with the publication of randomized clinical trials on new classes of drugs: angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose co-transporter 2 (SGLT2) inhibitors. Based on this evidence, the guidelines defined the four pillars of HFrEF treatment: ACEIs or ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors.^, In addition to pharmacological treatment, the implantation of a cardioverter-defibrillator and cardiac resynchronization therapy are also indicated for patients with specific clinical features.

Atrial fibrillation (AF) and HFrEF share common risk factors and often coexist, leading to exacerbation of clinical condition and poorer prognosis for both. The diagnosis of AF in patients with HFrEF is associated with increased mortality. HFrEF is a risk factor for increased incidence of AF and is associated with a higher risk of stroke in patients with AF. The importance of determining the best therapeutic approach for patients with AF and HFrEF led to randomized clinical trials comparing rhythm control and heart rate control strategies. The Dofetilide in Patients with Congestive Heart Failure and Left Ventricular Dysfunction (DIAMOND-CHF) study compared the use of dofetilide with placebo in patients with ventricular dysfunction. In the analysis of patients with AF, it was shown that the use of dofetilide resulted in a higher rate of reversion and maintenance of sinus rhythm, but with no effect on overall mortality. The Rhythm Control versus Rate Control for Atrial Fibrillation and Heart Failure (AF-CHF) study compared rhythm control strategies (cardioversion and antiarrhythmic drug, with amiodarone being the drug of choice) to heart rate control in patients with LVEF ≤ 35%. The rhythm control strategy did not show a reduction in cardiovascular mortality compared to heart rate control. It is important to note that, during follow-up, 58% of the patients in the rhythm control group had a recurrence of AF. In fact, the rhythm control strategy was not very effective in maintaining patients in sinus rhythm.

[…]

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ABC

Original Article

Esophageal Protection Strategies for Ablation of Atrial Fibrillation: Comparative Results of Consecutive Endoscopic Evaluation

Alberto Pereira Ferraz et al. Cristiano Faria Pisani Esteban Wisnivesky Rocca Rivarola Tan Chen Wu … Francisco Carlos da Costa Darrieux Rafael Alvarenga Scanavacca Muhieddine Omar Chokr Carina Abigail Hardy Sissy Lara de Melo Denise Tessariol Hachul Beatriz Hachul de Campos Mauricio Ibrahim Scanavacca

Abstract

Background

Atrial-esophageal fistula following AF ablation remains a concern. There is no standardized approach to minimize its risk and morbidity.

Objective

To present the seven-year experience of a systematic endoscopic surveillance of esophageal injury after AF catheter ablation.

Methods

This is a retrospective single center registry of systematic endoscopic evaluation after AF ablation in consecutive procedures performed from 2016 to 2022. A p-value of <0.05 was considered statistically significant.

Results

823 AF ablation with controlled esophagogastroduodenoscopy (EGD) were analyzed. Most patients (n=588, 71.4%) were male, 575 (69.9%) had paroxysmal AF. Esophageal temperature monitoring was performed using a single sensor in 310 patients (40.3%) and a multi–sensor probe in 306 (39.8%). Lesions were presented in 217 EGD (26.5%): hematoma-ecchymosis in 27 (3.3%), erythema in 14 (1.7%), erosion in 78 (9.5%) and ulcer in 67 (8.2%) patients. No esophageal protective strategy was associated with more ulcers, except the use of 8mm tip-catheter (14.7% of ulcers with 8mm tip catheter vs 6.7% with other catheters, p = 0.001). Thermal lesions were early detected and treated. Most lesions were considered healed at endoscopy, but one patient who underwent pulmonary vein isolation with an 8m tip catheter had esophageal fistula, treated successfully with endoscopic metal clip and endoloop technique.

Conclusion

The incidence of esophageal lesions at routine EGD following AF ablation is high, although in most of the cases they heal spontaneously. Patients who underwent ablation with the 8mm tip catheter had more severe thermal lesions. Early esophagus endoscopy may help the diagnosis of early-stage lesions and the prevention of fistula formation after AF ablation.

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ABC

Editorial

Does Posterior Wall Isolation in Catheter Ablation of Persistent Atrial Fibrillation Change Clinical Outcomes?

Luiz Eduardo Montenegro Camanho

Atrial fibrillation (AF) is arguably the most common arrhythmia in clinical practice, characterized by chaotic and rapid atrial electrical activity with consequent loss of atrial contraction and its serious clinical consequences, which are already widely known. The diagnosis is electrocardiographic and has several forms of presentation, with the persistent form, being classically, that which lasts more than 7 days and less than a year. The early persistent form is when the duration is more than 7 days but less than 3 months, and the long-term persistent form is when it has persisted for more than a year. The progressive change from the paroxysmal to the persistent form of the arrhythmia varies from 8 to 36% depending on the observation time of the cohort and is always associated with worse clinical outcomes.^,

Electrical isolation of the pulmonary veins, regardless of the energy source used, has become the gold standard invasive strategy for the treatment of AF in all its forms of presentation, with widely proven efficacy and results based on the pathophysiology of the arrhythmia.

[…]

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ABC

Original Article

Efficacy and Safety of Adjunctive Posterior Wall Isolation in Patients with Persistent Atrial Fibrillation: A Systematic Review and Meta-Analysis

João Vitor Levindo Coelho Novaes et al. David de Pádua Brasil Flavia Maria de Freitas Faria Isadora Soares Bicalho Garcia … Camila Ribeiro Pimenta Nathalia Sernizon Guimarães Marcus Vinicius Bolivar Malachias

Abstract

Background

In patients with persistent atrial fibrillation (AF), addition of posterior wall isolation (PWI) to pulmonary vein isolation (PVI) is controversial.

Objective

Compare PVI plus PWI versus PVI alone in patients with persistent AF.

Methods

We searched PubMed (by MEDLINE), Embase, LILACS, CENTRAL (by Cochrane Library), and Clinicaltrials.gov databases for randomized trials comparing PVI + PWI and PVI alone in persistent AF. The outcomes were: (i) AF recurrence; (ii) composite of recurrent atrial arrhythmias (i.e., AF, atrial tachycardia, or atrial flutter); (iii) major clinical complications (i.e., pericardial effusion or tamponade, sinus node dysfunction, or atrioesophageal fistula); (iv) mean ablation time. Risk of bias and quality of evidence were evaluated using the Cochrane Risk of Bias 2.0 tool and GRADE, respectively. Statistical significance was set at 5%, and subgroup and sensitivity analyses were performed.

Results

We included eight studies and 1119 patients, of which 561 underwent PVI + PWI. During follow-up (12 – 24 months), recurrence of AF was significantly reduced with adjunctive PWI (RR 0.66, 95% CI 0.44-0.98). Composite of recurrent atrial arrhythmias did not differ significantly (RR 0.83, 95% CI 0.65-1.06). Major clinical complications (RR 0.81, 95% CI 0.42-1.58) were similar, with PVI alone having a shorter mean procedure time (mean difference -23.37 minutes, 95% CI -30.23, -16.50).

Conclusion

Adjunctive PWI appears to be effective in improving recurrent AF, but not recurrence of all atrial arrhythmias. Procedure time was longer with PVI + PWI without significant change in overall safety. Further studies should focus on long-term benefit.

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ABC

Original Article

The Southern Brazilian Registry of Atrial Fibrillation (SBR-AF Registry): Predictors of Atrial Arrhythmia Recurrence after First-Time Catheter Ablation

Caique M. P. Ternes et al. Luis E. Rohde Alexander Dal Forno Andrei Lewandowski … Helcio Garcia Nascimento Gabriel Odozynski Claudio Ferreira Enrico G. Ferro Carisi A. Polanczyk André Zimerman Lucas S. Faganello Eric Pasqualotto Grazyelle Damasceno Leandro I. Zimerman Andre d’Avila

Abstract

Background

Treatment of atrial fibrillation (AF) with catheter ablation (CA) has evolved significantly. However, real-world data on long-term outcomes are limited, particularly in low- and middle-income countries.

Objective

This multicenter prospective cohort of consecutive patients aimed to evaluate the safety and efficacy of first-time CA for AF in Southern Brazil from 2009 to 2024.

Methods

The primary outcome was any atrial tachyarrhythmia (ATA) recurrence. Multivariable Cox proportional hazards model assessed independent predictors of recurrence.

Results

Among 1,043 patients (mean age 67.3 ± 11.3 years, 27.9% female), 75.5% had paroxysmal AF. At a median follow-up of 1.4 (1.0 – 3.4) years, 21.4% had ATA recurrence. Recurrence rates were 18.6% for paroxysmal and 29.8% for persistent AF, and 67.3% of events occurred within the first year after CA. Predictors of recurrence were persistent AF at baseline (hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.15-2.13; p = 0.004), enlargement of left atrial diameter (HR 1.03, 95% CI 1.00-1.05; p = 0.033), and higher EHRA score of AF symptoms (HR 1.60, 95% CI 1.18-2.18; p = 0.003). Recurrence rates decreased over time according to the procedure’s calendar year, with a 9% relative reduction per consecutive year (HR 0.91; p < 0.001). There was a 2.1% rate of procedure-related adverse events.

Conclusions

In the largest cohort study of consecutive AF ablations in Latin America, predictors of ATA recurrence were related to later stages of AF. Complication and recurrence rates were comparable to those in high-income countries, underscoring the global applicability of CA for AF management.

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Original Article

High Power Short Duration Atrial Fibrillation Ablation: Long-Term Predictors of Success and Recurrence – A Multivariate Analysis

Fabricio Vassallo et al. Christiano Cunha Lucas Corsino Eduardo Serpa … Aloyr Simões Jr Dalton Hespanhol Carlos Volponi Lovatto Dalbian Gasparini Luiz Fernando Barbosa Andre Schmidt

Abstract

Background

Point-by-point ablation with a high-power short-duration (HPSD) technique in atrial fibrillation (AF) ablation is used worldwide. Little data is available with the HPSD and dragging technique (DT).

Objective

To perform a multivariate analysis of clinical and procedural predictors of success and recurrence in HPSD with DT.

Methods

214 patients in the first AF ablation in sinus rhythm were prospectively enrolled. DT with radiofrequency power of 50 W and contact force (CF) of 10–20 g and 5–10 g at a flow rate of 40 mL/min were applied on the anterior and posterior walls, respectively. Statistical significance was defined as p < 0.05.

Results

143 (66.8%) males, paroxysmal AF (PAF) in 124 (57.9%), with 61.1±12.3 years and followed for 32.8±13.2 months. After 90 days, AF occurred in 43 (20.1%) patients, 19 (15.3%) from PAF, and 24 (26.7%) in persistent AF (PersAF). Multivariate analysis indicated as clinical predictors of recurrence: age ≥ 65 years (p=0.006); obesity [body mass index > 30 (p=0.009)]; CHA₂DS₂VASC score ≥ 3 (p=0.003); and PersAF (p=0.045). The procedural predictor of recurrence was a heart rate increase < 10% (p=0.006). Predictors of success were an increase in heart rate ≥ 30% (p=0.04) and < 60 min in left atrium time (LAT) (p=0.007).

Conclusion

AF ablation with DT and HPSD clinical and procedural predictors of recurrence were ≥ 65 years, obesity, a CHA₂DS₂VASC ≥ 3, PersAF, and a heart rate increase of < 10% after ablation. Success predictors were an increase of ≥ 30% in heart rate and low LAT (< 60 min).

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Editorial

Impact of Pulsed Field Ablation on Atrial Fibrillation

Mauricio Scanavacca et al. Cristiano Pisani

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice, with an increasing incidence in more elderly patients. It is well known that AF is a substantial risk factor for cardiovascular events, increasing morbidity and mortality among affected patients, in addition to causing reduced physical and cognitive capacity and quality of life.^– Current treatment of AF is based on modification of aggravating clinical factors, introduction of anticoagulants based on individualized risk-benefit ratio, medications to control heart rate and antiarrhythmics to control rhythm, and electrical cardioversion in patients with persistent AF.

In patients who are refractory or intolerant to medical treatment, catheter ablation with electrical pulmonary vein isolation has been recommended with increasing enthusiasm by international guidelines. In fact, technological adjustments achieved in recent years in point-to-point radiofrequency ablation and balloon cryoablation have promoted greater effectiveness of the procedure and increased safety with both technologies, as demonstrated in numerous recent comparative scientific studies.^,

[…]

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IJCS

Case Report

Arrhythmogenic Substrate Ablation in a Patient With Brugada Syndrome and Electrical Storm

Arnóbio Dias da Ponte Filho et al. Ronaldo Vasconcelos Tavora Francisco Rodrigues dos Santos Neto André Gustavo da Silva Rezende Ieda Prata Costa

Abstract

Despite being a rare condition, Brugada syndrome (BrS) poses a significant risk of arrhythmic death, and managing associated ventricular arrhythmias is particularly challenging. Here, we present a case where percutaneous ablation targeted an arrhythmogenic substrate in a patient with BrS and recurrent ventricular fibrillation (VF). Epicardial mapping revealed abnormal potential areas in the right ventricle’s outflow tract and free wall. Injection of warmed saline into the pericardial space caused further delay in local electrograms and expanded the abnormal potential area. Radiofrequency applications in this region successfully eliminated abnormal electrograms, leading to the disappearance of the coved-shape ST-segment elevation in leads V1-V2. No recurrence of ventricular arrhythmias was reported in a twelve-month follow-up.

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Editorial

Can Pre-Ablation Serum Biomarkers be Used to Predict Arrhythmia Recurrence after Ablation Index-Guided Atrial Fibrillation Ablation?

Muhieddine Omar Chokr

Invasive treatment of atrial fibrillation (AF) has been established as the most effective treatment in controlling and curing this arrhythmia. In most cases, triggers originating from the pulmonary veins are responsible for triggering AF in its paroxysmal form. In its persistent form, different electrophysiological mechanisms are involved. The longer the evolution time, the more complex the invasive treatment strategy becomes. Despite the technological evolution with different electroanatomical mapping systems and the formation of increasingly effective radiofrequency lesions in the atrium wall, recurrences remain a challenge to be avoided.

Creating long-lasting ablation lesions during pulmonary vein isolation for AF is of critical importance to prevent late vein reconnection. Such reconnection is responsible for the vast majority of arrhythmia recurrences in patients with paroxysmal AF. Despite technological improvements, the proportion of veins that remain chronically isolated after radiofrequency ablation is still disappointingly low. This has led to great interest in producing more effective ablation lesions.

[…]

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ABC

Editorial

Evaluation of Catheter Ablation Using the PVAC Gold Catheter in Elderly Patients with Atrial Fibrillation

José Carlos Pachon-M et al. Tomas G. Santillana-P Enrique I. Pachon-M

Atrial fibrillation (AF) represents one of the most significant challenges in contemporary cardiological practice, especially in elderly patients, where the complexity of treatment is amplified by prevalent comorbidities and the fragility of this population. In this context, the study “Randomized Study Comparing Radiofrequency Ablation with the PVAC Gold System vs. Antiarrhythmic Drugs in Elderly Patients with Symptomatic Atrial Fibrillation” recently published in the ABC Cardiol by Martins et al., is remarkable. It offers crucial insights into therapeutic options, risks, and benefits for these patients. Additionally, this article is led by a team with remarkable international experience in AF ablation, navigating the challenges with astute clinical judgment having been a pioneer in several procedures.

This group of frequently polymedicated patients constantly inspires the search for therapies that reduce medication dependence and enhance quality of life. The prospect of eliminating AF through ablation and reducing multiple medications is highly appealing.^,

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Original Article

Randomized Study Comparing Radiofrequency Ablation with the PVAC Gold System vs. Antiarrhythmic Drugs in Elderly Patients with Symptomatic Atrial Fibrillation

Luiz Claudio Berhmann Martins et al. Cristiano F. Pisani Fabio K. Dorfman Francisco C. C. Darrieux … Tan C. Wu Alberto P. Ferraz Denise T. Hachul Claudio Campi de Castro Rogério Ruscitto do Prado Luciana V. F. Souza Luciana Sacilloto Gabrielle D. A. Pessente Cesar J. Grupi Muhieddine Omar Chokr Cesar H. Nomura Kátia Rodrigues de Oliveira Conrado P. Balbo Sissy L. Melo Pedro Veronese Mauricio I. Scanavacca

Abstract

Background

There are no randomized studies comparing the maintenance of sinus rhythm after catheter ablation (CA) concerning treatment with antiarrhythmic drugs (AA) in elderly patients with paroxysmal atrial fibrillation (AF).

Objectives

To compare the clinical results of pulmonary vein (PV) isolation with the second-generation PVAC Gold catheter against AA treatment in elderly people with recurrent symptomatic paroxysmal AF, refractory to at least one AA, and without structural heart disease.

Methods

Sixty patients with paroxysmal AF ≥ 65 years old were randomized to two forms of treatment: group 1: CA and group 2: AA drugs. The primary outcome was the AF recurrence-free rate after at least one year of follow-up. Secondary outcomes were: progression to persistent forms of AF, impact on quality of life (QOLF), and complications. The significance level adopted in the statistical analysis was 5% (p<0.05).

Results

The AF recurrence-free rate was 80% (10% with amiodarone) in the CA group, after 1.3 procedures per patient and 65% in the AA group (60% with amiodarone), (p = 0.119) in an average follow-up of 719 days (Q1: 566; Q3: 730). The persistent AF free rate was 83.4% in the AC group and 67.7% in the AA group (p = 0.073) Both strategies showed an improvement in the AFQoL score during follow-up (p < 0.001), with no difference between the groups. Although without clinical repercussions or impact on the intellectual assessment test, 25% of patients in the CA group showed signs of cerebral embolization on brain MRI.

Conclusions

Both strategies for maintaining sinus rhythm promoted an improvement in the quality of life of elderly patients with symptomatic AF, with no statistical difference in the clinical outcomes. Additional studies using technologies with a better safety profile are needed to evaluate the benefits of CA in elderly patients with AF.

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Original Article

Can Pre-Ablation Biomarkers Be Used to Predict Arrhythmia Recurrence after Ablation Index-Guided Atrial Fibrillation Ablation?

Andreia Palma et al. Pedro A. Sousa Carolina Saleiro Sérgio Barra … Natália António Luis Adão João Primo Ana Lebreiro Paulo Fonseca Luís Elvas Lino Gonçalves

Abstract

Background:

Ablation Index (AI) software has allowed better atrial fibrillation (AF) ablation results, but recurrence rates remain significant. Specific serum biomarkers have been associated with this recurrence.

Objectives:

To evaluate whether certain biomarkers could be used (either individually or combined) to predict arrhythmia recurrence after AI-guided AF ablation.

Methods:

Prospective multicenter observational study of consecutive patients referred for AF ablation from January 2018 to March 2021. Hemoglobin, brain natriuretic peptide (BNP), C-reactive protein, high sensitivity cardiac troponin I, creatinine clearance, thyroid-stimulating hormone (TSH) and free thyroxine (FT₄) were assessed for their ability to predict arrhythmia recurrence during follow-up. Statistical significance was accepted for p values of<0.05.

Results:

A total of 593 patients were included – 412 patients with paroxysmal AF and 181 with persistent AF. After a mean follow-up of 24±6 months, overall single-procedure freedom from atrial arrhythmia was 76.4%. Individually, all biomarkers had no or only modest predictive power for recurrence. However, a TSH value >1.8 μUI/mL (HR=1.82 [95% CI, 1.89-2.80], p=0.006) was an independent predictor of arrhythmia recurrence. When assessing TSH, FT₄ and BNP values in combination, each additional “abnormal” biomarker value was associated with a lower freedom from arrhythmia recurrence (87.1 % for no biomarker vs. 83.5% for one vs. 75.1% for two vs. 43.3% for three biomarkers, p<0.001). Patients with three “abnormal” biomarkers had a threefold higher risk of AF recurrence compared with no “abnormal” biomarker (HR=2.88 [95% CI, 1.39-5.17], p=0.003).

Conclusions:

When used in combination, abnormal TSH, FT₄ and BNP values can be a useful tool for predicting arrhythmia recurrence after AI-guided AF ablation.

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