Search Results (14)

Background/Objectives: Data on predictors of atrial fibrillation (AF) recurrence after cryoballoon pulmonary vein isolation (PVI) in persistent AF (PeAF) remain limited. We evaluated clinical, echocardiographic, and procedural parameters associated with recurrence. Methods: We retrospectively studied 192 PeAF patients who underwent cryoballoon PVI and had ≥6 months of follow-up. Recurrence was any atrial tachyarrhythmia > 30 s beyond a 3-month blanking period. Cox models assessed predictors, including number of veins with first-pass isolation (FPI), left atrial volume index (LAVI), hemoglobin, and prespecified covariates. Results: During a median follow-up of 670 days (interquartile range 425–944), recurrence occurred in 75 patients (39.1%). On multivariable analysis, reduced extent of FPI (<3 veins) independently predicted recurrence (HR 2.48, 95% CI 1.48–4.16; p = 0.001). In continuous analysis, each one-vein decrement in FPI was associated with a 58% higher hazard. Lower hemoglobin was also independently associated; each 1 g/dL decrease corresponded to a 29% higher hazard (HR 1.29, 95% CI 1.05–1.58; p = 0.015). Male sex showed approximately a twofold higher recurrence risk than female sex (HR 2.23, 95% CI 1.06–4.68; p = 0.034). In PeAF patients treated with cryoballoon PVI, intraprocedural FPI extent was a strong independent predictor, outperforming anatomical remodeling after adjustment. Achieving FPI in fewer than three pulmonary veins predicted higher recurrence. Hemoglobin provides an accessible systemic risk marker, while male sex identifies a higher-risk subgroup. Conclusions: In PeAF patients, the extent of FPI in cryoballoon PVI is a strong independent predictor of outcome, and maximizing the number of veins with FPI could be a pragmatic procedural goal. Full article

Atrial fibrillation (AF) is a common arrhythmia associated with major adverse cardiovascular events. Early detection and short-horizon risk prediction are therefore clinically critical. Prior attention-based electrocardiogram (ECG) models typically treated subtype classification and short-horizon onset risk prediction as separate tasks and optimized attention in only one representational dimension rather than in a coordinated hierarchy. We propose a hierarchical multiattention temporal fusion network (HMA-TFN). The proposed framework jointly integrates lead-level, morphology-level, and rhythm-level attention, enabling the model to simultaneously highlight diagnostically informative leads, capture waveform abnormalities, and characterize long-range temporal dependencies. Moreover, the model is trained for dual tasks—AF subtype classification and 30-min onset prediction. Experiments were conducted on three open-source databases and the Fuzhou University–Fujian Provincial Hospital (FZU-FPH) clinical database, comprising thousands of dual-lead ECG recordings from a diverse subject population. Experimental results show that HMA-TFN achieves 95.77% accuracy in classifying paroxysmal AF (PAAF) and persistent AF (PEAF), and 96.36% accuracy in predicting PAAF occurrence 30 min in advance. Ablations show monotonic gains as each attention level is added, delivering 14.0% accuracy over the baseline for subtyping and 5.2% for prediction. Grad-CAM visualization highlights clinically relevant features such as absent P-waves, confirming model interpretability. On the FZU-FPH clinical database, it achieves a generalization performance of 94.31%, demonstrating its strong potential for clinical application. Full article

Background: Pulmonary vein isolation (PVI) is a foundational treatment for persistent atrial fibrillation (PeAF), but the effectiveness of adding posterior wall isolation (PWI) and selective complex fractionated atrial electrogram (CFAE) ablation in the roof and anterior wall remains debated. The potential of these additional ablation techniques to improve long-term outcomes for PeAF patients is still uncertain. Methods: This retrospective study included 151 PeAF patients who underwent first-time catheter ablation at our center. The choice of ablation strategy was based on the operator’s clinical judgment, taking into account the patient’s specific condition and anatomical features. Patients were divided into two groups: the PVI group, which received PVI alone, and the modified PWI (MPWI) group, which received PVI along with additional PWI and selective CFAEs ablation in the roof and anterior wall. The primary endpoint was the absence of atrial arrhythmia lasting more than 30 s, without antiarrhythmic drugs, at 12 months. Results: At the 12-month follow-up, 77.3% of the patients in the MPWI group and 52.1% of the patients in the PVI group remained in sinus rhythm without an atrial arrhythmia recurrence (p = 0.001). The BIC-based Cox regression analysis identified the ablation strategy and atrial fibrillation (AF) duration as independent predictors of recurrence across the cohort. It was found that MPWI significantly reduced the risk of recurrence, while a longer AF duration increased it. In the MPWI group, AF duration, left ventricular internal diameter in systole (LVIDs), and moderate or greater tricuspid regurgitation were independent predictors of recurrence. In the PVI group, only the left atrial low voltage area (LVA) index was a significant predictor. Conclusion: The addition of PWI and selective CFAE ablation to PVI significantly improves 12-month arrhythmia-free survival compared to PVI alone, demonstrating the superiority of this combined approach in improving long-term outcomes for patients with persistent AF. Full article

Background: The TactiFlex™ ablation catheter, Sensor Enabled™ (Abbott, Minneapolis, MN, USA), is an open-irrigation radiofrequency (RF) ablation catheter with flexible tip technology. This catheter delivers high-power short-duration (HPSD) RF ablations and has been adopted for atrial fibrillation (AF) ablation. HPSD is well-established not only in pulmonary vein isolation (PVI) but also when targeting extra-pulmonary vein (PV) targets. This study aims to determine the safety, effectiveness, and acute outcomes of PVI plus posterior wall isolation (PWI) in patients with persistent atrial fibrillation (Pe-AF) using HPSD and the TactiFlex™ ablation catheter. Methods: Consecutive patients who underwent the ablation of Pe-AF in our centre between February 2023 and February 2024 were prospectively enrolled in the study. All patients underwent PVI plus PWI using TactiFlex™ and the HPSD strategy. The RF parameters were 50 W on all the PV segments and the roof, and within the posterior wall (PW). Left atrial mapping was performed with the EnSite X mapping system and the high-density multipolar Advisor HD Grid, Sensor Enabled™ mapping catheter. We compared the procedural data using HPSD with TactiFlex™ (n = 52) vs. a historical cohort of patients who underwent PVI plus PWI using HPSD settings and the TactiCath ablation catheter (n = 84). Results: Fifty-two consecutive patients were included in the study. PVI and PWI were achieved in all patients in the TactiFlex™ group. First-pass PVI was achieved in 97.9% of PVs (n = 195/199). PWI was obtained in all cases by delivering extensive RF lesions within the PW. There were no significant differences compared to the TactiCath group: first-pass PVI was achieved in 96.3% of PVs (n = 319/331). Adenosine administration revealed PV reconnection in 5.7% of patients, and two reconnections of the PW were documented. Procedure and RF time were significantly shorter in the TactiFlex™ group compared to the TactiCath group, 73.1 ± 12.6 vs. 98.5 ± 16.3 min, and 11.3 ± 1.5 vs. 23.5 ± 3.6 min, respectively, p < 0.001. The fluoroscopy time was comparable between both groups. No intraprocedural and periprocedural complications related to the ablation catheter were observed. Patients had an implantable loop recorder before discharge. At the 6-month follow-up, 76.8% of patients remained free from atrial arrhythmia, with no significant differences between groups. Conclusions: HPSD PVI plus PWI using the TactiFlex™ ablation catheter is effective and safe. Compared to a control group, the use of TactiFlex™ to perform HPSD PVI plus PWI is associated with a similar effectiveness but with a significantly shorter procedural and RF time. Full article

Background and Objectives: Pulmonary embolism (PE) incidence has been increasing in the last 10 years. Computed thoracic pulmonary angiography (CTPA) had a major role in PE diagnosis and prognosis. The main purpose of this study was as follows: the prognostic value of a CTPA parameter, pulmonary artery obstruction index (PAOI), in PE risk assessment and the predictive accuracy of biomarkers, D-dimer and cardiac Troponin T (c-TnT), in 7-day mortality. A second objective of the research was to investigate the relationship between imaging by PAOI and these biomarkers in different etiologies of PE. Materials and Methods: This study comprised 109 patients with PE, hospitalized and treated between February 2021 and August 2022. They had different etiologies of PE: deep vein thrombosis (DVT); persistent atrial fibrillation (AF); chronic obstructive pulmonary disease (COPD) exacerbation; COVID-19; and cancers. The investigations were as follows: clinical examination; D-dimer testing, as a mandatory method for PE suspicion (values ≥500 µg/L were highly suggestive for PE); c-TnT, as a marker of myocardial injury (values ≥14 ng/L were abnormal); CTPA, with right ventricle dysfunction (RVD) signs and PAOI. Treatments were according to PE risk: systemic thrombolysis in high-risk PE; low weight molecular heparins (LWMH) in high-risk PE, after systemic thrombolysis or from the beginning, when systemic thrombolysis was contraindicated; and direct oral anticoagulants (DOAC) in low- and intermediate-risk PE. Results: PAOI had a high predictive accuracy for high-risk PE (area under curve, AUC = 0.993). D-dimer and cTnT had a statistically significant relationship with 7-day mortality for the entire sample, p < 0.001, and for AF, p = 0.0036; COVID-19, p = 0.003; and cancer patients, p = 0.005. PAOI had statistical significance for 7-day mortality only in COVID-19, p = 0.045, and cancer patients, p = 0.038. The relationship PAOI–D-dimer and PAOI–c-TnT had very strong statistical correlation for the entire sample and for DVT, AF, COPD, and COVID-19 subgroups (Rho = 0.815–0.982). Conclusions: PAOI was an important tool for PE risk assessment. D-dimer and c-TnT were valuable predictors for 7-day mortality in PE. PAOI (imaging parameter for PE extent) and D-dimer (biomarker for PE severity) as well as PAOI and c-TnT (biomarker for myocardial injury) were strongly correlated for the entire PE sample and for DVT, AF, COPD, and COVID-19 patients. Full article

Background: The best ablation treatment for persistent atrial fibrillation (PeAF) patients is still debated. The vein of Marshall (VOM) seems to be a promising target for ablation and could be combined with a linear set of ablation lesions. The aim of our study is to evaluate the incidence of AF recurrences in a PeAF population treated with a comprehensive ablation approach consisting of VOM ethanol infusion (EI), pulmonary vein isolation (PVI), a left atrial (LA) roofline, a mitral line (guided by the newly formed lesion after alcohol infusion into the VOM and validated by pacing), and a cavotricuspid isthmus line. Methods: Consecutive patients undergoing the first ablation procedure of catheter ablation (CA) for PeAF were enrolled. All patients underwent VOM-EI, PVI, and ablation lines along the roof of the LA, mitral, and cavotricuspid isthmus. LA voltage mapping before and after VOM-EI was also performed. An implantable loop recorder (ILR) was implanted at the end of the ablation in each patient. Results: Thirty-one consecutive patients (66 ± 8 years and 71% male) affected by PeAF were included in this study. The VOM-EI procedural phase lasted 21.4 ± 10.1 min. PV isolation and lines were validated in all subjects. The ML block was achieved within 10.8 ± 8.7 min. At a mean follow-up of 12 ± 7 months, 27 out of 31 (87%) patients remained free from AT/AF recurrences. Among the patients with recurrences, two (50%) had incomplete ablation lesions and three (75%) had “suboptimal” VOM-EI. In 23/31 patients (74%), antiarrhythmic drugs (AADs) were discontinued after 1 month of follow-up. No significant complications were reported during the follow-up. Conclusions: this single-center experience demonstrates that VOM-EI systematically combined with an anatomical ablation set in patients with PeAF resulted in feasible, safe, and effective freedom from AF/AT recurrences in 87% of the population after a 1-year follow-up period according to an ILR. Full article

Background: High-power short-duration (HPSD) radiofrequency (RF) ablation has been adopted to improve atrial fibrillation (AF) ablation. Although the role of HPSD is well-established in pulmonary vein isolation (PVI), fewer data have assessed the impact of HPSD when addressing extra-pulmonary veins (PVs) targets. Therefore, this study aims to determine the safety, effectiveness, and acute outcomes of HPSD lesion index (LSI)-guided posterior wall isolation (PWI) in addition to PVI as an initial strategy in persistent atrial fibrillation (Pe-AF). Methods: Consecutive patients who underwent ablation of Pe-AF in our center between August 2021 and January 2022 were retrospectively enrolled. All patients’ ablation strategy was PVI plus PWI using HPSD LSI-guided isolation. RF parameters included 50 W targeting LSI values of ≥5 on the anterior part of the PVs and anterior roofline and ≥4 for the posterior PVs aspect, bottom line, and within the posterior wall (PW). We compared the LSI values with and without acute conduction gaps after the initial first-pass PWI. Left atrial mapping was performed with the EnSite X mapping system and a high-density multipolar Grid-shaped mapping catheter. We compared the procedural characteristics using HPSD (n = 35) vs. a control group (n = 46). Results: Thirty-five consecutive patients were included in the study. PWI on top of PVI was achieved in all cases in the HPSD group. First-pass PVI was achieved in 93.3% of PVs (n = 126/135). First-pass roofline block was obtained in most patients (n = 31, 88.5%), while first-pass block of the bottom line was only achieved in 51.4% (n = 18). There were no significant differences compared to the control group; first-pass PVI was achieved in 94.9% of PVs (n = 169/178), first-pass roofline block in 89.1%, and bottom-line in 45.6% of patients. To achieve complete PWI with HPSD, scattered RF applications within the PW were necessary. No electrical reconnection of the PW was found after adenosine administration and the waiting period. The procedure and RF times were significantly shorter in the HPSD group compared to the control group, with values of 116.2 ± 10.9 vs. 144.5 ± 11.3 min, and 19.8 ± 3.6 vs. 26.3 ± 6.4 min, respectively, p < 0.001. Fluoroscopy time was comparable between both groups. No procedural complications were observed. At the 12-month follow-up, 71.4% of patients remained free from AF, with no differences between the groups. Conclusions: HPSD LSI-guided PWI on top of PVI seems effective and safe. Compared to a control group, HPSD is associated with similar rates of first-pass PWI and PVI but with a shorter procedural and RF time. Full article

Background: Patients with acute pulmonary embolism (PE) may have various types of atrial fibrillation (AF). The role of AF in hemodynamic states and outcomes may differ between men and women. Methods: In total, 1600 patients (743 males and 857 females) with acute PE were enrolled in this study. The severity of PE was assessed using the European Society of Cardiology (ESC) mortality risk model. Patients were allocated into three groups according to their electrocardiography recordings taken during hospitalization: sinus rhythm, new-onset paroxysmal AF, and persistent/permanent AF. The association between the types of AF and all-cause hospital mortality was tested using regression models and net reclassification index (NRI) and integrated discrimination index (IDI) statistics with respect to sex. Results: There were no differences between the frequencies of the types of AF between men and women: 8.1% vs. 9.1% and 7.5% vs. 7.5% (p = 0.766) for paroxysmal and persistent/permanent AF, respectively. We found that the rates of paroxysmal AF significantly increased across the mortality risk strata in both sexes. Among the types of AF, the presence of paroxysmal AF had a predictive value for all-cause hospital mortality independent of mortality risk and age in women only (adjusted HR, 2.072; 95% CI, 1.274–3.371; p = 0.003). Adding paroxysmal AF to the ESC risk model did not improve the reclassification of patient risk for the prediction of all-cause mortality, but instead enhanced the discriminative power of the existing model in women only (NRI, not significant; IDI, 0.022 (95% CI, 0.004–0.063); p = 0.013). Conclusion: The occurrence of paroxysmal AF in female patients with acute PE has predictive value for all-cause hospital mortality independent of age and mortality risk. Full article

Background: Durable pulmonary vein isolation (PVI) is recommended for symptomatic paroxysmal atrial fibrillation (AF) treatment, but it has been demonstrated that it may not be enough to treat persistent AF (Pe-AF). Therefore, posterior wall isolation (PWI) is among the strategies adopted on top of PVI to treat Pe-AF patients. However, PWI using contiguous and optimized radiofrequency lesions remains challenging, and few studies have evaluated the impact of the Ablation Index (AI) on the efficacy of PWI. Moreover, previous papers did not evaluate arrhythmia recurrences using continuous monitoring. Methods: This is a prospective, observational, single-center study on patients affected by Pe-AF undergoing treated PVI plus AI-guided PWI. Procedures were performed using the CARTO mapping system, SmartTouch SF ablation catheter, and PentaRay multipolar mapping catheter. The AI settings were 500–550 for the anterior PV aspect and roofline, while the settings were 450–500 for the posterior PV aspect, bottom line, and/or PW lesions. All patients received an implantable loop recorder (ILR). All patients underwent clinical evaluation in the outpatient clinic at 1, 3, 6, 12, 18, and 24 months. A standard 12-lead ECG was performed at each visit, and device data from the ILR were reviewed to assess for arrhythmia recurrence. Results: Between January 2021 and December 2021, forty-one consecutive patients underwent PVI plus PWI guided by AI at our center and were prospectively enrolled in the study. PVI was achieved in all patients, first-pass roofline block was obtained in 82.9% of the patients, and first-pass block of the bottom line was achieved in 36.5% of the patients. In 39% of the patients, PWI was not performed with a “box-only” lesion set, but with scattered lesions across the PW to achieve PWI. AI on the anterior aspect of the left PVs was 528 ± 22, while on the posterior aspect of the left PVs, it was 474 ± 18; on the anterior aspect of the right PVs, it was 532 ± 27, while on the posterior aspect of the right PVs, it was 477 ± 16; on the PW, AI was 468 ± 19. No acute complications occurred at the end of the procedure. After the blanking period, 70.7% of the patients reported no arrhythmia recurrence during the 12-month follow-up period. Conclusions: In patients with Pe-AF undergoing catheter ablation, PWI guided by AI seems to be an effective and feasible strategy in addition to standard PVI. Full article

Catheter ablation for persistent atrial fibrillation (PeAF) is particularly challenging, as the clinical outcomes are modest. Pulmonary vein isolation (PVI) plus linear ablation is one of the main strategies for PeAF ablation. Completely durable transmural lesions are difficult to achieve by catheter ablation during mitral isthmus ablation. The ligament of Marshall contains the vein of Marshall (VOM), myocardial tracts and innervation, and serves as arrhythmogenic foci that make it an attractive target in catheter ablation of atrial fibrillation. Additionally, it co-localizes with the mitral isthmus, and may serve as a part of the perimitral isthmus reentrant circuit. Ethanol infusion into the VOM results in rapid ablation of the neighboring myocardium and its innervation. Its incorporation into PVI significantly increases the success rate of mitral isthmus block and the clinical outcome of PeAF ablation. Full article

Introduction: Cryoballoon ablation (CBA) has become a standard treatment for paroxysmal atrial fibrillation (PaAF) but limited data is available for outcomes in patients with persistent atrial fibrillation (PeAF). Methods: We analyzed the first 944 patients included in the Spanish Prospective Multi-center Observation Post-market Registry to compare characteristics and outcomes of patients undergoing CBA for PeAF versus PaAF. Results: A total of 944 patients (57.8 ± 10.4 years; 70.1% male) with AF (27.9% persistent) were prospectively included from 25 centers. PeAF patients were more likely to have structural heart disease (67.7 vs. 11.4%; p < 0.001) and left atrium dilation (72.6 vs. 43.3%; p < 0.001). CBA of PeAF was less likely to be performed under general anesthesia (10.7 vs. 22.2%; p < 0.001), with an arterial line (32.2 vs. 44.6%; p < 0.001) and assisted transeptal puncture (11.9 vs. 17.9%; p = 0.025). During an application, PeAF patients had a longer time to −30 °C (35.91 ± 14.20 vs. 34.93 ± 12.87 s; p = 0.021) and a colder balloon nadir temperature during vein isolation (−35.04 ± 9.58 vs. −33.61 ± 10.32 °C; p = 0.004), but received fewer bonus freeze applications (30.7 vs. 41.1%; p < 0.001). There were no differences in acute pulmonary vein isolation and procedure-related complications. Overall, 76.7% of patients were free from AF recurrences at 15-month follow-up (78.9% in PaAF vs. 70.9% in PeAF; p = 0.09). Conclusions: Patients with PeAF have a more diseased substrate, and CBA procedures performed in such patients were more simplified, although longer/colder freeze applications were often applied. The acute efficacy/safety profile of CBA was similar between PaAF and PeAF patients, but long-term results were better in PaAF patients. Full article

Background: Staging of atrial fibrillation (AF) is essential to understanding disease progression and the accompanied increase in therapy failure. Blood-based heat shock protein (HSP) levels may enable staging of AF and the identification of patients with higher risk for AF recurrence after treatment. Objective: This study evaluates the relationship between serum HSP levels, presence of AF, AF stage and AF recurrence following electrocardioversion (ECV) or pulmonary vein isolation (PVI). Methods: To determine HSP27, HSP70, cardiovascular (cv)HSP and HSP60 levels, serum samples were collected from control patients without AF and patients with paroxysmal atrial fibrillation (PAF), persistent (PeAF) and longstanding persistent (LSPeAF) AF, presenting for ECV or PVI, prior to intervention and at 3-, 6- and 12-months post-PVI. Results: The study population (n = 297) consisted of 98 control and 199 AF patients admitted for ECV (n = 98) or PVI (n = 101). HSP27, HSP70, cvHSP and HSP60 serum levels did not differ between patients without or with PAF, PeAF or LSPeAF. Additionally, baseline HSP levels did not correlate with AF recurrence after ECV or PVI. However, in AF patients with AF recurrence, HSP27 levels were significantly elevated post-PVI relative to baseline, compared to patients without recurrence. Conclusions: No association was observed between baseline HSP levels and the presence of AF, AF stage or AF recurrence. However, HSP27 levels were increased in serum samples of patients with AF recurrence within one year after PVI, suggesting that HSP27 levels may predict recurrence of AF after ablative therapy. Full article

Atrial fibrillation (AF), the most common, progressive tachyarrhythmia is associated with serious complications, such as stroke and heart failure. Early recognition of AF, essential to prevent disease progression and therapy failure, is hampered by the lack of accurate diagnostic serum biomarkers to identify the AF stage. As we previously showed mitochondrial dysfunction to drive experimental and human AF, we evaluated whether cell-free circulating mitochondrial DNA (cfc-mtDNA) represents a potential serum marker. Therefore, the levels of two mtDNA genes, COX3 and ND1, were measured in 84 control patients (C), 59 patients undergoing cardiac surgery without a history of AF (SR), 100 paroxysmal (PAF), 116 persistent (PeAF), and 20 longstanding-persistent (LS-PeAF) AF patients undergoing either cardiac surgery or AF treatment (electrical cardioversion or pulmonary vein isolation). Cfc-mtDNA levels were significantly increased in PAF patients undergoing AF treatment, especially in males and patients with AF recurrence after AF treatment. In PeAF and LS-PeAF, cfc-mtDNA levels gradually decreased. Importantly, cfc-mtDNA in serum may originate from cardiomyocytes, as in vitro tachypaced cardiomyocytes release mtDNA in the medium. The findings suggest that cfc-mtDNA is associated with AF stage, especially in males, and with patients at risk for AF recurrence after treatment. Full article