Atrial Fibrillation

doi:10.1002/joa3.12267

. 2019 Dec 29;35(Suppl 1):76–327. doi: 10.1002/joa3.12267

Atrial Fibrillation

In pairwise analysis interrupted apixaban (Ai) [AR 0.01, 95% CI 0.00‐0.02] and interrupted edoxaban (Ei) [AR 0.01, 95% CI 0.00‐0.05] regimen had the lowest bleeding complications and uninterrupted edoxaban (Eu) [AR 0.09, 95% CI 0.03‐0.22] had the highest (Figure, Absolute Plot). While comparison with uninterrupted VKA (Wu), all the NOACs regimen were comparable except uninterrupted edoxaban (Eu) which had significantly more bleeding complications [OR 0.19, 95% CI 0.03‐0.67] (Figure, Contrast Plot). The estimated value of between‐study variance for the network meta‐ analysis is 0.051 and I ² = 24.2%.

Conclusion:

Available evidence suggests that interrupted apixaban strategy was associated with least bleeding complications for catheter ablation of AF.

AP19‐00008

Improvement in quality of life in patients that underwent catheter ablation for persistent atrial fibrillation

kazuaki nakajima

Keio University School of Medicine, Japan

Introduction:

Maintenance of the sinus rhythm (SR) is important component in management of patients with atrial fibrillation (AF) frequently leading to better quality of life (QOL). However, whether use of catheter ablation would lead to better QOL in comparison to antiarrhythmic (AA) drugs is largely unclear.

Methods:

The Keio interhospital Cardiovascular Studies (KiCS) AF Registry is an observational and multicenter outpatient‐based AF registry. In this registry, the electro‐cardiograms were recorded after the initial and 1st year outpatient visit. For QOL evaluation, the participating patients were asked to answer internationally‐validated questionnaire (AFEQT), which comprises four subsets that include 20 questions concerning symptom, daily activity, treatment concern and satisfaction, at the time of registration and at the 1st year. For the present analysis, we divided patients with persistent AF into four groups; patients who underwent catheter ablation and maintained sinus rhythm (group 1), patients who underwent catheter ablation and had non‐sinus rhythm at the 1 year follow‐up (eg. AF or atrial tachycardia [AT]: group 2), patients who maintained sinus rhythm by AAs (group 3) and patients who did not undergo catheter ablation or AA treatment (group 4). The total QOL scores were compared by one‐way ANOVA between these four groups. Also, the scores were compared between each group by Tukey test.

Result:

Overall, 1040 patients with persistent AF were analyzed. 432 patients completed 1‐year follow‐up (107 patients were in group 1, 22 in group 2, 50 in group 3 and 253 in group 4). Although total AFEQT scores at baseline showed no difference between the four groups (77 ± 16 vs 79 ± 13 vs 78 ± 16 vs 78 ± 16, respectively: Figure 1a), the scores in group 1 were better than the others at 1 year follow‐up (91 ± 14 vs 78 ± 13 vs 84 ± 14 vs 82 ± 14 [P < .01]: Figure 1b). Importantly this trend could be seen in the subgroup of patients who had better QOL (AFEQT scores equal to or more than 80 at baseline: 90 ± 5 vs 90 ± 6 vs 91 ± 5 vs 90 ± 6 at baseline and 95 ± 10 vs 88 ± 10 vs 86 ± 9 vs 86 ± 10 at 1 year [P < .01]).

Conclusion:

Maintaining SR by catheter ablation is associated with better QOL for persistent AF patients in comparison to AA therapy.

AP19‐00010

Association between acute hepatitis B flare and long‐term clinical outcomes in patients with atrial fibrillation

Sung Il Im

Kosin University Gospel Hospital, South Korea

Keita Tsukahara

University of Occupational and Environment Health, Japan

Keerthika Ravella

NIMS, India

Introduction:

Atrial flutter (AFl) is uncommon in young patients with uncorrected atrial septal defect (ASD). Although rare, it has been reported in young patients following device closure of ASD/PFO. A case of persistent atypical atrial flutter following device closure of atrial septal defect, refractory to aggressive pharmacotherapy requiring electrical cardioversion is being presented here. Cardioversion was not done in initially due to risk of device embolization. After cardioversion patient remained in sinus rhythm with no recurrence of flutter.

Methods:

A 28 year old, asymptomatic man was found to have an RBBB during a routine medical check‐up. On further evaluation he was found to have a large ostium secundum ASD with dilated right sided chambers. His transesophageal echocardiographic (TEE) examination revealed the defect to be 27 mm in diameter with adequate surrounding rims for device closure. He underwent successful closure of his ASD with an Amplatzer Septal Occluder (32 mm). Three weeks following the closure, he complained of palpitations. His ECG showed atypical atrial flutter with 2:1 AV conduction and a ventricular rate of 150/min

graphic file with name JOA3-35-76-g004.jpg

Result:

He was admitted and administered heparin and I.V. amiodarone (1 gm over 24 hours), which reduced the ventricular rate but did not restore sinus rhythm. Subsequently, he was started on metoprolol succinate (50 mg BD) and dabigatran (150 mg BD). After 4 weeks, it was decided to give him a trial with flecainide which was started, initially 50 mg twice daily, and later increased to 100 mg twice daily. Over the next 2 months, while his pulse rate was within the normal range, the atrial flutter persisted. Hence flecainide was stopped and oral amiodarone was instituted. Two months later, he still complained of palpitations on effort; his ECG showed atrial flutter @ 300/min, varying AV conduction and a ventricular rate of 80/min (Figure 2). Given the adverse effects of amiodarone in the long term, it was decided to go back to the original regimen consisting of metoprolol succinate and dabigatran. During all this time, cardioversion was not used in view of the possibility of device embolization during the delivery of the shock.

graphic file with name JOA3-35-76-g005.jpg

graphic file with name JOA3-35-76-g006.jpg

Conclusion:

After 6 months following the device closure since the flutter persisted, it was presumed to be safe to convert him electrically. He was subjected to TEE which confirmed the device to be in proper position (Figure 3a) without any thrombus over the device or in the LA appendage; there was no residual shunt (Figure 3b). He was subsequently cardioverted with 100J biphasic DC Shock and sinus rhythm was restored (Figure 4). Six weeks later, his antiarrhythmics and anticoagulant were discontinued. At 6 months following cardioversion, he continues to remain in sinus rhythm.

AP19‐00065

Feasibility and safety of his bundle pacing and left bundle branch area pacing in atrial fibrillation patients in need of pacing

Yang Ye, Kai Zhang, Yiwen Pan, Ying Yang, Dongmei Jiang, Bei Wang, Chan Yu, Zuwen Zhang, Shiquan Chen, Jiefang Zhang, Yunxian Cheng, Yaxun Sun, Xia Sheng, Guosheng Fu, Chenyang Jiang

Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, No. 3 Qin, China

Introduction:

Studies have indicated the feasibility of his bundle pacing (HBP) in atrial fibrillation (AF) patients with potential long term right ventricular pacing (RVP) irrespective of left ventricular ejection fraction (LVEF). Left bundle branch area pacing (LBBAP) is a new pacing approach and also produces narrow QRS duration. This study explores the feasibility of his bundle system pacing (HBSP) including HBP or LBBAP in AF patients in need of RVP.

Methods:

A total of 16 pacing‐necessary AF patients were prospectively enrolled. Patients with AF and atrial ventricular block (AVB) (n = 14) or patients with tachycardia AF combined with atrial ventricular nodal (AVN) ablation (n = 2) were attempted to undergo both HBP and LBBAP in our center. Electrocardiogram characteristics, pacing parameters, pacing sites, and safety events were assessed at implantation and 3 months. New York Heart Association (NYHA) functional class, echocardiography, QRS duration (QRSd), use of diuretics and lead parameters were measured at baseline and at the 3 months‐follow‐up.

graphic file with name JOA3-35-76-g007.jpg

Result:

All 16 AF Patients (mean age 71.2 ± 5.7 years; male 68.8%)were attempted with HBSP successfully in our center. 13 patients (13/16) underwent both HBP and LBBAP successfully. Another three were attempted to LBBAP (n = 1) or HBP (n = 2) with routine RVP successfully. Electrocardiogram pattern during LBBAP showed right bundle branch conduction delay. In patients with narrow QRSd (n = 15), the native QRSd was 91.00 ± 10.00 milliseconds. The QRS duration was 100.67 ± 9.04 milliseconds in HBP group and was 112.80 ± 6.88 milliseconds in LBBAP group (P = .005 for HBP vs LBBAP). One patient had left bundle branch block (LBBB) with native QRSd 168 milliseconds, and got QRSd corrected to 92 milliseconds by HBP and to 112 milliseconds by LBBAP respectively. Ten of 16 patients had edema of extremity before the procedure and 7 of 10 patients got their diuretics reduced or stopped at 3 months follow up. One patient with LBBB correction by HBP got his LVEF increased and the left ventricular end‐diastolic diameter (LVEDD) improved. The pacing parameters were stable in LBBAP and this kept stable during the follow up though the paced QRSd was wider in LBBAP than in HBP. One patient was shifted to LBBAP mode because of increased HBP threshold one month after AVN ablation. After the 3 months’ follow‐up, 7 Patients had their diuretics reduced or stopped with improvement of symptoms and NYHA class with down trend in LVEDD without significance of LVEF. No perforation or dislodgement happened in our study.

Conclusion:

This study demonstrates the clinical feasibility and application of both HBP and LBBAP in patients of AF in need of pacing . LBBAP had better parameters though wider QRS duration than HBP and could be a new pacing physiological strategy. Our preliminary study indicates physiological pacing by LBBAP could be another option in patients of AF pacing needed or AF patients with LBBB.

AP19‐00066

Efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonist (VKA) among patients with atrial fibrillation and hypertrophic cardiomyopathy: A systematic review and meta‐analysis

Pongprueth Rujirachun, Nipith Charoenngam, Phuuwadith Wattanachayakul, Arjbordin Winijkul, Weerapat Owattanapanich, Patompong Ungprasert

Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

Vikas Kataria, Mohan Nair, Gautam Singal, Amitabh Yaduvanshi, Vipul Malpani, Pritam Kittey

Holy Family Hospital, India

Introduction:

About 15‐20% of ischemic strokes are attributable to documented atrial fibrillation (AF). Additionally, up to 20% of patients not known to have AF before the stroke are diagnosed as AF on cardiac monitoring during or after the stroke. The exact incidence and the clinical impact of such AF detected after stroke (AFDAS) is not clear and is currently being investigated. The objective of our study was to find the incidence of AFDAS in hospitalized patients with ischemic stroke. We also wanted to see if AFDAS was associated with the same worse prognosis as in patients with previously diagnosed AF.

Methods:

All patients admitted with first ischemic stroke during a span of 3 years were included in this study. Patients with previous history of ischemic stroke and those with documented AF were excluded. Cardiac rhythm was continuously monitored throughout the hospital stay and with 72 hours. Holter monitoring after discharge. All patients were evaluated for (a) In‐ hospital outcomes and (b) for recurrence of ischemic stroke /TIA, up to one year from the index event.

Result:

Of 545 ischemic stroke patients admitted over 3 years, 114(20.9%) had documented AF(DAF group). Of the remaining 431, 78 patients (18.09%) were detected to have AF(AFDAS group) during cardiac monitoring, whereas 353 (81.9%) remained arrhythmia free(SR group). Four patients in the SR group (1.1%), two patients in DAF group(1.7%) and one patient in AFDAS (1.2%) died during the hospital stay (P = NS). The duration of hospital stay was not different among the groups. During the follow‐up period of 1 year, recurrence of stroke occurred in eight patients of SR group (2.2%), three patients of ASDAF group (3.8%, P = .43) and 16 patients of AF group (14%, P = .001 vs SR group, P = .046 vs AFDAS).

Conclusion:

The lack of difference in 1‐year ischemic stroke recurrence between AFDAS and SR but lower than the DAF group suggests that the underlying pathophysiology of AFDAS may differ from that of KAF. These findings may have important implications on anticoagulation strategy in such patients.

graphic file with name JOA3-35-76-g009.jpg

AP19‐00081

Preoperative multidetector computed tomography is adequate enough to detect intracardiac thrombi at atrial fibrillation ablation

Shinji Ishimaru, Mariko Kawasaki, Teppei Sugaya, Kuniharu Nishimura, Tadashi Igarashi, Kaoru Komuro, Hiroaki Okabayashi, Jungo Furuya, Keiichi Hanaoka

Hanaoka Seishu Memorial Cardiovascular Clinic, Japan

Introduction:

Transesophageal echocardiography (TEE) is routinely performed as gold standard to evaluate intracardiac thrombi in atrial fibrillation (AF) ablation in spite of its invasiveness and patient's physical discomfort. Meanwhile, multidetector computed tomography (MDCT) has rapidly progressed as 3‐dimensional imaging modality. Most patients planned to take catheter ablation for AF undergo MDCT to clarify the anatomy of both pulmonary veins and left atrium (LA) to improve the accuracy of the electroanatomical maps. Furthermore, recent meta‐analyses suggest that MDCT is a reliable alternative to TEE in detecting LA and left atrial appendage (LAA) thrombi, particularly when delayed imaging is performed with contrast agent. We aimed to estimate the usefulness of preprocedural MDCT to detect intracardiac thrombi at AF ablation.

Methods:

We performed delayed imaging MDCT with contrast enhancement to evaluate intracardiac thrombi within 24 hours before AF ablation from September 2016 to May 2019. Delayed imaging was performed in five minutes after arterial phase. All subjects took oral anticoagulants at least for three weeks before the operation. And they underwent the ablation therapy under the condition of continuous oral anticoagulants.

Result:

A total of 140 patients underwent AF ablation during the term. All of them were screened by MDCT alone prior the operation. There was no patient who was detected intracardiac thrombi. 62 were treated by radiofrequency catheter ablation (RFCA) alone, 36 by cryoballoon alone, and 42 by both cryoballoon and touch up RFCA . None of them had thromboembolic complications in perioperative period.

Conclusion:

Preoperative TEE is not always essential modality to detect intracardiac thrombi before AF ablation especially in patients who underwent delayed imaging of cardiac MDCT that showed no evidence of thrombus. Delayed imaging MDCT is adequate enough to detect intracardiac thrombi before AF ablation.

AP19‐00084

Catheter ablation of atrial fibrillation prevents cardiovascular events and death in over 80‐year‐old patients

Satoshi Taya, Keisuke Okawa, Masahiko Takahashi, Ryu Tsushima, Keisuke Yamamoto, Yuya Sudo, Masahiro Sogo, Satoko Ugawa, Tomoaki Okada, Kazumasa Nosaka, Kosuke Sakane, Masayuki Doi

Kagawa Prefectural Central Hospital, Japan

Introduction:

We already know the fact that the efficacy and safety of catheter ablation is established even in elderly patients with atrial fibrillation (AF). However, the impact of catheter ablation on the prognosis in very elderly AF patients is unclear.

graphic file with name JOA3-35-76-g010.jpg

Methods:

We prospectively investigated 186 consecutive AF patients over 80‐years‐old from March 2011 to January 2018 in two key acute care hospitals in Kagawa prefecture. We compared the patients who underwent CA with those who received medical therapy alone (ablation group [n = 65] vs medication group [n = 121]). All patients had taken anticoagulants, and were followed up for at least 6 months. We defined the primary end point as death from any cause and cardiovascular events including heart failure, acute coronary syndrome, and stroke. We defined the secondary end point as death from any cause and cardiovascular events, respectively.

Result:

The follow‐up period was 478 days (median). Any therapy related adverse events did not occur. The incidence of primary end point was significantly lower in the ablation group than in the medication alone group (n = 4 [6.2%] vs n = 40 [33%]; hazard ratio = 0.19, confidence interval 0.087‐0.69, Logrank P < .01) (Figure). Multivariate analysis revealed that independent predictor of primary end point was only medication alone therapy (odds ratio [OR] = 4.37, P = .007). Even though there were several other elements which tended to get poor prognosis, for example age (over 83‐year‐old; OR = 1.29, P = .50), low cardiac function (OR = 1.61, P = .25), prior cardiovascular events (OR = 1.57, P = .16), female (OR = 1.75, P = .093), and persistent or chronic atrial fibrillation (OR = 1.56, P = .18), there were no significant difference.

Conclusion:

CA of AF could prevent cardiovascular events and death in over 80‐year‐old patients.

AP19‐00087

Significance of advanced coronary atherosclerosis in development of atrial fibrillation

Hyo Eun Park, Heesun Lee, Yunwhan Lee, Su‐Yeon Choi

Seoul National University Hospital, South Korea

Introduction:

Atrial fibrillation (AF) has emerged as a major public health problem with increasing age of the society. Although coronary computed tomography angiography (CCTA) provides comprehensive evaluation of coronary atherosclerosis, one of the well‐known risk factors of AF, data regarding the risk of AF occurrence according to CCTA results remain paucity. We aimed to examine the association between risk of AF and CCTA‐derived characteristics in general population.

Methods:

We retrospectively reviewed 24 826 cases who performed 12‐lead electrocardiography (ECG) and CCTA with calcium scan on the same day for a routine health checkup between 2003 and 2017. The primary endpoint was AF documentation on ECG. Coronary artery calcium scores (CACS) were presented using Agatston units. The presence, location, and extent of coronary atherosclerosis and maximal diameter stenosis (DS) were evaluated on CCTA. Plaque composition was categorized as non‐ calcified, mixed, or calcified according to the volume of calcified component (>130 Hounsfield Units).

graphic file with name JOA3-35-76-g011.jpg

Result:

Of total enrolled subjects (mean age 56.6 year, male 72.7%), AF was detected in 210 subjects (0.8%). Univariate analysis showed age ≥60, male sex, obesity, smoking, a history of hypertension, diabetes mellitus, hyperlipidemia, and chronic kidney disease, and elevated serum T4 level were significantly associated with AF. Among CCTA parameters, CACS ≥400, presence of calcified plaque (CP), DS ≥50%, left main disease, and 3‐vessel involvement were significantly related with AF occurrence. Particularly, CACS and extent of coronary atherosclerosis had a stepwise association with AF. After adjusting for clinical parameters which were significant in the univariate analysis, CACS ≥400 (adjusted OR 2.15, P = .011), 3‐vessel involvement (adjusted OR 1.34, P = .041), and presence of CP (adjusted OR 3.61, P < .001) each remained significant.

Conclusion:

Advanced coronary atherosclerosis, presented by higher CACS, multi‐vessel involvement, and presence of CP, was significantly associated with AF. It can provide a new insight of pathophysiology of AF and a solid evidence for AF prevention via effective management of atherosclerosis risk factors.

Trend Plot for Afib and coronary calcification

AP19‐00089

Factors related to clinically low dose direct oral anticoagulant use in real‐world practice

Takashi Kanda, Masaharu Masuda, Takuya Tsujimura, Yasuhiro Matsuda, Hiroyuki Uematsu, Masaharu Masuda

Kansai Rosai Hospital, Japan

Introduction:

The appropriate dose of direct oral anticoagulants (DOACs) is determined by several patient‐specific factors such as the age, renal function, weight, and concurrent medications. However, in clinical practice, physicians sometimes prescribe under‐dosed DOACs considering bleeding risks.

Methods:

The study population consisted of 877 consecutive patients who were taking DOACs for thromboembolism prevention at our institution. Those receiving the required DOAC dose were classified as an ‘appropriate dose’ and the rest as a ‘clinically adapted dose’. Those requiring standard doses but receiving reduced doses were regarded as a ‘clinically low dose’, and those requiring reduced doses but receiving standard doses were considered as a ‘clinically high dose’.

Result:

A total of 877 patients were prescribed DOACs: 134 dabigatran, 181 rivaroxaban, 247 apixaban, and 315 edoxaban. A standard DOAC dose was prescribed in 321 patients (37%) and reduced dose in 556 (63%). A total of 692 patients received appropriate doses (79%) and 185 (21%) clinically adapted doses (clinically low dose, 162 [18%], and clinically high dose, 23 [3%]). In the multivariate analysis comparing appropriate standard dose and clinically low dose group, age, female and Dabigatran use was an independent factor associated with a clinically low dose.

Conclusion:

In real‐world clinical practice, a considerable number of patients received a clinically low dose of DOACs. Patients’ background and the choice of DOACs were independent factors associated with a clinically low dose.

TABLE Factors associated with clinically low dose

	Univariate			Multivariate
	OR	95% CI	P value	OR	95% CI	P value
Age (per 10 years increase), years	1.80	1.44‐2.26	<.01	1.99	1.48‐2.70	<.01
Female	2.71	1.78‐4.15	<.01	2.59	1.55‐4.33	<.01
Body weight (per 10 kg increase), kg	0.80	0.69‐0.92	<.01	0.94	0.78‐1.13	.50
eGFR level (per 10 mg/dL increase), mg/dL	0.91	0.82‐1.005	.06	0.90	0.80‐1.01	.06
Prior catheter intervention	1.19	0.70‐2.00	.52	—	—	—
Heart failure	0.79	0.49‐1.26	.32	—	—	—
Hypertension	0.96	0.65‐1.41	.83	—	—	—
Diabetes mellitus	0.95	0.60‐1.51	.83	—	—	—
Stroke	0.86	0.49‐1.50	.60	—	—	—
CHADS2 score	1.09	0.92‐1.23	.35	—	—	—
HASBLED score	1.34	1.05‐1.72	.02	0.93	0.67‐1.29	.67
Number of antiplatelet	1.41	0.996‐1.99	.053	1.36	0.93‐1.99	.12
Prescribed by a cardiologist	0.68	0.41‐1.14	.15	—	—	—
Dabigatran use	2.78	1.51‐5.14	<.01	6.34	3.05‐13.20	<.01
Rivaroxaban use	0.96	0.64‐1.49	.91
Apixaban use	0.995	0.66‐1.50	.98
Edoxaban use	0.62	0.39‐0.97	.04	1.44	0.84‐2.45	.18
Verapamil use	2.38	1.14‐4.96	.02	1.99	0.90‐4.42	.09

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Factors with P < .10 in the univariate analysis were incorporated in the multivariate analysis. OR, odds ratio; CI, confidence interval.

AP19‐00090

Clinical profile and adherence to guidelines directed stroke prevention therapy in patient with atrial fibrillation in Department of Cardio Vascular Medicine, Mandalay General Hospital

Khin Oo Lwin, Than Than Kyaing, Kyaw Soe Win, Myint Ngwe, Khin Maung Win, Hein Htet Aung

Department of Cardio Vascular Medicine, Mandalay General Hospital, Mandalay, Myanmar, Burma

Introduction:

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. Even in developed countries suboptimal anticoagulation and low adherence to guidelines is frequently observed in Atrial fibrillation (AF) patients. There is no national and local data about the utilization patterns and adherence to guidelines directed therapy for stroke prevention in patients with AF in Myanmar population

Methods:

It was a single Centre one year observational study from May 2018 to May 2019. All patients admitted in Department of Cardio Vascular Medicine, Mandalay General Hospital with AF were included. Detailed history, examination and relevant investigations were carried out and CHA2DS2VASc score was used for risk stratifying and prescribing oral anticoagulants in non‐valvular AF.

Result:

Total one hundred and sixty two patients were studied, 43.2 % were male and 56.79% were female. Sixty nine patients were valvular AF and ninety three patients were non‐valvular AF. Among non‐ valvular AF, hypertension was most common risk factor (54.8%) and the rest were 31.1% associated with smoking, 15.0% with Diabetes Mellitus and 19.35% with Coronary Artery Diseases. Mean CHA2DS2VASc score was 2.06 ± 1.22 in non‐valvular AF, median score 2. Out of ninety three patients, sixty four patients were found to have indication for prescription of OAC as per guidelines, out of which only 22(34.4 %%) patients actually received OAC. OAC prescription was significantly higher in valvular vs. non‐valvular AF (P < .01).

Conclusion:

Oral anticoagulant was underused in non‐valvular AF cases in this study. Optimal anticoagulation needs to be emphasized on both patients as well as physicians to prevent strokes and achieve better outcomes.

AP19‐00095

Uninterrupted vs interrupted dabigatran. Uninterrupted dabigatran is associated with optimal ACT control during catheter ablation

Shunsuke Miyauchi, Yukiko Nakano, Yoshihiro Ikeuchi, Sho Okamura, Yosaku Okubo, Naoya Hironobe, Takehito Tokuyama, Yasuki Kihara

Hiroshima University Graduate School of Biomedical and Health Sciences, Japan

Introduction:

Recent randomized controlled study revealed that anticoagulation with uninterrupted dabigatran was associated with fewer bleeding complications than uninterrupted warfarin in patients undergoing catheter ablation (CA) of atrial fibrillation (AF). Just recently, uninterrupted dabigatran during perioperative period has been identified as Class I in the updated guideline. However, comparisons of necessary heparin amount and activated clotting time (ACT) during procedure between the cases of interrupted and uninterrupted dabigatran have not been clarified. In the present study, we aimed to assess the safety and usefulness of uninterrupted dabigatran and investigate dynamics of activated clotting time (ACT) during the procedure.

Methods:

From January 2012 to January 2015, 62 patients with AF who were administrated uninterrupted (N = 28) or interrupted (N = 34) dabigatran during perioperative period of CA of AF in Hiroshima University Hospital were retrospectively enrolled to the study. In the uninterrupted dabigatran group, dabigatran was continued till in the morning of the CA day. In the interrupted dabigatran group, dabigatran was discontinued in the evening of the previous day of CA with unfractionated heparin bridge. The dose of dabigatran was decided according to the age, body weight, and creatinine clearance level by the attending physicians (300 mg/d or 220 mg/d). During the CA procedure, unfractionated heparin was infused with target ACT 250‐300 seconds. ACT was constantly measured every 10 to 30 minutes after the first unfractionated heparin infusion by the consistent device (Hemochron^® Signature, ITC, Edison, NJ, USA).

Result:

The baseline characteristics including the CHADS2 score and HASBLED score were similar between the uninterrupted and interrupted dabigatran group. ACT before unfractionated heparin infusion was significantly higher (168 ± 24 vs 142 ± 21 seconds, P < .0001) and required heparin dose for target ACT was significantly lower (3.1 ± 0.4 vs 7.6 ± 0.4, P < .0001; Figure 1) in the uninterrupted group. Require time to target ACT was shorter in the uninterrupted dabigatran group than in the interrupted dabigatran group (21.1 ± 1.9 vs 27.1 ± 1.7 minutes, P = .02; Figure 2). When we defined over target ACT as >330 seconds in our protocol, rate of patients with over target ACT was higher in the uninterrupted dabigatran group than in the interrupted dabigatran group (7 % vs 47 %, P = .0003; Figure 3). Multivariate analysis revealed that uninterrupted dabigatran was independently associated with lower incidence of over target ACT during CA procedure (Odds ratio: 27.3, P = .003).

Conclusion:

Uninterrupted dabigatran contributed to early attain to target ACT by small amount of heparin and low incidence of over target ACT during CA of AF. Uninterrupted dabigatran may help to get optimal control of ACT during CA compared to interrupted dabigatran, supporting safety of uninterrupted dabigatran.

graphic file with name JOA3-35-76-g012.jpg

AP19‐00097

The incidence and origin of atrial tachycardia after cryoballoon ablation

Tsuyoshi Sakai, Masahiro Nauchi, Naohiko Sahara, Yuta Sugizaki, Yoshiaki Ito, Keisuke Hirano

Saiseikai Yokohamashi Tobu Hospital, Japan

Introduction:

Atrial tachycardia (AT) recurrence after atrial fibrillation (AF) ablation with radiofrequency (RF) is not rare, and it is difficult to control in some cases. However, the incidence and origin of AT after cryoballoon ablation is not clear.

Methods:

Two hundred eighty patients underwent second‐generation cryoballoon (Arctic Front Advance, Medtronic, Inc., Minneapolis, MN, USA) ablation from July 2016 to February 2019 in our hospital and followed up for at least 3 months after ablation were included in this study. Pulmonary vein (PV) isolation was performed with cryoballoon. Additional left atrial (LA) linear ablation was not performed. We examined the origin of AT by electrophysiological study.

Result:

Fifty patients (17.9%) had recurrence after cryoballoon ablation. Among them, recurrence of AF occurred in 38 patients (76%), AT in 8 (16%) and premature atrial contractions in 4 (8%). PV reconnection was observed in 21 patients. The distribution of reconnected PV was 11 LSPVs, 8 LIPVs, 12 RSPVs, 15 RIPVs. The origins of AT were 2 RIPVs, 1 RSPV, 1 of both RPVs, 1 LSPV, 1 base of left atrial appendage, 1 posterior of LA and 1 carina.

Conclusion:

The majority of AT after cryoballoon ablation were originated from RPV and carina. Our study shows that freezing of RPV was not enough due to the phrenic nerve palsy and incomplete occlusion of RIPV. Also, the carina area could not be ablated enough by cryoballoon. The LA voltage map after cryoballoon ablation and additional RF ablation for those areas might be the breakthrough.

AP19‐00101

Thoracoscopic left atrial appendage excision plus atrial fibrillation ablation as a secondary prevention strategy against stroke: Initial experience and two year outcome data

Zidun Wang

The First Affiliated Hospital with Nanjing Medical University, China

Introduction:

Atrial fibrillation (AF) patients with a previous stroke are often at a high risk of recurrent stroke and bleeding. Anticoagulation therapy in such patients is a challenging dilemma. Currently, thoracoscopic left atrial appendage excision (LAAE) plus AF ablation is an interventional approach offered to some AF patients. We hypothesized that this approach may be suitable as a secondary stroke prevention strategy for these high‐risk patients.

graphic file with name JOA3-35-76-g013.jpg

Methods:

Between January 2013 and December 2016, a total of 44 patients (26 male; mean age 65.0 ± 9.1 years) with nonvalvular AF and a previous stroke or systemic thromboembolic event were enrolled in our study. The patients underwent thoracoscopic LAAE plus AF ablation by experienced operators and were followed up for 2 years (at 1, 3, 6, 9, and 12 months postoperatively and every 6 months thereafter). Thromboembolic and major bleeding events were recorded. Cerebral computed tomography or magnetic resonance imaging and 7‐day Holter monitoring were performed annually.

Result:

Mean CHA2DS2‐VASc and HAS‐BLED scores were 4.2 ± 1.2 and 3.3 ± 0.7, respectively. All patients discontinued oral anticoagulation (OAC) therapy after the surgical intervention. One patient suffered a periprocedural transient ischemic attack, and another was diagnosed with a new ischemic stroke at 491 days after surgery. The annual rate of total thromboembolism was 2.05%. No deaths or major bleeding events were observed postoperatively. The rate of successful AF ablation with no AF recurrence is 76.3%.

Conclusion:

Trans‐thoracoscopic LAAE plus AF ablation may be a promising approach for this high‐ risk population. Thromboembolism prevention in this secondary prevention cohort was low, even without OAC treatment.

AP19‐00127

AF anticoagulation—DOACs breaking the bank?

Stephen Cookson, James Oldman, Carina Joanes, Rachel Mackay

Royal Brompton Hospital, United Kingdom

Kyu Kim, Pil‐Sung Yang, Eunsun Jang, Hee Tae Yu, Tae‐Hoon Kim, Jae‐Sun Uhm, Jong‐Youn Kim, Jung‐Hoon Sung, Hui‐Nam Pak, Moon‐Hyoung Lee, Gregory Y.H. Lip, Boyoung Joung

Yonsei University College of Medicine, South Korea

Introduction:

Atrial fibrillation (AF) commonly occurs in the patients who had hyperthyroidism. AF associated with hyperthyroidism is thought to be transient and not to recur after hyperthyroidism is controlled. However, the data of prognosis was limited. We aimed to evaluate the risk of the AF related to hyperthyroidism.

Methods:

Using a National Health Insurance Service (NHIS) database, between January 1, 2005 and December 31, 2016, we identified 626 699 new‐onset, nonvalvular AF aged ≥18 years who were oral anticoagulation naïve. Among them, 21 348 AF patients were associated with hyperthyroidism. After 3:1 propensity score (PS) matching, stroke/systemic embolism (SE) and all‐cause death were compared between hyperthyroidism related AF group and general AF group.

Result:

During median follow‐up of 5.9 years, 53.3% of hyperthyroidism related AF recurred. The risk of stroke/SE was higher in hyperthyroidism related AF (hazard ratio [HR] 1.06; 95% confidence interval [CI] 1.00‐1.12; P = .037). The risk of all‐cause death was similar (HR 1.02; 95% CI 0.95‐1.05; P = .394). Within 1 year from AF diagnosis, hyperthyroidism related AF had much higher stroke/SE risk than general AF group. (HR 1.25; 95% CI 1.14‐1.37; P < .001). After 1 year of AF diagnosis, the risk of stroke SE become similar (HR 0.98; 95% CI 0.92‐1.05; P = .516). The results were similar according to different age and CHA2DS2‐VASc score subgroups.

Conclusion:

Hyperthyroidism related AF was not transient and associated with higher stroke/SE risk. The risk was higher within 1 year after AF diagnosis. Like general AF, patients with hyperthyroidism related AF should had regular follow‐up and anticoagulation should be considered.

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AP19‐00144

Participation of posterior wall for strategy of atrial fibrillation ablation

Shun Kikuchi, Kazuo Kato, Shin Hasegawa, Noubuo Ishiguro, Masayuki Nakamura, Shingo Yoshioka, Akimitu Tanaka, Miyuki Ando, Hidakazu Aoyama, Ryosuke Kametani

Nagoya Tokushukai General Hospital, Japan

Introduction:

Encircling wider PVI (pulmonary vein isolation) i.e., box PVI (box shaped encircling isolation of 4 PVs and the posterior wall [PW]) could be expected to obtain better outcome for some atrial fibrillation (AF) despite requiring more delicate procedure. However, the clinical course in patients performed box PVI have not fully elucidated. We investigated the difference of the recurrence rate among patients with various severities of the AF performed completion of the box PVI.

graphic file with name JOA3-35-76-g016.jpg

Methods:

We enrolled 270 patients (73 in paroxysmal AF (paroAF), 165 in persistent AF (perAF), and 32 with repeat session [reAF]) performed box PVI. Bidirectional blocks of both PVs including their carinas were confirmed in all patients, while the PW was isolated bidirectionally in 80.7% (218/270: 59 in paroAF, 132 in perAF, and 27 in reAF) patients (Bi‐PWI), or isolated unidirectionally in 19.3% (52/270: 14 in paroAF, 33 in perAF, and 5 in reAF) patient (Uni‐PWI).

Result:

The AF free survival, which was comparable between Bi‐PWI and Uni‐PWI groups, was highest in the paroAF group. However, Bi‐PWI was associated with lower AF recurrence in the perAF. The reAF group showed the highest AF recurrence independent of the complete PW isolation.

Conclusion:

The PW isolation might be dispensable for paroAF, while the reAF might require beyond the PW isolation. On the other hand, bidirectional PW isolation in addition to the complete PVI could be crucial for perAF.

AP19‐00146

Heart rate control resistant minor allele of GJA‐1 gene polymorphism in patients with persistent atrial fibrillation

Ikeuchi Okamura, Ikeuchi Nakano, Ikeuchi Miyauchi, Ikeuchi Yoshihiro, Yousaku Okubo, Naoya Hironobe, Takehito Tokuyama, Yasuki Kihara

Hiroshima University, Japan

Introduction:

Beta‐blockers are the first‐line rate control therapy in patients with atrial fibrillation (AF). However, several patients show drug resistant. The previous genome‐wide association studies identified single nucleotide polymorphisms (SNPs) associated with heart rate (HR). We hypothesized that these HR‐associated SNPs were related to HR control in AF patients.

Methods:

We enrolled 395 patients with persistent AF who took equal amount of β‐blocker. We genotyped HR‐associated SNPs in all the AF patients. They underwent 24‐hour Holter monitoring and electrophysiological study.

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Result:

Only the GJA‐1 SNP (rs1015451, C>T) was associated with total HR in patients with persistent AF after Bonferroni correction. (Table) In addition, the conduction times of the right and left atriums were shorter in AF patients with GJA‐1 SNP minor allele C than those without.(Figure)

Conclusion:

The GJA‐1 SNP, a coding gap junction protein (CX43), may be related to resistivity of HR control in AF patients.

AP19‐00148

Home‐based cardiac rehabilitation versus conventional care for patients with atrial fibrillation treated with catheter ablation: A randomized controlled trial

Cheng Cai, Gang Yang, Zhipeng Bao, Fengxiang Zhang, Weizhu Ju, Hongwu Chen, Mingfang Li, Kai Gu, Guozhen Sun, Minglong Chen

The First Affiliated Hospital of Nanjing Medical University, China

Introduction:

Radiofrequency ablation (RFA) is often undertaken in symptomatic patients and has been achieved a very high success rate. However, the symptoms like palpitations, dyspnea and fatigue are common and the exercise capacity decreases. This study was aimed to assess the effects of comprehensive home‐based cardiac rehabilitation compared with usual care on cardiac function and mental health for patients treated with catheter ablation for atrial fibrillation.

Methods:

Patients with atrial fibrillation treated by catheter ablation were randomized to cardiac rehabilitation consisting 8‐week home‐based physical exercise and smartphone‐based follow‐up versus usual care. The exercise proposal required the patients to exercise at the target heart rate for at least 150 minutes per week and report completion via a smartphone‐based follow‐up system. The primary endpoint was the value of VO2 peak. The secondary outcomes included performance in 6‐minute walk, self‐rated mental health measured by the Short Form‐36 questionnaire and Zung's Self‐Rating Anxiety Scale, sleep quality assessed by Pittsburgh sleep quality index scale.

Result:

Fifty‐six patients (mean age: 55.2 ± 9.2, 78.6% male, 27 subjects in control and 29 in cardiac rehabilitation group) completed the follow‐up. Baseline characteristics were comparable between the two groups. Compared with usual care, the cardiac rehabilitation group showed a significant improvement in cardiac function assessed by VO2 peak (baseline vs 8‐week follow‐up, 18.8 ± 5.6 vs 28.9 ± 7.5 mL/kg·min; P < .001) and 6‐minute walk (baseline vs. 8‐week follow‐up, 456(408, 496) vs 495(480, 543) m; P < .001). Meanwhile, there was significant improvement in self‐rated mental health in cardiac rehabilitation group, but not in usual care group. In addition, multivariate logistic regression analysis showed that rehabilitation was the only factor associated with improvement in exercise performance measured by VO2 peak after adjustment (OR [95% CI], 16.3 [2.9‐92.4]; P = .002).

Conclusion:

Comprehensive home‐based cardiac rehabilitation had a positive effect on physical capacity compared with usual care in atrial fibrillation patients treated with catheter ablation in a short period, as well as on mental health.

Variables

Control

CR group

P value⧧

P value baseline adjusted#

Vo2 max

Baseline

FU

FU‐Baseline

18.9±5.0

19.9±5.3

1.1±5.8

18.8±5.6

28.9±7.5*

10.2±8.0

.965

<.001

6‐minute walk

Baseline

FU

FU‐Baseline

420(390, 497)

420(374, 495)

0(‐45, 15)

456(408, 496)

495(480, 543)*

48(23,1105)

.517

<.001

Systolic BP

Baseline

FU

FU‐Baseline

124.0±11.8

125.6±15.6

1.6±16.3

125.9±10.9

115.5±12.7*

‐10.4±13.4

.527

.010

.004

Diastolic BP

Baseline

FU

FU‐Baseline

81.7±10.2

81.0±10.9

‐4.0±12.6

81.1±10.9

77.1±11.1*

‐.7±11.0

.822

.195

.313

.193

Resting HR

Baseline

FU

FU‐Baseline

80.8±9.9

78.4±12.1

‐2.4±14.5

79.5±10.1

70.0±12.4*

‐9.5±13.9

.630

.013

.067

.016

BMI

Baseline

FU

FU‐Baseline

26.0±3.2

26.5±3.3

.5±.7

25.1±3.2

Michifumi Tokuda, Seigo Yamashita, Seiichiro Matsuo, Hidenori Sato, Eri Okajima, Hirotsugu Ikewaki, Hirotsuna Oseto, Masaaki Yokoyama, Ryota Isogai, Kenichi Tokutake, Kenichi Yokoyama, Ryosuke Narui, Mika Kato, Shin‐ichi Tanigawa, Michihiro Yoshimura, Teiichi Yamane

The Jikei University School of Medicine, Japan

Introduction:

Even symptomatic cerebral thromboembolism (CE) occurred during radiofrequency catheter ablation for atrial fibrillation (AF) is rare, an asymptomatic CE which was sometimes detected by postprocedural MRI. Recently, cryoballoon, hot balloon, laser balloon had been developed for pulmonary vein isolation of paroxysmal AF. The purpose of this study was to evaluate the incidence and the risk factor of CE among radiofrequency catheter and 3 types of balloon catheter.

Methods:

A total of 717 patients who underwent the initial catheter ablation for paroxysmal AF were included. Pulmonary veins were isolated using RF catheter, cryoballoon, hot balloon, laser balloon in 362, 296, 33 and 26 patients, respectively. Cerebral MRI was performed one or two days after the procedure in all patients. The presence of CE was evaluated by the radiologist who is blinded to the study.

Result:

Peri‐procedural CE was detected in 25.6% of patients by postprocedural MRI. Only one patient after cryoballoon ablation had complained of mild left‐hand muscle weakness and was diagnosed as symptomatic stroke. In patients with CE, age was older (60.2 ± 9.9 vs 57.2 ± 10.1 years, P = .001), left atrial diameter was larger (38.0 ± 5.9 vs 36.8 ± 3.0 mm, P = .01), serum BNP level was higher (61.9 ± 69.1 vs 47.9 ± 68.0 pg/mL, P = .02) and hypertension were more frequently observed (48% vs 36%, P = .002) than those without. Both CHADS2 and CHA2DS2 VASc score were higher in the patients with CE than those without (0.8 ± 0.9 vs 0.6 ± 0.9 and 1.4 ± 1.3 vs 1.1 ± 1.1, respectively). Among 4 types of ablation devices, incidences of CE were higher in laser balloon ablation than either RF or cryoballoon ablation (Figure). After propensity score matching between each two groups, incidence of CE was higher in laser balloon ablation than cryoballoon ablation (50% vs 15%, P = .008) and tend to be higher in laser balloon ablation than RF catheter ablation (51% vs 26%, P = .07).

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Conclusion:

After the catheter ablation of paroxysmal atrial fibrillation, peri‐procedural silent CE is detected in 25.6% of the patients by MRI. Laser balloon ablation has a higher risk of asymptomatic procedural cerebral embolism than either RF or cryoballoon ablation.

AP19‐00161

The application of novel segmentation software to create left atrial geometry for atrial fibrillation ablation: The implication of spatial resolution

Chye Gen Chin, Fa‐Po Chung, Yenn‐Jiang Lin Lin, Shih‐Lin Chang, Li‐Wei Lo, Yu‐Feng Hu, Ming‐Hsiung Hsieh, Shih‐Ann Chen

Wanfang Hospital, Taiwan

Introduction:

The application of the new imaging software, CARTO^® Segmentation Module on left atrium (LA) geometry for atrial fibrillation (AF) ablation, has not been well investigated.

Methods:

Twenty‐seven patients undergoing AF ablation using the CARTO system was studied (phase I). High‐density LA mapping using PentaRay was merged with CT‐based geometry from the auto‐ segmentation module. The spatial distortion between the two LA geometries was analyzed and compared by Registration Match View (Figures 1 and 2). The associated contact force on the two LA shells was prospectively validated in 16 AF patients (phase II).

Result:

Of the 5 LA regions, the roof area had the highest quality score between the 2 LA shells (1.7 ± 0.6). In addition, among the pulmonary veins (PVs), the higher quality score was observed in bilateral PV carinas (both are 1.8 ± 0.1) (Figure 3). It means that these areas had the highest spatial distortion. Furthermore, there is a significantly higher contact force surrounding the PV ostium for the on‐surface points when targeting the high‐density fast anatomical mapping (FAM) shell than those by the auto‐ segmentation module (RSPV, 20.7 ± 5.8 vs 12.5 ± 4.4; RIPV, 19.3 ± 6.8 vs 11.8 ± 4.8; LSPV, 22.5 ± 7.3 vs 11.2 ± 4.5; LIPV, 15.7 ± 6.9 vs 9.7 ± 4.4, P < .05 to each group). (Figure 4)

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Result:

RVA pacing patients had a higher frequency of significant TR (degree ≥ 2) compared to Non‐ RVA pacing (63% vs 42%, P < .01). For RVA pacing, the lead was more likely to positioned at the anterior, posterior and septal compared to Non‐RVA pacing (51% vs 33%, P < .01). Importantly, leads were more likely to be positioned in the central portion with Non‐RVA pacing compared to RVA pacing (30% vs 13%, P < .01). Among 284 patients with pre‐& post‐ implantation Echocardiography, RVA pacing is associated with the development of significant TR compared to Non‐RVA pacing (59% vs 41%, P = .012). Further, the conditions of male patients were better than female patients (P < .05).

Conclusion:

The study demonstrates that RVA pacing is more likely to develop significant TR compared to Non‐RVA pacing. Significantly, this study is the first to demonstrate that lead impingement is one of the possible mechanisms that could explain the higher frequency of TR in RVA pacing compared to Non‐RVA pacing by 3DE.

AP19‐00174

Efficacy of left atrial roof linear ablation in fixed atrial fibrillation

Akihiko Takenaka, Akihiko Ueno, Takashi Uchiyama

Toda Chuo General Hospital, Japan

Introduction:

Fixed atrial fibrillation (AF) ablation is inadequate by pulmonary vein isolation (PVI) alone. The efficacious strategy is likely to combine isolation of the pulmonary veins with limited linear ablation within the left atrium. We evaluated the efficacy of the left atrial roof line joining the superior PVs (LARL) in fixed AF patients.

Methods:

We selected 79 patients (age: 65 ± 11 years; duration of fixed AF: 2 ± 2 years) who took fixed AF ablation. We performed PVI, LARL and cavotricuspid isthmus line (CTIL) ablation for all patients. Intercardiac defibrillation was performed before PVI. If not terminated AF, performed after PVI, LARL, and CTIL ablation also.

Result:

AF was terminated in 67 patients (85%) before and after PVI, 8 (10%) after LARL. Three patients (4%) needed another line creation (LA anterior or mitral isthmus), and AF was not terminated in 1 (1%). Sixty‐two patients (78%) could maintain sinus rhythm at 1‐year follow‐up. During follow‐up periods (2.2 ± 0.8 years), 27 patients recurred AF. 26 of those took second session. Reconduction of PV was found in 13 patients, LARL in 1, CTIL in 1. Other additional line(s) were created for 9 patients with low voltage area(s) in LA. Multiple firing from thoracic veins was found in 8 patients, 2 of whom could not keep sinus rhythm. Sixty‐seven (85%) of 79 patients (14 patients required a second session), only PVI, LARL and CTIL created, have passed without no recurrence.

Conclusion:

In conclusion, the creation of LARL is extremely effective in fixed AF ablation, which could control the arrhythmogenic substrate for AF.

AP19‐00179

Quantification of the parasympathetic modulation by extracardiac vagal stimulation during cryoballoon ablation

Thiago Guimarães Osório, Juan Sieira, Pedro Brugada, Gian‐Battista Chierchia, Carlo de Asmundis

Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium

Introduction:

The cardiac autonomic nervous system (CANS) might play a critical role in the onset and maintenance of atrial fibrillation (AF). The ganglionated plexi (GP), as well as the PV ostia, are richly innervated by both the sympathetic and parasympathetic autonomic systems. Consequently, it is not a surprise that the second‐generation cryoballoon (CB‐A) ablation can acutely modulate the parasympathetic tone. Pulmonary vein isolation (PVI) has become the most prevalent invasive technique in the treatment of paroxysmal atrial fibrillation (PAF) after the discovery of triggers in the pulmonary veins. According to the literature, modification in CANS activity might be important and apparently desired collateral effect in the setting of PVI. In fact, the appearance of vagal responses (VR), during PVI, commonly witnessed in the left superior pulmonary vein (LSPV), might produce a better long‐term outcome. Nevertheless, a detailed analysis of the direct effect on the parasympathetic denervation after ablation of the right or left‐sided pulmonary veins (PV) is still unknown. With this goal in mind, we sought to evaluate the contribution of the right or left PVs in the acute vagal denervation after ablation with the CB‐A by the means of external cardiac vagal stimulation (ECVS) in 20 patients.

Methods:

Twenty consecutive patients, ten starting from the LSPV and ten from the right superior pulmonary vein (RSPV), with drug‐refractory symptomatic PAF, having undergone ECVS before the first and after the right or left PVs ablation by means of CB‐A ablation were included in this study.

Result:

The ECVS performed pre‐ablation provoked cardioinhibitory responses in all cases with mean pause duration of 11053.6 ± 3249.6 milliseconds. In the group started from the LSPV, after the ablation of the left‐sided PVs the VR were reduced by 23.19 %, 8490.2 ± 1040 milliseconds (P = .01) if compared to baseline response. Noteworthy, in the group started from the RSPV, after the right‐sided PVs ablation, VR was diminished by 91.8%, 902.7 ± 271.04 milliseconds (P < .001) if compared to baseline response.

graphic file with name JOA3-35-76-g023.jpg

Methods:

The national retrospective cohort study enrolled AF population was derived from Taiwan National Health Insurance Research Database in the 4.3 ± 3.2 year follow up period. The final analysis included 3,880 AF patients with concomitant hyperthyroidism (HT AF group), and 178 711 non‐thyroid AF patients. The index date was when new‐onset AF was diagnosed, and the interested outcome was thromboembolic event included ischemic stroke and systemic thromboembolism. The comparison between the HT AF and non‐thyroid AF groups was made in a propensity score matched cohort and in a real‐world setting of which the CHA2DS 2‐VASc level was treated as a stratum variable.

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Conclusion:

We present a case of septal incisional flutter. This is rarely seen and likely was due to the unusual surgical approach to the mitral valve and PFO repair.

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AP19‐00214

A case report of juvenile onset familial atrial fibrillation due to genetic defect

Ryo Azakami, Jun Kumanomido, Taisuke Ishikawa, Shogo Ito, Masahiro Sasaki, Jinya Takahashi, Kensuke Hori, Aya Obuchi, Go Haraguchi, Masanori Ohtsuka, Masatsugu Ohe, Naomasa Makita, Yoshihiro Fukumoto

Kurume University School of Medicine, Japan

Introduction:

Atrial fibrillation (AF) is a common arrhythmia and morbidity increases with age. Genetic factors are considered as the key in the development of AF, and familial forms of AF were reported more than 80 years ago. KCNQ1‐V241F was reported to be a gene that causes both bradycardia and AF. However, it is rare for three relatives in family with a history of AF have same genetic defect.

Methods:

A 24‐year‐old man suffered from bradycardia since birth and was diagnosed with AF at the age of 18 years. We performed cardiac examination of cardiomyopathy and coronary artery disease to differentiate juvenile onset familial AF. In family history, 2 relatives of him had AF, 1 had SSS with AF (sick sinus syndrome type 3; pacemaker was implanted), and we examined their genetic defects.

Result:

There were no special findings in cardiac examination. But we identified same genetic defect of KCNQ1‐V241F in his family tree, his sister, his mother and his grandmother.

Conclusion:

This case report has highlighted of gene defect in KCNQ1‐V241F. This gene defect causes both bradycardia and AF. Therefore, in order to prevent the onset and complications of juvenile onset familial AF, it is important to conduct genetic tests on close relatives, even in the case of a genetic defect where family history is rarely reported.

AP19‐00216

Impact of balloon‐based atrial fibrillation ablation on cardiac autonomic nerve activity: A comparison between cryoballoon and hotballoon ablation

Takehito Sasaki, Kohki Nakamura, Wataru Sasaki, Yoshinori Okazaki, Shingo Yoshimura, Shohei Kishi, Inoue Mitsuho, Hiroyuki Motoda, Katsura Niijima, Kentaro Minami, Koji Goto, Yuko Miki, Yutaka Take, Shigeto Naito

Gunma Prefectural Cardiovascular Center, Japan

Introduction:

We aimed to evaluate the impact of cryoballoon and HotBalloon ablation (CBA/HBA) on cardiac autonomic nerve activity (CANS) in patients with paroxysmal atrial fibrillation (PAF).

Methods:

This study prospectively enrolled 34 patients undergoing balloon‐based pulmonary vein isolation (PVI) (CBA, 10; HBA, 24). All patients underwent a 24‐hour Holter monitoring before and 1 month after the ablation to analyze the heart rate (HR) variability (HRV).

Result:

A PVI was successfully performed in all patients. The mean HR significantly increased, and low frequency components (LF), high frequency components (HF), and root mean square of successive NN interval differences (RMSDD) significantly decreased after the ablation in both the CBA and HBA groups. These parameters did not significantly differ between the two groups both before and after the ablation. In 29 patients with a follow‐up period of >3 months, 28 patients (96.5%) maintained sinus rhythm.

Conclusion:

Both the CBA and HBA patients revealed a similar degree of change in the CANS, and similar clinical outcomes after the ablation.

Comparison of the HRV parameters between CBA and HBA group

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AP19‐00218

Combination impact of transcatheter atrial septal defects closure and radiofrequency catheter ablation on atrial fibrillation recurrence through bi‐atrial reverse remodeling

Masashi Kamioka, Akiomi Yoshihisa, Naoko Hijioka, Minoru Nodera, Shinya Yamada, Takashi Kaneshiro, Kazuhiko Nakazato, Takafumi Ishida, Yasuchika Takeishi

Fukushima Medical University, Japan

Introduction:

Atrial fibrillation (AF) often coexists with atrial septal defects (ASD). Although transcatheter ASD closure and radiofrequency catheter ablation (RFCA) for AF are recognized as the first‐line therapy, its combined therapeutic effect on AF recurrence is unclear. The aim of the current study was to investigate the clinical impact of ASD closure following RFCA on AF recurrence.

Methods:

Forty‐two ASD patients (17 males and 54 ± 20 years old) were enrolled and classified into three groups: ASD occlusion‐sinus rhythm (ASO‐SR) (n = 26), No AF history prior to ASD closure; ASO‐AF‐RFCA (n = 11), RFCA was performed due to AF history before ASD closure; and ASO‐AF‐ antiarrhythmic drug (ASO‐AF‐AAD) (n = 5), AF was treated with AAD before and after ASD closure. AF occurrence among the 3 groups was evaluated.

Result:

Kaplan‐Meier analysis showed that ASO‐SR and ASO‐AF‐RFCA groups showed a lower AF occurrence ratio than ASO‐AF‐AAD group during the 14 ± 9 months follow‐up periods (P = .013) as shown in Figure. AF occurrence in ASO‐SR and ASO‐AF‐RFCA groups was comparable (P = .480). Bi‐ atrial reverse remodeling, such as decrease in left atrial volume index (P = .049) and right atrial area (P = .046), and significant decrease in high sensitivity C‐reactive protein levels (P = .049) were identified in ASO‐AF‐RFCA group, but not in ASO‐AF‐AAD group.

Conclusion:

A combination of the two percutaneous therapies was proven to be effective and induced atrial reverse remodeling in association with inflammatory reaction.

AF occurrence after ASO

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AP19‐00224

Three dimensional rotational angiography for preprocedural imaging before atrial fibrillation ablation using second generation cryoballoon

Vedran Velagic, Domagoj Kardum, Borka Pezo‐Nikolic, Mislav Puljevic, Martina Lovric‐Bencic, Davor Puljevic, Davor Milicic

University Hospital Center Zagreb, Croatia

Introduction:

Integration of left atrium (LA) images obtained by computer tomography or magnetic resonance could reduce atrial fibrillation (AF) ablation procedural time because it enables a more accurate reconstruction of the anatomy. Rotational angiography (RA) enables reconstruction of LA immediately before the procedure, but it is the least used method of LA imaging.

Methods:

Data included in our analysis was retrospectively collected from the beginning of AF ablation program in our institution. Decision to use rotational angiography as preprocedural imaging was left to the first operator in nonrandomized way. Segmented reconstructions of left atria were merged to live fluoroscopy screen. A 28 mm second generation cryoballoon was used via single transeptal puncture guided by intracardial ultrasound. A single 180 seconds freeze strategy was employed. We sought to compare procedural characteristics and outcomes of cryoballon ablation procedures done with the help of rotational angiography (RA arm) versus ablations performed without preprocedural imaging (non‐RA).

Result:

We have analyzed 167 successional second generation cryoballon procedures, 67 in RA group and 100 in nonRA group (74.3% male, 56.9 ± 11.2 years). Paroxysmal AF was present in 78.6% of patients and early persistent in the rest. Mean left ventricle ejection fraction was 60.7 ± 7.1% and mean left atrium diameter was 42.5 ± 5.6 mm. The mean procedure times were significantly shorter for non‐RA group (77.5 ± 30.45 minutes) than RA group (125.3 ± 40.8 minutes) (P < .001). The mean fluoroscopy times was also shorter for non‐RA group (12.9 ± 7.9 minutes) than RA group (22.3 ± 10.6 minutes) (P < .001). Furthermore X –ray dosage and contrast expenditure were also significantly lower in non‐RA group. X ray dosage was 1005.2 ± 850 mGy vs 355.9 ± 421.5 mGy (P < .001) and contrast expenditure was 190.1 ± 32.5 mL vs 85.2 ± 22.1 mL for RA and non RA group respectively. There was no significant differences in success rates between groups, after follow up of 1 year 77.9% of patients were free from any atrial arrhythmia. Furthermore there was no differences in complication rates, which consisted solely of phrenic nerve palsy and groin complications.

Conclusion:

In our patient cohort, the use of rotational angiography significantly prolonged procedure times, X ray exposure and contrast expenditure. Omitting left atrium imaging did not influence the procedure safety and success rates. Preprocedural imaging is not mandatory for successful pulmonary vein isolation but it may be useful to inexperienced operators or in low volume centers.

RA N = 67	Non RA N = 100	P
Duration (min)	125.3 ± 40.8	77.5 ± 30.5	<.0001
Fluoroscopy (min)	22.3 ± 10.6	12.9 ± 7.9	<.0001
X ray dosage mGy	1005.2 ± 850	355.9 ± 421.5	<.0001
Contrast (mL)	190.1 ± 32.5	85.2 ± 22.1	<.0001
Complications (N, %)	4 (5.9)	5 (5)	1
Recurrences (N, %)	16 (23.8)	21 (21)	1

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AP19‐00226

Correlation between the impedance drop, force time index, ablation index, and lesion formation: Which is the most preferable parameter to evaluate the lesion formation?

Introduction:

Pulmonary vein (PV) isolation (PVI) by cryoballoon‐ablation (CrA) has been established for curing atrial fibrillation (AF). It has been known that the ectopic firings from superior vena cava (SVC) in relation to its myocardial sleeve extension from right atrium (RA) are implicated in AF recurrence (≈10‐20%) even after PVI by radiofrequency‐ablation (RFA). Whether the ectopic firings originated from such an extended myocardial sleeve are also related to AF recurrence after CrA for PVs remains unknown because the greater influence of CrA on such a myocardial sleeve may occur compared to RFA thus, AF recurrence would be less after CrA than RFA for paroxysmal AF.

Methods:

This study was consisted of 57 patients (37 Male: 65 ± 11 y/o), undergoing CrA for paroxysmal AF. All the patients underwent SVC venography and the following right atriography. The distance from SVC‐right atrium junction (SRJ) to the most cranial level of SVC where the SVC potentials could be recorded (d‐SVCp) was measured. According to the median value of d‐SVCp obtained (range: 22‐59 mm), the patients were divided into the following two groups; Group‐A (d‐SVCp ≤ 35 mm, N = 25: 67 ± 10y/o) and Group‐B (d‐SVCp > 35 mm N = 32: 62 ± 12 y/o). The level difference in length between the bottom of right inferior PV (RIPV) orifice and SRJ (d‐RIPV) was also assessed.

Result:

The AF recurrence rate did not differ between Groups A and B (2.7 vs 3.1% ns) during mean follow‐up of 12 months. The bottom level at the RIPV orifice was all located at caudal level to SRJ (d‐ RIPV: 23.8 ± 9.7 mm) and no difference for d‐RIPV was found between Groups A and B (26.6 ± 7.4 vs 21.6 ± 10.8 mm ns). The location of the earliest SVC‐potentials that could be recorded at the SRJ level during sinus rhythm after CrA were more frequently recorded at the anterior wall than that posterior wall of SVC, which was anterior to RIPV antrum and spatially close to right PV antrum (61 vs 15% P < .05), although that at the most caudal level of the SVC with myocardial sleeve extension did not differ (40 vs 35 % NS).

Conclusion:

This study might imply that CrA affects the myocardial sleeve of SVC on its posterior side extended from RA, which may trigger AF initiation even after PVI by ablation, as well as its adjacent third fad pad located posteriorly to SVC which contains ganglionated plexi. These combined influences by CrA may lead to less AF recurrence than RFA, particularly in the paroxysmal AF patients who had the myocardial sleeve extension long enough to evoke trigger AF.

AP19‐00235

Biatrial tachycardia involving excitation conduction from the left atrial epicardium

Soonil Kwon, So‐Ryoung Lee, Eue‐Keun Choi, Kyung‐Do Han, Jin‐Hyung Jung, Myung‐Jin Cha, Seil Oh, Gregory Lip

Seoul National University Hospital, South Korea

Introduction:

Although non‐vitamin K antagonist oral anticoagulant (NOAC) have superior efficacy and at least comparable safety to warfarin in patients with non‐valvular atrial fibrillation (NVAF), there are limited evidences among the NVAF patients with history of gastrointestinal bleeding (GIB). We aimed to study the effectiveness and safety of NOAC among the NVAF patients and prior GIB.

Methods:

Using the claims database of the Health Insurance Review and Assessment from January 2010 to April 2018, we constructed a retrospective cohort constituted of 42 048 oral‐anticoagulant‐naïve individuals (24 781 with NOAC and 17 267 with warfarin) with both AF and prior GIB. Primary outcomes were ischemic stroke, intracranial hemorrhage (ICH), GIB, major bleeding (ICH and GIB), and composite outcome. Also, the fatal events (mortality during hospitalization) for each outcome were evaluated to reflect severity. Cox proportional regression analysis was used to adjust covariates between the groups. Additional analysis was performed by the groups with warfarin and each NOAC category.

Result:

There were total 1426 (3.4%) ischemic stroke, 235 (0.6%) ICH, 825 (2.0%) GIB, 286 (0.7%), 1,053 (2.5%) major bleeding, and 2386 (5.7%) composite outcomes during the follow‐up. Fatal events for each outcome were 286/1426 (20.1%), 77/825 (9.3%), 29/286 (10.1%), 106/1,053 (10.1%), and 390/2386 (16.3%) for ischemic stroke, ICH, GIB, major bleeding, and composite outcome, respectively. During the follow‐up, there were total 2616/42 048 (6.2%) all‐cause deaths. NOAC users were older and had a more female proportion, and had higher CHA2DS2‐VASc scores compared to warfarin users, (mean age 72.9 vs. 69.7 years; female 44.9% vs. 40.5%; CHA2DS2‐VASc score 4.3 vs. 4.0; all p‐values < 0.001). NOAC users showed lower risks than warfarin users in recurrent GIB, ischemic stroke, ICH, major bleeding, and composite outcome (adjusted hazard ratio (HR) [95% confidence interval (CI)] =0.81 [0.70‐0.94]; 0.61 [0.54‐0.69], 0.48 [0.36‐0.65], 0.73 [0.64‐0.83], and 0.66 [0.60‐0.72], respectively, Figure). For fatal outcomes, NOAC was associated with lower risks of ischemic stroke, ICH, major bleeding, and composite outcome, whereas it had a comparable risk of GIB to warfarin. By NOAC categories, edoxaban was associated with the lowest risk for all the 5 clinical outcomes and also all‐cause death; 0.34 [0.25‐0.46], 0.40 [0.20‐0.83], 0.64 [0.46‐0.88], 0.58 [0.43‐0.78], 0.43 [0.35‐0.54], and 0.59 [0.50‐0.71] for ischemic stroke, ICH, major bleeding, composite outcome, and all‐cause death, respectively.

Conclusion:

NOAC was associated with lower risks of recurrent GIB, ischemic stroke, ICH, and fatal events in patients with AF and prior GIB.

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AP19‐00256

Right atrial fibrosis quantified using voltage mapping is associated with sinus node dysfunction in patients with non‐paroxysmal atrial fibrillation

Shunsuke Kawai, Yasushi Mukai, Kazuhiro Nagaoka, Kazuo Sakamoto, Shujiro Inoue, Daisuke Yakabe, Shota Ikeda, Akiko Chishaki, Hiroyuki Tsutsui

Japanese Red Cross Fukuoka Hospital, Japan

Introduction:

Induction of atrial fibrillation (AF) by atrial burst pacing following completion of ablation procedure may reflect the presence of residual substrates in the atria that maintain AF. However, the relation between the inducibility and left atrial low voltage area (LVA) remains unknown.

Methods:

Fifty‐nine patients (65 yo, 43 males) with persistent AF who underwent pulmonary vein isolation (PVI)‐based ablation were studied. All patients underwent left atrial voltage mapping during sinus rhythm and atrial burst pacing following the completion of PVI. Left atrial LVA and other co‐variates were validated regarding burst pacing positivity.

Result:

AF was induced by burst pacing in 23 patients (39%). Univariate analysis revealed that past history of stroke, CHADS2 score and left atrial LVA significantly associated with the inducibility of AF. Multivariate analysis revealed that only LVA was associated with the inducibility (OR 1.5: per 10% increase; P = .04).

Conclusion:

Left atrial LVA is an independent predictor for the AF inducibility in patients with persistent AF undergone PVI.

Characteristics	Positive induction of atrial fibrillation (n = 23 [39%])	Negative induction of atrial fibrillation (n =36 [61%])	P
Age (y)	66.9 ± 6.4	64.1 ± 8.9	.19
Body mass index (kg/m2)	25.5 ± 4.7	23.9 ± 3.6	.15
Female	8 (34.8)	8 (22.2)	.37
Diabetes mellitus	3 (13.0)	11 (30.6)	.21
Hypertension	17 (73.9)	18 (50.0)	.1
Structural heart diseases	6 (26.1)	7 (20.0)	.75
Coronary artery disease	2 (8.7)	3 (8.3)	1.0
History of congestive heart failure	7 (30.4)	7 (19.4)	.36
History of stroke	5 (21.7)	2 (5.6)	.09
CHADS2	1.7 ± 1.4	1.1 ± 1.0	.05
BNP (pg/mL)	186 ± 168	130 ± 127	.16
CRP (mg/dL)	0.18 ± 0.25	0.17 ± 0.29	.91
Creatinine clearance (ml/min)	73.1 ± 20.6	78.8 ± 25.2	.36
LAD (mm)	44.3 ± 4.9	42.5 ± 6.5	.27
LAVI (ml/m2)	46.8 ± 11.8	45.3 ± 14.8	.69
LVEF (%)	63.8 ± 10.7	62.5 ± 11.8	.68
Left atrial low voltage area (%)	24.4 ± 27.4	9.1 ± 12.1	.005

Conclusion:

Addition of GP cryoablation during open heart surgery did not significantly reduce the risk of POAF in this pilot study.

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AP19‐00289

Value of left atrial systolic and diastolic volume measured by computed tomography for the prediction of post‐ablation recurrence of atrial fibrillation

Young Choi, Sun‐Hwa Kim, Ju Yeol Baek, Youmi Hwang, Ju Youn Kim, Tae‐Seok Kim, Sung‐Hwan Kim, Ji‐Hoon Kim, Sung‐Won Jang, Man‐Young Lee, Hwa‐Joong Kim, Yong‐Seog Oh

Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, South Korea

Fusae Doi, Shingo Maeda, Tomokazu Chijimi, Yasuhide Tsuda, Hirofumi Suda, Mihoko Kawabata, Hirotsugu Atarashi, Kenzo Hirao

AOI Universal Hospital, Japan

Navid Berenji, Debanshu Roy, Gregory Kendall, Evan Saenger, Auroa Badin, Manoj Panday, Dhanunjaya Lakkireddy, Jayasree Pillarisetti

UT Health San Antonio, USA

Introduction:

Early post operative atrial fibrillation (POAF) occurring after lung transplant has been described but the incidence and risk factors for long term recurrence of AF (> 3 months) in patients who develop POAF is not known. The objective of this study is to determine the risk of recurrence and prognosis of POAF in lung transplant patients.

Methods:

We performed a retrospective study of single and bilateral lung transplant recipients from January 2010 to December 2015. Patients with prior history of AF were excluded. Incidence of POAF was noted. Patients with POAF were followed for recurrent AF and compared with those who did not have long term AF recurrence. Binary logistic regression was used to identify independent predictors of early POAF and for recurrent AF.

Result:

A total of 207 patients underwent lung transplant with mean age of 57 ± 12 years, of which 34% (n = 71) of patients developed early POAF. Age was the only significant predictor of early POAF (P = .009). Among these patients, long term recurrent AF was noted in 17% (n = 12/71) of patients. Median follow up duration was 60 months (range 16‐72 months). Mean age was 61 ± 8 years with 58% males. Mean EF was 58 ± 8%. All‐cause mortality was higher at 50% in patients with long term recurrent AF as compared to 32% in those without recurrence but did not reach statistical significance (P = .20). Patients with recurrent AF had higher incidence of CAD (21% vs 8%, P = .017) and DM (9% vs 0%, P = .02) based on bivariate analysis.

Conclusion:

Late recurrent AF in POAF patients is common and is associated with 50% mortality. POAF is not benign and these patients should be followed closely.

AP19‐00321

Efficacy and safety of non‐vitamin K antagonist oral anticoagulants versus warfarin in patients with atrial fibrillation and cancer: A meta‐analysis of randomized controlled trials

Chenxi Wang, Qinghua Wu

The Second Affiliated Hospital of Nanchang University, China

Introduction:

The efficacy and safety of non‐vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with cancer are unclear. The present study aims to assess the efficacy and safety of NOACs in AF patients with cancer.

Methods:

To find all randomized controlled trials (RCTs) in which NOACs were compared against vitamin K antagonists (VKA) in AF with cancer, we have searched the Cochrane Library, PubMed, Embase databases and so on. Risk ratio (RR) was chosen as the statistic for dichotomous variables. Interval estimates use a 95% confidence interval (95% CI). Heterogeneity was evaluated in the I2 statistic. Differences between groups were examined statistically significant at P < .05.

Result:

Four RCTs with a total of 3135 participants (male 67.5%) were included. Regarding the risk of stroke or systemic embolism (SE) [risk ratio (RR) 0.75, 95% confidence interval (95% CI) 0.52‐1.09; P = .14], venous thromboembolism (VTE) [RR 0.91, 95% CI 0.33‐2.50; P = .86] and all‐cause death [RR 0.95, 95% CI 0.65‐1.38; P = .78], there was no significant difference between DOACs and VKAs in patients with AF and cancer. However, the NOACs group had a significantly lower incidence of major bleeding [RR 0.80, 95% CI 0.64‐0.98; P = .03], and anti‐Xa were more effective than VKAs in reducing major bleeding [RR 0.79, 95% CI 0.62‐0.99; P = .04].

Conclusion:

The present study for the first time finds that NOACs and VKAs are equally effective in preventing VTE and stroke in patients with AF and cancer, but the former has a lower risk of major bleeding. The efficacy and safety of NOACs in patients with AF and cancer still requires more trials to provide information.

Keywords: direct oral anticoagulants; cancer; warfarin; venous thromboembolism; atrial fibrillation.

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Conclusion:

Radiofrequency ablation guided by AI/LSI was associated with lower acute PV reconnection rates and improved AF freedom after PVI. There was no difference in fluoroscopy, ablation or procedure time with the use of these novel parameters.

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AP19‐00337

BOX isolation versus extensive encircling pulmonary vein isolation in atrial fibrillation ablation

Naoaki Onishi, Maki Oi, Toshikazu Jinnai, Kazuaki Kaitani

Otsu Red Cross Hospital, Japan

Introduction:

Extensive encircling pulmonary vein isolation (EEPVi) is a gold standard therapy in atrial fibrillation (AF) ablation. Additional ablation (linear ablation, CFAE ablation, low voltage ablation, rotor ablation, and so on) remains controversial, but it is reported that BOX isolation (BOXi; left atrium posterior wall isolation) is effective especially in the cases of persistent AF in several papers.

Methods:

Consecutive 200 AF patients who underwent initial radiofrequency catheter ablation from November 2016 to January 2019 in our hospital were retrospectively analyzed. In 121 paroxysmal AF (PAF) patients, BOXi was performed in 36 patients (30.0%). In 79 non PAF patients, BOXi was performed in 71 patients (89.9%). Sinus rhythm maintenance rate (AF free rate) at two years after ablation with the blanking period of 90 days was compared in BOXi group and EEPVi group.

Result:

In PAF patients, there was no statistically significant difference in sinus rhythm maintenance rate between BOXi group and EEPVi group (86.5%, 76.1%, respectively, Log‐rank P = .44, figure left). However, in non PAF patients, sinus rhythm maintenance rate in BOXi group was significantly higher than in EEPVi group (59.0%, 33.3%, respectively, Log‐rank P = .029, figure right)

Conclusion:

In non PAF patients, BOX isolation could be a good strategy in 1st session of AF ablation.

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AP19‐00339

The role of Indonesian herbal medicine (Garcinia mangostana linn extract) for controlling the rhythm, reducing inflammation and oxydative stress in patient's with atrial fibrillation: A Randomized Clinical Trial

Muhamad Rizki Fadlan, Ardian Rizal, Djanggan Sargowo

Saiful Anwar General Hospital, Indonesia

Introduction:

Accumulating evidence has established an important role of inflammation and oxidative stress in the pathogenesis of atrial fibrillation (AF). Garcinia mangostana Linn extract (GMLE) contain xanthones,α‐Mangostin and γ‐mangostin that can suppress the expression of pro‐inflammatory genes and oxidative stress in rats. The aim of this study was to examine the effectivity of GMLE for controlling rhythm and reducing inflammatory process and oxidative stress in patients with AF.

Methods:

A randomized, Single‐blind, placebo‐controlled clinical trial was conducted in 38 patients with atrial fibrillation. There were determined based on ECG and medical record. The patients were divided into two group who were matched for age,sex, diabetes,smoking status and medication. Intervention group (IG) was given 2520 mg/d Garcinia mangostana Linn extracts in 3 divided dose for 90 days and Controlled group (CG) given placebo. The parameters were inflammatory marker (HsCRP, IL‐1,IL‐6,and TNF‐α) and oxidative stress marker (superoxide dimustase (SOD), malondialdehyde (MDA)) measured at baseline and after 90 day's of treatment.

Result:

At 90 days, there wasn't difference in conversion from AF to sinus rhythm between IG and CG (10.5% vs 0%, P = .135, respectively),interestingly, in subgroup analysis (paroxysmal AF), we found that CG, had higher conversion from sinus to AF compared with IG (2/8 vs 0/7, P = .46, respectively). The change in heart rate was significance in IG compared with placebo (−6.13 ± 9.6/min vs 1.43 ± 3.04/min; P = .021) GMLE significantly reduce tnf‐α level compared with placebo (−185.34 ± 164.9 pg/mL vs −21 ± 87.12 pg/mL; P = .001). we found that the plasma il‐6 and il‐1 concentration was significantly lower compared with placebo (−23.03 ± 107.3 pg/mL vs 58.53 ± 134.64 pg/mL; P = .000; −23.03 ± 19.46 pg/mL vs 15.7 ± 28.65 pg/mL; P = .025, respectively). sod level in IG significantly increased compared with placebo, P = .021. mda concentration significantly reduced in IG compared with placebo, P = .002.

Conclusion:

These results suggest that a lack of a significant difference in the outcome of a rhythm control strategy using GMLEconsumption. GMLE process the anti‐inflammatory effect by reducing IL‐6, IL‐1, and TNF‐ α production. Its process antioxidative stress by increasing SOD level and decreasing MDA level.

Keywords: Garcinia mangostana, inflammation, atrial fibrillation, rhythm, antioxydant

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AP19‐00340

Characterization of plasma oxidative stress and inflammatory biomarkers levels in patients with atrial fibrillation

Muhamad Rizki Fadlan, Ardian Rizal, Djanggan Sargowo

Saiful Anwar General Hospital, Indonesia

Introduction:

Inflammation and oxidative stress have been associated with cardiovascular disease and the burden of atrial fibrillation (AF). Inflammation has been implicated in various AF‐related pathological processes, including oxidative stress, fibrosis, and thrombogenesis. There were associated with increased mortality and morbidity in atrial fibrillation (AF). The aims of this study to examined inflammatory biomarkers and plasma oxidative status in patients with AF.

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Methods:

It was observational analytic with case control design, inflammatory biomarkers and plasma oxidative status were compared between 38 patients with atrial fibrillation and 29 control patients. they were matched for age,sex, diabetes, and smoking status, known confounding variables for the measurement of oxidative stress and inflammatory marker. AF was determined at baseline by self‐report (medical record) and electrocardiogram (ECG). We used superoxide dimustase (SOD), malondialdehyde (MDA) concentration to quantify oxidative stress. We also measured inflammatory markers, including high‐sensitivity C‐reactive protein, interleukins 1 and 6, and tumor necrosis factor .

Result:

The inflammatory markers IL‐1, IL‐6,and TNF‐α were significantly higher in the AF group compared with controls (4.44 ± 1.72 vs 3.5 ± 0.69, P = .006 ; 91.3 ± 31.2 vs 76.44 ± 22.4, P = .033; 4.16 ± 2.36 ± 3.09 ± 1.55, P = .039, repectively). SOD was significantly lower in AF group compared with control (2.35 ± 0.85 vs 2.81 ± 0.68, P = .018, respectively), MDA was significantly higher in AF group compared with control (23.24 ± 13.6 vs 17.7 ± 7.08, P = .039), interestingly, there was no difference in HsCRP level between AF group compared with placebo. In subgroup analysis, Persistent AF patients had a higher HsCRP level (38.3 ± 7.19) than paroxysmal AF patients (27.50 ± 10.6; P = .026), both groups had higher HsCRP levels than controls (P = .014). HsCRP level was a predictor of rehospitalization in AF patient (OR = 1.267, 95%CI 1.004‐1.59, P = .034).

Conclusion:

In this study, we suggest that levels of circulating biomarkers of inflammation and oxidative stress, oxLDL, were higher AF patients compared to control. HsCRP was higher in persistent AF compared with paroxiysmal AF, Although the cause of elevated HsCRP levels in AF patients remains unknown, elevated of HsCRP level was a predictor fro rehospitalization in atrial fibrillation.

Keywords: atrial fibrillation, inflammation, oxidative stress, SOD, MDA

AP19‐00341

Ibutilide cardioversion for long standing persistent atrial fibrillation in post operative rheumatic heart disease

Ulhas Pandurangi, Jaya Pradhap, Kotti K, Radhika B, Aishwarya S, Sabari S, Mahima P Manoj, Nithin G, Benjamin S, Ravi Kumar, Nirmala S, Dasari Himaja, Sandini S

The Madras Medical Mission, India

Introduction:

Long standing persistent atrial fibrillation (AF) in post‐operative rheumatic heart disease (RHD) without residual valvular lesion may require restoration of sinus rhythm when quality of life and ventricular function progressively decline even after adequate rate control. Ibutilide has emerged as an effective agent for pharmacological conversion of AF. Its rapid and high conversion rate may avoid electrical cardioversion. It is known to reduce defibrillation threshold. The data regarding the efficacy of ibutilide in RHD is scarce.

Methods:

A prospective study of 21 such patients. Hemodynamically significant valvular lesions, severe LV dysfunction (EF < 25%), intracardiac clot and baseline QTc > 480 ms were excluded. Electrolyte and acid‐base disturbances were corrected. Prophylactically one gram of magnesium was administered intravenously. If INR was less than 2, I.V. 5000U of heparin administered. An infusion containing 10 ml ibutilide solution (0.1 mg/mL of ibutilide) and 40 ml of 5% dextrose was given through a peripheral vein over 10 minutes. Another similar dose of ibutilide was administered if cardioversion was not achieved within 10 minutes. Primary end point was conversion of AF to sinus rhythm within 90 minutes. Secondary end points included adverse events (Bradycardia, QT prolongation, ventricular arrhythmias, stroke and death) ventricular rate, transformation to AFL and need for electrical cardioversion. If pharmacological cardioversion failed, DC cardioversion beginning with 50J was performed. The QTc was continuously monitored and documented just before successful cardioversion, at the 10th and 90th minute and 4th hour of infusion. Patients were observed for 4 hours in intensive care unit.

Result:

The patients characteristics has been described in enclosed image. Acute successful ibutilide cardioversion was seen in 12 (57.1%) patients, 7 (33.3%) with first dose and 5 (35.7%) with second dose. Nine (42.9%) patients were cardioverted with 50J DC shock under intravenous sedation. Two patients required additional 100J DC shock. Two (9.52%) patients had short runs of TdP. One patient had AF recurrence during the observation period. No stroke or death observed.

Conclusion:

Ibutilide is a safe and an effective option when restoration of sinus rhythm is considered before electrical cardioversion even in long standing persistent AF in post‐operative RHD.

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AP19‐00343

MENARI PLUS as self assessment checklist for detecting atrial fibrillation in general population

Ardian Rizal, Muhamad Rizki Fadlan

Saiful Anwar General Hospital, Indonesia

Introduction:

Atrial fibrillation (AF) is associated with high morbidity and mortality. Accordingly, occult AF may cause stroke before it is clinically diagnosed. Early diagnosis is likely to improve therapy and prognosis. MENARI (Self Pulses Assesment) is national program to detect atrial fibrillation, its has low sensitivity and specificity for detecting atrial fibrillation. We developed clinical scoring for increasing their sensitivity and specificity. The aims of this study to examined accuracy of MENARI complemented with clinical scoring (MENARI PLUS) to detect atrial fibrillation

Methods:

Atrial fibrillation (AF) is associated with high morbidity and mortality. Accordingly, occult AF may cause stroke before it is clinically diagnosed. Early diagnosis is likely to improve therapy and prognosis. MENARI (Self Pulses Assesment) is national program to detect atrial fibrillation, its has low sensitivity and specificity for detecting atrial fibrillation. We developed clinical scoring for increasing their sensitivity and specificity. The aims of this study to examined accuracy of MENARI complemented with clinical scoring (MENARI PLUS) to detect atrial fibrillation

Result:

Atrial fibrillation (AF) is associated with high morbidity and mortality. Accordingly, occult AF may cause stroke before it is clinically diagnosed. Early diagnosis is likely to improve therapy and prognosis. MENARI (Self Pulses Assesment) is national program to detect atrial fibrillation, its has low sensitivity and specificity for detecting atrial fibrillation. We developed clinical scoring for increasing their sensitivity and specificity. The aims of this study to examined accuracy of MENARI complemented with clinical scoring (MENARI PLUS) to detect atrial fibrillation

Conclusion:

In this study, we suggest that MENARI PLUS has a high sensitivity but relatively low specificity for atrial fibrillation. It is therefore useful for ruling out atrial fibrillation. It may also be a useful screen to apply opportunistically for previously undetected atrial fibrillation.

Keywords: atrial fibrillation, MENARI, pulse palpation

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AP19‐00344

Evaluation of pulmonary vein isolation with new Ensite Precision magnetic sensor technology

Atsushi Hiratsuka, Takatoshi Wakeyama, Takahiro Iwami, Masakazu Tanaka, Nozomu Harada, Junya Nawata, Tetsuya Matsuyama, Hiroshi Ogawa, Masafumi Yano

Tokuyama Central Hospital, Japan

Introduction:

Ensite Precision enables more accurate mapping by performing not only conventional impedance correction but also correction using a magnetic sensor.

Methods:

We examined one year success rate after pulmonary vein isolation (PVI) in 45 consecutive patients (paroxysmal atrial fibrillation or short‐standing persistent atrial fibrillation) before (n = 22) and after (n = 23) using a magnetic sensor. In the patients which underwent PVI with magnetic sensor, to evaluate its accuracy, the left atrium geometry with and without magnetic correction were compared with the CT image.

Result:

One year success rate off anti‐arrhythmic drugs in the magnetic sensor use group (91%) was significantly higher than that in non‐use group (64%) (P = .04). As a result of measuring each point in the created left atrium geometry and compared with the CT image, the difference between the created geometry and the CT image was smaller if magnetic correction was performed (Appendix).

Conclusion:

Addition of magnetic sensor correction improves left atrial mapping accuracy and improves clinical outcome of pulmonary vein isolation.

Difference between created geometry and CT image (n = 23)

Measurement point	Geometry with magnetic correction (mm)	Geometry with only impedance correction (mm)	P values
RPV roof to LPV roof	1.43	4.35	<.01
RPV carina to LPV carina	2.17	6.96	<.01
RPV bottom to LPV bottom	1.35	5.48	<.01
LPV roof to LPV carina	2.00	3.09	.07
LPV bottom to LPV carina	1.22	2.43	.02
RPV roof to RPV carina	1.04	2.22	<0.01
RPV bottom to RPV carina	1.30	3.09	<0.01
LPV roof to LPV bottom	2.00	3.39	0.07
RPV roof to RPV bottom	2.48	3.13	0.30

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RPV; right pulmonary vein, LPV; left pulmonary vein

AP19‐00345

A novel circulating hsa_circ_0032931 predicts recurrence of atrial fibrillation after radiofrequency catheter ablation

Yongping Lin, Qi Jiang, Minglong Chen

Nanjing Medical University, China

Introduction:

Atrial fibrillation (AF) is the most frequent arrhythmogenic disease, and radiofrequency ablation plays a key role in the treatment of AF. However, the recurrence rate of atrial fibrillation after ablation is an important issue. Therefore, developing new and reliable biomarkers for predicting the recurrence of AF after ablation and screening AF patients who respond well to ablation therapy is an important subject.

Methods:

RNA‐seq was used to compare the difference of plasma circRNAs expression between atrial fibrillation and normal subjects. We applied RT‐PCR to detect the content of target circRNA in large sample population. Then we followed up patients after AF ablation for 12 months and drew ROC curve to evaluate the predictive significance of different factors for recurrence of atrial fibrillation.

Result:

The results of RNA‐seq of plasma from five patients with isolated persistent atrial fibrillation and five healthy controls showed significant differences in circRNA expression between the two groups. After GO and pathway analysis, we selected circRNAs related to the recurrence of AF for validation in a large sample including 70 samples from isolated atrial fibrillation patients and 80 non‐atrial fibrillation individuals. All patients were followed up for 12 months. After ablation, we found 6 recurrent patients. The ROC curves showed that AUC was 0.826 for the plasma level of hsa_circ_0032931 as a single predictor. However, the AUC was increased to 0.933 for the combination of hsa_circ_0032931 and AF duration.

Conclusion:

Hsa_circ_0032931 plus AF duration can better predict the recurrence of AF. This finding is of clinical significance when managing AF patients.

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AP19‐00347

Cardiac fibrotic marker predict catheter ablation outcome.

Ayako Okada, Morio Shoda, Ken Kato

Shinshu University School of Medicine, Japan

Introduction:

Background:

As the mechanisms of left atrium (LA) fibrosis associated with the recurrence of pulmonary vein atrium isolation (PVI) are unclear, this study investigated for relationships between the non‐invasive fibrosis marker Galectin‐3 (Gal‐3) and recurrence at 6 months after ablation in patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PSAF). The apnea hypopnea index (AHI) was evaluated as well.

Methods:

A total of 161 consecutive patients who underwent radiofrequency catheter ablation (RFCA) for AF at Shinshu University Hospital between 2015 and 2018 were retrospectively enrolled (mean age: 62.3 ± 7.4 years; 121 male; 52 PAF and 109 PSAF). Blood samples were obtained from the LA, right atrium, coronary sinus vein (CS), and femoral artery during RFCA to evaluate Gal‐3. The AHI was determined using standard methods before ablation and at 6 months afterwards.

Result:

Gal‐3 levels in the CS were significantly higher than at any other site in PSAF patients (P < .05). CS Gal‐3 and mean LA pressure were significantly correlated with 6‐month clinical recurrence after RFCA (P = .001). The area under the receiver operating characteristic curve for LA pressure associated with AF recurrence was 0.882 at a cut‐off of 13 mmHg. AHI scores were significantly correlated with AF recurrence, with no improvements seen in the recurrence group at 6 months after ablation. The pre‐RFCA AHI cut‐off value associated with AF recurrence was 24 events/hr.

Conclusion:

PVI achieved sinus rhythm maintenance in approximately 78% of cases during 6 months of follow‐up. CS Gal‐3 at RFCA and mildly high apnea scores may predict procedural outcome.

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AP19‐00351

Feasibility and efficacy of His‐Purkinje conduction system pacing combined with atrioventricular node ablation in patients with persistent atrial fibrillation and implantable cardioverter defibrillator therapy

Weijian Huang, Songjie Wang, Shengjie Wu, Lan Su, Lei Xu, Fangyi Xiao, Pugazhendhi Vijayaraman

Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China

Introduction:

Persistent atrial fibrillation (AF) may lead to higher probability of inappropriate shocks in heart failure (HF) patients with implantable cardioverter defibrillator (ICD) implantation. The aim of the study was to evaluate the impact of His‐Purkinje conduction system pacing (HPSP) combined with atrioventricular node (AVN) ablation in preventing inappropriate shock therapy and improving heart function in these patients.

Methods:

96 consecutive patients with persistent AF and HF who had indications for ICD implantation were enrolled from Jan, 2010 to Mar, 2018. With patients consent, HPSP with dual chamber ICD and AVN ablation was attempted in 62 patients, while the remaining patients underwent single chamber ICD implantation only. Left ventricular ejection fraction (LVEF), left ventricular end‐ systolic volume (LVESV), New York Heart Association (NYHA) heart failure classification, shock therapies and use of drugs were assessed during follow‐up.

Result:

36 patients received only ICD therapy, 1 of them failed AVN ablation (Group 1). AVN ablation combined with HPSP was successfully achieved in 62 patients (Group 2), 4 of who had prior single chamber ICD implantation (Figure 1). During follow‐up, patients in group 2 had lower incidence of inappropriate shock (P < .01) and adverse event (P = .011). Meanwhile, improvements in LVEF (37.89 ± 14.41% to 43.61 ± 14.36% vs 35.15 ± 11.66%‐48.79 ± 14.39%, P = .01) and LVESV (138.27 ± 68.37 mL to 127.37 ± 82.86 mL vs 126.03 ± 67.35 mL to 82.11 ± 58.01 mL, P < .01) were significantly higher in group 2 (Figure 2). NYHA class improved from a baseline 2.57 ± 0.68 to 1.73 ± 0.74 in group 1, from a baseline 2.73 ± 0.59 to 1.42 ± 0.53 in group 2.

Conclusion:

HPSP combined with AVN ablation is feasible and safe with high success rate in persistent AF patients with HF and ICD implantation. It can significantly reduce the incidence of inappropriate shocks and improve left ventricular function.

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AP19‐00354

Smartphone application self checklist for detecting atrial fibrillation in general population

Ardian Rizal, Muhamad Rizki Fadlan

Saiful Anwar General Hospital, Indonesia

Introduction:

The asymptomatic nature and frequency of AF lead to suboptimal early detection. We developed Self checklist based on smartphone application for AF screening. However, there has been limited validation of mobile phone compared to 12‐lead electrocardiograms (ECG).

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Between November 2016 and October 2017, 45 patients underwent an initial PVI for AF in our hospital. First, we investigated following data ; age, sex, hypertension (HT), diabetes (DM), chronic renal failure (CRF), CHA2DS2‐VASc score, echocardiographic measurement data (left ventricular end diastolic diameter, left ventricular end systolic diameter, left ventricular ejection fraction, left atrial diameter), types of AF (paroxysmal or persistent), PVI success rate, AF recurrence rate at one year after ablation, total delivered energy for PVI, procedure time, fluoroscopy time, and number of clinical complications. Second, We divided them into two groups ; 25 cases using TC (TC group) and 20 cases not using TC(non‐TC group) , and compared between the groups. All statistical analyses were performed with Stat Flex Version 6.

Result:

Among 45 patients, paroxysmal AF was 73%, PVI success rate was 97% , AF recurrence rate was 22% and no clinical complications occurred. The total delivered energy for PVI was significantly lower (P < .001) and the number of persistent AF was significantly higher (P = .02) in TC group.

Conclusion:

PVI with TC reduced the total delivered energy for PVI than without TC. The usefulness of TC was suggested in PVI.

AP19‐00358

Surgical intervention for cardiac tamponade during ablation of AF: who and when? A single center experience

Nan Wu, Minglong Chen, Cheng Cai, Gang Yang, Fengming Wu

China

Introduction:

Cardiac tamponade (CT) is the most common potential life threatening complication associated with radio‐frequency catheter ablation (RFCA) for atrial fibrillation (AF). Based on current clinical practice, the decision of conservative therapy or surgical intervention remains unclear. The aim of this study is to retrospectively analyze the occurrence and management of CT during RFCA for AF in our experienced medical center.

Methods:

All patients with a cardiac tamponade perforation who have undergone radio‐frequency catheter ablation for atrial fibrillation in our center were included.

Result:

Of 2890 procedures performed from 2013 to 2018, 28 (0.97%) patients occurred cardiac tamponade. Among them, the left atrium dimension was 35.5 ± 3.7 mm on average. 22 (78.6%) patients were noted during ablation procedure, 6(21.4%) patients were noted within 1 hour after the procedure. 25 (89.3%) patients were required to perform pericardiocentesis immediately. 10 patients underwent emergency surgical repairs due to the hemodynamic unstable state among whom the average of drainage was 2250 ml(627.5‐3050).The perforation sites could be identified during the surgical repairs: 5 at right superior pulmonary vein, 2 at coronary sinus, 1 at left atrium appendage, 1 at left superior pulmonary vein and 1 at tricuspid isthmus, respectively. During the surgical procedure, Cox maze procedure (4/10) and left atrial appendage excision (2/10)were performed accordingly. The drainage volume was strongly associated with decision of surgical repair (OR: 1.003, P = 0.033), the cutoff value was 400 ml (AUC: 0.919, sensitivity: 100%, specificity: 72.22%, P < 0.001). No patient died of CT in our cohort.

Conclusion:

The incidence of CT(0.97%) was lower than 1% in our center.The annual incidence rate was 0.19%.Latent CT occured in 6(21.4%) patients.The dimension of left atrium was small (35 mm) in patients with CT. The most common perforation site was RSPV. If the drainage was more than 400 ml during the procedure, emergency surgical repair should be recommended.

TABLE 1 Baseline characteristics

Characteristicsa	Overall (n=28)	Conservative (n=18)	Surgical (n=10)	P value
Male sex	17 (60.7)	12 (66.7)	5 (50)	.444
Age, mean±SD, y	59.9±11.9	59.9±12.0	59.8±12.3	.976
Atrial fibrillation type	Paroxysmal	24 (85.7)	15 (83.3)	9 (90)	1
Atrial fibrillation type	Persistent	4 (14.3)	3 (16.7)	1 (10)	1
Previous catheter ablationb	3 (10.7)	2 (11.1)	1 (10)	1
CHA2DS2‐VASc score, median (interquartile range)	1.5 (0‐2)	1 (0‐2.25)	2 (1‐2.25)	.265
HASBLE score, median (interquartile range)	0 (0‐1)	0 (0‐1)	1 (0‐1)	.08
Comorbidities	hypertension	12 (42.9)	8 (44.4)	4 (40)	1
	diabetes	3 (10.7)	0	3 (30)	.037
	CHD	1 (3.6)	1 (5.6)	0	1
	stroke	1 (3.6)	1 (5.6)	0	1
	Valvular heart diseasec	2 (7.1)	1 (5.6)	1 (10)	1
	Patent ovalis	1 (3.6)	1 (5.6)	0	1
	Persistent left superior vena cava	1 (3.6)	1 (5.6)	0	1
NYHA	I	21 (75.0)	14 (77.8)	7 (70)	.674
	II	7 (25.0)	4 (22.2)	3 (30)	.674
	III & IV	0	0	0	—
Anticoagulantsd	Warfarin	11 (39.3)	5 (27.8)	6 (60)	.125
	LWMH	5 (17.9)	5 (27.8)	0	.128
	Dabigatran	8 (28.6)	5 (27.8)	3 (30)	1
	Rivaroxaban	1 (3.6)	1 (5.6)	0	1
Echocardiography	Aod, mean±SD, mm	30.8±3.2	30.9±2.6	30.4±4.1	.672
	LAD, mean±SD, mm	35.5±3.7	35.2±3.5	36.1±4.1	.53
	LVEF, mean±SD, %	65.1±2.1	64.5±2.1	66.2±1.5	.032
	LVPW, median (interquartile range), mm	10 (9‐10)	10 (9‐10)	10 (8‐10)	.724

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Abbreviations: CHD = Coronary Heart Disease; NYHA = New York Heart Association; LMWH = Low Molecular Weight Heparin; Aod=Aorta diameter; LAD = left atrium dimension; LVEF = left ventricular ejection fraction; LVPW = left ventricular posterior wall.

The P value was evaluated between the conservative and surgical group.

aValues are presented as number and percentage of patients unless specified otherwise.

b In conservative group, 2 patients underwent ablation for AVNRT and 1 patient underwent ablation for atrial fibrillation, respectively. In surgical group, 1 patient underwent ablation for AVNRT.

c1 patient had in surgical group moderate aortic regurgitation and the other patient in conservative group had moderate tricuspid regurgitation.

dData of anticoagulation were available among 26 patients. The remaining 1 patient who had AF ablation in the old days only received antiplatelet therapies.

TABLE 2 Characteristic of the ablation procedures and cardiac tamponade

Variablesa	Overall	Conservative	Surgical	P value
Ablation strategy	Pulmonary vein isolation	24 (100)	15 (100)	9 (100)	—
	Mitral isthmus line	1 (4.2)	1 (6.7)	0	1
	Cavo‐tricuspid isthmus line	4 (16.7)	2 (13.3)	2 (22.2)	.615
	Roof line	1 (4.2)	1 (6.7)	0	1
	Superior vena cava isolation	2 (8.3)	1 (6.7)	1 (11.1)	1
	Left atrial anterior wall fractionated potential	1 (4.2)	1 (6.7)	0	1
	Coronary sinus ablation	2 (8.3)	2 (13.3)	0	.511
	Left sides accessory pathway	1 (4.2)	1 (6.7)	0	1
Mapping systems	Carto	16 (64)	8 (53.3)	8 (80)	.229
Mapping systems	Ensite	9 (36)	7 (46.7)	2 (20)	.229
Types of catheter	Contact force‐sensing cathetersb	11 (44)	5 (33.3)	6 (60)	.241
	Non‐contact force‐sensing catheters	Thermocool	5 (20)	7 (46.7)	2 (20)	.229
	Non‐contact force‐sensing catheters	Coolflex	9 (36)	3 (20)	2 (20)	1
Progress when CT identified	Before transseptal puncture or mapping completion	5 (17.9)	4 (22.2)	1 (10)	.626
Progress when CT identified	Before ablation completion or after the procedure	23 (82.1)	14 (77.8)	9 (90)	.626
Time frame when CT identified	During the procedure	22 (78.6)	15 (83.3)	7 (70)	.634
	20 min after the procedure	4 (4.3)	2 (11.1)	2 (20)	.601
	40 min after the procedure	2 (7.1)	1 (5.6)	1 (10)	1
Volume of drainage when CT identified (interquartile range), mL	500 (212.5‐1215)	325 (131.25‐570)	2250 (627.5‐3050)	.000

Conclusion:

In this study, we suggest that pulse palpation has relatively lower sensitivity and specificity for detecting atrial fibrillation. We need added some clinical scoring to increase their accuracy

Keywords: atrial fibrillation, MENARI, pulse palpation

AP19‐00371

Patient views of success of atrial fibrillation ablation in long term follow‐up

George Leef, Rafael Arias, Bhradeev Sivasambu, Hugh Calkins, David Spragg

Johns Hopkins Hospital, Division of Cardiology, United States

Introduction:

Long term follow up data after atrial fibrillation ablation has shown that recurrences are common, and complete elimination of AF is difficult in many patients. However since the majority of AF ablations are performed to improve patients symptoms, complete freedom from AF may not be the most clinically relevant endpoint. We followed up patients > 1 year out from ablation at Johns Hopkins to assess their views of the success of the procedure and compare to AF recurrence data.

Methods:

We sent a follow up questionnaire to patients from the Johns Hopkins Atrial Fibrillation database who underwent an AF ablation between 12 and 60 months ago. Patients were asked to rate their ablation procedures as “completely successful”, “partially successful”, or “unsuccessful” in controlling their atrial fibrillation symptoms, in addition to other questions about long term AF management. Replies from this survey were compared to baseline demographic data and ˜1 year recurrence data.

Result:

Out of 350 patients to whom surveys were sent, we received 128 responses, age 62.9 ± 13.5, CHADS‐VASc 2.2 ± 1.5, 66.4% paroxysmal AF. The mean time since ablation was 50.3 months. 59.4% of respondents reported their ablation as “completely successful”, 28.9% reported it as “partially successful”, and only 11.7% reported it as “unsuccessful”. One‐year recurrence data was available for 64/129 of these patients, based on the standard “30 seconds of AF” definition of recurrence. Of these patients, only 56.3% were recurrence‐free after the 3 month blanking period, at a mean follow up of 14.9 months. In contrast, 59.4% of these patients reported “complete success” at a mean follow up time of 42.7 months, and 28.1% reported partial success. Interestingly 42.8% of the patients with known recurrence at ˜1 year reported their procedures as “completely successful” now.

Conclusion:

These results are derived from an unrandomized survey, but they still illustrate two significant points. First, that AF ablation often has quite durable results in terms of patient‐reported symptom control. And second, that the endpoint of “any recurrence” does not always correlate with patient‐reported symptoms control, and may not be the most relevant to capture what matters to patients undergoing this procedure. Future studies in the field may wish to consider additional endpoints assessing symptom control in addition to recurrences of AF.

AP19‐00372

Long term use of anticoagulation after atrial fibrillation ablation

George Leef, Rafael Arias, Bhradeev Sivasambu, Hugh Calkins, David Spragg

Johns Hopkins Hospital, Division of Cardiology, USA

Introduction:

Although atrial fibrillation is strongly associated with death and disability from stroke, previous studies have generally shown low use of anticoagulation. There is currently a lack of data on very long term use of anticoagulation in AF, and also on use of anticoagulation after AF ablation procedures. We followed up patients 1‐5 years out from ablation at Johns Hopkins to assess their use of anticoagulation. These patients were followed in a variety of practice settings, not just at the tertiary care center of Johns Hopkins Hospital.

Methods:

We sent a follow up questionnaire to patients from the Johns Hopkins Atrial Fibrillation database who underwent an AF ablation between 12 and 60 months ago. Patients were asked to report whether they were still being prescribed anticoagulation, the type of anticoagulation (warfarin, dabigatran, rivaroxaban, or apixaban), and the specialty of the physician managing their anticoagulation (PCP, general cardiologist, or EP). Replies from this survey were compared to stroke risk scores derived from baseline demographic data obtained from the electronic medical record.

Result:

We received 128 responses out of 350 patients to whom surveys were sent. Mean age was 62.9 ± 13.5, mean CHADS‐VASc score was 2.2 ± 1.5. The mean time since ablation was 50.3 months. Use of anticoagulation increased with increasing CHADS‐VASc score (Table), however even in the highest risk group, use of anticoagulation was suboptimal (84.0% for CHADS‐VASc scores >= 4). Overall 77.8% of patients with a CHADS‐VASc score >= 2 reported taking anticoagulation. The vast majority (88.9%) reported taking NOACs rather than warfarin. There was no association between the specialty of the managing physician and use of AC (P = .6).

Conclusion:

Although these results are derived from an unrandomized survey, they offer insight into real world anticoagulation management. Long term use of anticoagulation in AF patients remains suboptimal, even in high risk patients. More than one in five patients with a CHADS‐VASc score >= 2 was not being prescribed anticoagulation, and increasing physician specialization in arrhythmia management was not associated with higher rates of anticoagulation use. Further studies will investigate the reasons for discontinuation of anticoagulation, and patient or procedure factors that predict use of anticoagulation.

CHADS‐VASc score	Number of patients	Percent taking AC
0	21	9.5%
1	27	52.9%
2	38	71.1%
3	27	81.5%
≥4	25	84.0%

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AP19‐00376

Left atrial appendage closure with zero fluoroscopic exposure via intracardiac echocardiographic guidance

Xianfeng Du, Huimin Chu, Bin He

Ningbo First Hospital, China

Ju Yeol Baek, Young Choi, Sung‐Hwan Kim, Ju Youn Kim, Tae‐Seok Kim, Youmi Hwang, Ji‐Hoon Kim, Sung‐Won Jang, Man Young Lee, Yong‐Seog Oh

Seoul St. Mary's Hospital, Catholic University Seoul, Korea, South Korea

Weijian Huang, FangYi Xiao, XiaoDong Zhou

Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China

Introduction:

Left atrial appendage (LAA) closure is an attractive alternative for stroke prevention in patients with atrial fibrillation (AF). The risk of stroke in patients with AF after LAA closure is still lacking of thorough studies. Our objective was to evaluate the potential risk factors of stroke in patients with AF after LAA closure

Methods:

Non‐valvular AF patients at high risk of stroke were enrolled in the study and underwent LAA closure. Follow‐up was performed at 45 days, 6 months, and 12 months. Univariate Cox regression analysis was computed to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for exploring the potential risks for incidence of stoke after LAA closure. Multivariable Cox proportional hazards regression analysis was performed for exploring independent clinical predictors for stroke.

Result:

The multivariate Cox proportional hazards regression analyses showed that the peri‐device flow (HR = 4.584, 95% CI: 1.65‐12.739, P = .004) and continue coagulation (HR = 0.272, 95% CI: 0.089‐0.829, P = .022) was association with stroke in patients with AF after LAA closure. The stroke rate for patients in the leak group was significantly higher, compared with the no‐leak group (12.3 events/100 patient‐years versus 1.9 events/100 patient‐years, P < .001). Furthermore, patients with persistent peri‐ device flow may have an increased rate of strokes (HR = 5.041 (95% CI: 1.668‐15.230)).

Conclusion:

Peri‐device flow was associated with the rate of strokes at short‐term follow‐up.

TABLE 1 Primary efficacy event rates in patients with and without peri‐device flow at first and second TEE follow‐up

First TEE	No LEAK	LEAK	P‐value
Follow‐up (45d‐4y)	N=324	0.93% (5/535.7)	N=86	5.10% (8/157.0)	.002
Short term (45d‐1y)	N=324	0.39% (1/259.2)	N=86	9.36% (6/64.1)	<.001
Long term (1‐4y)	N=247	1.45% (4/276.5)	N=55	2.15% (2/92.9)	.643
1‐2y	N=247	1.61% (3/186.5)	N=55	2.25% (1/43.1)	.748
2‐3y	N=128	1.46% (1/68.7)	N=41	2.88% (1/34.7)	.603
3y+	N=37	0.0% (0/21.3)	N=25	0.0% (0/15.1)	1.000
Second TEE	No LEAK	LEAK	P‐value
Follow‐up (0.5‐4y)	N=263	1.25% (4/402.4)	N=53	3.78% (4/105.9)	.041
Short term (0.5‐1y)	N=263	0.0% (0/120.2)	N=53	4.40% (2/45.4)	.020
Long term (1‐4y)	N=232	1.42% (4/282.2)	N=39	1.65% (1/60.5)	.884
1‐2y	N=232	2.02% (3/182.1)	N=39	0.0% (0/30.6)	.310
2‐3y	N=134	1.64% (1/75.5)	N=26	4.88% (1/20.5)	.493
3‐4y	N=42	0.0% (0/24.6)	N=16	0.0% (0/9.4)	1.000

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TABLE 2 Univariate and multivariate analyses of the association between

Univariate analysis	Multivariate analysis
HR 95% CI	P	HR 95% CI	P
Sex	0.564 (0.224‐1.422)	.225
Age	1.023 (0.965‐1.085)	.441
Hypertension	1.443 (0.418‐4.988)	.562
Diabetes	2.798 (1.11‐7.053)	.029
History of stroke	3.522 (1.018‐12.192)	.047	5.391 (1.221‐23.806)	.026
Vascular disease	2.195 (0.865‐5.572)	.098
Congestive heart failure	1.382 (0.492‐3.879)	.539
Continue anticoagulation	0.272 (0.089‐0.829)	.022	0.463 (0.144‐1.487)	.463
Peri‐device	4.584 (1.65‐12.739)	.004	4.205 (1.468‐12.045)	.007

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AP19‐00411

Recurrence rate and predictors of electrophysiology study induced atrial fibrillation

Kyung Min Min, Tae Ho Youn, Min Jung Bak, David Hong, Sang Yoon Lee, Seong Soo Lee, Young Jun Park, Seung Jung Park, Kyoung Min Park, June Soo Kim, Young Keun On

Samsung Medical Center, South Korea

Introduction:

When atrial fibrillation was induced during the electrophysiology study (EPS), the incidence of atrial fibrillation (AF) was higher, compared to when it was not induced. However the incidence rate and predictive factors were not well known. For more effective stroke prevention, it is important to know the predictive factors of AF recurrence.

Methods:

From July 2010 to December 2018 at Samsung Medical Center, when AF was induced during the EPS, each patient was registered in the registry ‘AF during EPS’. 237 patients were assessed for eligibility and 35 patients were excluded. 10 patients had already been diagnosed with AF or AFL, and 25 patients were ineligible because they had been monitored for less than 3 days. Finally, 202 were enrolled for analysis. The primary outcome of the study included the recurrence of AF or AFL. Clinical and electrophysiology factors were investigated: Age, hypertension, CAD, duration of AF or AFL, isoproterenol usage during the EPS and corrected sinus node recovery time (CSNRT). Univariate and multivariate logistic regression analysis were performed to investigate the predictive factors.

Result:

In this study, 19 of 202 (9.4%) patients developed documented AF or AFL. Mean follow‐up duration of enrolled patients was 546 ± 670 days. Older age, hypertension and CAD were associated with incidence of AF in univariate analysis. Two anticipated electrophysiology predictors show no statistical significance with the use of univariate logistic regression analysis: duration of AF or AFL and CSNRT. But induction of AF or AFL before isoproterenol infusion was a negative risk factor for recurrence of AF or AFL (odds ratio, 0.28; 95% CI, 0.08 to 0.94; P = .04).

Conclusion:

We observed that 9.4 percent of patients developed documented AF or AFL. It has been demonstrated that induction of AF or AFL before isoproterenol infusion was a negative risk factor for recurrence.

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AP19‐00412

Efficacy and safety of catheter ablation combined with left atrial appendage occlusion in patients with atrial fibrillation

Weijian Huang, FangYi Xiao, XiaoDong Zhou

Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China

Introduction:

Catheter ablation is an effective therapy for symptomatic, drug‐refractory atrial fibrillation (AF) patients. Left atrial appendage occlusion (LAAO) was an attractive alternative for stroke prevention. The concomitant catheter ablation and LAAO may be a feasible way to relieve symptom, reduce stroke and abolish anticoagulation simultaneously. The aim was to evaluate the feasibility and efficacy of the novel one‐stop procedure.

Methods:

Patients with AF at high risk of thromboembolic events and bleeding who underwent one‐ stop combined ablation and LAAO for drug‐refractory and high risk of thromboembolic events were included. Follow‐up was performed at 45‐day, 6‐ and 12‐month. Adverse events were recorded in the hospital's on‐line information systems. Transoesophageal echocardiography was utilized to detect device‐ related thrombus and evaluate the device position and width of residual flow. Holter monitoring was performed to screening the recurrence of AF. Baseline and 1‐year brain computed tomography were used to detect symptomatic and silent stroke.

Result:

238 patients underwent concomitant catheter ablation and LAAO and were included (mean age 69.4 ± 7.5 years; 145 men). The mean CHA2DS2‐VASc score was 3.9 ± 1.6. Cryoballoon ablation (CBCA) was used in 99 patients and radiofrequency ablation (RFCA) was used in 139 patients. A mean follow‐up of 26.2 ± 10.1 months showed 54 documented atrial arrhythmias recurrence of AF. 2 patients died at 10‐day and 6‐month follow‐up respectively. 3 patients have major bleeding and 5 patients has stroke (Table). Device thrombus occurred in 3 patients.

Conclusion:

The one‐stop combined LAAO and catheter ablation may be a feasible and efficacious therapeutic option to relieve symptom and reduce stroke simultaneously in patients with AF at high risk of thromboembolic events and bleeding.

TABLE Follow‐up

Variables	ALL N=238	CBCA N=99	RFCA N=139
Follow‐up period	26.2±10.1	30.9±9.7	23.4±8.1
Ischaemic stroke	0.97% (5/514.0)	0.79% (2/254.5)	1.2% (2/259.5)
<3 months	4	2	2
≥3 months	1	0	1
Haemorrhagic stroke	0.19% (1/515.4)	0% (0/254.9)	0.38% (1/260.8)
<3 months	1	0	1
≥3 months	0	0	0
Major bleeding	0.58%(3/514.6)	0.78% (2/254.0)	0.38% (1/260.6)
<3 months	3	2	1
≥3 months	0	0	0
Device related thrombus	0.84% (3/238)	2.02% (2/99)	0.72% (1/139)
Post‐procedure	1	0	1
The first TEE	1	1	0
The second TEE	1	1	0

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AP19‐00413

Impact of non‐pulmonary vein foci in the patients with atrial fibrillation: Clinical difference according to the localization of atrial fibrillation

Junpei Saito, Kennosuke Yamashita, Wataru Igawa, Morio Ono, Masahiko Ochiai

Showa University Northern Yokohama Hospital, Japan

You‐Jung Choi

Seoul National University Hospital, South Korea

Introduction:

Atopic triad consists of asthma, allergic rhinitis, and atopic dermatitis, which are linked by a shared mechanism of the immune system. Although asthma has been reported to have an increased risk of atrial fibrillation (AF), the relationship between multiple atopic diseases (i.e., atopic triad) and AF has not been fully elucidated. We aimed to investigate atopic triad is associated with the development of AF.

Methods:

This study used the database from the National Health Insurance Services‐Health Screening Cohort in 2009. We identified patients with the atopic disease, who have visited the hospital more than three times per year for each disease. The primary outcome was new‐onset AF in subjects without a history of previous AF (n = 6 699 738). Of them, 1 156 729 (17.4%) subjects had at least one of atopic diseases, and 5 543 009 (82.7%) were defined non‐atopic subjects.

Result:

During 8.8 years of follow‐up, 161 374 subjects were newly diagnosed with AF (125 760 in the atopic group and 35,614 in the non‐atopic group). The incidence rate (IR) of AF was 4.3 per 1000 person‐year in the atopic group and 3.6 per 1000 person‐year in the non‐atopic group. The atopic group had a 24% (95% confidence interval, 22.5%‐25.5%) higher risk of AF development (Figure 1). The risk of incident AF showed a dose‐response association with the number of atopic diseases (Table 1).

Conclusion:

The atopic triad, including asthma, allergic rhinitis, and atopic dermatitis, was associated with an increased risk of AF development. Multiple combination atopic disease is a potential risk factor of AF development.

Number at risk
Non‐atopic group	5 534 009	5 464 827	5 375 356	5 273 373	2287
Atopic group	1 156 729	1 135 179	1 111 197	1 084 248	429

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TABLE 1 The risk of atrial fibrillation development

Number	AF events	IR*	Hazard ratio (95% Confidence interval)
Number	AF events	IR*	Model 1	Model 2
Non‐atopic group	5 543 009	125 760	3.16	1 (reference)	1 (reference)
Atopic group	1 156 729	35 614	4.32	1.29 (1.273–1.303)	1.24 (1.225–1.255)
Number of atopic diseases
1	1 014 309	29 738	4.10	1.25 (1.23–1.261)	1.20 (1.189–1.22)
2	140 305	5781	5.86	1.56 (1.52–1.602)	1.46 (1.422–1.499)
3	2115	95	6.47	1.63 (1.329–1.987)	1.50 (1.226–1.833)

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*Incidence rate (IR) was presented per 1000 person‐year within the population who were over 20 years old and not previously diagnosed with atrial fibrillation.

Model 1: adjusted for age and sex.

Model 2: adjusted for age, sex, history of smoking, drinking level, low income, diabetes mellitus, hypertension, and dyslipidemia.

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AP19‐00463

The effects of single nucleotide polymorphisms in Korean patients with early‐onset lone atrial fibrillation after catheter ablation

Yae Min Park, In Suck Choi, Seung Young Roh, Jaemin Shim, Jong‐Il Choi, Young‐Hoon Kim

Gachon University Gil Medical Center, South Korea

Introduction:

The status of SNPs among patients with extremely early‐onset lone AF and the association with outcome of catheter ablation has not been evaluated before. This study evaluated the status of single nucleotide polymorphisms (SNPs) in Korean patients with early‐onset (<40 years old) lone AF and effects on the outcome after catheter ablation.

Methods:

A total of 89 consecutive patients (mean age 35.7 ± 3.7 years, 81 males) with drug‐ refractory AF (paroxysmal 64.0%) who underwent catheter ablation were included. Sixteen SNPs including rs13376333, rs10465885, rs10033464, rs2200733, rs17042171, rs6843082, rs7193343, rs2106261, rs17570669, rs853445, rs11708996, rs6800541, rs251253, rs3807989, rs11047543 and rs3825214 were genotyped. Serial 48‐day Holter electrocardiographic recordings were acquired to detect AF recurrences during long‐term follow up.

Result:

Wild type of rs7193343 [CC; 0/7 (0%) vs CT; 22/40 (55.0%) vs TT; 18/41 (43.9%), P = .025] and rs11047543 [GG; 26/69 (37.7%) vs GA; 13/18 (72.2%) vs AA; 0/0, P = .009] and homozygous variant of rs3825214 [AA; 16/31 (51.6%) vs AG; 22/43 (51.2%) vs GG; 2/13 (15.4%), P = .05] were significantly associated with lower rate of late recurrence. When the patients were assigned to four groups according to the number of risk alleles (n = 0‐3), Kaplan‐Meier survival analysis showed incremental prognostic value according to the number of variant alleles (P = .002).

Conclusion:

Polymorphisms on rs7193343, rs3825214 and rs11047543 modulate the risk for AF recurrence after catheter ablation during long term follow up in Korean patients with early‐onset lone AF.

AP19‐00465

Left atrial conduction time by 3D‐echocardiography in patients with atrial fibrillation is a novel predictor of recurrence after catheter ablation

Miyako Igarashi, Yoshihiro Seo, Tomoko Ishizu, Tomoko Machino, Satoshi Simoo, Masayuki Hattori, Yuta Oishi, Chihiro Ota, Noboru Ichihara, Akira Kimata, Yuki Komatsu, Takeshi Machino, Hiro Yamasaki, Yukio Sekiguchi, Akihiko Nogami, Kazutaka Aonuma, Masaki Ieda

University of Tsukuba, Japan

Jose Osorio, Tina D. Hunter, Anil Rajendra, Gustavo Morales

Grandview Medical Center, USA

Introduction:

A 56‐hole porous tip catheter was designed to improve cooling with less fluid delivery than a prior 6‐hole design. There are limited publications on real‐world procedural and clinical outcomes comparing these cooling tip designs. Therefore, the objective of this study was to report on procedural efficiency and clinical outcomes after paroxysmal atrial fibrillation (PAF) ablation with 6‐hole and 56‐hole irrigated tip contact force (CF) catheters at a high‐volume center in the US.

Methods:

Consecutive de novo RF ablations for PAF were performed with the 6‐hole design throughout 2016 and subsequently with the 56‐hole porous tip in 2017. Similar parameters were used for ablations with the two catheters, including CF between 10‐20 g, catheter moved every 10‐20 s and RF energy of 40‐45 W. In all cases, pulmonary veins were isolated by wide area circumferential ablation using catheter stability software (maximum range: 2.5 mm; minimum time: 4 seconds). Patients were followed for a year post ablation, with monitoring at 6 months, 12 months, and additionally as needed.

Result:

A total of 168 de novo PAF ablations with the 6‐hole catheter and 157 with the 56‐hole catheter had similar patient characteristics, procedure times, safety, and 1‐year clinical outcomes, while more ablations were performed without fluoroscopy and a 30% reduction (407 mL) in total fluids was delivered with the 56‐hole porous tip.

Conclusion:

In a real‐world setting, PAF ablation performed with the porous tip design led to significantly reduced fluid delivery, with otherwise similar outcomes. The associated clinical benefit of the fluid reduction to patients with heart failure requires further evaluation.

Baseline patient characteristics	6‐Hole Tip (N = 168)	56‐Hole Tip (N = 157)	P‐value (6 vs. 56 Hole Tip)
Baseline patient characteristics	n*	Mean ± SD	P‐value (6 vs. 56 Hole Tip)	n*	Mean ± SD
Age	168	61.4 ± 11.4	157	62.7 ± 11.5	0.3282
Sex = Male	100/168 (59.5 %)	86/157 (54.8 %)	0.3874
CHA2DS2‐VASc	168	2.3 ± 1.5	157	2.3 ± 1.5	0.9755
Procedural Efficiency	n *	Mean ± SD	n *	Mean ± SD	P ‐Value
Total procedure time, min	168	81.8 ± 30.9	157	76.2 ± 29.8	.0950
Radiofrequency time, min	163	31.1 ± 9.1	157	31.3 ± 10.4	.8833
Fluoroscopy time, min	168	.056 ± .136	156	.046 ± .285	.6785
No Fluoroscopy Used	118/168 (70.2 %)	140/157 (89.7 %)	<.0001
Total Fluids (IV + Catheter), ml	55	1348 ± 454	152	941 ± 274	<.0001
Fluids via Catheter, ml	0	Not recorded	90	577 ± 197	NA
Procedural Effectiveness	N	Count (%)	N	Count (%)	P ‐value
Recurrence through 1 Year (90‐day blanking)	168	21 (12.5 %)	157	15 (9.6 %)	.3978
Reablations through 1 Year	168	8 (4.8 %)	157	6 (3.8 %)	.6765

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*n = number of patients in cohort with non‐missing values for the measure

AP19‐00487

Investigation of recurrence after atrial fibrillation ablation assessed by PentaRay catheter

Takahiro Furuya

Showa Koto Toyosu Hospital, Japan

Introduction:

The left atrium (LA) volume and the LA voltage are said to be predictors of recurrence after ablation for atrial fibrillation (AF).We measured LA volume and LA voltage using CARTO 3 system PentaRay catheter, and evaluated recurrence group and nonrecurrence group.

Methods:

In consecutive 234 patients (pts) with AF who underwent pulmonary vein isolation (PVI) from Jun 2016 to December 2017, we evaluated 128 pts (mean age 66.3 ± 11.8, Male 66%), that LA was constructed by Fast Anatomical Mapping using PentaRay catheter during LA pacing. We measured LA total volume (LATV), RightPV+antrum volume (RPAV), LeftPV+antrum volume (LPAV), LA central volume (LACV) and the LA bipolar voltage. We followed the observation with 0 days as the day of ablation. Recurrence was defined as AF detected by electrocardiogram.

Result:

Out of 128pts, 26 were PerAF (recurrence:4pts) and 102 were PAF (recurrence: 7pts). The observation period was 137 ± 80 days on average. In PAF, the median value of the propotion of LPAV to LATV was divided into two groups (Median value of LPAV/LATV × 100:8.67%, low < 8.67%:n=51, high > 8.67:n = 51). 6 out of 7pts who relapsed PAF were included in the high group. Although there was no significant difference in each volume between recurrence group and nonrecurrence group in PerAF, LA bipolar voltage in recurrence group was significantly lower than nonrecurrence group (0.50 ± 0.17 vs 0.73 ± 0.23 mV, P < .05).

Conclusion:

The higher proportion of LPAV to LATV in PAF, the more likely it is for relapse. In addition, it was considered that a decrease in LA voltage was involved in recurrence for PerAF.

AP19‐00499

Accessoriy pathway ablation from atrial insertion in a patient with pre‐excited atrial fibrilation

Deni Agustian Muhidin, Mohammad Iqbal, Giki Karwiky, Chaerul Achmad

InaHRS, Indonesia

Dian Aristi Nugraheni, Irnizarifka —

Dr. Moewardi Hospital, Surakarta, Indonesia

Introduction:

Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and often requires treatment in adults. There have not been many studies investigating the incidence of AF in asthma patients. The aim of this study is to investigate whether AF is increased in asthmatic patients using P wave dispersion (PWD) or not.

Methods:

Methods: In this retrospective study, we collected data from the medical records of asthma patients who were hospitalized in Moewardi Hospital from January to December 2018 and 32 healthy volunteers. The lead ECG was recorded PWD. Data analysis was performed using multivariant analysis test.

Result:

Of the 100 asthma patients 62 (62%) had asthma, 20 (20%) had asthma with hypertension, 16 (16%) had asthma with diabetes, and 32 others were controlled. From the parameters of PWD from the group of patients with asthma, asma with diabetes, asthma with hypertension and in the control, there were significant differences (P = .02). The highest PWD is in asthma patients with diabetes (PWD 58.711) followed by asthma with hypertension (PWD 51.577), the asthma group (PWD 42.375) and the control group (PWD 33.398). Haemoglobin, WBC, creatinine and kalium in patient with asthma indicates that there is a significant difference. However, it doesn't indicate its impact on PWD. There were no significant (P > .05) differences in BMI, heart rate, hemoglobin, platelets, urea and sodium between groups.

Conclusion:

We found that PWD values increased in asthma patients with diabetes compared to the control group. These results indicate that the risk of developing AF in asthma patients with diabetes is higher than the normal population.

Keywords: P wave dispersion, asthma, atrial fibrilation

AP19‐00513

Is pulmonary vein isolation enough for persistent atrial fibrillation? Multi‐center randomized trial

Jung Myung Lee, Jaemin Shim, Junbeom Park, Hee Tae Yu, Tae‐Hoon Kim, Jin‐Kyu Park, Jae‐Sun Uhm, Jin‐Bae Kim, Boyoung Joung, Moon‐Hyoung Lee, Young‐Hoon Kim, Hui‐Nam Pak

Kyung Hee University, South Korea

Introduction:

Although STAR AF2 proved no additional benefit of additional extra‐pulmonary vein (PV) left atrial (LA) ablation in patients with persistent atrial fibrillation (AF), long‐term recurrence rate was still high. We hypothesized that posterior wall isolation may improve rhythm outcome of catheter ablation of persistent AF.

Methods:

We randomly assigned 213 patients with persistent AF (male 83.1%, 58.6 ± 10.7 years old) in a 1:1 ratio to ablation with circumferential PV isolation (CPVI group, n = 106) and CPVI with additional linear ablation group (posterior wall isolation and anterior line, LINE group, n = 107). We achieved electrical isolation of LA posterior wall by roof line, posterior inferior line, and/or focal ablation of remnant atrial potentials. The primary end point was AF recurrence after single procedure, and the secondary end point was recurrence pattern and response to antiarrhythmic drugs (AAD).

Result:

Randomization of two groups was well matched, and LA posterior wall isolation and bidirectional block of anterior line were achieved in 94% and 70%, respectively. Ablation time was significantly longer in additional linear ablation group (CPVI group 4211 ± 1920 seconds vs LINE group 5340 ± 2373 seconds, P < .001). Major complication rate was not significantly different between CPVI group and additional linear ablation group (4.7% vs 0.9%, P = .119). During 16.1 ± 8.9 months follow‐up, clinical recurrence rate was not significantly different between two groups (21.7% vs 23.4%, P = .771; log rank p = 0.585), but about half of patients were taking AAD (48.1% vs 42.1%, P = .382) at the time of first clinical recurrence of AF. Recurrence as atrial tachycardia (AT) was 8.7% in CPVI group and

20% in additional linear ablation group (p = 0.506), and electrical cardioversion was required in 15.1% and 20.6%, respectively (p = 0.297). Finally, maintenance of sinus rhythm without AAD was achieved in 44.5% and 52.5% without significant difference across the treatment groups (p = 0.243).

TABLE 1 Baseline clinical characteristics

Overall	CPVI	Line	P‐value
(n = 213)	(n = 106)	(n = 107)	P‐value
Age, years	58.6 ± 10.7	58.7 ± 11.0	58.5 ± 10.6	.866
Male, n (%)	177 (83.1)	85 (80.2)	92 (86)	.259
AF duration	39.3 ± 39.9	32.8 ± 32.1	45.6 ± 45.5	.03
Longstanding PeAF	139 (65.3)	65 (61.3)	74 (69.2)	.23
Comorbidities, n (%)
Heart failure	49 (23)	24 (22.6)	25 (23.4)	.9
Hypertension	100 (46.9)	55 (51.9)	45 (42.1)	.151
Diabetes mellitus	31 (14.6)	18 (17)	13 (12.1)	.317
Stroke	23 (10.8)	13 (12.3)	10 (9.3)	.493
TIA	3 (1.4)	1 (0.9)	2 (1.9)	1
Vascular disease	13 (6.1)	6 (5.7)	7 (6.6)	.775
CHA2DS2‐VASc score	1.7 ± 1.4	1.9 ± 1.5	1.5 ± 1.3	.08
Echocardiographic parameters
LA dimension, mm	44.7 ± 6.0	44.5 ± 6.6	44.9 ± 5.4	.642
LA volume index, ml/m2	43.5 ± 12.9	43.1 ± 11.4	43.8 ± 14.2	.71
LV ejection fraction, %	58.8 ± 9.4	58.9 ± 8.7	58.8 ± 10.2	.931
E/Em	10.0 ± 4.3	10.5 ± 4.9	9.6 ± 3.5	.128
LVEDD, mm	50.3 ± 5.3	50.4 ± 5.0	50.2 ± 5.7	.818

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TABLE 2 Procedure related characteristics

Overall (n = 213)	CPVI (n = 106)	Line (n = 107)	P‐ value
Procedure time, min	218.3 ± 74.7	206.4 ± 77.4	230.1 ± 70.4	0.02
Ablation time, sec	4778.7 ± 2227.8	4211.3 ± 1920.2	5340.8 ± 2373.4	<0.001
Fluoroscopy time, min	36.4 ± 17.3	35.0 ± 18.1	37.8 ± 16.5	0.24
Complications†	12 (5.6)	7 (6.6)	5 (4.7)	0.541
Major Complications	6 (2.8)	5 (4.7)	1 (0.9)	0.119
Tamponade	4 (1.9)	4 (3.8)	0	0.090
SSS	2 (0.9)	0	2 (1.9)	0.498
AE fistula	2 (0.9)	1 (1)	1 (0.9)	0.748

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†Complications: pericarditis, pseudoaneurysm, pericardial effusion, Tamponade, SSS, AE fistula

TABLE 3 Clinical rhythm outcomes

Post‐ABL medication	Overall (n = 213)	CPVI (n = 106)	Line (n = 107)	P‐value
ARB, n (%)	72 (33.8)	42 (39.6)	30 (28.0)	.074
Beta blocker, n (%)	84 (39.4)	46 (43.4)	38 (35.5)	.341
Statin, n (%)	71 (33.3)	37 (34.9)	34 (31.8)	.562
AAD, n (%)	94 (44.1)	55 (51.9)	39 (36.4)	.059
Follow‐up, months	16.1 ± 8.9	16.3 ± 8.8	15.9 ± 9.1	.724
Early recurrence, n (%)	92 (43.2)	44 (41.5)	48 (44.9)	.622
Recurrence type AF, n (%)	56 (60.9)	29 (66.0)	27 (56.3)	.232
Recurrence type AT, n (%)	24 (26.1)	8 (18.2)	16 (33.3)	.232
Clinical recurrence, n (%)	48 (22.5)	23 (21.7)	25 (23.4)	.771
Recurrence type AF, n (%)	39 (84.4)	19 (90.5)	20 (80)	.428
Recurrence type AT, n (%)	7 (15.2)	2 (9.5)	5 (20)	.428
AAD at recurrence, n (%)	32 (66.7)	15(65.2)	17 (68.0)	.723
Cardioversion, n (%)	38 (17.8)	16 (15.1)	22 (20.6)	.297
Final rhythm type AF or AT n (%)	30 (14.1)	14 (13.2)	16 (15)	.714
Final rhythm type SR, n (%)	183 (85.9)	92 (86.8)	91 (85)	.714
Continued use of AAD	99 (46.5)	55 (51.9)	44 (41.1)	.115
Maintenance of NSR without AAD	103 (48.4)	47 (44.3)	56 (52.3)	.243

The total procedure, ablation, and fluoroscopy times were 149.4 ± 34.0, 29.1 ± 9.3 and 9.1 ± 4.3 minutes, respectively. During the 3‐month period, atrial arrhythmia recurred in 27 patients (31.4%). Among the initial 30 patients in whom RF energy was delivered for 5 seconds per lesion, 13 (43.3%) had a recurrence of atrial arrhythmia. After prolongation of the RF time to 10 seconds in the anterior and superior antra, atrial arrhythmia occurred in 14 (25.0%) of 56 patients. Among the 42 patients followed up over the blanking period, 10 (28.5%) showed atrial arrhythmic recurrence during a median follow‐up period of 152 days (interquartile range, 104–190 days). Cardiac tamponade or stroke did not occur in any patient. Among 75 patients (87.2%) who underwent upper gastrointestinal endoscopy after ablation, one had a superficial esophageal ulcer.

Conclusion:

High‐power RF ablation for pulmonary vein isolation was associated with short procedural and RF times and was effective and safe.

TABLE Patients’ baseline characteristics according to the recurrence during the blanking period

Characteristics	Overall patients (n = 86)	Non‐recurrence group (n = 59)	Recurrence group (n = 27)	P value
Age, y	63 ± 10	62 ± 11	66 ± 8	.05
Body mass index, kg/m2	25.9 ± 3.7	25.6 ± 3.8	26.8 ± 3.6	.16
Male sex	62 (72.1)	43 (72.9)	19 (70.4)	.81
Paroxysmal AF	43 (50.0)	34 (57.6)	9 (33.3)	.04
Persistent AF	43 (50.0)	25 (42.4)	18 (66.7)
Long‐standing persistent AF	20 (23.3)	11 (18.6)	9 (33.3)	.76
CHA2DS2‐VASc score	1.9 ± 1.5	1.7 ± 1.4	2.4 ± 1.5	.03
Hypertension	43 (50.0)	27 (45.8)	16 (59.3)	.25
Prior stroke	8 (9.3)	5 (8.5)	3 (11.1)	.70
Prior heart failure	17 (19.8)	10 (16.9)	7 (25.9)	.33
Hypertrophic cardiomyopathy	6 (7.0)	5 (8.5)	1 (3.7)	.66
Valvular heart disease	4 (4.7)	1 (1.7)	3 (11.1)	.05
Coronary artery disease	12 (14.0)	9 (15.3)	3 (11.1)	.75
LA diameter, mm	44.4 ± 7.0	43.8 ± 7.5	46.0 ± 5.4	.17
LV ejection fraction, %	56.1 ± 9.9	55.9 ± 10.3	56.4 ± 9.0	.82
Procedure time, min	149.4 ± 34.0	149.4 ± 32.1	149.3 ± 38.5	.99
Ablation time, min	29.1 ± 9.3	28.3 ± 9.2	31.0 ± 9.4	.21
Fluoroscopy time, min	9.1 ± 4.3	8.8 ± 3.7	9.9 ± 5.3	.32
Initial RF protocol (5 seconds)	30 (34.9)	17 (28.8)	13 (48.1)	.08
Prolonged RF time (10 s)	56 (65.1)	42 (71.2)	14 (51.9)
Additional ablation lesion sets
LA roof line	26 (30.3)	17 (28.8)	9 (33.3)	.84
Posterior box isolation	25 (29.0)	15 (25.4)	10 (37.0)	.47
Cavotricuspid isthmus	26 (30.2)	18 (30.5)	8 (29.6)	.93
Mitral isthmus	20 (23.3)	11 (18.6)	9 (33.3)	.19
Superior vena cava	27 (31.4)	17 (28.8)	10 (37.0)	.62
Post‐RFCA AAD
Class Ic	33 (38.4)	25 (42.4)	8 (29.6)	.52
Amiodarone	13 (15.1)	7 (11.9)	6 (22.2)
Sotalol	4 (4.7)	3 (5.1)	1 (3.7)

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Data are presented as mean ± standard deviation or number (%).

AF, atrial fibrillation; LA, left atrium; LV, left ventricle; RFCA, radiofrequency catheter ablation; AAD, antiarrhythmic drug.

†Renal insufficiency was defined as an estimated glomerular filtration rate of < 60 mL/min/1.73 m2.

AP19‐00528

Impact of vagal denervation on recurrence of atrial fibrillation after pulmonary vein isolation

Ungjeong Do

Asan Medical Center, South Korea

Introduction:

Besides elimination of pulmonary vein trigger, vagal denervation is one of mechanisms of atrial fibrillation prevention after pulmonary vein isolation (PVI). We sought to evaluate (1) vagal denervation as assessed by change of sinus cycle length (SCL), AV block cycle length (AVBCL) and refractory period of AV node (AVNERP) after PVI and impact of vagal denervation on recurrence of AF in (2) paroxysmal AF and (3) persistent AF patients.

Methods:

A total of 50 consecutive paroxysmal AF (PAF) patients who underwent their first PVI was selected from our prospective AF registry. All patients underwent measurement of SCL, AVBCL, AVNERP before and after PVI. Additional 103 patients with persistent AF patients underwent measurement of SCL, AVBCL, AVNERP after PVI. Systematic follow‐up for recurrence of atrial fibrillation was done in all patients.

Result:

(1) SCL, AVBCL and AVNERP decreased by 231 ± 143, 87 ± 75, 98 ± 137 ms respectively after PVI in PAF patients. (2) AF recurred in 14 patients (28.0%) within 3 months after PVI in PAF patients. There was no difference AVBCL, AVNERP between PAF groups with and without recurrence. The SCL post PVI was the only significant different between no recurrence and recurrence group (762 ± 96 ms vs 683 ± 101 milliseconds, P = .015). Optimal cut‐off post‐PVI SCL for predicting the early recurrence was 693 milliseconds. During the median follow up period 220 days, AF recurred in 12 patients. There was no difference in SCL, AVBCL, AVNERP after PVI, delta SCL, delta AVBCL, delta AVNERP between groups with AF recurrence and without recurrence in PAF group. (3) Post ablation SCL, AVBCL, AVNERP was not different in persistent AF patients with and without both early and late recurrence

Conclusion:

Vagal denervation was observed in majority of AF patients undergoing PVI. However, markers of vagal denervation were not associated with recurrence of AF in paroxysmal and persistent AF patients.

TABLE 1 Baseline and procedural characteristics of the patients according to the recurrence during the blanking period (within 3 months)

Characteristics	Overall Patients (n = 50)	Recurrence Group (n = 14)	Non‐ recurrence Group (n = 36)	P value
Age, years	60 ± 10	59 ± 8	60 ± 11	.69
Male sex	33 (66.0)	9 (64.3)	24 (66.7)	>.99
CHA2DS2‐VASc score	1.3 ± 1.3	0.9 ± 1.2	1.5 ± 1.3	.11
Beta‐blocker or non‐ dihydropyridine CCB	27 (54.0)	8 (57.1)	19 (52.8)	.78
Hypertension	17 (34.0)	3 (21.4)	14 (38.9)	.33
Stroke	3 (6.0)	0 (0)	3 (8.3)	.55
Prior heart failure	2 (4.0)	1 (7.1)	1 (2.8)	.49
Hypertrophic cardiomyopathy	3 (6.0)	2 (14.3)	1 (2.8)	.19
LA diameter, mm	40 ± 5	41 ± 6	39 ± 5	.19
LV ejection fraction, %	62 ± 6	61 ± 6	63 ± 5	.28
Radiofrequency time, min	47.3 ± 9.6	47.0 ± 8.0	47.4 ± 10.3	.40
Additional ablation lesion
Posterior wall box isolation	1 (2.0)	0 (0)	1 (2.8)	>.99
Cavotricuspid isthmus	12 (24.0)	4 (28.6)	8 (22.2)	.72
Mitral isthmus	2 (4.0)	0 (0)	2 (5.6)	>.99
Superior vena cava	5 (10.0)	1 (7.1)	4 (11.1)	>.99

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Data are presented as mean ± standard deviation or number (%). CCB, calcium channel blocker; LA, left atrium; LV, left ventricle.

TABLE 2 Electrophysiologic study during sinus rhythm at pre‐ablation and immediate post‐ablation according to the recurrence during the blanking period

Characteristics	Overall Patients (n = 50)	Recurrence Group (n = 14)	Non‐ recurrence Group (n = 36)	P value
Baseline study
Sinus CL	936 ± 110	919 ± 133	943 ± 102	.50
AVN BCL (anterograde)	419 ± 84	419 ± 87	419 ± 84	.99
AVN ERP (anterograde)	346 ± 95	355 ± 118	343 ± 86	.68
Post‐ablation study
Sinus CL	705 ± 105	762 ± 96	683 ± 101	.015
AVN BCL (anterograde)	332 ± 55	329 ± 64	334 ± 51	.77
AVN ERP (anterograde)	262 ± 44	276 ± 56	257 ± 39	.21
Pre‐post sinus CL	231 ± 143	157 ± 149	260 ± 132	.021
Pre‐post AVN BCL	87 ± 75	91 ± 75	85 ± 76	.82
Pre‐post AVN ERP	98 ± 137	138 ± 193	83 ± 108	.33

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CL, cycle length; AVN, atrioventricular node; BCL, block cycle length; ERP, effective refractory period.

AP19‐00530

Mesh‐type flexible tip catheter or contact force catheter for paroxysmal atrial fibrillation: Prospective randomized trial

Geun‐Hee Park, Tae‐Hoon KIM, Hee‐Tae Yu, Jae‐Sun Uhm, Bo‐Young Journg, Moon‐Hyung LEE, Hui‐Nam Pak

Severance Hospital, South Korea

Introduction:

Catheter technology has been evolving to improve the efficacy and safety of atrial fibrillation (AF) catheter ablation. Mesh‐type flexible tip (MFT) catheter is developed to generate bigger radiofrequency (RF) lesion, and contract force (CF) catheter improves the maintenance of catheter‐tissue contact. We compared MFT catheter and CF catheter in AF ablation.

Methods:

We randomly assigned 230 patients with AF (paroxysmal AF 73.5%, male 69.1%, 59.93 ± 10.69 years old) in a 1:1 ratio to ablation by MFT catheter (Flexibility) and CF catheter (Tacticath). We performed circumferential PV isolation (CPVI) and cavotricuspid isthmus (CTI) ablation in all patients, and additional extra‐PV left atrial (LA) ablation was done by the operator's discretion in patients with persistent AF. The primary end point was AF recurrence after single procedure, and the secondary end point was response to antiarrhythmic drugs (AAD).

Result:

1. Randomization of two groups was well matched, but ablation time was significantly longer in MFT group than in CF group (4426.6 ± 1302.0 vs 3712.0 ± 1131.6, P < .001), and Fluoroscopy time was longer in CF group than in MFT group (31.4 ± 11.4 vs 26.8 ± 8.0, P = .001) 2. RA ablation was performed more by MFT catheter than by CF catheter (94.1% vs 65.2%, P < .001). CPVI and CTI ablation only showed that using CF catheter higher than MFT catheter (33.9% vs 3.4%, P < .001) 3. Major complication rate was not statistically different between MFT group and CF group. (0.8% vs 4.5%, P = .112). 4. During 15.3 ± 4.7 months follow‐up, clinical recurrence rate was not significantly different between two groups (19.5% vs 16.1%, P = .498; log rank P = .538), but 28.0% in MFT group and 39.3% in CF group were taking AAD (P = .069). 5. When the logistic regression analysis was performed, there was no significant difference in recurrence of AF according to the site of operation in both types of catheters.

Conclusion:

MFT catheter and CF catheter result in similar effectiveness in AF rhythm control by catheter ablation, and there was no significant difference between two catheters with regard to overall safety.

TABLE 1 Baseline clinical characteristics

Overall (n = 230)	Flexibility (n = 118)	Tacticath (n = 112)	P‐value
Age, years	59.93 ± 10.69	59.97 ± 11.23	59.88 ± 10.14	.954
Male, n (%)	159 (69.1)	85 (72.0)	74 (66.1)	.328
AF duration, months	36.4 ± 42.6	38.0 ± 44.6	34.8 ± 40.5	.572
Paroxysmal AF, n (%)	169 (73.5)	87 (73.7)	82(73.2)	.930
BMI, kg/m2	24.84 ± 3.06	24.53 ± 3.11	25.16 ± 2.99	.122
Comorbidities, n (%)
Heart failure	30 (13)	19 (16.1)	11 (9.8)	.157
Hypertension	102 (44.3)	47 (39.8)	55 (49.1)	.157
Diabetes mellitus	38 (16.5)	15 (12.7)	23 (20.5)	.110
Stroke or TIA	18 (7.8)	9 (7.6)	9 (8.0)	.908
Vascular disease	9 (3.9)	5 (4.2)	4 (3.6)	.795
CHA2DS2‐VASc score	1.68 ± 1.35	1.64 ± 1.36	1.72 ± 1.34	.657
Echocardiographic parameters
LA dimension, mm	40.6 ± 6.1	40.9 ± 6.4	40.2 ± 5.8	0.430
LA volume index, ml/m2	37.5 ± 12.2	37.9 ± 13.6	37.2 ± 10.5	0.663
LV ejection fraction, %	63.9 ± 8.5	64.0 ± 8.6	63.8 ± 8.3	0.859
E/Em	9.9 ± 3.8	9.3 ± 3.8	10.4 ± 3.8	0.034
LVEDD, mm	49.8 ± 4.3	49.9 ± 4.5	49.7 ± 4.2	0.770

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TABLE 2 Procedure related characteristics

Overall (n = 230)	Flexibility (n = 118)	Tacticath (n = 112)	P‐value
Procedure time, min	160.6 ± 35.0	161.9 ± 32.7	159.2 ± 37.3	.555
Ablation time, sec	4078.6 ± 1270.8	4426.6 ± 1302.0	3712.0 ± 1131.6	<.001
Fluoroscopy time, min	29.1 ± 10.0	26.8 ± 8.0	31.4 ± 11.4	.001
Ablation lesion
Extra‐PV† LA ablation	57 (24.8)	41 (34.7)	16 (14.3)	<.001
SVC+RA ablation	184 (80)	111 (94.1)	73 (65.2)	<.001
CPVI+CTI only	42 (18.3)	4 (3.4)	38 (33.9)	<.001
Major complications, n (%)	6 (2.6)	1 (0.8)	5 (4.5)	.112
Hemopericardium	2 (0.9)	0 (0)	2 (1.8)	.236
Cardiac tamponade	2 (0.9)	0 (0)	2 (1.8)	.236
Sinus node dysfunction	1 (0.4)	0 (0.0)	1 (0.9)	.487
GI bleeding	1 (0.4)	1 (0.8)	0 (0)	1.000

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Extra‐PV† : Roof , Left lateral isthmus, Posteroinferior

TABLE 3 Clinical Rhythm Outcome

Overall (n = 230)	Flexibility (n = 118)	Tacticath (n = 112)	P‐value
AAD* current status	77 (33.5)	33 (28.0)	44 (39.3)	0.069
Free AAD	153 (66.5)	85 (72.0)	68 (60.7)	0.069
Post‐ABL medication
ARB, n (%)	76 (33.0)	41 (34.7)	35 (31.3)	0.573
Beta blocker, n (%)	95 (41.3)	32 (27.1)	63 (56.3)	<0.001
Statin, n (%)	83 (36.1)	38 (32.2)	45 (40.2)	0.208
AAD, n (%)	46 (20.0)	17 (14.4)	29 (25.9)	0.030
Follow‐up, months	15.3 ± 4.7	15.3 ± 4.4	15.3 ± 4.9	0.995
Early recurrence††, n (%)	66 (28.7)	33 (28.0)	33 (29.5)	0.802
Clinical recurrence†††, n (%)	41 (17.8)	23 (19.5)	18 (16.1)	0.498
Late recurrence, months	8.2 ± 4.0	8.5 ± 4.4	8.0 ± 3.5	0.709

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Early recurrence†† < 3 months, Clinical recurrence††† = Late recurrence > 3 months.

AAD*, antiarrhythmic drug.

TABLE 4 AF recurrence rate according to catheter when ablation lesion is controlled

Odds ratio	P‐value	Confidence index
MFT Catheter	1.135	0.741	0.534	2.413
Extra‐PV† LA ablation	1.460	0.361	0.648	3.288
SVC+RA ablation	1.298	0.836	0.110	15.251
CPVI+CTI only	1.206	0.891	0.082	17.739

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Extra‐PV† : Roof , Left lateral isthmus, Posteroinferior

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AP19‐00532

Clinical outcome of catheter ablation in patients with atrial fibrillation and sinus node dysfunction

Tae Hyun Hwang, Hee Tae Yu, Tae‐Hoon Kim, Jae‐Sun Uhm, Jong‐Youn Kim, Boyoung Joung, Moon‐Hyoung Lee, Hui‐Nam Pak

Severance Hospital, South Korea

Introduction:

Although catheter ablation of atrial fibrillation (AF) can be considered as a strategy before pacemaker implantation in patients with AF associated bradycardia as class IIA indication, there is limited information on their long‐term rhythm outcome in a large number of patients.

Methods:

Among total consecutive 3,068 patients who underwent AF catheter ablation (AFCA), this study included 222 patients (7.2%; men 53.2%, 63.7 ± 9.2 years old, 81.5% paroxysmal AF) with underlying sinus node dysfunction (SND) and regular rhythm follow‐up. We analyzed the rhythm outcomes, heart rate changes and the permanent pacemaker (PM) implantation rate.

Result:

During 54.4 ± 25.4 months of follow‐up, 25 (11.3%) patients received PM implantation due to symptomatic SND. More than half of them (56.0%, 14/25) underwent PM implantation within 3 months after AFCA, and annual PM implantation rate was 2.0% afterwards. During 54.4 ± 25.4 months follow‐ up, both early (68.0% vs 31.0%, P < .001) and clinical AF recurrence (68.0% vs 32.5%, p = 0.001) rates, and continuous antiarrhythmic drug use after 3 months (44.0% vs 24.4%, P = .036) were significantly higher in patients who required PM implantation compared to those without.

Conclusion:

After AFCA in patients with AF and SND, one out of nine patients needed PM implantation and half of them within 3 months. AF recurrence rate was significantly higher in patients who required PM implantation after AFCA.

TABLE 1 Baseline clinical characteristics in patients with SND and those without.

Total (n = 2331)	SND (n = 222)	No SND (n = 2109)	P‐value
Age, years	58.2 ± 10.8	63.7 ± 9.2	57.6 ± 10.8	<.001
Male, n (%)	1730 (74.2)	118 (53.2)	1612 (76.4)	<.001
Paroxysmal AF, n (%)	1635 (70.2)	181 (81.5)	1454 (69.0)	<.001
AF duration, months	38.7 ± 47.1	31.2 ± 32.9	39.5 ± 48.4	.296
BMI, kg/m2	25.0 ± 3.1	24.5 ± 3.0	25.1 ± 3.1	.014
Comorbidities
Heart failure, n (%)	215 (9.2)	19 (8.6)	196 (9.3)	.719
Hypertension, n (%)	1080 (46.3)	125 (56.3)	955 (45.3)	.002
Diabetes, n (%)	348 (14.9)	33 (14.9)	315 (14.9)	.975
Stroke/TIA, n (%)	269 (11.5)	43 (19.4)	226 (10.7)	<.001
Vascular disease, n (%)	259 (11.1)	29 (13.1)	230 (10.9)	.331
CHA2DS2‐VASc score	1.7 ± 1.5	2.4 ± 1.7	1.6 ± 1.5	<.001
Echocardiographic measures
LA dimension, mm	41.1 ± 6.0	41.3 ± 6.2	41.1 ± 6.0	.602
LV ejection fraction, %	63.6 ± 16.9	64.2 ± 8.0	63.5 ± 17.6	.085
E/Em	10.0 ± 4.1	11.6 ± 4.5	9.8 ± 4.0	<.001
Medications
ACEi/ARB, n (%)	787 (33.8)	87 (39.2)	700 (33.3)	.076
β‐blocker, n (%)	813 (35.0)	53 (23.9)	760 (36.1)	<.001
Statin, n (%)	683 (29.4)	82 (36.9)	601 (28.6)	.009
AAD, n (%)	431 (18.5)	16 (7.2)	415 (19.7)	<.001

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2AF, atrial fibrillation; BMI, body mass index; TIA, transient ischemia attack; E/Em, mitral inflow velocity/mitral annulus tissue velocity; LA, left atrium; LV, left ventricle; ACEi, angiotensin‐converting enzyme inhibitor; ARB, angiotensin receptor blocker; AAD, antiarrhythmic drug.

TABLE 2 Baseline clinical characteristics in patients who required PM and those did not after AFCA

Total (n = 222)	PM (n = 25)	No PM (n = 197)	P‐value
Age, years	63.7 ± 9.2	64.3 ± 8.9	63.6 ± 9.2	.735
Male, n (%)	118 (53.2)	12 (48.0)	106 (53.8)	.584
Paroxysmal AF, n (%)	181 (81.5)	20 (80.0)	161 (81.7)	.834
AF duration, months	31.2 ± 32.9	33.7 ± 41.1	30.9 ± 32.2	.524
BMI, kg/m2	24.5 ± 3	24.2 ± 2.8	24.6 ± 3.0	.826
Sick sinus node syndrome, n(%)	93 (41.9)	14 (56.0)	79 (40.1)	.129
Tachy‐bradycardia syndrome, n(%)	123 (55.4)	10 (40.0)	113 (57.4)	.100
Mixed type, n (%)	6 (2.7)	1 (4.0)	5 (2.5)	.516
Comorbidities
Heart failure, n (%)	19 (8.6)	1 (4.0)	18 (9.1)	.703
Hypertension, n (%)	125 (56.3)	16 (64.0)	109 (55.3)	.410
Diabetes, n (%)	33 (14.9)	4 (16.0)	29 (14.7)	.772
Stroke/TIA, n (%)	43 (19.4)	5 (20.0)	38 (19.3)	.933
Vascular disease, n (%)	29 (13.1)	6 (24.0)	23 (11.7)	.085
CHA2DS2‐VASc score	2.4 ± 1.7	2.7 ± 1.8	2.4 ± 1.6	.548
Echocardiographic measures
LA dimension, mm	41.3 ± 6.2	41.2 ± 7.1	41.3 ± 6.1	.739
LV ejection fraction, %	64.2 ± 8.0	66.6 ± 7.5	63.9 ± 8.1	.172
E/Em	11.6 ± 4.5	13.6 ± 6.2	11.3 ± 4.2	.104
Medications
ACEi/ARB, n (%)	87 (39.2)	14 (56.0)	73 (37.1)	.068
β‐blocker, n (%)	53 (23.9)	7 (28.0)	46 (23.4)	.607
Statin, n (%)	82 (36.9)	9 (36.0)	73 (37.1)	.918
AAD, n (%)	16 (7.2)	4 (16.0)	12 (6.1)	.089

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AF, atrial fibrillation; BMI, body mass index; TIA, transient ischemia attack; E/Em, mitral inflow velocity/mitral annulus tissue velocity; LA, left atrium; LV, left ventricle; ACEi, angiotensin‐converting enzyme inhibitor; ARB, angiotensin receptor blocker; AAD, antiarrhythmic drug.

TABLE 3 Procedure related characteristics in patients with SND.

Overall (n = 222)	PM (n = 25)	No PM (n = 197)	P‐value
Procedure time, min	181 ± 54.9	214.5 ± 74.8	176.7 ± 50.5	.009
Ablation time, sec	4673.6 ± 1473.1	5225.4 ± 1601.2	4603.6 ± 1445.4	.044
Fluoroscopy time, min	38.6 ± 15.3	44.2 ± 19.6	37.9 ± 14.6	.093
Complications†	9 (4.1)	1* (4.0)	8 (4.1)	1.000
Major complications	5 (2.3)	0	5 (2.5)	1.000
Tamponade	4 (1.8)	0	4 (2.0)	1.000
Arteriovenous fistula	1 (0.4)	0	1 (0.5)	1.000
Extra‐PV LA Ablation (%)
Roof line (%)	64 (29.4)	13 (52.0)	51 (26.4)	.008
Posterior inferior line (%)	51 (23.0)	11 (44.0)	40 (20.3)	.008
Anterior line (%)	47 (21.2)	14 (29.8)	33 (16.8)	<.001
Left lateral isthmus line (%)	8 (3.6)	1 (4.0)	7 (3.6)	1.000
Cavotricuspid isthmus line (%)	207 (93.2)	25 (100)	182 (92.4)	.229
SVC‐septal line (%)	142 (64.0)	15 (60.0)	127 (64.5)	.661
Extra‐PV triggers (IRAF, %)	22 (13.6)	1 (6.3)	21(14.4)	.699
Follow‐up, (months)	47.5 ± 28.8	54.4 ± 25.4	46.6 ± 29.2	.158
Early recurrence, n (%)	78 (35.1)	17 (68.0)	61 (31.0)	<.001
Recurrence as AT, n (%)	28 (36.4)	7 (41.2)	21 (35.0)	.640
Clinical recurrence, n (%)	81 (36.5)	17 (68.0)	64 (32.5)	.001
Recurrence as AT, n (%)	26 (31.7)	8 (47.1)	18 (27.7)	.127
AADs at discharge, n (%)	16 (7.2)	4 (16.0)	12 (6.1)	.089
AADs 3 months after RFCA, n (%)	59 (26.6)	11 (44.0)	48 (24.4)	.036
AADs at recurrence, n (%)	71 (32.0)	12 (48.0)	59 (29.9)	.068
AADs at final follow‐up, n (%)	67 (30.2)	18 (72.0)	49 (24.9)	<.001
CV for recurrence, n (%)	27 (12.2)	5 (20.0)	22 (11.2)	.203
Final rhythm in sinus, n (%)	197 (88.7)	21 (84.0)	176 (89.3)	.497

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PV, pulmonary vein; LA, left atrium; SVC, superior vena cava; IRAF, immediate reinitiation of atrial fibrillation; AT, atrial tachycardia; AAD, antiarrhythmic drug; RFCA, radiofrequency catheter ablation; CV, cardioversion; ^†Complications: Pericarditis, cardiac tamponade, mild jugular hematoma, Femoral Arteriovenous fistula; * jugular hematoma : self‐resolved; Major complications: tamponade which needed pericardiocentesis; Femoral Arteriovenous fistula which needed Fistulectomy.

TABLE 4 Logistic regression analyses for PM implantation after AFCA in patients with underlying SND

Univariate analysis	Multivariate analysis
OR (95% CI)	P‐value	OR (95% CI)	P‐value
Age*	1.009 (0.964‐1.056)	0.705
Male sex*	0.792 (0.344‐1.823)	0.584
Paroxysmal AF*	0.894 (0.315‐2.542)	0.834
BMI	0.961 (0.834‐1.108)	0.586
Heart failure	0.414 (0.053‐3.245)	0.401
Hypertension	1.435 (0.605‐3.404)	0.412
Diabetes mellitus	1.103 (0.353‐3.449)	0.866
Stroke or TIA	1.046 (0.369‐2.965)	0.933
Vascular disease	2.389 (0.865‐6.596)	0.093
CHADS2‐VASc*	1.116 (0.875‐1.422)	0.378
LA size	0.999 (0.934‐1.068)	0.969
LV ejection fraction*	1.049 (0.988‐1.113)	0.116
E/Em*	1.103 (1.014‐1.199)	0.022	1.146 (1.023‐1.284)	0.018
Mean LA voltage (mV) *	0.415 (0.152‐1.134)	0.086
PreAFCA Mean heart rate	1.001 (0.963‐1.041)	0.962
Roof line*	3.016 (1.293‐7.038)	0.011
Posterior inferior line*	3.084 (1.302‐7.307)	0.011
Anterior line*	6.325 (2.640‐15.154)	<0.001	9.371 (3.034‐28.948)	<.001
SVC‐septal line	0.827 (0.353‐1.938)	0.662

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AF, atrial fibrillation; BMI, body mass index; TIA, transient ischemia attack; LA, left atrium; LV, left ventricle; E/Em, mitral inflow velocity/mitral annulus tissue velocity; AFCA, Atrial fibrillation catheter ablation; SVC, superior vena cava; *The variables used in the multivariate analysis are as follows : Age, Sex, Paroxysmal AF, CHADSVASC2 Score, LVEF, E/Em, Mean LA voltage (mV), PreAFCA rMSSD, ms, Roof line, Posterior inferior line, Anterior line

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B. Patients who required PM implantation vs. no PM implantation. C. AAD free recurrence rates in PM group vs. no PM group.

D. AF recurrence under AAD in PM group vs. no PM group

AP19‐00533

Safety and efficacy of intravenous propafenone in Wolff‐Parkinson‐White syndrome with atrial fibrillation

Ji Yeoun Seo

Ajou University, South Korea

Introduction:

Atrial fibrillation is an emergency when rapid anterograde conduction over an accessory pathway occurs in Wolff‐Parkinson‐White syndrome. If atrial fibrillation develops, rate‐limiting effect of atrioventricular node is bypassed and excessive ventricular rates can lead to ventricular fibrillation or sudden death. It is important to control ventricular rate in Wolff‐Parkinson‐White syndrome with atrial fibrillation. We evaluated the effects of intravenous (IV) propafenone on the conduction system in Wolff‐ Parkinson‐White syndrome patients with atrial fibrillation.

Methods:

We reviewed electrophysiology (EP) findings of Wolff‐Parkinson‐White syndrome patients who developed sustained atrial fibrillation (>10 minutes) during EP study. There were 4 patients (3 men, aged 33‐67 years) with a manifest accessory atrioventricular pathway and history of supraventricular arrhythmia. All patients have normal echocardiogram (ECG) and laboratory test findings. We performed baseline EP study. After infusion of propafenone (2 mg/kg up to 140 mg into a peripheral vein over 10 minutes), we analyzed the change in mean R‐R interval, which is the average of 10 R‐R intervals at 5, 10, 20 and 30 minutes after propafenone. And we also analyzed the change of delta wave, blood pressure and surface ECG findings.

Result:

All patients had typical Wolff‐Parkinson‐White syndrome with delta wave in sinus rhythm. Atrial fibrillation was occurred during atrial pacing in two patients, catheter insertion in one patient and ablation in one patient. After propafenone, atrial fibrillation was spontaneously terminated within 30 minutes in one of four patients. Atrial fibrillation was sustained in the other three patients and it was terminated after direct current (DC) cardioversion (100J). All patients showed prolonged mean R‐R interval after IV propafenone (Table 1). Delta wave was disappeared within 5 minutes in three of four patients and it was recurred after 30 minutes to 1 hour. During procedure after IV propafenone, vital signs of all patients were stable. The location of bypass tract was left in two of four patients and right in the other two of four patients.

Conclusion:

IV propafenone is a promising safe and effective agent for the ventricular rate control of Wolff‐Parkinson‐White syndrome with atrial fibrillation.

TABLE 1 Baseline characteristics and EP study findings after IV propafenone of patients

Patients	Patient 1	Patient 2	Patient 3	Patient 4
Characteristics	Patient 1	Patient 2	Patient 3	Patient 4
Age	45	67	33	35
Gender	Male	Male	Female	Male
Existence of delta	Yes	Yes	Yes	Yes
Location of ablation	Left	Right	Right	Left
AVERP (msec)	280	320	320	260
After propafenone
Mean R‐R intervals (msec)
Baseline	170	227	198	167
5minutes	225	254	210	178
10minutes	267	312	247	279
15minutes	305	334	274	292
20minutes	317	367	298	305
Termination of a‐fib	No	No	Yes	No
Disappearance of delta	No	Yes	Yes	Yes
Delta recurrence time	—	60 minutes	30 minutes	40 minutes
Event of shock	No	No	No	No

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AP19‐00538

Outcome of catheter ablation of atrial arrhythmias after surgical maze procedure—A descriptive study

Nee Hooi Tan, Khine Sein, Hernandez Jemelee, Paul Chun Yih Lim, Kelvin Chi Ming Chua, Eric Tien Siang Lim, Kah Leng Ho, Boon Yew Tan, Daniel Thuan Tee Chong, Wee Siong Teo, Chi Keong Ching

National Heart Centre Singapore, Singapore

Introduction:

Adjuvant surgical Maze procedure may be performed in open heart surgery to treat atrial fibrillation (AF). The recurrence rate is reported to be up to 43% (Ishii Y, Gleva MJ, Gamache MC, et al. Circulation. 2004; 110 [supplement II]: II‐164–II‐168). Catheter ablation may be pursued in the patients with AF recurrence after surgical Maze.

Methods:

We conducted a retrospective study of eight patients who underwent radiofrequency catheter ablation (RFCA) in 2017‐2018 for atrial arrhythmias after surgical Maze procedure. We aim to describe the electrophysiological (EP) findings & procedure details.

Result:

Mean age was 61 ± 6.1 years old (5 male). Median time to presentation of atrial arrhythmias after surgical Maze procedure was 16.5 months (ranging from 1 to 119 months). All patients underwent surgical Maze procedure in addition to another surgical procedure: mitral valve surgery with tricuspid valve annuloplasty/repair (n = 6), coronary artery bypass graft surgery with aortic valve surgery (n = 1) and septal myomectomy with resection of chords for HOCM (n = 1). Mean LVEF was 54.9 ± 4.0% & mean indexed left atrial (LA) volume was 39.0 ± 11.0 ml/m2. Indications for RFCA were persistent atrial flutter (AFL) (n = 7) and paroxysmal AF/flutter (n = 1). All patient presented in atrial tachyarrhythmia at time of RFCA with mean tachycardia cycle length (TCL) of 332 ± 99 milliseconds. With activation mapping, the EP diagnoses were mitral annular dependent AFL (37.5%, n = 3), pulmonary vein re‐entry (25%, n = 2) and others (37.5%, RA scar reentry in 1, RA upper loop re‐entry in 1 and CTI dependent flutter in 1). Mean procedure time was 223.5 ± 70.9 minutes & mean fluoroscopy screening time was 28.76 ± 13.0 minutes. Mean RFCA time was 2708 ± 1894 seconds. Acute procedural success rate was 100% without any complication. Residual electrical reconnection of surgical block lines in the LA after surgical Maze procedure were found in 75% of patients (n = 6). Re‐isolation of pulmonary veins (LIPV, n = 5; LSPV, n = 4; RSPV, n = 3; RIPV, n = 3) and re‐ablation of the surgical block lines in the LA posterior wall & roof (n = 4) were achieved with RFCA. 4 patients were evaluated at 12 months follow‐up show no recurrence of atrial arrhythmias.

Conclusion:

In this single centre study, catheter‐based mapping and RFCA of these arrhythmias seems to be feasible and effective. However, longer‐term follow up is required to identify the recurrence of atrial arrhythmias.

AP19‐00540

Zero fluoroscopy atrial fibrillation ablation and the role of a new steerable sheath visualizable on the electroanatomic mapping system

Jose Osorio, Anil Rajendra, Paul Zei, Kenneth Quadros, Gustavo Morales

Grandview Medical Center, USA

Introduction:

Steerable sheaths can facilitate ablation of paroxysmal atrial fibrillation (PAF). However, its role is not clear when procedures are performed with minimal or no fluoroscopy, under the guidance of the Electroanatomic Mapping system (EAM) and intracardiac echocardiography. A new steerable sheath (SS) (Vizigo) that has electrodes for visualization in the EAM has recently been introduced. Its impact during PAF ablation has not been studied. The objective of this study was to determine the impact of the Vizigo SS on acute procedural endpoints during PAF ablation performed without fluoroscopy.

Methods:

Fifty consecutive patients underwent PAF ablation without fluoroscopy using the new sheath. Acute procedural endpoints were compared against 169 patients that had undergone ablation using similar techniques, EAM and catheters, but without a SS.

Result:

Patients in the Vizigo SS group had a mean age of 65 ± 9 years and CHADS2Vasc of 2.5 (vs 63 ± 11 years and 2.2 in the control group, P > .05). There was a significant decrease in time to left and right pulmonary vein (PV) isolation (247 ± 133 seconds and 359 ± 170 seconds, vs 301 ± 186 and 451 ± 247 with P = .01 and P = .002 respectively). First pass isolation was similar in both groups for the left (86% vs 86%, P = .9) and right PVs (81% vs 68%, P = .09). PV reconnection with adenosine (8% vs 17%, P = .11) and isuprel (14% vs 18%, P = .6) was similar as well. There was a significant decrease in PV RF time (17 ± 6 minutes vs 21 ± 7 minutes, P < .0001) and procedure time (68 ± 26 minutes vs 76 ± 30 minutes, P = .03). There were no severe complications in either group.

Conclusion:

A new SS, visualizable on the EAM system produced significant improvements in procedural efficiency, while maintaining similar acute efficacy and safety.

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AP19‐00542

Ablation Index‐guided catheter ablation for paroxysmal atrial fibrillation could improve the durability of pulmonary vein isolation

Junjiroh Koyama, Yasuaki Tanaka, Takuo Tsurugi, Hideharu Okamatsu, Ken Okumura

Saiseikai Kumamoto Hospital, Cardiovascular Center, Japan

Introduction:

Pulmonary vein isolation (PVI) has established the standard strategy for paroxysmal atrial fibrillation (PAF), and the reconnection of LA‐PV conduction is also considered its primary mechanism of recurrence of PAF after ablation. We investigated whether PVI using Contact Force and Ablation Index (AI) could improve the durability of pulmonary vein isolation and resulted to better long term AF free rate.

Methods:

Consecutive 339 patients with PAF (64.9 ± 12.7 years old, male 220 patients) who underwent initial radiofrequency catheter ablation at our institute from April 2016 to March 2018 were analyzed. 232 patients were performed PVI using contact force guided ablation [AI (‐) group] and 107 patients using contact force sensing and AI guided additionally [AI (+) group] were compared with the mechanism of AF recurrence were analyzed on the 2nd ablation session retrospectively.

Result:

The recurrence rate of all atrial tachy‐arrhythmias at a mean follow‐up period of 12.3 months after initial ablation without blanking period 3 months after ablation session are 14.2% (n = 33) in AI (‐) group vs. 9.3% (n = 10) in AI (+) group, which was a significant decrease in AI (+) group (P < .05). In the evaluation at the 2nd session regarding to the estimated recurrence mechanism of AF, the durable rate of both pulmonary vein isolation was significantly higher in AI (+) group than that of AI (‐) group [50% (4/8) vs 28.6% (6/21)]. In AI (+) group during 2nd session, AF was induced originating from non‐ pulmonary vein focus in 3 patients (37.5%) and radiofrequency application targeting the focus was performed.

Conclusion:

Ablation Index guided PVI ablation using contact force sensing could improve the chronic durability of pulmonary vein isolation, and non‐pulmonary vein foci has become more important as a major mechanism of AF recurrence after initial PVI.

AP19‐00543

Cryoballoon atrial fibrillation ablation with Dacron patch puncture from the internal jugular vein

John Fitzgerald, Ehsan Mahmoodi, Austin May, Michael McGee, Haris Haqqani, Stuart Turner, James Leitch, Nicholas Jackson

John Hunter Hospital, Australia

Introduction:

A 57‐year‐old female attended with recurrent symptomatic paroxysmal atrial fibrillation (AF) despite treatment with sotalol. Her cardiac history was significant for an atrial septal defect (ASD) with Dacron (Polyethylene terephthalate) patch closure performed at the age of 16 years, and an interrupted inferior vena cava (IVC). Computed tomography (CT) showed a dilated azygous venous system with poly‐splenia. Long‐term amiodarone was an unattractive option due to side‐effect profile and with limited other safe rhythm‐control medical options, the decision was made to perform atrial fibrillation cryoballoon ablation.

Methods:

Due to the likely absence of a negotiable inferior vena‐cava, pre‐procedure planning was for a superior approach. Venography performed from the right femoral vein at the start of the procedure confirmed a lack of inferior access and the coronary sinus was subsequently cannulated from the left axillary vein. Left internal jugular vein access was used for phrenic pacing and for trans‐septal puncture and subsequent cryo‐ablation which required trial of multiple sheaths before the combination of a medium‐curve Agilis^™ (St Jude Medical) deflectable sheath and HeartSpan^® transseptal needle (Merit Medical) was successful under trans‐oesophageal echocardiographic (TOE) guidance.

Result:

Despite significant tenting of the inter‐atrial septum with careful needle advancement it was necessary to apply radiofrequency (RF) energy to the trans‐septal needle to puncture the Dacron patch. All four pulmonary veins were then successfully isolated with cryoballoon ablation and AF terminated following the final freeze.

Conclusion:

This case illustrates the possibility of overcoming significant anatomical challenges to left atrial access, enabling application of cryoballoon ablation for atrial fibrillation utilising a superior approach. To our knowledge, this is the first documented case of this type to be performed in Australia, and the first in the literature with the added requirement of prosthetic material in the inter‐atrial septum for puncture from a superior vena caval approach.

graphic file with name JOA3-35-76-g109.jpg

AP19‐00544

Learning curve for pulmonary vein isolation with a multi‐electrode radiofrequency balloon catheter in six European centers from the SHINE study

Richard Schilling, Claudio Tondo, Stefania Riva, Massimo Grimaldi, Dhiraj Gupta, Gian‐Battista Chierchia, Baohui Zhang, Vivek Reddy

Barts Health NHS Trust, Afghanistan

Dhiraj Gupta, Gian‐Battista Chierchia, Josiah Gillespie, Moe Bishara

Biosense Webster, Inc, USA

Introduction:

The extent of posterior wall ablation during pulmonary vein isolation (PVI) has been shown to be associated with success rates of AF ablation. Single shot PVI technologies are associated with variable levels of left atrial (LA) posterior wall ablation. A new multi‐electrode radiofrequency balloon catheter (RFB) enables a single‐shot approach to PVI with its 10 irrigated, flexible gold surface electrodes to directionally‐tailor energy delivery. The level of isolation achieved with RFB has not been studied. We sought to assess the extent of posterior wall ablation by performing electroanatomical voltage mapping (EAM) before and after PVI with RFB.

Methods:

Seven patients with paroxysmal AF were studied (age 63.0 ± 5.7 years, LA size 42.0 ± 4.4 mm). CARTO EAM of the LA was performed with a Lasso catheter, and maps merged with CT/ MR imaging. All 28 PVs were isolated successfully; average time to isolation was 11.9 ± 7.1 seconds. EAM was repeated with the Lasso catheter, and automatic surface area measurements were made in the Carto system after tracing the posterior wall limited by a roof line from the superior margins of isolation of superior veins, a floor line from the inferior margins of the inferior veins, and line of voltage transition (voltage less than 0.2 mV). This was compared to areas using the same roof and floor lines extending back to the pulmonary vein ostia.

Result:

In all 7 patients, the line of isolation extended to the antrum of the posterior wall. In 2 cases with complete delineation of the line of block allowing detailed quantitative assessment, 39.3% of the posterior wall was seen to be ablated (10.9/23 cm² and 10.5/30.2 cm²) (Figure).

Conclusion:

The compliant multielectrode radiofrequency balloon catheter produces antral lesions with extensive debulking of the LA posterior wall.

graphic file with name JOA3-35-76-g111.jpg

AP19‐00554

Severe multiple coronary artery spasm associated with pulmonary vein isolation: A case report

Naruya Ishizue, Hidehira Fukaya, Shinichi Niwano, Shuhei Kobayashi, Yuki Shirakawa Shirakawa, Yuki Arakawa, Ai Horiguchi, Ryo Nishinarita, Jun Oikawa, Jun Kishihara, Junya Ako

Kitasato University, Japan

Introduction:

Coronary artery spasm is a rare complication associated with pulmonary vein isolation (PVI). We experienced a case of severe multiple coronary artery spasm that was induced by PVI in the patient with paroxysmal atrial fibrillation (AF).

Methods:

The patient was 78 years old male, who have a history of coronary stenting for angina and CRT‐D implanted for dilated cardiomyopathy, was admitted to undergo the catheter ablation for symptomatic paroxysmal AF.

Result:

All procedures were performed under general anesthesia. After a trans‐septal puncture, we started extensive PVI from left PV. During radiofrequency (RF) application to the left PV, ST segment elevation was observed in precordial and inferior leads. Since ST segment elevation was resolved by interruption of RF application, we continued and successfully completed the left PVI. Thereafter, we proceeded to the right PVI. However, during RF application to posterior side in the right PV, ST segment level was elevated again in precordial and inferior leads, followed by a hemodynamic collapse. We immediately performed coronary angiography, which reveled severe coronary artery spasm in the both right and left coronary arteries. Intra‐coronary injection of nicorandil and nitroglycerin was successfully ameliorated coronary spasm, stabilizing the hemodynamics. Finally, we completed bilateral PVI under systemic infusion of nicorandil and nitroglycerin. After the PVI procedure, coronary artery spasm did not recur under the administration of Ca channel blocker and nicorandil.

Conclusion:

In this case, coronary artery spasm was caused by various factors including autonomic tone imbalance, anesthesia and thermal injury. It is difficult to anticipate coronary artery spasm during PVI. Early detection of coronary artery spasm is necessary for avoiding hemodynamic collapse.

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AP19‐00556

The “big hockey stick” technique for cryoballoon‐base pulmonary vein isolation

Kaijun Cui, ruikun Jia, Song Zou

West China School of Medicine, China

Introduction:

Cryoballoon ablation is increasingly used for pulmonary veins isolate (PVI) in patients with paroxysmal atrial fibrillation (PAF) and Hockey Stick manoeuvre is commonly performed in LIPV and RIPV. However, this approach is challenging even for skilled operators and remains high occurrence of complications. Here, We introduced a new technique (Big hockey stick) to facilitate ablation of RIPV and compared its efficacy and safety with Hockey Stick is manoeuvre.

Methods:

Patients with paroxysmal atrial fibrillation (PAF) were prospectively recruited and underwent 1:2 randomization to either big hockey stick (BHS) group (n = 20) or hockey stick (HS) group (n = 40). Big hockey stick was performed as following steps: Firstly, the sheath was curved to the maximum bending with the tip of the sheath directed towards the mitral annulus. Secondly, clockwise rotating the sheath toward RIPV. Thirdly, placing the Achieve in the early branching RIPV and pulling the sheath to one or two balloon height on the RIPV port, then, the sheath was further pulled down to guide the balloon over the Achieve into the RIPV ostium. The primary endpoint is acute PVI. Complications and operation details were taken into consideration.

Result:

Patients were largely comparable between groups and PVI was achieved in all patients. Big hockey stick approach reduced X‐ray exposure (354.28 ± 218.4 vs 239.25 ± 101.87, P = .017), time to balloon inflation (14.25 ± 4.44 vs 11.56 ± 2.10, P = .007) without increased of operation time (41.06 ± 8.99 vs 37.5 ± 9.84, P = .23). Hemoptysis occurred in one patient in HS, no Cardiac tamponade and phrenicus palsy occurred.

Conclusion:

Big hockey stick manoeuvre is efficient without increased the occurrence of complications.

AP19‐00559

Detection of risk factors for atrial fibrillation in patients of hypertrophic cardiomyopathy by electrocardiography and echocardiography

Ravindra Sangolkar, Soumen Devidutta, Chandramukhi Sunehra, Narsimhan Calambur

Care Hospitals, India

Introduction:

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disorder. Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with HCM. This study focused on identification of electrocardiographic (ECG) and echocardiographic predictors of AF in HCM patients.

Methods:

We included 90 patients of HCM. They were divided into two groups, HCM‐PAF (Paroxysmal AF) group (n = 30) and HCM‐SR group (Sinus rhythm, no history of PAF) (n = 60). All patients were in sinus rhythm at the time of study. Patients with persistent AF were excluded. Patients with conditions which can lead to secondary left ventricular hypertrophy like hypertension, valvular aortic stenosis, coarctation of aorta etc were excluded. Detailed ECG and 2‐D echocardiographic parameters were studied.

Result:

There was no significant difference in age, gender distribution, prevalence of diabetes mellitus, and family history of sudden cardiac death in two groups. Patients in HCM‐PAF group had significantly higher mean maximum P wave duration (Pmax) and P wave dispersion (PWD) on ECG. Echocardiographic parameters like left atrial (LA) diameter, LA volume, severity of diastolic dysfunction were significantly higher in HCM‐PAF group. There was no significant difference in left ventricle (LV) size, LV wall thickness, LV outflow tract gradient and severity of mitral regurgitation in both the groups. On Univariate regression analysis, ECG parameters like Pmax, PWD; echocardiographic parameters like LA diameter and LA volume, grade of diastolic dysfunction were predictors for AF. Pmax and PWD were independent risk factors for AF on multivariate regression analysis.

Conclusion:

LA remodeling is the cornerstone for predicting AF. Pmax, PWD on ECG and LA diameter, LA volume, degree of diastolic dysfunction on echocardiography predict increased risk of development of AF in HCM patients.

HCM‐PAF group (n = 30)	HCM‐SR group (n = 60)	P value
ECG parameters
Pmax (ms)	131.33 ± 12.52	105.67 ± 14.77	<.001
Pmin (ms)	72.67 ± 13.37	67.67 ± 12.80	.089
PWD (ms)	58.33 ± 14.87	38 ± 11.47	<.001
ECHO parameters
LADAP (cm)	4.74 ± 0.57	4.18 ± 0.56	<.001
LADAP/BSA (cm/m2)	2.71 ± 0.52	2.33 ± 0.35	<.001
LAV (mL)	84.41 ± 22.91	68.36 ± 26.71	.006
LAV/ BSA (mL/m2)	47.68 ± 13.33	38.06 ± 15.78	.005
IVSd (cm)	2.01 ± 0.31	2.01 ± 0.53	.99
Associated apical hypertrophy	2 (6.67%)	10 (16.66% )	.19
LVEDD (cm)	4.48 ± 0.57	4.37 ± 0.65	.13
EF (%)	66.57 ± 7.30	69.05 ± 5.71	.08
E (cm/s)	103.57 ± 25.11	86.62 ± 23.39	.002
A (cm/s)	65.57 ± 37.10	72.08 ± 27.71	.35
E/A	1.80 ± 0.80	1.44 ± 0.88	.06
DT (ms)	199.77 ± 66.07	206 ± 65.37	.65
e’ (cm/s)	4.72 ± 1.69	5.16 ± 2.07	.31
E/e’	24.13 ± 8.84	19.27 ± 10.70	.035
Diastolic dysfunction grade ≥ 2	27 (90%)	40 (66.7%)	.017
SAM	12 (40%)	23 (38.33%)	.88
MR grade ≥ 2	18 (60%)	32 (53.3%)	.55
LVOT gradient ≥30 mm Hg	12 (40%)	17 (28.33%)	.26

Over 70% patients received recommended dose of edoxaban in the Asian countries of Korea and Taiwan of the global ETNA program. It appears that the sickest population is the one on recommended 30 mg whereas the least sick population is the one on recommended 60 mg. Age, history of major bleeding/CRNM bleeding and ischemic stroke seem to be among the factors that influence non‐ recommended dosing. Long‐term follow‐up is needed to assess the impact of non‐recommended edoxaban dosing on clinical events

TABLE Baseline characteristic of South Korean and Taiwanese patients combined by dosing appropriateness

Recommended 60 mg N=1,136	Non‐recommended 30 mg N=573	Recommended 30 mg N=948	Non‐recommended 60 mg N=302
Age, median (IQR)	68.0 (62.0, 74.0)	72.0 (66.0, 78.0)	77.0 (72.0, 83.0)	72.0 (67.0, 77.0)
Age, ≥75 years (%)	21.0	40.5	63.7	39.7
Gender, male (%)	78.7	64.6	38.8	47.4
Weight [kg], median (IQR)	72.0 (66.0, 78.0)	70.0 (65.0, 77.0)	56.0 (51.0, 60.0)	58.0 (54.0, 60.0)
Body mass index, mean (SD)	26.4 (3.2)	26.7 (3.4)	23.1 (3.4)	23.2 (2.8)
Type of AF (%)
paroxysmal,	41.3	44.8	45.4	47.2
persistent,	28.1	24.0	21.9	16.6
long lasting AF	13.6	18.9	12.4	15.0
permanent	17.0	12.4	20.3	21.3
CHA2DS2‐VASc, mean (SD)	2.5 (1.34)	2.9 (1.32)	3.7 (1.36)	3.1 (1.30)
HAS‐BLED§, mean (SD)	2.1 (1.02)	2.3 (1.01)	2.4 (1.06)	2.1 (1.06)
CrCl [mL/min],	74.8	68.7	44.1	50.5
median (IQR)	(63.6, 88.3)	(59.0, 83.3)	(34.7, 54.2)	(43.9, 65.1)
Medical History
Hypertension, %	70.4	72.4	73.3	66.6
Myocardial infarction, %	1.4	0.7	1.7	1.3
Congestive heart failure, %	4.8	6.8	11.8	7.3
Diabetes mellitus, %	31.1	30.5	28.4	23.2
Major or CRNM bleeding, %	1.4	2.4	4.3	1.7
Major GI bleeding	0.0	0.3	0.9	0.0
Intracranial hemorrhage	1.0	1.6	1.6	1.7
Ischemic stroke, %	14.3	12.0	13.8	18.5
Transient ischemic attack, %	1.8	1.2	2.1	2.0
Peripheral artery disease, %	0.6	0.5	1.4	0.0
Chronic obstructivepulmonary disease, %	4.0	4.0	6.1	5.0

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§Modified HAS‐BLED: without “labile INR”.

AP19‐00568

Atrial functional mitral and tricuspid regurgitation associated with biatrial remodeling predict early recurrence in atrial fibrillation patients with preserved left ventricular ejection fraction

Keijiro Nakamura, Takahito Takagi, Yoshinari Enomoto, Rina Ishii, Masako Asami, Hikari Hashimoto, Mahito Noro, Kaoru Sugi, Masato Nakamura, Mahito Noro, Kaoru Sugi

Toho University Ohashi Medical Center, Japan

Introduction:

Atrial fibrillation (AF) induces atrial functional mitral and tricuspid regurgitation. However, the contribution of mitral and tricuspid regurgitation to the bi atrial substrate or remodeling in AF with normal ejection function is unclear.

Methods:

Consecutive patients with AF and normal left ventricular ejection fraction (LVEF > 50%) undergoing AF ablation were enrolled. The patients with reduced LVEF were excluded. Atrial functional mitral and tricuspid regurgitation, left and right atrial volume were evaluated. During AF procedure, voltage and conduction velocity were assessed by bi atrial electroanatomic mapping.

Result:

A total of 98 patients were enrolled. Moderate or greater degree of functional MR and of TR was seen in 4 (4.0%) and in 11 (11.2%) patients. The severity of MR and TR significant correlated with eGFR, NT‐pro BNP, high sense troponin T, LV and RA volume. Moreover, TR was associated with significantly more the average of bi atrial voltage (RA; r = −.42, LA; r = −.35) and RA conduction velocity time (r = .33). Multiple regression analysis showed that NT‐pro BNP were independent variables of increased atrial functional MR and TR On the recurrence, the presence of both significant functional MR and TR (n = 13) was associated with high early recurrence rate to compare to no MR and TR at 3 month after procedure (38% vs 16%; P < .05)

Conclusion:

The functional TR is associated with significantly reduced biatrial tissue voltage, which have implications for the intensive progression of remodeling. These functional MR and TR combination may predict early recurrence after AF ablation.

AP19‐00569

Ultra‐high‐density mapping to characterize recurrent atrial tachycardia and conduction gaps after single‐ring isolation of the posterior left atrium for atrial fibrillation

Shinsuke Iwai, Stuart Thomas, Anand Thiyagarajah, Kadhim Kadhim, Lauren Wilson, Mehrdad Emami, Saurabh Kumar, Dominik Linz, Dennis H. Lau, Rajiv Mahajan, Prashanthan Sanders

South Australian Health & Medical Research Institute, University of Adelaide, Royal Adelaide Hospital, Australia

Introduction:

En bloc electrical isolation of the posterior wall of the left atrium (LA) remains challenging and may result in recurrent intra‐atrial reentrant tachycardia (IART) due to gaps along the isolation lines. Utilizing ultra‐high‐density three‐dimensional electroanatomical mapping provides novel insights into the isolation gaps and arrythmia mechanisms. We sought to identify isolation gaps and IARTs mechanisms after single‐ring posterior LA isolation utilizing ultra‐high‐density mapping.

Methods:

Consecutive patients presented with recurrence of arrhythmia following single‐ring posterior LA isolation for atrial fibrillation (AF) undergoing the repeat ablation utilizing ultra‐high‐density mapping were included in this study.

Result:

27 pts (age 61 ± 11; 56% males; 34% with non‐paroxysmal AF) were studied. A total of 20 atrial tachycardias (ATs) in 13 patients observed during the procedures. 90% of these tachycardias were IARTs and only 10% were focal ATs. IARTs were gap related reentries utilizing gaps of previous isolation line (n = 7), peri‐mitral reentries (n = 4), dual loop reentry with peri‐mitral reentry and reentry around left atrial appendage (n = 1), cavo‐tricuspid isthmus dependent reentry (n = 5), and LA localized micro reentry (n = 1). A single acquired activation map during AT (Figure A‐F) or pacing from coronary sinus could identify multiple conduction gaps simultaneously. The gaps in the box were more commonly seen at three locations, the roof line adjacent to the right superior pulmonary vein (PV), mid portion of the roof line, and the antero‐inferior aspect of the left inferior PV (Figure G). Posterior LA isolation was successfully achieved by targeting isolation gaps detected by ultra‐high‐density mapping in all patients.

Conclusion:

Ultra‐high‐density mapping is useful in identifying gaps in isolation lines in the box and in elucidating mechanism of recurrent IARTs after single‐ring posterior LA isolation.

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AP19‐00570

One‐year major bleeding, stroke and mortality in 2345 atrial fibrillation patients From Asia (Korea and Taiwan) treated with edoxaban in routine clinical practice: Snapshot from the non‐interventional ETNA‐AF program

Eue‐Keun Choi, Wei‐Hsiang Lin, Gyo‐Seung Hwang, Paulus Kirchhof, Raffaele De Caterina, Paul Reimitz, Heiko Rauer, Hiroshi Higashiyama, Il‐Hyung Hwang, Cathy Chen, Martin Unverdorben, Chun‐Chieh Wang, Young‐Hoon Kim

Seoul National University Hospital, South Korea

Introduction:

Edoxaban is approved for stroke prevention in patients with atrial fibrillation (AF) based on the phase III ENGAGE AF‐TIMI 48 trial. ETNA‐AF provides information on the effectiveness and safety of edoxaban in unselected patients with AF in routine clinical practice from countries in Asia and Europe.

Methods:

From Asian countries (Korea, Taiwan), 3008 patients were enrolled at 47 hospitals and medical practices from 2017 to 2019. We have performed analysis in 2345 patients who have 1‐year follow‐up data available, with the focus on safety and efficacy events.

Result:

Mean age was 71.6 ± 9.4 years and mean BMI 25.0 ± 3.6 kg/m². The most frequent stroke risk factors and comorbidities were hypertension (71.6%), diabetes mellitus (28.9%), history of ischemic stroke (15.1%), valvular heart disease (9.4%), congestive heart failure (7.1%), and myocardial infarction (1.3%). Edoxaban 60 mg was used in 49.0% and 30 mg in 51.0% of patients. According to approved local labels, 71.5% of patients received the recommended edoxaban dose. ISTH major bleeding occurred in 0.8% of patients and ischemic stroke in 0.7% of patients during the first year.

Conclusion:

In the Asian countries of Korea and Taiwan of the global ETNA program, the rates of major bleeding, stroke and systemic embolic events were low. Compared with patients from Korea, those from Taiwan appeared to exhibit a somewhat higher risk profile for major events, along with a trend towards higher rates of bleeding, stroke and all‐cause/cardiovascular death.

TABLE 1 Key baseline characteristics and major clinical events during 1‐year follow‐up

S. Korea & Taiwan (N = 2345)	S. Korea (N = 1670)	Taiwan (N = 675)
Age, median (IQR)	72.0 (66.0, 78.0)	72.0 (66.0, 77.0)	74.0 (67.0, 81.0)
Age ≥75 years (%)	40.6	37.6	48.1
Gender, male (%)	59.8	60.7	57.6
Weight [kg], median (IQR)	65.0 (58.0, 73.0)	65.0 (58.0, 73.0)	65.0 (57.0, 74.0)
CHA2DS2‐VASc, mean (SD)	3.1 (1.4)	3.0 (1.4)	3.2 (1.4)
HAS‐BLED§, mean (SD)	2.3 (1.0)	2.2 (1.0)	2.4 (1.1)
CrCl [mL/min], median (IQR)	60.9 (47.7, 77.2)	62.8 (49.6, 79.5)	56.6 (41.2, 72.3)
Edoxaban 60mg/30mg, %	49.0 / 51.0	50.8 / 49.2	44.4 / 55.6
1‐year outcome, n (%/year)
Major Bleeding (ISTH)*	18 (0.81)	7 (0.44)	11 (1.76)
Intracranial hemorrhage*	7 (0.31)	3 (0.19)	4 (0.64)
Major GI bleeding*	6 (0.27)	2 (0.13)	4 (0.64)
Any Stroke*	21 (0.95)	13 (0.82)	8 (1.28)
Ischemic stroke*	16 (0.72)	10 (0.63)	6 (0.96)
Hemorrhagic strokes*	5 (0.22)	3 (0.19)	2 (0.32)
Systemic Embolic Events*	1 (0.04)	1 (0.06)	0 (0.00)
All‐cause Death	27 (1.21)	12 (0.75)	15 (2.38)
CV death#	11 (0.49)	7 (0.44)	4 (0.64)

AP19‐00577

Giant left atrial thrombus during catheter ablation: One way to deal with

Dony Yugo, Yoga Yuniadi, Sunu Budhi Raharjo, Dicky Hanafy

Faculty of Medicine University of Indonesia, Indonesia

Introduction:

Left Atrial Thrombus is a common finding in patient with Atrial Fibrillation (AFib). Likewise, catheter ablation in Afib have to face the risk of thrombus formation even during procedure. Some conflicting data exist whether oral anticoagulation should be resumed during catheter ablation.

Methods:

Case report : We herein report a case of an adult with symptomatic Paroxysmal Atrial Fibrillation who underwent catheter ablation procedure. The patient had warfarin as her oral anticoagulation drugs with unstable INR levels. She had transesohageal echo (TEE) one day prior to catheter ablation procedure without evidence of any left atrial thrombus. Pre‐procedural TEE protocol required her to stop anticoagulation medicine 3 days before, so she did not take any antithrombotic drugs 4 days before catheter ablation. Soon after trans‐septal puncture and catheter insertion to left atrium, a giant thrombus was noticed dangling around at one of the catheters. Afterwards, two carotid artery filter was deployed in order to prevent distal embolization. Thrombo‐suction procedure was done using 8F long sheath catheter under fluoroscopic and transesophageal echo guide. Big thrombus was removed safely. During hospitalization, signs and symptoms related to distal embolization did not occurred.

Result:

Discussion : The reason for the thrombus formation was likely due to the lack of anticoagulation that the patient had during procedure. Warfarin discontinuation before invasive procedure was a common practice. However, some papers said that warfarin should be maintained throughout procedure without significant risk for major bleeding. Thus, maintaining warfarin with optimal INR levels should be done in this case. In dealing with intra‐atrial thrombus during procedure, there were no standard procedure exist. Some case reports mentioned about the usage of intracardiac echocardiography to guide the thrombosuction, and the other method is using intra‐atrial thrombolysis using alteplase. We demonstrated one of the options that could be used if this problem ever occurred

Conclusion:

Keeping a good anticoagulation level within therapeutic targets for patient undergoing catheter ablation is mandatory. Thrombosuction using long sheath with cerebral protection device could offer an alternative way to deal with intracardiac thrombus during catheter ablation.

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Nithi Summashipvitsavakul, Voravut Rungpradubvong

King Chulalongkorn Memorial Hospital, Thailand

Introduction:

Atrial fibrillation (AF) is a common arrhythmia in critical care units and the treatment of atrial fibrillation can lead to ventricular tachyarrhythmias (VA) due to QT interval prolongation. There is still no standard method for QT interval measurement in AF to prevent ventricular tachyarrhythmias from happening.

Methods:

Patients with ICD10 records from 1st January 2014 to 30th September 2018 were identified from all in‐hospital AF patients in four critical care units at King Chulalongkorn Memorial Hospital. The QT interval was measured from 12‐lead Electrocardiograms (EKG) mainly in lead II and V3 by using Fridericia's QT interval correction (QTc) formula and tangent method. Four intervention methods were used in all patients. (a) Average of QTc intervals following the longest and shortest RR intervals (Long & short method). (b) Average of 3 QTc intervals where the middle QTc interval follows right after the longest RR interval (3 consecutive beats method). (c) Average of QTc intervals for 10 beats that include QTc interval that follows the longest RR interval (10 consecutive beats method). (d) Automated QTc interval from Fridericia's QT correction method by Phillips DXL‐12 lead algorithm. Primary outcome was to determine the accurate QTc measurement method to predict VA events in AF patients and the secondary outcome was the accurate QTc measurement method to predict torsades de pointes (TdP) events in AF patients.

Result:

239 from 684 atrial fibrillation patients were included in the study (only 59 samples had adequate automated 12‐lead EKGs). Out of all patients included, 48 patients had VA events (20.1%) and 19 patients had TdP events (7.9%). The accuracy to predict VA at QTc ≥500 milliseconds are 82.8% for Long & short method (interclass correlation coefficient [ICC] 0.822; 95% confident interval [CI] 0.717, 0.893), 84.9% for three consecutive beats method (ICC 0.809; 95% CI 0.694, 0.886), 84.9% for 10 consecutive beats method (ICC 0.846; 95% CI 0.725, 0.915) and 69.5% for Automated QTc interval. The accuracy to predict TdP at QTc ≥500 milliseconds are 91.6% for Long & short method, 95.4% for three consecutive beats method, 95.4% for 10 consecutive beats method and 74.6% for Automated QTc interval.

Conclusion:

Among four methods for QT interval measurement studies, 3 and 10 consecutive beats methods have acceptable accuracy to predict ventricular tachyarrhythmias and torsades de pointes events in atrial fibrillation patients. The reproducibility of all three methods was acceptable. Automated QTc interval measurement method is easy to use but still needs more evidence to be implemented in clinical practice.

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AP19‐00594

Factors associated with esophageal injury and preventing it after catheter ablation of atrial fibrillation

Miwa Ito, Hisanori Kanazawa, Yusuke Kanemaru, Takuya Kiyama, Yusei Kawahara, Kenichi Tsujita

Kumamoto University Hospital, Japan

Introduction:

Esophageal injury (EI) is a serious complication occurs after catheter ablation of atrial fibrillation (AF), however predictable factor of EI is unclear. We investigated the factors associated with the occurrence of EI after catheter ablation and the usefulness of esophageal temperature monitoring for avoiding EI.

Methods:

Among 465 patients who underwent catheter ablation of AF, endoscopy was performed the next day after catheter ablation to examine for EI. The incidence of EI was compared between 167 patients who used esophageal temperature probe (ETP) (ETP group) and 308 patients who did not used ETP (Non‐ETP group) during catheter ablation. The Shortest Distance between esophagus and posterior left atrium measured on contrast Computed Tomography (SD‐CT) was also compared between the ETP and Non‐ETP groups.

Result:

In all patients, EI was found in 35 patients (7.3%). SD‐CT in patients with EI was significantly lower than that in patients without EI (2.4 ± 0.4 vs 4.3 ± 0.9 mm, P < .001). No differences were observed between the two groups in total amount of radiofrequency energy applications, or the location of SD‐CT. However, EI occurred more frequently in Non‐ETP group (8/167 patients; 4.7% vs 27/308 patients; 8.8%, P = .042). The severity diagnosed as moderate (erosion) in three patients and mild (erythema) in five patients of ETP group, and as severe (ulcer) in 23 patients and mild in four patients of Non‐ETP group. There was no significant difference in SD‐CT between ETP and Non‐ETP group (3.96 ± 0.98 vs 4.19 ± 1.01 mm, P = .54). However, SD‐CT in patients with EI was significantly shorter than SD‐CT in patients without EI, both in ETP (2.4 ± 0.7 vs 4.3 ± 0.9 mm, P < .001) and in Non‐ETP group (2.5 ± 0.2 vs 4.2 ± 0.9 mm, P = .017), respectively. Multiple regression analysis revealed that only SD‐CT significantly correlated with EI. The area under a receiver operating characteristic curve using ST‐CT as a predictive marker in EI patients was 0.971 (P < .001). When the cut‐off value of EI was set at 2.8 mm, the sensitivity and specificity for EI diagnosis were 96.6% and 87.5%.

Conclusion:

The incidence of EI was significantly correlated with SD‐CT. Esophageal temperature monitoring reduced EI and alleviated the severity of EI, especially in patients with short SD‐CT.

AP19‐00595

Baseline impedance and impedance drop are good surrogate markers for electrode‐tissue contact and contiguous lesion formation with a novel irrigated radiofrequency balloon catheter

Tushar Sharma, Atsushi Ikeda, Jace Valls, Hiroshi Nakagawa

Biosense Webster, Johnson & Johnson, USA

Introduction:

Continuous, circumferential, transmural lesions are desired to facilitate pulmonary vein isolation (PVI). Real‐time indicators of adequate lesion creation with ablation are needed, to improve the durability of ablation lesions and prevent recurrence. The purpose of the study was to examine the relationship between ablation electrode impedance (baseline and decrease of impedance during ablation), electrode‐tissue contact and RF lesion size using a novel irrigated radiofrequency balloon catheter in the canine thigh muscle preparation.

Methods:

In 15 dogs, the skin over the thigh muscle was incised and raised to form a cradle which was superfused with heparinized blood at 37°C. A 10F ablation catheter (Biosense Webster, Inc) with a 28 mm balloon, containing a central lumen for external saline irrigation and 10 flexible gold electrodes (each: 14.5 mm x 3 mm with 4 irrigation holes and a thermocouple) surrounding the balloon surface (3 mm spacing, Figure) was held against the thigh muscle with a contact force of 20 grams, with full (n = 24) or partial contact (n = 22) of electrodes. RF (15W per electrode) was delivered for 15, 30 or 60 sec (electrode temperature < 65°C) between 2 adjacent electrodes and a skin patch with saline irrigation at 35 ml/min in low blood flow (<0.1 m/s) to favor thrombus formation. The baseline impedance and impedance drop were recorded and compared between full and partial electrode contact ablations

Result:

There was a significant difference in the baseline impedance (mean 83 ± 1.3Ω vs 71 ± 1.3Ω, P < .01) and impedance drop (mean 18 ± 0.9Ω vs 13 ± 0.8Ω, P < .01) between electrodes with full contact vs. electrodes with partial contact. For ablations with electrodes in full contact with tissue, there was a significant difference in the impedance drop (mean 20 ± 0.9Ω vs 14 ± 0.4Ω, P < .05) observed in lesions with no gap (contiguous lesions) compared to lesions with gap. For ablations with electrodes in partial contact with tissue, there was no significant difference in impedance drop between contiguous lesions and lesions with gap (mean 12 ± 0.8Ω vs 11.6 ± 0.8Ω, P = NS).

Conclusion:

Baseline impedance provides a good indication of amount of electrode‐tissue contact (full or partial). During ablation, impedance drop provides a good indication of contiguous lesion formation when simultaneously ablating from adjacent electrodes.

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AP19‐00596

Isthmus shifting detected by high‐density grid catheter in mapping of atrial flutter

Sung‐hao Huang, Shih‐Lin Chang, Yenn‐Jiang Lin, Li‐Wei Lo, Yu‐Feng Hu, Fa‐Po Chung, Ting‐Yung Chang, Chin‐Yu Lin, Da‐Chuan Duan, Tze‐Fan Chao, Jo‐Nan Liao, Shih‐Ann Chen

National Yang‐Ming University Hospital, Taiwan

Introduction:

New developing high‐density (HD) grid mapping catheter allowed HD wave bipolar recordings along and across the splines to identify isthmus. The role of mapping directionality in isthmus detection is not well investigated. We aimed to analyze whether different splines types creating local activation time (LAT) maps affected isthmus identification or not in atrial flutter (AFL) patients.

Methods:

Baseline right atrium (RA) or left atrium (LA) maps were created by HD grid catheter (Abbott, CA) regarding the rhythm. Isthmus location and/or size were dragged by the following methods: combined splines, along splines and across splines.

Result:

This pilot study included 3 AFL cases. Total and selected points were 26 487 and 3704, respectively in case 1 (Panel A). Isthmus located over anterior‐superior LA appendage (LAA) base was created by combined splines (Panel B). By along splines method, isthmus was downward and downsize to 0.1 cm2 in area and 6 mm in length (Panel C). When across splines LAT was applied, upper part of the aforementioned isthmus re‐appeared. The isthmus distance between different ways collection was 6 mm (Panel D). In case 2, as compared to combined splines based LAT (Panel E), the reentry arrhythmia circuit center moved toward RA anterior wall and lost its obvious circuit center in along splines based LAT (Panel F). In case 3, the functional block line distance of cavotricuspid isthmus differed in across splines based LAT (10 mm) and along splines based LAT (14 mm).

Conclusion:

Our study proves shifting and downsize of isthmus when changing the vector of bipolar electrodes in HD grid. The critical isthmus could be identified by omnipolar mapping.

Case 1: (A) HD grid catheter located LAA base for LAT creation. (B) The isthmus size measured by combined splines based LAT method (0.4 cm² in area and 13 mm in length) (C) Along splines based LAT dragged isthmus (0.1 cm² in area and 6 mm in length). (D) Across splines based LAT showed isthmus upward movement (0.2 cm² in area and 7 mm in length) and the isthmus distance between different ways collection was 6 mm; Case 2: (E) Combined splines based LAT, reentry circuit center is clear. (F) The reentry circuit center moved toward RA anterior wall and lost its obvious circuit center in along splines based LAT

graphic file with name JOA3-35-76-g139.jpg

AP19‐00600

Pre‐clinical evaluation of a novel irrigated radiofrequency balloon ablation catheter for pulmonary vein isolation in a canine model—Safety and durability of lesions

Tushar Sharma, Qun Sha, Josiah Gillespie, Ahmed Abdelaal, Moe Bishara

Biosense Webster, Johnson & Johnson, USA

Introduction:

Durable Pulmonary vein isolation (PVI) is the cornerstone in the treatment of Drug‐ refractory Atrial Fibrillation. Biosense Webster Inc. has developed a novel radiofrequency (RF) irrigated balloon ablation catheter to create continuous circumferential lesions. Objective: In a preclinical model, assess the safety (incidence of char, steam pop, pulmonary vein stenosis, injury to cardiac tissue, pericardial effusion, collateral damage, peripheral thrombi) and ability of the novel irrigated RF balloon to electrically isolate PVs. The study also assessed the long‐term durability of PVI at 30 day and 90 day follow up

Methods:

In 7 canines, PVI procedure was performed using a 10F ablation catheter (Biosense Webster Inc.) with a 28 mm balloon, containing a central lumen for external saline irrigation and 10 flexible gold electrodes (each: 14.5 m x 3 mm with 4 irrigation holes and a thermocouple) surrounding the balloon surface (3 mm spacing, Figure). All ablations were performed at 15W on all 10 electrodes, for a duration of 60 seconds, using an irrigation flow rate of 35 ml/min and target electrode temperature of 55°. 6/8 canines were sacrificed following the acute ablation procedure. 2/8 canines were followed up until 90 days, with an electrophysiological study performed at 30 days and 90 days to check for isolation of PVs and for presence of any PV stenosis or narrowing. Gross and histological examination of heart and surrounding organs (lungs, esophagus) was performed at necropsy for both acute and survival animals.

Result:

All target PVs (n = 7, 7/7, 100%) in the 7 canines were isolated acutely, requiring a mean of 3 RF applications per vein. No char, coagulum or steam pop were observed in this study. 5/7 animals were sacrificed acutely. No PV stenosis or narrowing was observed in these acute animals. 2/7 animals were survived and then sacrificed at 90 days. In both animals, the PVs remained isolated at 30 days and 90 days, with no stenosis or narrowing of PVs observed in either animal. Gross pathological examination of the hearts revealed no thrombi, endothelial damage or hemorrhage. No incidence of clinically significant collateral damage, injury to cardiac tissue, or pericardial effusion were observed in these study animals. Histological examination revealed contiguous ablation lesion at treated PV sites (Figure)

Conclusion:

This study demonstrates the safety and effectiveness of the novel irrigated RF balloon catheter to produce circumferential, contiguous transmural lesions that can isolate PVs in a canine animal model. The lesions created were safe and durable as demonstrated by the isolated PVs at 30 days and 90 days post ablation procedure and the absence of any adverse events like PV stenosis or damage to surrounding organs.

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AP19‐00604

(CASE REPORT) Radiofrequency ablation of atypical atrial flutter around an atrial septal defect patch

Roxanne Camina, Lisa Marie Pimentel, Giselle Gervacio

Philippine Heart Association, Philippines

Introduction:

Atypical atrial flutter is a complication of post surgically corrected atrial septal defect (ASD). The 2015 ACC/AHA/HRS/SVT Guideline gave catheter ablation a Class IIa Level C recommendation as primary therapy for this arrhythmia. There were no prospective randomized controlled trials comparing the efficacy or safety between anti‐arrhythmic drugs and catheter ablation.

Methods:

Objective: To present a case of a successful radio frequency ablation of an atypical atrial flutter around an ASD patch in a patient who had late correction of sinus venosus atrial septal defect with right ventricular dysfunction and pulmonary hypertension

Result:

Case Presentation: A 58‐year old woman with sinus venosus ASD and partial anomalous pulmonary venous return who underwent surgical correction at the age of 44. She developed failure symptoms and had episode of atrial flutter that warranted cardioversion. She was admitted due to worsening failure symptoms with concomitant pneumonia. During hospital stay, she had recurrence of atrial flutter with low blood pressure. There was improvement of symptoms and hemodynamics on conversion to sinus rhythm with electrocardioversion. She subsequently underwent electroanatomical mapping and radiofrequency catheter ablation.

Conclusion:

Arrhythmias that develop later after surgical correction of congenital heart disease which in this case is an atypical atrial flutter in a post ASD repair patient, can still be treated successfully. This presents catheter ablation as a primary therapy in maintaining and restoring sinus rhythm and can significantly decreased the need for long‐term anti‐arrhythmic drug treatment that have potentially side effects. It is important that in every procedure, a physician should carefully weigh potential risks and benefits of treatment options.

AP19‐00605

Adenosine‐induced atrial fibrillation originated from right atrial appendage

Takeshi Ishihara, Nobuhiro Takasugi, Genki Naruse, Yuki Sahashi, Toshiki Tanaka, Hiromitsu Kanamori, Hiroyuki Okura

Gifu University, Japan

Yuta Seki, Kenji Hashimoto, Terumasa Yamashita, Hiroshi Miyama, Taishi Fujisawa, Kazuaki Nakajima, Yoshinori Katsumata, Takehito Kimura, Seiji Takatsuki

Keio University School of medicine, Japan

Han Joon Bae

Daegu Catholic University Hospital, South Korea

Introduction:

Atrial fibrillation is known to cause thrombosis and cause systemic embolism. The DC cardioversion was easy to perform, the procedure time was short, and the effect of sinus conversion rate was more than 90%. However, long term follow up data was not surveyed.

Methods:

From January 2011 to December 2016, 332 patients who underwent dc conversion for cardiac rhythm conversion in patients with atrial fibrillation were enrolled in the cardiac department of Keimyung University Dongsan Medical Center. Recurrence of atrial fibrillation after conversion was classified as recurrent if atrial fibrillation was recorded even once based on the standard electrocardiogram measured at the time of outpatient visit. The type of recurrence was recurrence 3 months before the conversion, but early conversion after 3 months. There was no recurrence before 3 months, but late recurrence after 3 months and continuous recurrence were classified as mixed.

Result:

There were 90 patients with no recurrence for 2 years, and 242 patients with recurrence. The recurrence rate was 15 cases in the early type, 59 cases in the late type, 168 cases in the mixed type. The mean age of the patients was approximately 60 years. Among the parameters that can be quantitatively measured by echocardiogram, parameters showing differences between normal group and recurrent group were statistically significant difference between left ventricular diastolic diameter, left atrial diameter and left atrial volume index. The more severe the tricuspid regurgitation, the more recurrence of atrial fibrillation. According to decision tree analysis, the most important factor in maintaining rhythm after atrial fibrillation was the size of the sinus atrium, and the prognosis was best when the size of the left atrium was less than 3.74 cm. The factors predisposing to the prognosis were the left ventricular volume index and gender, and the next step was the right ventricular diastolic diameter and the length of the mitral regurgitation.

Conclusion:

The prognosis of DC Conversion is good when the size of the left atrium is 3.74 cm or less, when it is male, and when there is mitral regurgitation.

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AP19‐00616

The clinical impact of the patent foramen ovale for the cerebral lesions on magnetic resonance imaging in patients with atrial fibrillation

Taishi Fujisawa, Kenji Hashimoto, Terumasa Yamashita, Hiroshi Miyama, Kazuaki Nakajima, Yoshinori Katsumata, Takehiro Kimura, Seiji Takatsuki

Keio University Hospital, Japan

Introduction:

Patent foramen ovale (PFO) is well known etiology of embolic stroke of undetermined source. However, the incidence of cerebral lesion in patients with PFO is still not enough elucidated. Therefore, we evaluated the incidence of cerebral lesion in atrial fibrillation (AF) patients with PFO.

Methods:

We analyzed the patients with non‐valvular AF undergoing radiofrequency catheter ablation. They had at least 1 month of adequate anticoagulation and the presence of PFO was verified with trans‐ esophageal echocardiography before the catheter ablation. Cerebral magnetic resonance imaging (MRI) was also performed before the procedure. The cerebral lesions on the MRI consisted of periventricular hyperintensities, deep and subcortical white matter hyperintensities, old lacunar infarction or old cortical infarction. We investigated the predictors of cerebral lesions before the ablation procedure, using the logistic regression analysis.

Result:

we retrospectively analyzed 117 patients (59.0 ± 10.1 years, 100 [85.5%] males, 75 [64.1%] paroxysmal atrial fibrillation). PFO was identified in 14 (12%) of patients. Of those, 4 patients underwent previous atrial septal puncture in the prior catheter ablation. Right to left shunt was identified in 1 patient. Cerebral lesions were observed in 26 (22.2%) patients (3 periventricular hyperintensities, 18 deep and subcortical white matter hyperintensities, 13 old lacunar infarction, 5 old cortical infarction in total). In univariate analysis, the presence of PFO, diabetes, the type of AF and serum creatinine level were not associated with the presence of the cerebral lesions. However, CHADS2 score, age, hypertension and serum brain natriuretic peptide level were associated with the presence of the cerebral lesion (odds ratio [OR] 2.69, P < .001; OR 1.09, P = .003: OR 2.89, P = .023; OR 1.01, P < .001, respectively). In multivariate analysis, CHADS2 score and serum brain natriuretic peptide level were independent predictors of cerebral lesions (OR 2.18, P = .043; OR 1.01, P = .011 respectively).

Conclusion:

The PFO was not associated with the cerebral lesions in patients with AF. CHADS2 score and serum brain natriuretic peptide level were independently predictive of the cerebral lesions in patients with atrial fibrillation.

AP19‐00617

Catheter ablation for treatment of patients with atrial fibrillation and heart failure: A meta‐ analysis of randomized controlled trials

Yingxu Ma, Fan Bai, Qiming Liu

The Second Xiangya Hospital, China

Introduction:

There is a little evidence for the effects of catheter ablation (CA) on hard endpoints in patients with atrial fibrillation (AF) and heart failure (HF).

Methods:

PubMed, Embase and Cochrane Library were searched for randomized controlled trials (RCTs) enrolling patients with AF and HF who were assigned to CA, rate control or medical rhythm control groups. This meta‐analysis was performed by using random‐effect models.

Result:

Seven RCTs enrolling 856 participants were included in this meta‐analysis. CA reduced the risks of all‐cause mortality (risk ratio [RR] 0.52, 95% CI 0.35‐0.76), HF readmission (RR 0.58, 95% CI 0.46‐0.66) and the composite of all‐cause mortality and HF readmission (RR 0.55, 95% CI 0.47‐0.66) when compared with control. But there was no significant difference in cerebrovascular accident (RR 0.56, 95% CI 0.23‐1.36) between two groups. Compared with control, CA was associated with improvement in left ventricular ejection fraction (mean difference [MD] 7.57, 95% CI 3.72‐11.41), left ventricular end systolic volume (MD −14.51, 95% CI −26.84 to −2.07), and left ventricular end diastolic volume (MD −3.78, 95% CI −18.51 to 10.96). Patients undergoing CA exhibited increased peak oxygen consumption (MD 3.16, 95% CI 1.09‐5.23), longer 6‐min walk test distance (MD 26.67, 95% CI 12.07‐41.27), and reduced Minnesota Living with Heart Failure Questionnaire scores (MD −9.49, 95% CI −14.64 to −4.34) than those in control group. Compared with control, CA was associated with improved New York Heart Association class (MD −0.74, 95% CI −0.83 to −0.64) and lower B‐type natriuretic peptide levels (MD −105.96, 95% CI −230.56 to 19.64).

Conclusion:

CA was associated with improved survival, morphologic changes, functional capacity and quality of life relative to control. CA should be considered in patients with AF and HF.

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Fan Bai, Qiming Liu

The Second Xiangya Hospital, China

Introduction:

Previous studies have documented altered energy metabolism in atrial fibrillation (AF). Footprints of the Warburg effect are observed. Metformin can inhibit the Warburg effect and is associated with decreased risk of AF.

Methods:

A qualitative and quantitative analysis of proteomics in the left atrial appendage (LAA) of eighteen patients with mitral stenosis was conducted, including nine with chronic AF and nine with sinus rhythm (SR). Eighteen beagle dogs were divided into SR, AF and AF+MET group. Key factors of Warburg effect, expression of glucose transporters, signaling pathways involved, and electrophysiological parameters were assessed.

Result:

The proteomic study demonstrated the role of metabolic remodeling in AF and suggested the existence of the Warburg effect. The animal trial further proved that the use of metformin can decrease inhibit the Warburg effect and decrease the incidence of AF.

Conclusion:

Metabolic remodeling and the Warburg effect exists in chronic AF and metformin can alleviate these, probably via the inhibition of the PI3K/AKT/mTOR and HIF‐1α signaling pathway.

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AP19‐00635

Effect of intrinsic QRS morphology on response to His‐Purkinje system pacing in atrial fibrillation patients with atrioventricular node ablation

Weijian Huang, Shengjie Wu, Mengxing Cai, Lan Su, Songjie Wang, Tiancheng Xu

Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China

Hidenori sato

Department of Cardiology, The Jikei University School of Medicine, Japan

Withaya Tragulmongkol, Warangkna Boonyapisit

Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Introduction:

A large proportion of patients with atrial fibrillation (AF) are asymptomatic. Data about the clinical characteristics and prognostic endpoint of asymptomatic AF patients were limited and diversity from previous studies. This study was to investigate clinical characteristics and prognostic endpoints of patients with asymptomatic AF in Siriraj hospital.

Methods:

An observational retrospective cohort study, patients who was diagnosed with AF at outpatient department, Siriraj hospital and followed up between January 2014 and December 2018 were enrolled. Baseline clinical characteristics and clinical endpoint of symptomatic and asymptomatic AF were collected. The primary endpoint was 5‐years survival free of the composite of all‐cause mortality, cardiovascular related mortality, ischemic stroke, systemic embolism and heart failure hospitalization.

Result:

A total of 459 patients (male 277, 60.3%), mean age 69.9 ± 10.8 years old were enrolled. Mean follow up duration 4.1 ± 1.0 years. One hundred and ninety two patients (41.8%) were asymptomatic AF. Male gender, BMI, persistent AF type, history of ischemic stroke prior to enrollment, peripheral arterial disease, history of smoking, high CHA2DS2VASc score (5‐8) and HAS‐BLED score were significantly associated with asymptomatic AF patients (all P < .05). The primary endpoint occurred in 34 (17.7%) asymptomatic AF patients and 48 (18%) in symptomatic AF patients. After Multivariate analysis, no significantly difference in survival free of the primary endpoint in patients with asymptomatic AF compared to symptomatic AF. (Cox regression analysis, Hazard ratio 0.82 (95% CI 0.51‐1.32), P = .412).

Conclusion:

Patients with asymptomatic AF were more male gender and associated with previous cardiovascular comorbidity, previous ischemic stroke history and higher CHA2DS2VASc score. No significantly difference in survival free of the composite endpoint of all‐cause mortality, cardiovascular related mortality, ischemic stroke, systemic embolism and heart failure hospitalization in asymptomatic compared to symptomatic AF patients.

TABLE 2 Primary and secondary endpoints in asymptomatic AF patients versus symptomatic AF patients

End point	Asymptomatic AF	Symptomatic AF	Hazard ratio (95% CI )	P‐value
Primary endpoint*	34 (17.7)	48 (18)	1.10 (0.71‐1.71)	.374
Secondary endpoint **	28 (14.6)	41 (15.4)	1.05 (0.65‐1.70)	.538
All cause death	11 (5.7)	17 (6.4)	0.98 (0.46‐2.10)	.838
CV death	3 (1.6)	2 (0.7)	2.18 (0.36‐13.05)	.367
Ischemic stroke	12 (6.2)	18 (6.7)	1.02 (0.49‐2.13)	.682
Systemic embolism	2 (1.0)	2 (0.7)	1.46 (0.20‐10.42)	.573
Heart failure hospitalization	15 (7.8)	21 (7.9)	1.08 (0.56‐‐2.10)	.696
Bleeding	44 (22.9)	47 (17.6)	1.48 (0.98‐2.24)	.058

Methods:

Simultaneous intra‐operative mapping of endocardial (Endo) and epicardial (Epi) lateral RA wall was performed during sinus rhythm (SR), pacing drive (600 ms and 400 ms CL) and premature extra‐ stimulation (PES) using two HD Grid catheters (16 electrodes, 3 mm spacing). Filtered uni‐ and bipolar electrograms (EGM's) and electrode locations were exported into MATLAB for analyses. Activation (AM) and phase analyses (PM) were performed on unipolar EGM's. The finite difference technique was used to assess conduction velocity (CV). Signal fractionation and voltage analyses were performed on bipolar EGM's and comparisons made between Endo and Epi along the two orthogonal planes (horizontal [H] and vertical [V] bipolar configurations) for SR, pacing drive and PES. Signal phase at each location of the Endo surface was compared to phase timing at the opposing Epi surface. Difference of ≥20 milliseconds between paired Endo and Epi electrodes defined dissociation. Bipolar EGM's fractionation was classified based on previously described criteria.

Result:

Sixteen patients with SHD (43% ischaemia, 57% valvular disease) were included. 9866 EGM's analysed. Compared to SR, PM and AM showed significant FEEED during pacing at 600 ms and 400 ms (PM: 22.4% vs 10%, P < .0001; 25.8% vs 10%, P < .0001 respectively; AM: 25.4% vs 7.8%, P < .0001 and 27.7% vs 7.8%, P < .0001 respectively) and PES (PM: 34% vs 10%, P < .0001; AM: 29.5% vs 7.8%, P < .0001). Marked CV slowing was also with PES compared to SR (Endo: 45.9 vs 56.1 cm/s, P < .0001; Epi: 41.3 vs 52.4 cm/s, P < .0001). Signal fractionation was higher during pacing drive at 600 ms (Endo: 38.4% vs 28.9%, P = .002; Epi: 42.1% vs 29.9%, P = .002), 400 milliseconds (Endo: 44% vs 28.9%, P = .0012; Epi: 44.3% vs 30.1%, P < .0001) and during PES (Endo: 48.9% vs 28.9%, P < .0001; Epi: 54% vs 28.9%, P < .0001). Bipolar voltages differed across the two planes (V vs H: 4.3 vs 3.0 mV, P = .0008 [SR], 2.6 vs2.0 mV, P = .03 [pacing drive] and 1.78 vs 1.06 mV, P = .049 [PES]) and consistent with asymmetrical wavefront propagation, a decreasing trend in voltage correlation was observed between the endo‐ and epicardium (R2: 0.91 [SR], 0.38 [pacing drive] and 0.42 [PES]).

Conclusion:

We have demonstrated for the first time in human atria significant FEEED with signal fractionation and CV slowing with PES on simultaneous endo‐epicardial mapping. Such complex 3D interaction in electrical activation provides mechanistic insights for atrial arrhythmogenesis with SHD.

Illustration (A) and photograph (B) of simultaneous epicardial and endocardial mapping of the RA lateral wall using two HD grid catheters is shown (❋endocardial grid, ❋epicardial grid) along with an epicardial quadripolar pacing catheter (orange). SVC: superior vena cava, IVC: inferior vena cava, RAA: right atrial appendage, RA: right atrium, RV: right ventricle, AO: aorta. (C) Phase mapping showing increasing dispersion of signal phase between the epicardial and endocardial surfaces with progression from sinus rhythm (SR) to pacing @400ms and programmed stimulation (PES). (D) Isochronal maps of an activation showing increasing functional dissociation with circuitous wavefront propagation, conduction slowing (isochronal crowding) and marked wavefront propagation asymmetry (yellow dot arrows) with progressive change from SR to pacing @400ms to PES. (E and F) Bipolar voltage maps along orthogonal planes are shown. Marked voltage differences are seen between vertical and horizontal bipole electrode orientations. Consistent with asymmetric wavefront propagation, voltage differences are also noted between endocardium and epicardium during pacing @ 400ms and PES

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AP19‐00731

Endocardial‐epicardial phase mapping of persistent atrial fibrillation: enhanced dissociation, marked conduction heterogeneities and driver characteristics

Ramanathan Parameswaran, Christophe Teuwen, Troy Watts, Chrishan Nalliah, Geoffrey Wong, Hariharan Sugumar, Robert Anderson, Ahmed Al‐Kaisey, David Chieng, Alistair Royse, John Goldblatt, Marco Larobina, Peter Kistler, Jonathan Kalman, Geoffrey Lee

Royal Melbourne Hospital, Australia

Introduction:

Mechanisms that sustain persistent atrial fibrillation (PeAF) remain poorly understood. Recent human data from activation mapping have suggested focal breakthroughs from endocardial‐ epicardial dissociation to maintain PeAF by constant multiplication of sources. However, detailed analyses of signal and driver characteristics and phase mapping from an endo‐epicardial perspective has not been described before. We tested the hypothesis that there will be endo‐epicardial electrical dissociation on phase mapping PeAF and intended to study the driver characteristics and signal complexities.

Methods:

Simultaneous intra‐operative mapping of endo‐ and epicardial lateral RA wall was performed in patients with PeAF using two HD Grid catheters (Abbott, 16 electrodes, 3 mm spacing). Filtered uni‐ and bipolar electrograms (EGM's) of continuous 2 minutes AF recordings and electrodes locations were exported onto MATLAB for phase analyses. Signal phase at each location of the endocardial surface was compared to phase timing at the opposing epicardial surface. Difference of ≥20 milliseconds between paired endo‐ and epicardial electrodes defined dissociation. Activation patterns were simultaneously compared between endo‐ and epicardial surfaces on dynamic phase maps and were characterized into single or multiple wavefronts, rotational circuits, focal sources or disorganized activity based on standard criteria. Bipolar EGM's with ≥5 directional changes were classified fractionated.

Result:

Fourteen patients with PeAF undergoing cardiac surgery (57.1% valvular, 42.9% ischemic) were included. Mean AF cycle length was 178 ± 47 milliseconds. Endo‐epicardial dissociation was seen in 50.3% of activations. The most common patterns seen were disorganised activity (Endo: 36.5 ± 11.2% vs Epi: 41.7 ± 9.1%, P = .0194) and single wavefronts (Endo: 31.3%±10.6% vs Epi: 28.1 ± 12.6%, P = .129). Transient rotors (median revolutions: 2, mean duration: 590 ± 140 milliseconds) were seen on phase mapping but were non‐sustained (Endo: 14.8 ± 1.9% vs Epi 15.6 ± 3%, P = .669). Transmural migration of rotors (n = 6) from the epi‐ to the endocardium were noted in two patients. No focal activations were seen. Simultaneous comparison of endo‐epicardial wavefront patterns showed significant heterogeneity (McNemar's test, P < .0001 (two‐tailed). Fractionation of bipolar EGM's was significantly higher in the epicardium than endocardium (81.2% vs 72.1%, P < .0001).

Conclusion:

Simultaneous endo‐epicardial phase mapping of human PeAF shows significant electrical dissociation, wavefront heterogeneities and complex fractionations. No focal activations were seen in our cohort and for the first time were able to demonstrate transmural migratory rotors. Such complex 3D‐ interactions provides compelling evidence to explain why current endocardial treatment approaches have suboptimal outcomes.

(A) Intraoperative photograph of simultaneous epicardial and endocardial AF mapping in the RA lateral wall using two HD grid catheters (❋endocardial grid, ❋ epicardial grid); RAA: right atrial appendage, RV: right ventricle. (B) Phase mapping showing increased dispersion of signal phase between the epicardial and endocardial surfaces. (C) Wavefront patterns with marked heterogeneity between endocardium and epicardium: Single wavefronts (i), Multiple wavefronts on epicardium with wavefront collision ( ) (ii), Endocardial counter‐clockwise rotor with disorganized activity on epicardium (iii), Epicardial counter‐clockwise rotor with multiple wavefront on endocardium (iv).

graphic file with name JOA3-35-76-g161.jpg

AP19‐00733

Sequential change in atrial low voltage area and recurrent atrial tachyarrhythmias in isolated cardiac sarcoidosis: A case report

Yuki Shimizu, Akira Mizukami, Jiro Hiroki, Hirofumi Arai, Kenji Yoshioka, Shu Yamashita, Daisuke Ueshima, Akihiko Matsumura

Kameda Medical Center, Japan

Jinzhu hu, Jianhua yu, Qi chen, Jianxin hu, Juxiang li, Ali J. Marian, Kui hong

The Second Affiliated Hospital of Nanchang University, China

Introduction:

Patients with Wolff‐Parkinson‐White syndrome (WPW) and atrial fibrillation (pre‐ excited AF), are at an increased risk of spontaneous ventricular fibrillation. As the increasing reports of accelerated pre‐excited ventricular responses and ventricular fibrillation, intravenous amiodarone is no longer considered the preferred recommendation for pre‐excited AF with impaired left ventricular function (ILVF). Therefore, there is a need for a new agent for treatment of pre‐excited AF in patients with ILVF. The efficacy of nifekalant in pre‐excited AF is unclear.

Methods:

The study populations were comprised of patients with sustained pre‐excited AF (n = 51), paroxysmal supraventricular tachycardia (PSVT, n = 201), and persistent AF without accessory pathway (AP) (n = 87). Effects of intravenous infusion of nifekalant was assessed on electrophysiologic and clinical parameters (Table 1).

Result:

Nifekalant prolonged the shortest pre‐excited R‐R, the average pre‐excited R‐R, and the average R‐R intervals from 290 ± 35 to 333 ± 44 milliseconds, 353 ± 49 to 443 ± 64 milliseconds, and 356 ± 53 to 467 ± 75 milliseconds, respectively, in patients with pre‐excited AF (all P < .001, Table 2). Nifekalant also decreased the percent of pre‐excited QRS complexes, heart rate and increased systolic pressure (all P < .001, Figure 1 and 2, Table 2). Nifekalant terminated AF in 33 of 51 patients (65%). Similar effects were also observed in a subgroup of 12 patients with pre‐excited AF and ILVF (Table 2). In patients with PSVT, nifekalant significantly prolonged effective refractory period (ERP), block cycle length (BCL) of antegrade AP and the atrial ERP (all P < .001, Figure 3). Nifekalant had no effect on ERP of antegrade atrioventricular node (AVN) (Figure 4). Finally, in patients with persistent AF without AP, nifekalant did not significantly decrease the ventricular rate of AF. One patient developed Torsades de pointes (TdP). No other adverse effects were observed.

Conclusion:

Nifekalant prolongs the ERP of antegrade AP and atrium, without blocking the antegrade conduction through the AVN, leading to slowing and/or termination of pre‐excited AF. Thus, nifekalant might be an effective and a relatively safe drug in patients with pre‐excited AF.

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TABLE 1 Clinical characteristics of the patients before nifekalant infusion

Characteristics
Patiens with pre‐excited AF (n=51)
Male sex ‐ no.(%)	33 (65)
Age ‐ yr	53±12
History of cardiac disease ‐ no.(%)	40 (78)
Spontaneous sustained pre‐excited AF ‐ no. (%)	20 (39)
Induced sustained pre‐excited AF ‐ no. (%)	31 (61)
Pre‐excitation and paroxysmal AF ‐ no. (%)	12 (24)
Pre‐excitation and PSVT (no documented AF) ‐ no.(%)	19 (37)
LVEF (non‐structural heart disease) ‐ %	61±5
Structural heart disease ‐ no. (%)	12 (24)
Rheumatic heart disease ‐ no. (%)	4 (8)
Primary dilated cardiomyopathy ‐ no. (%)	3 (6)
Ischemic cardiomyopathy ‐ no. (%)	2 (4)
Hypertrophic cardiomyopathy ‐ no. (%)	3 (6)
LVEF ‐ %	36±6
Patients with PSVT (n = 201)
Male sex ‐ no. (%)	128 (64)
Age ‐ y	38±13
Pre‐excitation‐ no. (%)	87 (43)
Concealed AP and dual AVN pathway	114 (57)
Structural heart disease ‐ no. (%)	1 (0.5)
Ebstein anomaly‐ no. (%)	1 (0.5)
Patients with persistent AF and no AP (n = 87)
Male sex ‐ no.(%)	52 (60)
Age ‐ y	53 ± 11
Structural heart disease ‐ no. (%)	23 (26)
Ischemic cardiomyopathy ‐ no. (%)	6 (7)
Rheumatic heart disease ‐ no. (%)	4 (5)
Primary dilated cardiomyopathy ‐ no. (%)	3 (3)
Hypertensive heart disease ‐ no. (%)	7 (8)
Hypertrophic cardiomyopathy ‐ no. (%)	3 (3)
LVEF ‐ %	39 ± 5

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AF, atrial fibrillation; LVEF, left ventricular ejection fraction; HR, heart rate; SBP, systolic blood pressure. PSVT, paroxysmal supraventricular tachycardia; AP, accessory pathway; AVN, atrioventricular node.

TABLE 2 Effects of nifekalant on the electrophysiologic and clinical indicators in patients with pre‐excited AF

SPRR (ms)	APRR (ms)	ARR (ms)	PP (%)	HR(beat/min)	BP (mmHg)
Total	ILVF Subgroup	Total	ILVF Subgroup	Total	ILVF Subgroup	Total	ILVF Subgroup	Total	ILVF Subgroup	Total	ILVF Subgroup
Baseline	290±35	281±30	353±49	350±41	356±53	354±45	100 (100‐100)	100 (100‐100)	172±25	172±24	84±9	76±3
Nifekalant	333±44**	327±37**	443±64**	445±47**	467±75**	471±55**	79 (70‐91)**	74 (52‐90)**	132±24**	129±19**	99±12**	88±6**

Conclusion:

In this propensity‐score matched nationwide cohort of non‐valvular AF patients, NOAC was associated with reduced risk of dementia, compared with warfarin. This association was pronounced for vascular dementia in patients with prior stroke.

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AP19‐00768

Effects of systolic blood pressure and hypertension duration on dementia in patients with atrial fibrillation

Daehoon Kim, Pil‐Sung Yang, Eunsun Jang, Hee Tae Yu, Tae‐Hoon Kim, Jae‐Sun Uhm, Jung‐Hoon Sung, Hui‐Nam Pak, Moon‐Hyoung Lee, Gregory Lip, Boyoung Joung

Yonsei College of Medicine, South Korea

Introduction:

Atrial fibrillation (AF) is associated with increased risk of cognitive impairment and dementia, even with no overt stroke. Hypertension is a potentially modifiable risk factor for dementia. We investigated the effects of systolic blood pressure (SBP) and hypertension duration on dementia among AF patients.

Methods:

This cohort study based on data from the Korean National Health Insurance Service enrolled participants with incident AF, aged ≥ 50 years, receiving antihypertensive treatment, and not previously diagnosed with dementia from 2005 to 2016 (n = 196 379). They were followed from AF diagnosis until dementia, death, or December 31, 2016. Primary exposure variables were SBP and hypertension duration, measured at baseline and updated over time. The primary outcome was incident dementia.

Result:

During 974 600 years of follow‐up, there were 37 485 new dementia diagnoses. In mid‐life patients (<70 years), high SBP (≥140 mm Hg) was associated with increased dementia risk (hazard ratio [HR] 1.13, 95% confidence interval [CI] 1.09‐1.17). Among these mid‐life patients with high baseline SBP, follow‐up SBP control to 120‐129 mm Hg was associated with decreased dementia risk (HR 0.85, 95% CI 0.74‐0.98). In later‐life patients (≥70 years), no significant associations of high SBP with dementia were observed. Instead, low SBP (<120 mm Hg) in age 70‐79 years correlated with increased dementia risk (HR 1.04, 95% CI 1.00‐1.08). Longer hypertension duration increased dementia risk in all ages, with stronger associations in older patients. The effects of SBP and hypertension duration were considerably different according to dementia subtypes (Alzheimer's disease or vascular dementia). Time‐ updated regression models revealed lowest dementia risks with SBP 120‐129 mm Hg in patients aged < 70 years and 130‐139 mm Hg in those aged 70‐79 years.

Conclusion:

In midlife AF patients, reducing SBP to 120‐129 mm Hg might lower their subsequent dementia risk. The optimal SBP range for preventing dementia differs according to age.

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AP19‐00769

Effect of lowering hypertension threshold in CHA2DS2‐VASc score system on stroke risk stratification

Daehoon Kim, Pil‐Sung Yang, Eunsun Jang, Hee Tae Yu, Tae‐Hoon Kim, Jae‐Sun Uhm, Jung‐Hoon Sung, Hui‐Nam Pak, Moon‐Hyoung Lee, Gregory Lip, Boyoung Joung

Yonsei College of Medicine, South Korea

Xiaoyao Li, Shuang Zhao, Xiaodi Xue, Bin Zhou, Shu Zhang

Fuwai Hospital, China

Introduction:

Atrial fibrillation(AF) occurrence in patients with ICDs is not clear.

Methods:

Four hundred and eighty two patients implanted with ICD or cardiac resynchronization therapy defibrillator with home monitoring were studied retrospectively. The primary endpoint was AF detected by the device, secondary endpoint was cardiac death.

Result:

During a mean follow‐up period of 42.8 ± 15.6 months, 186 patients (38.6%) experienced VA, 16(8.6%) of which detected AF by ICD/CRTD. 20 patients (16.8%) died in VA patients due to cardiac diseases. In Kaplan‐Meier survival analysis, VA was associated with increased incidence of AF (P < .001). In multivariate COX regression models, VA was an independent risk factor for AF (HR 8.264, 95%CI: 2.404‐28.410, P = .001).AF increased the possibility of cardiac death (25% vs 9.41%) (HR 4.080, 95%CI: 1.308‐12.729, P = .015).

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Li‐Wei Lo, Yu‐Hui Chou, Wei‐Lun Lin, Tzu‐Yen Peng, Pin‐Yi Lin, Shih‐Lin Chang, Fa‐Po Chung, Yu‐Feng Hu, Ting‐Yu Li, Shu‐Wei Huang, Shien‐Fong Lin, Shih‐Ann Chen

Taipei Veterans General Hospital, Taiwan

Introduction:

Skin sympathetic nerve activity (SKNA) can be used to estimate sympathetic tone noninvasively in human. Autonomic dysregulation is considered to be an underlying pathophysiology of AF. Objective: The study aimed to evaluated the differences of SKNA activations between AF patients (Group 1) and control (Group 2).

Methods:

Of consecutive 32 subjects, 13 were drug‐refractory symptomatic paroxysmal AF and 19 were healthy volunteers, all received patch electrodes to record SKNA continuously. The SKNA was recorded from ECG lead I configuration (ECG‐SKNA) and bipolar electrodes on the right arm (EMG‐ SKNA). Those signals were bandpass filtered between 500 to 1000 Hz to detect SKNA. The ECG was displayed with bandpass filtered the signals between 0.5 and 150 Hz.

Result:

All subjects received a 10 minutes of SKNA recording continuously. Average ECG‐SKNA (0.73 ± 0.49 vs 0.54 ± 0.18 μV, P = .03) and EMG‐SKNA (0.60 ± 0.32 vs 0.42 ± 0.017 μV, P = .015) were higher in Group 1 than those of Group 2, respectively. Intermittent surge of SKNA (sSKNA) was noted in both groups, there was a higher trend of surge frequency in Group 1 than that of Group 2 (2.54 ± 1.73 vs 1.89 ± 1.13 times/10 min, P = .08). In Group 1, 1.38 ± 2.25 times/10 minutes sSKNA were associated with the onset of APCs. The amplitude of sSKNA was higher in that with, when compare to that without APC (Table). The amplitudes of sSKNA were significant higher in Group 1 than that of Group 2 (Table). Figure shows examples of sSKNA with and without APC development from Group 1 and 2 patients.

Conclusion:

Both transient surge and average SKNA were higher in patients with AF than healthy individuals. AF patients tended to have a higher frequency of sSKNA during resting status, indicating that AF had an augmented sympathetic activity and those activations were associated with the onset of AF.

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AP19‐00811

Early repolarization and risk of atrial fibrillation: A meta‐analysis of observational studies

Jerome Reymatias, Lauren Kay Evangelista, Cecileen Anne Tuazon, Michael‐Joseph Agbayani

University of the Philippines ‐ Philippine General Hospital, Philippines

Introduction:

Early repolarization pattern is an electrocardiographic finding characterized by elevation of the J point in the inferior and/ or lateral leads. Recent studies have shown its association with an increased risk of ventricular tachyarrhythmias and sudden cardiac death, however, the association of early repolarization with risk of atrial fibrillation is not yet established. This study evaluated the association of early repolarization and the risk of atrial fibrillation.

Methods:

Using MEDLINE, EMBASE, ScienceDirect, Scopus, Google Scholar, ClinicalKey, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials databases, a search for eligible studies was conducted until May 2019. We identified 3 studies that met the inclusion criteria, and obtained full articles of all of them. Included studies were assessed for quality using the Newcastle‐Ottawa Quality Assessment Scale for observational studies. The outcome of interest was assessed using Mantel‐Haenzel analysis of random effects to compute for risk ratios, carried out using Review Manager (RevMan) Version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen).

Result:

Pooled analysis from the 3 studies involving 1,174 patients showed that the presence of early repolarization was associated with increased risk of atrial fibrillation [RR 2.2 (95% CI 1.3, 3.73; P = .003)].

Conclusion:

The presence of early repolarization is associated with significantly increased risk of atrial fibrillation. Large prospective studies are still warranted.

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AP19‐00815

Comparisons of efficacy, safety, and recurrence risk factors of paroxysmal and persistent atrial fibrillation catheter ablation using robotic magnetic navigation system

Xiaoxi zhao, ruxing Wang, kulin li, jie Zheng, xiaoyu Liu, shipeng Dang, zhiming Yu, changying Zhang

The Affiliated Wuxi People's Hospital of Nanjing Medical University, China

Introduction:

No data exist on comparisons of efficacy, safety, and recurrence risk factors of paroxysmal and persistent atrial fibrillation (AF) ablation using robotic magnetic navigation system (MNS), respectively.

Methods:

About 151 AF patients were prospectively enrolled and divided into paroxysmal AF group (n = 102) and persistent AF group (n = 49). Circumferential pulmonary vein antrum isolation (CPVI) was performed in all patients. Linear ablation at the left atrial roof and mitral isthmus was performed in patients with persistent AF in addition to CPVI. The procedural time, X‐ray exposure time, acute and long‐term success rates of CPVI, and procedure‐related complications were analyzed. The AF recurrence rates in the two groups were compared during 1 year, and Cox regression was used to analyze the recurrence risk factors.

Result:

The acute success rates of CPVI in the two groups were 98.04% and 97.96%, respectively.There were no significant differences in the procedural time, X‐ray exposure time, and ablation time between the two groups (P > .05). No serious complications appeared in either group. The AF ablation success rates were 70.6% and 57.1% for the paroxysmal and persistent groups respectively at 12‐month follow‐up (P = .102). AF duration and coronary heart disease prior to ablation were associated with the higher AF recurrence in patients with persistent AF.

Conclusion:

Ablation using MNS is effective and safe both in patients with paroxysmal and persistent AF. AF duration and coronary heart disease prior to ablation are two independent risk factors of AF recurrence in patients with persistent AF postoperatively

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AP19‐00816

Ibutilide cardioversion for recent onset atrial fibrillation in ischemic cardiomyopathy

Kotti K, Jaya Pradhap, Radhika B, Aishwarya S, Sabari S, Mahima P Manoj, Nithin G, Sailendri G, Benjamin S, Ravi Kumar, Nirmala S, Dasari Himaja, Sandini S, Swathi K

The Madras Medical Mission, India

Andreas Sitorus, Haikal Balweel, Larasati Mnuawar, Beny Hartono, Muhammad Munawar

Rumah Sakit Jantung Binawaluya, Indonesia

Introduction:

Stroke rates were higher in patients who developed Atrial Fibrillation (AF) after Atrial Flutter (AFL) ablation even it was non‐documented prior the procedure. Stroke events in patients with AFL could be due to coexisting AF. However, the guidelines do not clearly address the anticoagulation plan or prophylactic AF ablation after successful AFL ablation in patients with non‐documented prior AF.

Methods:

We reported a case of lethal ischemic stroke after successful CTI ablation in typical AFL with non‐documented prior AF.

Result:

A 67 years old man came to the outpatient clinic with chief complain of fatigue and leg swelling since 4 month ago. He was hospitalized before in other hospital due to heart failure symptoms. He has a history of stroke in 2011 and diabetes. At the outpatient clinic, his physical examination revealed normal finding. Electrocardiography showed typical AFL counter clockwise (CCW) with 2:1 AV block. Echocardiography showed slightly dilatation of the left ventricle and left atrium with left ventricle ejection fraction (LVEF) 48% and mild global hypokinetic. CTI ablations were performed with bidirectional block and directly convert to sinus rhythm. Coronary angiography showed CAD 2 VD. One day after CTI ablation, this patient felt better, then discharged. Two days after the procedure, he came with altered mental status since one hour before admission and his cardiac monitor showed sinus rhythm. His brain CT showed acute ischemic at sub‐cortex of the left parietal lobe. Percutaneous intra‐arterial thrombolysis (PIAT) directly performed with 100.000 IU streptokinase but showed no flow in the left media cerebral artery due to high thrombus burden. Holter monitoring was performed after PIAT and showed paroxysmal atrial fibrillation. One day after, this patient died in the intensive care unit.

Conclusion:

Patients with AFL who undergo successful ablation are still in a risk from embolic complications, mainly due to AF. Given the difficulties in detecting AF, oral anticoagulation or prophylactic AF ablation may be considered in high‐risk patients with underlying stroke risk factors.

Keywords: atrial fibrillation, typical atrial flutter, CTI ablation, stroke ischemic

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AP19‐00839

The additional effect of inferior ganglionated plexi ablation on pulmonary vein isolation in patient with non‐paroxysmal atrial fibrillation

Akinori Matsumoto, Naomasa Takeya, Koyo Sato

Nagoya Heart Center, Japan

Introduction:

Pulmonary vein isolation (PVI) has used as the corner stone strategy of atrial fibrillation (AF) therapy. However, PVI alone cannot cure of all patients with AF. Although the adjunctive therapy (e.g. complex fractionated atrial electrogram ablation (CFAE) or linear ablation) was conducted to the patient with non‐paroxysmal AF (non‐PAF) in addition to the PVI, that additional effect has reported to be little. On the other hand, the ganglionated plexi (GP) ablation was well known as another adjunctive therapy, but the additional effect on PVI was not still elucidated. The purpose of this study is to investigate the additional effect of the inferior GP ablation for non‐PAF.

Methods:

Ninety‐one consecutive patients with non‐PAF who were conducted radiofrequency catheter ablation from September 2017 to March 2019 were retrospectively enrolled. The patient with conducting PV isolation using a contact force or an ablation index of CARTO system were included in this study. Conversely, the patients with conducting PV isolation using EnSite NavX system or RHYTHMIA system were excluded. Moreover, the patients with prior cardiac surgery, 2nd session or empirically conducting any linear ablation or CFAE ablation were also excluded. Our strategy against non‐PAF is ablating the GP positive site in addition to PVI plus non‐PV foci ablation. Our PVI line was designed to include the marshall tract GP, superior left GP and anterior right GP. For that reason, in our strategy against non‐ PAF, we searched for the inferior GP (inferior left GP and inferior right GP(inf GP)) by 50 Hz high frequency stimulation and ablated the site where the GP response was positive in addition to PVI and non‐ PV foci ablation. However, if the durable lesion of PVI was not completed, we conducted internal cardioversion for easily detecting the ablation gap and completed PVI during sinus rhythm. Although we tried to induce AF, if AF not induced, we performed PVI and non‐PV foci alone. We divided the non‐ PAF into three groups (PVI and non‐PV foci ablation for non‐PAF, PVI and non PV foci ablation plus inf GP ablation for persistent AF (Per AF) and PVI and non‐PV foci ablation plus inf GP ablation for long standing persistent AF (LSAF)) and evaluated the additional effect of inferior GP ablation.

Result:

Sixty‐eight patients were male, mean age were 64.8 ± 11.6 year old. 50 patients were PerAF and 41 patients were LSAF. 41 patients were PVI +inf GP for Per AF, 37 patients were PVI + inf GP for LSAF, and 13 patients were PVI alone. Although there was no significant difference in three groups for survival rate (Figure), The effect of inf GP was high for PerAF

Conclusion:

The PVI and non‐PV foci ablation in addition to inf GP ablation was 97.6 % at high event free rate. The inf GP ablation might be effective for Per AF but might not be effective for LSAF.

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AP19‐00843

Faster mapping for targeted atrial fibrillation ablation using a novel algorithm with a high‐ density grid style catheter in a Japanese population

Shinji Kaneko, Masao Takemoto, Taku Asano, Satoru Sakagami, Asumi Takei, Masahito Suzuki, Takanao Mine, Kentaro Hayashi, Jun Kishihara, Hidehira Fukaya, Fumiharu Miura, Satoshi Higa, Koji Kumagai, Masaaki Kurata, Caroline Tao, Shunichiro Warita

Abbott, USA

Introduction:

Cardiac mapping is an integral part of cardiac electrophysiology studies. In atrial fibrillation (AF), identification of non‐PV (pulmonary vein) targets to increase success remains a challenge Creation of accurate activation and voltage maps not only provide guidance for ablation, but also allow for rapid diagnosis and monitoring of cardiac rhythms. Here, the use of a novel multielectrode grid catheter with the HD Wave configuration, which collects data using only electrodes with adjacent orthogonal bipoles, in mapping patients with AF was examined in a Japanese population.

Methods:

Prospectively collected procedural data in AF cases utilizing a new high‐density, grid‐style mapping catheter was evaluated across 37 centers in Japan. Procedural data including indication for mapping, mapping software configuration (standard bipole vs HD Wave), mapping time, points acquired, ablation locations, and acute outcomes were recorded. Maps were also reconstructed using both the standard and HD Wave mapping configurations for subjective post hoc comparison.

Result:

Procedural data from 150 atrial fibrillation (52% paroxysmal, 48% persistent) cases were collected. Double transseptal access was reported in 64 cases (42 paroxysmal, 22 persistent) The mapping catheter was delivered by a Swartz sheath in 78% of the cases, and Ensite AutoMap module was utilized in 91% of the cases. The HD Wave mapping configuration was used in 137 cases, vs. 13 cases mapped in standard bipole configuration. HD Wave collected an average of 11,686.4 ± 7866.2 points in 12.7 ± 5.1 minutes (926.1 points collected/ minute) compared to 5,318.8 ± 2844.5 points in 15.7 ± 5.5 minutes (338.8 points collected/ minute) using standard configuration. Retrospective, qualitative comparison of voltage maps in the two configurations revealed better point density and identification of smaller low voltage areas when HD Wave was used (Figure). PVI only procedures were reported in 27 of the 150 cases reported (22 in paroxysmal and 5 in persistent cases). Additional ablation target included CTI (52%), roofline (23%), and SVC (17%). 108 cases reported attempts to induce AF after the procedure, 56% of them reported non‐inducible AF (5 out of 9 in standard vs. 56 out of 99 in HD Wave).

Conclusion:

When a multielectrode, high‐density, grid‐style catheter was used in the HD Wave configuration, high quality activation and voltage images can be obtained in less than 15 minutes with three times the point collection speed compared to standard configuration. Rapid mapping and acquisition of electrograms with HD Wave result in better delineation of substrate and visualization of anatomical maps.

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AP19‐00847

Multinational experience with a high‐density grid‐style catheter

Isabel Deisenhofer, Kent Nilsson, Yan Huo, Ivo Roca Luque, Masao Takemoto, Firas Zahwe, Shinji Kaneko, Taku Asano, Satoru Sakagami, Mansour Razminia, Paul Haas; Peter, Gora, Philipp Sommer

Abbott, United States

Introduction

A high‐density grid‐style mapping catheter received CE Mark in December 2017, followed by regulatory clearances in the United States and Japan later in 2018. It is a closed‐frame, four spline catheter with electrodes configured in a grid pattern. Electrode spacing is equidistant along and across splines, enabling adjacent bipolar EGMs to be recorded in two dimensions simultaneously (HD Wave).

Methods

To characterize and compare the utilization of this high‐density catheter and the HD Wave technology across multiple geographies with diverse patient demographics. Self‐reported procedural data were collected in cases utilizing this high‐density catheter during the initial phases of commercialization in the US, Europe, and Japan. Recorded procedural characteristics included electrode configuration and indication for mapping.

Result

Procedural data was collected in 1,537 cases across 178 centers in Europe, US, and Japan. A total of 13 indications for mapping were represented, including AF, VT, and atypical flutter (Table 1). The HD Wave technology, which exclusively samples data from electrodes with adjacent orthogonal bipoles, was used in 87.3% of cases in the United States; 58.1% in Europe and 88.1% in Japan.

Conclusion

Each geography reported utilization of this high‐density mapping catheter in a wide variety of atrial and ventricular arrhythmias. Across all geographies, the majority of atrial and ventricular cases utilized a novel configuration which samples EGMs in two dimensions simultaneously.

Indication for Mapping	US Cases	Europe Cases	Japan Cases
PAF	47 (37.3%)	282 (23.0%)	78 (41.7%)
de novo	39 (31.0%)	171 (14.0%)	58 (31.0%)
Repeat	8 (6.3%)	111 (9.1%)	20 (10.7%)
PersAF	27 (21.4%)	258 (21.1%)	72 (38.5%)
de novo	13 (10.3%)	114 (9.3%)	47 (25.1%)
Repeat	14 (11.1%)	144 (11.8%)	25 (13.4%)
Ischemic VT	16 (12.7%)	158 (12.9%)	2 (1.1%)
Idiopathic VT	15 (11.9%)	118 (9.6%)	14 (8.0%)
Atypical Flutter	8 (6.3%)	144 (11.8%)	3 (1.6%)
NICM VT	5 (4.0%)	67 (5.5%)	0 (0.0%)
AT	3 (2.4%)	76 (6.2%)	7 (3.7%)
Typical Flutter	3 (2.4%)	59 (4.8%)	7 (3.7%)
Other/Undefined	1 (0.8%)	30 (2.4%)	1 (0.5%)
WPW	1 (0.8%)	9 (0.7%)	1 (0.5%)
Tetralogy of Fallot	0 (0.0%)	7 (0.6%)	0 (0.0%)
ISNT	0 (0.0%)	6 (0.5%)	0 (0.0%)
AVNRT	0 (0.0%)	6 (0.5%)	1 (0.5%)
Brugada	0 (0.0%)	5 (0.4%)	0 (0.0%)

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AP19‐00848

Efficacy and evaluation of catheter ablation for atrial fibrillation with heart failure in our hospital

Yoshimori An, Hisashi Ogawa, Masahiro Esato, Masaharu Akao

National Hospital Organization Kyoto Medical Center, Japan

Toshihiro Nakamura, Kunihiko Kiuchi, Koji Fukuzawa, Mitsuru Takami, Tomomi Akita, Hideya Suehiro, Makoto Takemoto, Jun Sakai, Atsusuke Yatomi, Yusuke Sonoda, Hiroyuki Takahara, Kazutaka Nakasone, Kyoko Yamamoto, Ken‐ichi Hirata, Takashi Ashihara

Kobe University, Japan

Abstract

We here report a case of 41‐year‐old man with persistent atrial fibrillation (AF) who underwent radiofrequency catheter ablation (RFCA) using online real‐time phase mapping system (ExTRa MappingTM, Nihon Kohden Co., Tokyo, Japan). This phase mapping system is characterized by the automatic creation of each phase map movie based on the 5‐second wave dynamics during AF. To identify the location of AF drivers, non‐passively activated areas (NPAs), where rotational activations were frequently observed, could be automatically detected. In this case, the NPAs were found at the septum near the mitral annulus (MA) and the posterior bottom of left atrium. Box isolation and subsequent RF applications on the NPA near MA could not terminate AF. AF could be converted to common atrial flutter immediately after RF applications on the NPA at the posterior bottom. After cavo‐tricuspid isthmus ablation was performed, any other atrial tachycardia could not be induced. Of interest, the NPA at the posterior bottom were located on the fibrotic tissue area assessed by the late‐gadolinium enhancement magnetic resonance imaging, while the NPA near the MA were located on the healthy tissue area. This indicated the possibility of the critical AF rotor meandering through the fibrotic tissue. We would like to discuss the relationship between AF rotor and atrial fibrosis through the current case.

AP19‐00870

Effects of exercise‐based cardiac rehabilitation on exercise capacity and cardiac function in patients with atrial fibrillation

Ilgyu Jeong, Dongsun Han, Seongdae Kim, Sangouk Wee, Sanghee Lee

Hannam University, South Korea

Introduction

We sought to determine whether exercise‐based cardiac rehabilitation (ECR) improves maximal exercise capacity, left ventricular function, and quality of life (QoL) in patients with atrial fibrillation (AF).

Methods

In a prospective study, a total of 53 patients with AF (age 64 ± 1 years) were randomized into supervised ECR program in addition to medical treatment (ECR, n = 25) or medical treatment alone (MT, n = 28) groups. Exercise training was performed as running or cycling on a treadmill or bicycle ergometer 3 times a week for 12 weeks. Each session started with a 10‐minute warmup at 60% to 70% of maximal heart rate (HRpeak), followed by four 4‐minute intervals at 80% to 90% of HRpeak with 3 minutes of active recovery at 60% to 70% of HRpeak between intervals, ending with a 5‐minute cooldown period. During AF, patients exercised at the same treadmill or cycling speed and watt as in the previous sessions in sinus rhythm. Peak exercise oxygen consumption (Vo2), left ventricular function, plasma lipid level, N‐terminal pro B‐type natriuretic peptide, and QoL were measured at baseline and follow‐up assessments. The primary endpoint was the change in peak Vo2 after 3 months. Secondary endpoints included effects on cardiac function, lipid status, and QoL.

Result

ECR increased the peak Vo2 (ECR: 25.2 ± 6.8 mL/kg/min vs MT: 22.0 ± 5.9 mL/kg/min, P = .0001) and the physical functioning score (36‐Item Short‐form Health Survey), and decreased the total cholesterol level (ECR: 143.7 ± 35.5 mg/dL vs MT: 175.8 ± 39.7 mg/dL, P = .045). However, resting left ventricular systolic and diastolic functions were not different after 3 months, with no intergroup differences.

Conclusion

These results suggest that as AF patients become more tolerant of exertion, they experience less fatigue and dyspnea, and become more comfortable in performing tasks of daily living. Further studies should be observed for long‐term ECR effects with a larger sample size.

AP19‐00871

Assessment of pre‐HTN in AF: Role of non‐invasive central blood pressure indices estimation and technical challenges

Kashif Khokhar, Dennis Lau, Martin F. Stiles, Rajiv Mahajan, Adrian Elliott, Dian Munawar, Kadhim Kadhim, Prashanthan Sanders

CHRD, Univeristy of Adelaide, Adelaide Australia, Australia

Kashif Khokhar, Dennis Lau, Martin K Stiles, Rajiv Mahajan, Adrian Elliott, Chritian Verdicchio, Ricardo Mishima, Dian Munawar, Celine Gallagher, Kadhim Kadhim, Prashanthan Sanders

CHRD, Univeristy of Adelaide, Adelaide Australia, Australia

Introduction

Increased arterial stiffness is an independent predictor of poor outcomes in atrial fibrillation (AF). The evaluation of central haemodynamic response to moderate exercise can help identify sub‐clinical aortic stiffness in individuals with AF.

Methods

Objective: To study the response of central blood pressure indices to moderate exercise in patients with a history of AF.

Method

The response of central blood pressure indices to moderate exercise was recorded in 46 consecutive patients with AF. Additionally, 31 subjects without a history of AF were recruited to act as controls. SphygmoCor XCEL (AtCor Medical, Australia) was used to characterise central and brachial blood pressure indices at rest and during early recovery after moderate exertion, quantified as achieving 80‐85% target hear rate (HR) on Bruce protocol. The change in blood pressure indices were compared by linear regression model between the two groups. The analysis was further adjusted for age, gender, left atrial volume, heart rate and medications.

Result

The characteristics of the study cohort are listed (Table). The resting central systolic BP (CSBP) was better controlled in patients with history of AF (123 ± 13 vs 128 ± 13 mm Hg, P = .006). However, the mean change in CSBP during exercise was comparable between the two groups (24 + /‐13 vs 21 + /‐13 mm Hg, p=NS). Further, patients with history of AF have exaggerated response of central augmentation pressure with a mean difference of 5.7 mm Hg (95%CI, 1 to 11.7, P = .04) to exercise, illustrating reduced central arterial compliance.

Conclusion

Assessment of the central haemodynamic response to moderate exercise can help expose central arterial stiffness in patients with AF.

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AP19‐00876

Depression and risk of atrial fibrillation: A nationwide population‐based study

Kwang‐No Lee, Jong‐Il Choi, Kyungdo Han, Ha Young Choi, Yun Young Choi, Ki Yung Boo, Do‐Young Kim, Yun Gi Kim, Seung‐Young Roh, Dae In Lee, Jaemin Shim, Jin Seok Kim, Young‐Hoon Kim

Korea University Anam Hospital, South Korea

Introduction

Although treatments of atrial fibrillation (AF) based on the biological mechanisms for initiation and maintenance of AF improve cardiovascular outcomes, psychosocial factors have been also implicated in the etiology and progression of cardiovascular disease. We aimed to evaluate the association between depression and incident AF using nationwide database from the National Health Insurance Service in South Korea.

Methods

A total of 9,075,224 participants with data of national health checkup in 2009 were included, and participants who were diagnosed with AF before the health checkup were excluded. Exposure to depression is determined by the precedence of depression diagnosed within 1 years.

Result

Depression was diagnosed in 1.37% (124,709) of participants at baseline. Compared to the non‐ depression group, depression group was likely to be female and had higher comorbidities. After adjusting covariates, depression group had a higher risk of incident AF compared with non‐depression group (hazard ratio, 1.30; 95% confidence interval, 1.26‐1.34). Repeated exposure to depression increased a risk of incident AF.

Conclusion

In this Korean nationwide cohort, depression increased the risk of incident AF, with a exposure‐response relationship.

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AP19‐00877

Atrial tachycardia after pulmonary vein isolation in patients with persistent left superior vena cava

Tsuyoshi Takada, Koji Fukuda, Hiroyuki Satake, Nobuyuki Shiba

International University of Health and Welfare Hospital, Japan

Introduction

A persistent left superior vena cava (PLSVC) is the embryological precursor of the ligament of Marshall, which has been implicated in the initiation and maintenance of atrial fibrillation (AF). We report 3 cases with PLSVC which became sources of tachyarrhythmias after pulmonary vein isolation of AF.

Methods

We experienced 3 AF patients with PLSVC which were sources of tachyarrhythmias after PV isolation (all men; 66, 71, and 63 years old).

Result

One patient had frequent ectopic beats originated from the bottom of the ostial coronary sinus (CS) and the remaining two patients had uncommon AFL involving PLSVC as a part of the mechanism. The frequent ectopic beats disappeared after RF deliver at the earliest excitation site in the PLSVC. The electrical connections between PLSVC and LA were recognized as parts of the tachycardia circuits in the two AFLs. The activation pattern in one AFL seemed that the excitation invaded from LA into the distal PLSVC site and went down to the RA without other connections between PLSVC and LA. The other AFL had multiple connections between PLSVC and LA, and the AFL circuit turned around through them. The former case was unsuccess of ablation though we ablated the connection site. On the other hand, we were able to terminate the latter AFL by ablating the critical connection site. After half a year, the 2 patients who had successful ablation have been keeping sinus rhythm without drugs and the failure case have developed AF.

Conclusion

The PLSVC can be not only the arrhythmogenic source of AF, but also be associated with AT after PV isolation. The electrical characteristics is complicated and challenging to ablation.

AP19‐00878

Impact of the duration and degree of hypertension and body weight on new‐onset atrial fibrillation: A nationwide population‐based study

Yun Young Choi, Jong‐Il Choi, Ha Young Choi, Yun Gi Kim, Ki Yung Boo, Do Young Kim, Kwang‐No Lee, Jaemin Shim, Jin Seok Kim, Young‐Hoon Kim

Korea University Anam Hospital, South Korea

Introduction

Hypertension and obesity are known risk factors for atrial fibrillation (AF). However, it is unclear whether uncontrolled and long‐standing hypertension has a more profound impact on AF. Due to their similar underlying pathophysiology, hypertension and obesity may act synergistically in the context of AF. We evaluated the impact of various stages of hypertension and body weight status on new‐ onset AF.

Methods

A total of 9,797,418 patients who underwent a national health check‐up in 2009 were analysed. Hypertension was classified into five stages: non‐hypertension, pre‐hypertension, hypertension without medication, hypertension with medication < 5 years, and hypertension with medication ≥ 5 years. The patients were also stratified based on body mass index (BMI) and waist circumference.

Result

During the 80,130,161 patient 10 year follow‐up, a total of 196,136 new‐onset AF occurred. The incidence of new‐onset AF gradually increased among the five stages of hypertension: the adjusted hazard ratio for each group was 1 (reference), 1.145, 1.390, 1.853, and 2.344 for each stage of hypertension. A graded escalation in the risk of new‐onset AF was observed in response to increased systolic and diastolic blood pressure. The incidence of new‐onset AF was related to BMI and waist circumference, with obese patients having a higher risk. Hypertension and obesity acted synergistically; obese patients with hypertension on medication ≥ 5 years showed the highest risk.

Conclusion

The degree and duration of hypertension, as well as the presence of hypertension, were important determinants of new‐onset AF. Body weight status was significantly associated with new‐onset AF and acted synergistically with hypertension.

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AP19‐00879

Safety and efficacy of cryoballoon ablation for paroxysmal atrial fibrillation in elderly patients

Kumamoto University Hospital, Japan

Introduction

It has been reported that the recurrence of atrial fibrillation (AF) after the initial catheter ablation (CA) procedure was caused by the reconnection of pulmonary vein (PV), presence of non‐PV foci and progression of left atrial remodeling. However, it has not been fully clarified if there was a difference in the mechanism of early and late recurrent AF after initial CA for AF. The purpose of this study was to investigate whether or not there was a difference in the mechanism of recurrent atrial fibrillation (AF) between the early and late phase recurrent cases after catheter ablation (CA). Furthermore, we investigated if this difference is related to the subsequent clinical outcome after the repeated ablation procedure.

Methods

The consecutive 183 patients (paroxysmal; n = 120, persistent; n = 63) who underwent CA for recurrent AF were included in this study. CA of AF was performed in a stepwise fashion using an AF termination as a procedural endpoint (pulmonary vein (PV) isolation, roof line/complex fractionated atrial electrogram ablation and non‐PV foci ablation) at the initial and repeated ablation sessions. During the repeated session, we investigated the mechanism of the recurrent AF and compared it between the early (recurrence within 1 year after previous session; Early‐Group) and late phase (recurrence more than 1 year after previous session; Late‐Group) recurrent cases. Also we compared the clinical outcome between the Early‐ and Late‐Groups.

Result

There were 133 patients in the Early‐Group and 50 patients in the Late‐Group. Prevalence of PV reconnection was significantly higher in the Early‐Group than that in the Late‐Group (76% vs 40%, P < .001). However, prevalence of non‐PV foci was significantly higher in the Late‐Group than that in the Early‐Group (56% vs 15%, P < .001). Multivariate Cox Hazard analysis revealed that the non‐PV foci significantly associated with poor AF free survival ratio (Hazard Ratio: 8.334, P < .001). Kaplan‐ Meier analysis revealed that recurrence of AF after repeated session in the Late‐Group was significantly higher than that in the Early‐Group (log‐rank test: P = 0.010). However, there was no significant difference of AF recurrence after repeated session when the reason of late recurrence of AF was non‐PV foci from superior vena cava (log‐rank test: P = 0.762).

Conclusion

PV reconnection was frequent in the early recurrence cases, while the non‐PV foci was often observed in the late recurrence cases. Non‐PV foci resulted in the poor clinical outcome in late recurrence cases, however non‐PV foci from superior vena cava were curable trigger for AF.

AP19‐00899

Non‐contrast‐enhanced T1‐weighted cardiac magnetic resonance identifies ablation lesion gaps with reversible conduction block after pulmonary vein isolation

Susumu Tao, Michael Guttman, Daniel Herzka, Aravindan Kolandaivelu, Tatsuya Hayashi, Masateru Takigawa, Yoshihide Takahashi, Masahiko Goya, Tetsuo Sasano, Henry Halperin

Tokyo Medical and Dental University, Japan

Shinichi Kurashima, Akihiko Ishida, Yoshiaki Mibiki, Yoshihiro Yamashina, Hirokazu Sato, Takashi Nakagawa, Eiji Sato, Kosuke Aoki, Tetsuo Yagi

Sendai City Hospital, Japan

Introduction

Right middle pulmonary vein (RMPV) is a relatively common pulmonary vein (PV) anomaly and a potential arrhythmogenic source of atrial fibrillation (AF). However, selecting RMPV during cryoballoon procedure (CRYO) is often difficult and poses a risk of phrenic nerve paralysis (PNP) because the phrenic nerve is in front of the right PV. Therefore, this study aimed to validate the usefulness and safety of selective CRYO‐RMPV isolation using the computed tomography (CT)‐fluoroscopy overlay system (EP navigator®).

Methods

In total, 35 consecutive patients who had AF with RMPV, confirmed by 3D‐CT prior to the CRYO, were included in this study. All patients underwent CRYO‐RMPV isolation based on the CT‐ fluoroscopy overlay system. The PVs were considered successfully isolated if (1) the PV potentials recorded by Achieve® during freezing disappeared and (2) no PV potentials were detected by Achieve®. Post‐ablation voltage mapping was performed on a 3D mapping system. During the ablation of the right PVs, we used the compound motor action potential (CMAP) for PNP monitoring by stimulating the phrenic nerve in the superior vena cava using a catheter. Transient PNP was defined as a hemidiaphragm paresis or paralysis detected by decreased CMAP, palpation, and X‐ray during the procedure, which completely resolved before the end of the procedure. Furthermore, persistent PNP was defined as an elevated hemidiaphragm paresis or paralysis that persisted after the procedure.

Result

Guided by the CT‐fluoroscopy overlay system, Achieve® was inserted into the RMPV in all 35 patients. All of the main PVs, including the RMPV, were isolated successfully in all patients. The number of applications owing to RMPV was 1.2 times (1‐5 times). Although transient PNP occurred in one patient (0.3%), persistent PNP did not occur. Post‐ablation map revealed that potentials in carina between the right superior PV and right inferior PV disappeared.

Conclusion

Selective CRYO‐RMPV isolation using the CT‐fluoroscopy overlay system to create a broad isolated region in the right PV is useful and safe for patients with RMPV.

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AP19‐00911

Examination about procedure time, acute phase success rate and 1 year no‐recurrence rate of the second generation Cryoballoon ablation for atrial fibrillation

Fumiya Yoneda, Takashi Yoshizawa, Munekazu Tanaka, Shintaro Yamagami, Takanori Aizawa, Akihiro Komasa, Satoshi Shizuta

Graduate School of Medicine, Kyoto University, Japan

Introduction

The second‐generation Cryoballoon ablation (CBA) for paroxysmal atrial fibrillation (PAF) has widely spread. There are some articles on the learning curve of CBA procedure time, but few articles on acute phase success rate.

Methods

We evaluated retrospectively consecutive 400 patients received CBA from September 2014 to January 2018 at Kyoto University Hospital. The mean age was 67 ± 11 year‐old. There were 140 women (35% of all) and 378 PAF patients (95% of all). The mean diameter of left atrium was 37.5 ± 5.9 mm. We separated those patients to 2 groups: T1; 1 to 200 patients (September 2014‐March 2016) and T2; 201 to 400 patients (March 2016‐January 2018) and compared in both groups. There was no significant difference between the two groups in age (T1:T2 = 67 ± 10: 67 ± 12 year‐old, P = 0.98) and the rate of women (T1:T2 = 33:37%, P = 0.40). The diameter of left atrium was significantly larger in T1 (T1:T2 = 38.6 ± 6.3: 36.3 ± 5.2 mm, P = .0001).

Result

Perioperative procedure time in the left atrium, fluoroscopy time and fluoroscopic dose were significantly shorter in T2 (procedure time in the left atrium T1:T2 = 98 ± 34 mm:82 ± 26 min; P < .001, fluoroscopy time T1:T2 = 57 ± 20 min:42 ± 13 min; P < .001, fluoroscopic dose T1:T2 = 453.7 ± 279.5 mGy: 302.1 ± 229.0 mGy; P < .001). Touch‐up frequency were less in T2 (T1:T2 = 22%:11%; P = .0017). Death and systemic embolism were not occurred in this study. Complications that required treat (acute gastric dilation, cardiac tamponade and vascular event, etc) were 5.3% of all and there was no significant difference between both groups (T1:T2 = 5.5%:5.0%; P = 0.82). There was no significant difference in 1 year no recurrence rate (T1:T2 = 85.1 ± 2.6%: 86.1 ± 2.5% P = 0.9272).

Conclusion

The rate of one‐year success and complication were similar in both groups, but procedure and fluoroscopy time were shorter and the rate of additional touch‐up procedure was lower in T2.

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AP19‐00912

Impact of breast cancer treatment on the development of low voltage areas in patients receiving left atrial catheter ablation

In‐Soo Kim, Jihei Sara Lee, Hee Tae Yu, Tae‐Hoon Kim, Jae Sun Uhm, Boyoung Joung, Moon‐Hyoung Lee, Hui‐Nam Pak

Yonsei University Health System, South Korea

Introduction

The radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) has been known as it can reduce AF burden and improve the left ventricular (LV) ejection fraction (EF). However, it remains to be investigated whether this procedure is also effective in patients with different types of cardiomyopathy, or even in patients with recurrence.

Methods

The 2028 consecutive patients (male 71.8 %, 58.7 ± 11.1 years old, paroxysmal AF 67.9 %), who underwent RFCA for AF, were divided into non‐ischemic/non‐hypertrophic cardiomyopathy (CMP, n = 142), ischemic cardiomyopathy (ICM, n = 37), hypertrophic cardiomyopathy (HCM, n = 60), and patients without cardiomyopathy (no CMP, n = 1879) groups, and their clinical outcomes and 1‐year follow‐up echocardiographic data were compared.

Result

1. Overall, the LVEF was improved in patients with CMP (±EF 9.2 ± 11.1%, P < .001), ICM (±EF 4.6 ± 12.3%, P = .030), and no CMP (±EF 1.0 ± 6.7%, P < .001) group 1‐year after the RFCA. 2. The improvement in LVEF was more profound in the CMP group compared to the ICM or no CMP groups (both P < .01). 3. In CMP group with recurrence within 1‐year after RFCA (n = 49), LVEF and stroke volume were also improved regardless of AF sustainment (P < .05). 4. As a non‐invasive parameter, pre‐ RFCA P‐wave amplitude of lead II on 12‐lead electrocardiogram was independently associated with LVEF improvement (±=65.75, 95% CI 25.83‐105.67, P = .002) in CMP group after adjusting clinical variables.

Conclusion

RFCA of AF improved LVEF and stroke volume even in CMP patients with recurrence within 1‐year after RFCA, and EF improvement was independently associated with pre‐RFCA P‐wave amplitude of lead II on 12‐lead electrocardiogram.

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AP19‐00937

Virtual antiarrhythmic drug tests in computational atrial modeling reflecting patient specific anatomy, histology, and electrophysiology: retrospective feasibility test

In‐Soo Kim, Byounghyun Lim, In‐Suk Hwang, Jae‐Hyuk Kim, Minki Hwang, Ah‐Jin Ryu, Hee Tae Yu, Tae‐Hoon Kim, Boyoung Joung, Moon‐Hyoung Lee, Eun Bo Shim, Hui‐Nam Pak

Yonsei University Health System, South Korea

Introduction

Since cardiac anatomy, histology, and ion channel characteristics differ from patient to patient, thus the effect of antiarrhythmic drug (AAD) is also variable with each patient. We evaluated the feasibility of virtual AAD test (V‐AAD) by utilizing computational atrial modeling in patients with AAD resistant atrial fibrillation (AF).

Methods

We retrospectively conducted V‐AAD in 10 patients (5 male, 59.4 ± 9.5 years old, 70.0% persistent AF) with AAD resistant AF (5 flecainide, 2 amiodarone, 1 sotalol, and 2 dronedarone resistant) who underwent catheter ablation. To conduct realistic V‐AAD, we integrated patients’ cardiac computed tomogram image, endocardial bipolar voltage, fiber orientation, and estimated ion current characteristics to in‐silico modeling of AF. Ion current characteristics were deducted by reverse engineering of rate dependent monophasic action potential duration (MAPD) adaptation. After induction of virtual AF, we conducted dose‐dependent V‐AAD (amiodarone 2 and 10 μM; flecainide 1 and 5 μM; sotalol 1 and 10 μM; dronedarone 3 μM and 7 μM) with observing wave‐dynamics and AF termination.

Result

In this realistic model of AF, spatial distribution of fibrosis was 64.4 ± 9.4%, and AF was induced and maintained >30 seconds in 100.0%. After V‐AAD intervention, AF was terminated by at low‐ doses amiodarone (20.0%), flecainide (10.0%), sotalol (0%), and dronedarone (10.0%), but was terminated at high‐doses amiodarone (60.0%), flecainide (10.0%), sotalol (10.0%), and dronedarone (10.0%), respectively. Correlation rate of clinically resistant AAD with V‐AAD was 80.0%. Patients with Smax higher than 1.0 showed that their clinical findings were well correlated with V‐AAD results. After adding V‐AAD, dominant frequency (DF; 10.2 ± 4.4 Hz to 4.8 ± 1.2 Hz, P < .001), number of phase singularities (PS; 44603.1 ± 51135.9 to 615.2 ± 983.4, P < .001), and maximal slope of restitution (Smax; 2.0 ± 2.2 to 0.5 ± 0.8, P < .001) changed significantly in dose dependent manner.

Conclusion

V‐AAD intervention is feasible in realistic computational modeling of AF that is integrated patient specific atrial anatomy, endocardial voltage, and electrophysiology. V‐AAD clearly shows dose‐dependent antiarrhythmic effects.

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AP19‐00941

Combed using midazolam with sufentanil sedation administered by nurses for patients undergoing catheter ablation for atrial fibrillation

Jinrui Guo

Fuwai Yunnan Cardiovascular Disease Hospital, China

Introduction

Catheter ablation (CA) is an established treatment option for atrial fibrillation (AF). It is required that patients remain in a stable position throughout the procedure to avoid the risk of cardiac perforation, unintended catheter movement, and threedimensional (3D) map shift. Here, we tested the hypothesis that atrial fibrillation ablation can be performed combed using midazolam with sufentanil sedation administered by nurses under a cardiologist's supervision.

Methods

Data of 205 procedures undergoing CA for AF under combed using midazolam with sufentanil sedation were analysed. Sedation protocol is as bellowed. patients were positioned fully recumbent on the catheter laboratory table. Induction of sedation was administered with a bolus of 2 mg midazolam (1 mg if age > 75 years). Sufentanil was administered (a bolus of 0.15ug/kg of body weight) after transseptal puncture. The primary endpoint was respiratory depression resulting in sustained oxygen saturation of < 90% and/or hypotension.

Results

The average age of patients was 66.7 (54.8‐72.6) years and 72% were male. CARTO was provided in all the cases. The average procedure time was 75 ± 12 min. Prior to sedation, the median SBP was 128 (115‐150) mm Hg, and the mean oxygen saturation was 96.2 + 2.5%. Eight patients (3.9%) experienced insufficient oxygenation, but that could be corrected by waking up. All of the 8 patients were older than 75 years. There was no patient has hypotension.

Conclusion

Sedation using midazolam with sufentanil can be safely performed for AF ablation under the supervision of cardiologists. Close oxygen saturation monitoring is required, especially in elderly patients, which carrying a higher risk for respiratory depression.

Keywords: atrial fibrillation, Catheter ablation, Sedation, midazolam, sufentanil

AP19‐00945

Relationship between diameter of circular mapping catheter and detection rate of disappearance of pulmonary vein potential during cryoballoon ablation of atrial fibrillation

Shinya Fujisaki, Yukio Hosaka, Kazuyoshi Takahashi, Keiichi Tsuchida, Komei Tanaka, Yuta Sakaguchi, Kenji Nakano, Norihito Oyanagi, Rie Akagawa, Yuka Sekiya, Masaomi Chinushi, Hirotaka Oda

Niigata City General Hospital, Japan

Introduction

Cryoballoon Ablation (CBA) is efficient for achieving pulmonary vein isolation (PVI) in atrial fibrillation. The time‐to‐isolation [time required till electrical isolation of pulmonary vein (TTI)]‐guided CBA has been reported to be effective and reduce complications. TTI‐guided CBA needs the detection of disappearance of pulmonary vein (PV) potential during CBA. We compared the detection rates of PV potential disappearance between 25 mm and 20 mm circular mapping catheters.

Methods

The cryoballoon was introduced guided by a 20 mm or 25 mm circular mapping catheter. The patients were consecutive 52 patients (208 PVs) who underwent initial CBA at our hospital from May 2018 to June 2019 (ring diameter; 25 mm = 26 cases, 20 mm = 26 cases). We retrospectively examined the disappearance of PV potential during CBA using circular mapping catheters.

Result

There was no difference in left atrial diameter (LAD) or PV diameter in two groups. 1) The disappearance of PV potential during CBA could be detected in 79.8% (25 mm) vs 41.3% (20 mm). The 25 mm mapping catheter demonstrated a significantly higher detection rate of PV potential disappearance than the 20 mm catheter (P < .05). 2) The PV potential detection rate was significantly higher with the 25 mm diameter circular mapping catheter than 20 mm catheter in both patients whose PV diameter is larger and smaller than the average (P < .05). 3) When a 20 mm diameter circular mapping catheter was used, the detection rate of PV potential was significantly higher in patients whose LAD were enlarged than in normal limit (P = .005). However, when the 25 mm diameter circular mapping catheter was used, there was no significant difference between large LAD patients and normal.

Conclusion

The 25 mm circular mapping catheter improved the detection rate of disappearance of PV Potential during CBA of Atrial Fibrillation compared with 20 mm catheter. It might suggest that we could get irreversible PVI with the short cooling time by using 25 mm circular mapping catheter.

AP19‐00946

A case of superior vena cava isolation with longitudinal linear ablation on both sides of the phrenic nerve

Koichiro Yamaoka, Rintaro Hojo, Shihoko Tsujihata, Soichiro Maeda, Kosuke Takeda, Shin Nakamura, Kohei Kawajiri, Sho Tanabe, Tomoyuki Arai, Sayuri Tokioka, Yasuki Koyano, Iwanari Kawamura, Takeshi Kitamura, Seiji Fukamizu

Tokyo Metropolitan Hiroo Hospital, Japan

Kadhim Kadhim, Adrian Elliott, Melissa Middeldorp, Dione Jones, Rajiv Mahajan, Jeroen Hendriks, R. Doug McEvoy, Dennis Lau, Jon Kalman, Prash Sanders, Dominik Linz

Centre for Heart Rhythm Disorders, Australia

Introduction

Sleep‐disordered breathing (SDB) is common in patients with atrial fibrillation (AF) and may be associated with daytime sleepiness. Increased daytime sleepiness can further exacerbate AF symptoms and have a potential negative impact on quality of life for patients. We sought to assess the correlation between self‐reported daytime sleepiness and objective sleep‐related measures of sleep‐ disordered‐breathing in patients with AF.

Methods

Prospectively‐collected data for 442 consecutive AF patients who were considered candidates for rhythm‐control and referred for polysomnography were analysed. Subjective effects of SDB on daytime sleepiness was quantified using the Epworth Sleepiness Scale (ESS, scale 0‐24). Polysomnography‐derived parameters included apnoea hypopnoea index (AHI, /h), total sleep duration (minutes), sleep efficiency (time asleep/time spent in bed, %) and arousal index (arousals/hour) were analysed. SDB severity was classified according to AHI as no SDB (AHI < 5), mild SDB (AHI 5‐14), and moderate‐to‐severe SDB (AHI ≥ 15).

Result

Two‐thirds (66%) of the population had SDB (AHI ≥ 5/h) of whom 56% had paroxysmal AF. Mean age for SDB patients was 62 ± 10 years, mean body mass index was 31.2 ± 5.3 kg/m² and 74% were men. Mean ESS was 6 ± 4 and did not differ as the severity of SDB increased (P = 0.2). There was a poor correlation between ESS and AHI (r = 0.135, P = .012). Patients with moderate‐to‐severe SDB (n = 149, 51%) slept less than those with mild SDB (n = 143, 49%), with total sleep durations of 286 ± 90.5 minutes and 322 ± 74 minutes respectively, P < .001. These patients also slept less efficiently (sleep efficiency: 68 ± 16% vs 73 ± 15%, P = .008), and with higher arousals per hour (arousal index 16.1 ± 6.6/h vs 30.2 ± 17.6, P < .001). However, there was no difference in the reported daytime sleepiness levels (ESS of 5 ± 4 for mild vs 6 ± 4 for moderate‐to‐severe SDB, P = 0.2). The proportion of patients with excessive daytime sleepiness (ESS > 10) did not differ significantly between the groups (9.1% for mild vs 14.8% for moderate‐to‐severe SDB, P = 0.14).

Conclusion

Self‐reported daytime sleepiness correlated poorly with AHI, the standard objective measure of SDB severity. Additionally, patients with more severe SDB had shorter sleeping durations, less efficient sleep and more arousals per hour, yet report no difference in daytime sleepiness. Lack of excessive daytime sleepiness should not preclude patients with AF from being investigated for potential SDB.

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AP19‐00950

The outcomes of preliminary study of peri‐procedural corticosteroid therapy for preventing early recurrence of atrial fibrillation after cryoballoon catheter ablation

Tomohiro Miyata

Osaka Saiseikai Nakatsu Hospital, Japan

Introduction

Cryoballoon (CB) ablation for atrial fibrillation (AF) creates larger lesion in the left atrium (LA) compared to conventional radiofrequency pulmonary vein isolation (PVI). Inflammatory reactions of ablation lesion creation are highly related to early recurrence of AF after catheter ablation. To the date, the effect of corticosteroid therapy on suppressing early recurrence of AF after cryoballoon ablation has not been clear. Therefore, the aim of this study was to investigate the efficacy of peri‐ procedural corticosteroid therapy for preventing early recurrence of AF after cryoballoon catheter ablation.

Methods

A total of 39 consecutive paroxysmal AF patients who underwent PVI using 2nd generation cryoballoon catheter were investigated. CB ablation was performed using standard protocols, freeze of 180 sec or additional 60 sec freeze after electrical PV isolation. Anti‐arrhythmic drugs were continued during 2 months blanking period. Intravenous hydrocortisone (2 mg/kg) was given immediately after CB ablation, and oral prednisolone (0.5 mg/kg/day) administration was followed for 2 days after the PVI in corticosteroid group. The outcomes of early recurrence of AF (AF recurrence ≤ 3 days after ablation and during blanking periods) and inflammatory parameters including body temperature (BT) and serum C‐ reactive protein (CRP) level were compared between patients with or without corticosteroid therapy.

Result

Eleven of 39 patients were received peri‐procedural corticosteroid therapy. Acute electrical isolation of all PVs was achieved in all patients. Number and duration of freeze and the prevalence of non PV AF foci were not different between the groups. The incidence of immediate AF recurrence (≤3 days after ablation) was significantly lower in the corticosteroid group than in the control (0% vs 28%, P = .047). The incidence of adverse event such as procedural complications, infection and digestive ulcer was not different between groups.

Conclusion

Peri‐procedural corticosteroid therapy immediately after CB ablation effectively prevented early recurrence of AF. Further investigation including long‐term outcomes is required to clarify the findings in the present study.

AP19‐00952

Successful cryoablation through inferior vena cava filter

Yu‐Lan Liu, Yuan Hung, Wen‐Yu Lin, Wei‐Shiang Lin

National Defense Medical Center, Taiwan

Introduction

Pulmonary vein (PV) isolation with the second generation cryoballoon is a common and efficient procedure. However, there was limited literature regarding using cryoballoon in a patient with an inferior vena cava (IVC) filter.

Methods

N/A.

Result

A 48‐year‐old man with symptomatic paroxysmal atrial fibrillation (AF) was referred to our institution for cryoablation. He underwent an IVC filter implantation (CelectTM Vena Cava Filter, Cook Medical) 8 years ago because of massive pulmonary embolism caused by deep venous thrombosis. After bilateral femoral venous access was established, an 8‐French transseptal sheath (SwartzTM FasthCath SL1, St. Jude Medical) was passed through the IVC filter without any resistance. Transseptal puncture was performed and we changed the transseptal sheath to a steerable 18‐French sheath (FlexCath Advance™ Steerable Sheath, Medtronic), which was carefully passed through the IVC filter under the guidance of fluoroscopy (Figure 1A). PV isolation was performed with a cryoballoon catheter (Arctic Front Advance Cardiac Cryoablation Catheter system, Medtronic) and all 4 PVs were electrically isolated with no difficulty in manipulating the catheter (Figure 1B). After the procedure was completed, the catheter was withdrawn smoothly and there was no deformity nor displacement of the IVC filter.

Conclusion

There are sporadic cases reported using femoral venous access for diagnostic or therapeutic procedures in patients with IVC filters. This is the first case to our knowledge that successfully perform cryoablation via transfemoral route. We provided this case to strengthen the safety and feasibility of manipulating cryoballoon through an IVC filter in selected cases.

graphic file with name JOA3-35-76-g209.jpg

AP19‐00953

High power short duration radiofrequency ablation for atrial fibrillation

Satoru Komura

Saiseikai Kawaguchi General Hospital, Japan

Introduction

The optimal radiofrequency (RF) power for atrial fibrillation (AF) ablation remain unclear. We evaluated the safety and efficacy of 50W RF power during AF ablation with using Ablation Index (AI).

Methods

we evaluated 17 patients, including 5 patients not using any contact medium, with paroxysmal (n = 3) or persistent (n = 14) AF undergoing initial AF ablation. RF was delivered for reaching AI > 370 at posterior wall and AI > 400 at anterior wall. The part of esophageal were performed by 50W RF ablation within 5 seconds. Internal esophageal temperature was monitored dynamically.

Result

First pass isolations for the left and the right pulmonary veins (PV) were 100% and 82.3%, respectively. The number of RF tags to enclose the PV was 34 ± 9. The time of applying a RF tag was 10.2 ± 3.8 seconds except the part of esophageal. Procedure and PV isolation times were 70.5 ± 12.7 min and 12.0 ± 4.4 min, respectively. There was no adverse event, including pericardial effusion, pericarditis, esophageal injury. Maximum esophageal temperature was 42.6℃, but it fell below 40℃ as 20 seconds passed.

Conclusion

high power short duration RF ablation for AF using AI is safe and effect with a high rate of first pass isolation and short procedure times.

AP19‐00954

A rare case of persistent atrial fibrillation due to atrial myopathy: Not amenable to catheter ablation and cardioversion

Rissa Ummy Setiani, Sunu Budhi Raharjo, Dony Yugo Hermanto, Dicky Armein Hanafy, Yoga Yuniadi

Indonesian Heart Association, Indonesia

Introduction

Atrial myopathy forms the substrate for atrial fibrillation (AF) and underlies the potential for atrial thrombus formation and subsequent stroke. The degree of fibrosis in atrial myopathy has therapeutic implications and associated with the successful outcome of catheter ablation for treatment of AF.

Methods

A 53‐year‐old man presented to outward patient clinic with palpitation and hypertension. There was neither history of infection nor routine medication use in this patient. Upon ECG examination, it was revealed that the patient had persistent atrial fibrillation. Echocardiography showed normal right and left ventricular function and dimensions, and normal heart valves. Coronary CT angiography revealed non‐significant stenosis. The patient underwent radiofrequency catheter ablation using 3D‐ Ensite Precision 2 System. Surprisingly, the voltage mapping in both left and right atrium showed huge scar area in the entire atria. The only region with normal voltage was the LAA area. Circumferential pulmonary veins isolation could not terminate the AF. Therefore, several attempts of pharmacological plus electrical cardioversion were performed, but no single sinus beat was recorded. Then, the procedure was stopped. One month later, LAA closure was performed to prevent thromboembolism in this patient.

Result

Atrial myopathy has been defined as the any complex of structural and electrophysiological changes affecting the atria with the potential to produce clinically‐relevant manifestations. Atrial myopathy has been occured as the result of atrial remodeling process, resulting in atrial myocyte abnormalities and causing fibrosis in patients with AF. Hypertension, diabetes, heart failure, myocarditis, and conditions like ageing and endocrine abnormalities are known to contribute to an atrial myopathy. The extent of atrial myopathy in persistent AF is associated with the successful outcome of catheter ablation for treatment of AF.

Conclusion

We have reported a case of a 53‐year‐old man with persistent atrial fibrillation. Voltage mapping indicated the presence of huge scar regions in the entire atria suggesting an atrial myopathy. Radiofrequency catheter ablation, pharmacological and electrical cardioversion failed to convert the rhythm.

graphic file with name JOA3-35-76-g210.jpg

AP19‐00955

The evaluation of the left atrial roof ablation in addition to pulmonary vein isolation by the cryoballoon application for patients with atrial fibrillation

Fumito Miyoshi, Takahiro Furuya, Miwa Kikuchi, Kaoru Tanno

Showa University Koto Toyosu Hospital, Japan

Introduction

The left atrial (LA) roof ablation in addition to pulmonary vein isolation (PVI) is associated with improved clinical outcomes in patients with atrial fibrillation (AF). However, the feasibility and safety of the LA roof ablation using the cryoballoon has never been fully investigated. This study aimed to evaluate of the LA roof ablation in addition to PVI by the cryoballoon application in patients with AF.

Methods

In our single center retrospective study, a total of 35 consecutive patients (male, n = 21 (60%): mean age, 66 ± 14 years) with paroxysmal or persistent AF (<1‐year duration of single episode) were enrolled. Mean duration of AF was 9.7 ± 15.4 months. Cryoballoon ablation was performed using a 28 mm second generation cryoballoon. The first 20 patients underwent only PVI (PVI alone), and the remaining 15 patients underwent LA roof ablation in addition to PVI (LA roof ablation + PVI).

Result

In total, 8 patients (22.8%) were persistent AF (PVI alone: n = 3 (8.5%), LA roof ablation + PVI: n = 5 (14.4%)). Acute PVI success rate were 100% using an average of 4.7 ± 0.8 cryoballoon applications and 11.5 ± 1.8 minutes of cryoablation, and the average Nadir cryoballoon temperature was ‐49.6 ± 4.3℃ during freezing. Total procedure time and fluoroscopic time for PVI were 2.3 ± 0.4 hours and 33.9 ± 8.5 minutes respectively. No touch up ablations were necessary for PVI. One patient had adverse event of phrenic nerve injury during the right inferior PVI. Acute success in LA roofline generation was achieved in 13 patients (86% acute success rate). The LA roof ablation was achieved using an average of 3.4 ± 1.2 cryoballoon applications and 7.0 ± 2.1 minutes of cryoablation. The average Nadir cryoballoon temperature was ‐44.4 ± 3.7℃ during freezing. Total procedure time and fluoroscopic time for LA roof ablation + PVI were 2.4 ± 0.3 hours and 29.4 ± 9.0 minutes respectively. There were no significant differences in characteristic parameters between success and unsuccess LA roof isolation. Even though the LA roof isolation was unsuccessful, by adding LA roof application, we were able to achieve LA antrum PVI. No adverse events occurred during the LA roof ablation. During a median follow‐up periods of 5.0 ± 3.1 months (short observation period),3 (15%) patients had recurrence of AF in PVI alone group. On the other hand, there has been no AF recurrence in the LA roof ablation + PVI group so far.

Conclusion

The LA roof ablation in addition to PVI can be achieved feasibility and safety using the cryoballoon. This approach may appear superior to PVI alone in patients with AF.

AP19‐00960

Novel risk prediction tool for identifying atrial fibrillation patients with significant sleep‐ disordered breathing

Kadhim Kadhim, Adrian Elliott, Melissa Middeldorp, Jeroen Hendriks, Dian Andina Munawar, Kashif Khokhar, Mehrdad Emami, Rajiv Mahajan, R. Doug McEvoy, Dennis Lau, Prash Sanders, Dominik Linz

Centre for Heart Rhythm Disorders, Australia

Kenichi Tokutake, Michifumi Tokuda, Hidenori Sato, Eri Okajima, Hirotsugu Ikewaki, Hirotsuna Oseto, Masaaki Yokoyama, Ryota Isogai, Kenichi Yokoyama, Mika Kato, Shinichi Tanigawa, Seigo Yamashita, Seiichiro Matsuo, Satoru Miyanaga, Kenichi Sugimoto, Michihiro Yoshimura, Teiichi Yamane

The Jikei University School of Medicine, Japan

Introduction

Cryoballoon ablation is an effective therapy to isolate pulmonary vein (PV). During cryoballoon PV ablation, its influence on structures other than PV remains to be determined. We evaluated the impact on mitral isthmus (MI) conduction after Cryoballoon PV ablation.

Methods

Cryoballoon ablation was performed in 102 patients with atrial fibrillation. Multipolar electrode catheter was positioned in the coronary sinus (CS). Pacing from distal CS, activation of CS was assessed before and after PV isolation. The length of MI was measured on 3D‐computed tomography.

Result

The conduction time from distal CS to proximal CS was prolonged after cryoballoon PV ablation compared with baseline (47.7 ± 11.3 vs 52.5 ± 13.8 milliseconds, P < .001). Conduction block and delay (>10 milliseconds) were observed in 3 (2.9%) and 9 (8.8%) patients, respectively (Figure). The length of MI was shorter in patients with conduction block or delay than those without (23.8 ± 3.0 vs 30.0 ± 7.5 mm, P = .01). Atrial tachycardia after the procedure did not occurred in patients with conduction block or delay.

Conclusion

Cryoballoon left PV ablation can affect the conduction of MI.

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AP19‐00982

Regulation of RNA expression and biomarkers in sinus node dysfunction induced atrial fibrillation in vivo

Seung‐Young Roh, Kwang‐No Lee, Jaemin Shim, Jong‐Il Choi, Young‐Hoon Kim

Korea University Medical Center, Guro Hospital, South Korea

Introduction

The sinus node (SN) is located at the apex of the cardiac conduction system. SN dysfunction, (SND) characterized by electrical remodeling, has usually been attributed to idiopathic fibrosis or ischemic injuries in the SN. SND is associated with increased risk of cardiovascular disorders, including syncope, heart failure, and atrial arrhythmias, particularly atrial fibrillation (AF). One of the histological hallmarks of SND is degenerative atrial remodeling linked with conduction abnormalities and increased right atrial refractoriness. Although SND is frequently accompanied by increased fibrosis in the right atrium (RA), molecular basis thereof remains elusive. Therefore, we aimed to examine whether SND evokes significant molecular changes in the RA that account for structural remodeling.

Methods

For this purpose, we induced cardiac dysfunctions such as bradycardia and atrial fibrosis in a rabbit model of experimental SND, and found that ablation of the SN leads to adverse fibrotic remodeling of the RA regardless of AF. Transcriptome analysis identified differentially expressed gene transcripts in the RA in response to impaired SN function, and accompanying gene enrichment analysis suggested extensive pro‐fibrotic changes including activation of transforming growth factor‐β (TGF‐β) signaling, and alterations in components of the extracellular matrix and their regulators.

Result

Of particular importance, our findings suggested that periostin, a matricellular factor controlling cardiac tissue development, might have a key role in mediating TGF‐β‐signaling–induced aberrant atrial remodeling.

Conclusion

In conclusion, the present study provides valuable information on the molecular signatures underlying the SND‐related atrial remodeling and implies a diagnostic potential of periostin in fibroproliferative cardiac dysfunctions.

AP19‐00983

Atrial Fibrillation is independently associated with the risk of falling & syncope in older patients: A systematic review and meta‐analysis

Varun Malik, Celine Gallagher Gallagher, Dominik Linz, Adrian Elliott, Mehrdad Emami, Ricardo Mishima, Kadhim Kadhim, Jeroen Hendriks, Rajiv Mahajan, Leonard Arnolda, Prashanthan Sanders, Dennis Lau

Royal Adelaide Hopsital, Australia

Kenichi Yokoyama, Seigo Yamashita, Hidenori Sato, Eri Hachisuka, Hirotsuna Ooseto, Masaaki Yokoyama, Ryota Isogai, Kenichi Tokutake, Ryousuke Narui, Mika Kato, Shinichi Tanigawa, Michifumi Tokuda, Seiichiro Matsuo, Satoru Miyanaga, Kenichi Sugimoto, Michihiro Yoshimura, Teiichi Yamane

JIkei University School of Medicine, Japan

Introduction

Although adenosine is useful to reveal dormant conduction (DC) after pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients, the differences of its incidence among different ablation devices are not thoroughly investigated.

Methods

A total of 499 paroxysmal AF patients who underwent the initial PVI (irrigated‐ radiofrequency; RF, n = 224, cryoballoon; CB, n = 221, hotballoon; HB, n = 40 and laserballoon; LB, n = 14) were included. Adenosine was injected under isoproterenol infusion to reveal DC after PVI in all patients. We compared the incidence of DC among 4 different ablation devices.

Result

Adenosine‐induced DC was observed in 50%, 10%, 35% and 0% of patients, and 21%, 3%, 12% and 0% of PVs in RF, CB, HB and LB, respectively. The incidence of DC was significantly lower in CB and LB compared to RF and HB (Figure).

Conclusion

CB and LB demonstrated extremely lower incidence of DC compared with RF and HB, which may indicate higher durability of PVI with CB and LB ablation. Further investigation will be needed to clarify its relation to the clinical outcomes.

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AP19‐01003

The impact of body weight and diabetes on new‐onset atrial fibrillation: A nationwide population based study

Kiyung Boo, Jong‐Il Choi, Ha Young Choi, Yun Young Choi, Do Young Kim, Yun Gi Kim, Kwang‐No Lee, Jaemin Shim, Jin Seok Kim, Kyung‐Do Han, Young‐Hoon Kim

Korea University Medical Center, South Korea

Patients with hyperthyroidism can develop a life threatening complication called thyroid storm or crisis, requiring urgent therapy with beta blockers, antithyroid medication and iodine. Patients with hyperthyroidism can develop a life threatening complication called thyroid storm or crisis. AF and atrial flutter management presents unique challenges in patients with associated hyperthyroidism. The usual guidelines should be followed except that efforts to restore sinus rhythm are ordinarily delayed until the patient is euthyroid. This reduces the likelihood of the rhythm reverting to atrial fibrillation. The principle objectives in treating atrial fibrillation associated with hyperthyroidism are rate control, prevention of thromboembolism, and restoration of sinus rhythm. But unfortunately, even we already followed the guideline, the patient still have a refractory arrhythmia.

Conclusion

AF in hyperthyroid patient is a challenging case. In unstable AF condition, electrical cardioversion is mandatory even in our case the result is unsatisfactory.

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AP19‐01068

Changes in haemodynamic parameters during pulmonary vein isolation using cryo‐balloon in patients with paroxysmal atrial fibrillation

Mohammad Alasti, Emily Kotschet, Logan Bittinger, Stewart Healy, David Adam, Jeffrey Alison

Australia

Introduction

Pulmonary vein isolation (PVI) is the most common ablation strategy in patients with symptomatic paroxysmal atrial fibrillation (PAF). The aim of this study was the evaluation of changes in haemodynamic parameters during PVI in comparison to slow pathway ablation.

Methods

We recruited patients with PAF who were candidates of pulmonary vein isolation using cryo‐ balloon, and patients with atrioventricular reentrant tachycardia (AVNRT) for radio‐frequency ablation. Finapres NOVA system was used to measure and record heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), stroke volume (SV), cardiac output (CO), inter‐beat interval (IBI), stroke volume index (SVI), cardiac output index (COI), dP/dT, systolic blood pressure index (SBPI), diastolic blood pressure index (DBPI) and rate pressure product (RPP) during the procedure. Ablation was performed with conscious sedation in all patients. All patients had successful pulmonary vein isolation and slow pathway ablation without any complications.

Result

Twenty patients with PAF during pulmonary vein isolation using cryo‐balloon (mean age: 59.5 ± 6.9 years) were compared to ten patients during AVNRT ablation (mean age: 55.6 ± 17 years). During PVI, mean RPP decreased from 8027 mm Hg/min to 6816 mm Hg/min, then increased to 9032 mm Hg/min at the end; mean dP/dT rose from 896 mm Hg/s to 1478 mm Hg/s while other parameters including HR and IBI did not change significantly. In comparison, during SVT ablation, mean HR, mean SV, mean SVI, mean CO, mean COI and mean RPP increased and IBI diminished (from 1185 milliseconds to 815 milliseconds) , whilst mean dP/dP did not alter significantly. Moreover, we observed vagal reaction in 6 (30%) patients during PVI, while there was none in patients during SVT ablation.

Conclusion

Our data shows that PVI using cryo‐balloon causes different haemodynamic changes in comparison to AVNRT ablation. Vagal stimulation is postulated to be the main mechanism of these haemodynamic changes during PVI.

Key words: Cryo‐balloon, Haemodynamic parameter, Pulmonary vein isolation, Vagal reaction

AP19‐01069

The association between left atrial strain and left atrial voltage in patients undergoing catheter ablation for atrial fibrillation

Yuya Takahashi, Takanori Yamaguchi, Takayuki Kitai, Tomohiko Watanabe, Koichi Node, Tsutomu Fujita

Cardiovascular Medicine Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Japan

Celine Gallagher, Christopher X Wong, Jeroen M Hendriks, Jana M Bednarz, Adrian D Elliott, Dominik Linz, Melissa E Middeldorp, Rajiv Mahajan, Dennis H Lau, Prashanthan Sanders

University of Adelaide, Australia

Introduction

Atrial fibrillation (AF) is associated with significant health care burden. Hospitalisations are the main driver of health care resource utilisation and cost in AF. Consistent predictors of AF related emergency department (ED) presentations and hospitalisations have not been well characterised. The aim of this study is to characterise predictors of repeat ED presentations and hospital admissions in a cohort of individuals with AF.

Methods

Individuals presenting to the ED of three major tertiary centres in Adelaide, South Australia from March 2013 to March 2014 with a primary diagnosis of AF, were screened by electronic health records. Clinical, socio‐demographic and other variables, including the provision of advice to manage future AF episodes and referral to a cardiologist for follow up care, were collected to identify predictors of repeat AF related ED presentations and hospital admissions.

Result

The study cohort comprised of 437 individuals with an AF related index presentation. Mean age was 69 ± 15 years and 49.9% were male. Individuals were followed for a mean of 3.7 ± 0.4 years to determine reasons for re‐presentation to hospital. There were 2304 repeat unplanned presentations that occurred during follow up. The index presentation to ED with AF resulted in admission to hospital in 72.3% of cases. AF accounted for 21% of all repeat hospital admissions, with 17% attributable to other cardiovascular causes and 62% of all hospital admissions over follow up due to other causes. Multivariate analysis did not identify any demographic or clinical factors predictive of re‐presentation to hospital. The presence of non‐standardised advice to manage future AF episodes (“AF action plan”) was associated with a significant increase in the risk of repeat ED presentations (Odds Ratio [OR] 6.7, 95% confidence interval [CI] 2.4‐18.3; P < .0001), and hospital admissions for AF (OR 2.8, 95% CI 1.00‐7.63; P = .05; see Table).

Conclusion

A hospital presentation with a primary diagnosis of AF identifies individuals who pose significant health care burden. Non‐standardised advice to manage future episodes of AF is associated with an increased risk of ED re‐presentation and hospital admission for AF. Further research is required to understand this finding. This data supports the need for structured comprehensive interventions targeted at improving patient education and self‐management strategies to reduce the growing tide of AF related health care burden.

Predictors of repeat AF related hospital admissions

Predictor	Univariable			Multivariable
Predictor	Odds Ratio	(95% CI)	P‐value	Odds Ratio	(95% CI)	P‐value
Male	0.92	(0.61‐1.39)	.70	1.10	(0.57‐2.11)	.77
Age at index presentation, per year increase	1.30	(1.01‐1.68)	.04	1.01	(0.97‐1.05)	.62
Heart failure	0.82	(0.44‐1.50)	.51	0.82	(0.33‐2.04)	.67
Hypertension	2.22	(1.45‐3.39)	<.01	1.59	(0.73‐3.50)	.25
Diabetes	1.56	(0.93‐2.63)	.09	1.43	(0.65‐3.15)	.38
Prior stroke/TIA/TE	1.38	(0.73‐2.59)	.32	1.06	(0.34‐3.36)	.92
AF action plan	2.11	(0.85‐5.23)	.10	2.76	(1.00‐7.63)	.05
Cardiologist referral	1.04	(0.67‐1.62)	.86	1.52	(0.88‐2.62)	.14
Index presentation CHA2DS2‐VASc score, per unit increase	1.18	(1.06‐1.32)	<.01	0.96	(0.63‐1.47)	.85

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AP19‐01110

A transient drop in blood pressure upon deflation after cryoballoon pulmonary vein isolation indicates successful ablation

Mena Yacoub

Tampa Bay Heart Institute, USA

Introduction

Cryoballoon ablation is an effective method of pulmonary vein isolation as treatment for atrial fibrillation. Since continuous recording of pulmonary vein potentials is not always possible during Cryoballoon ablation, correlates are often relied upon to determine successful isolation. We noted that immediately upon deflation after ablation, vagal response, defined as a transient drop in blood pressure, would at times occur. Accordingly, we sought to determine if a vagal response was a reliable marker for successful cryoballoon ablation.

Methods

We recorded the drop in systolic blood pressure that occurred immediately after deflation of the balloon in 88 pulmonary veins (22 LSPV/22 LIPV/22 RIPV/22 RSPV) in 22 consecutive patients (11 M/11F), with mean age 70 (IQR 52‐86) years. We tested if a vagal response, defined as a drop in blood pressure of > 20 mm Hg, was correlated with gender, age, left atrial pressure, a specific pulmonary vein or nadir temperature (NT) of < ‐50 C (a measure of successful cryoballoon ablation).

Result

151 applications of cryoballoon ablation were delivered to 88 pulmonary veins. All veins achieved isolation. Cryoballoon temperatures ranged from ‐35 C to ‐72 C (mean ‐53.3 C). Females experienced a vagal response more often than males (31/44 veins (71%) vs 21/44 veins (47%), P = .03). Older age was also associated with a vagal response (mean age with vagal response 72y vs 67y, SEM 1.02, P = .03). The degree of drop in blood pressure (r = .187, P = .04), and nadir temperatures were associated with a vagal response. Specifically, balloon temperatures below ‐50 C correlated with achieving a vagal response (OR 2.45, P = .003), implying it was an accurate marker for pulmonary vein isolation success. There was no relationship between vagal response and left atrial pressure on a continuous scale (P = .211), or to superior vs inferior PV (13/22 vs 13/22, P = 1.0) and left vs right PV (13/22 vs 12/22, P = .67).

Conclusion

A transient drop in blood pressure upon deflation after cryoballoon ablation correlates with nadir temperature, especially if < ‐50C, indicating successfulIy pulmonary vein isolation. Vagal response is more prevalent in females, and older age, but not related to left atrial pressure, and is not associated with any particular pulmonary vein.

AP19‐01115

Clinical impact of acute termination as an endpoint for induced tachyarrhythmia after pulmonary vein isolation in paroxysmal atrial fibrillation

Ju Yeol Baek, Young Choi, Sung‐Hwan Kim, Sun Hwa Kim, Ju Youn Kim, Tae‐Seok Kim, Ji‐Hoon Kim, Sung‐Won Jang, Man Young Lee, Yong‐Seog Oh

Seoul St. Mary's hospital, Catholic university Seoul, Korea, South Korea

Introduction

The effect of additional substrate modification for inducible atrial arrhythmia after pulmonary vein isolation (PVI) during radiofrequency catheter ablation (RFCA) of paroxysmal atrial fibrillation (PAF) in reducing the incidence of recurrent atrial arrhythmia is controversial. We sought to assess the impact of procedural termination of inducible atrial arrhythmia after PVI in comparison with PVI alone and failed termination of inducible atrial arrhythmia after PVI.

Methods

Among patients who underwent RFCA for PAF, we enrolled 149 patients who were in sinus rhythm after PVI (PVI alone), 169 patients who achieved termination of inducible atrial arrhythmia after pulmonary‐vein isolation (TIAA), and 27 patients who failed to terminate inducible atrial arrhythmia after PVI (non‐TIAA). The incidence of recurrent atrial arrhythmia were compared between the three groups. The primary end point was 3‐year atrial arrhythmia freedom after a single ablation procedure. The secondary endpoints were all‐cause death and stroke.

Result

After 3 years, 74.9% of patients in PVI alone group were free from recurrent atrial arrhythmia, as compared with 66.8% of patients in TIAA and 71.4% of patients in Non‐TIAA group (log rank, P = 0.51). There were also no significant differences among the three groups for the secondary end points. Procedure time was significantly longer in non‐TIAA group than in the other two groups (P = .028) and fluoroscopy time was shortest in the patients with PVI alone (P = .013)

Conclusion

Acute termination of induced atrial arrhythmia after PVI of PAF would not provide an additional benefit of reducing recurrence compared to PVI alone or failed termination of inducible atrial tachyarrhythmia after PVI. Therefore, the termination of inducible atrial tachyarrhythmia may not be a reliable strategy for the endpoint during substrate modification after PVI in the patients with PAF.

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AP19‐01116

Cryoablation for paroxysmal atrial fibrillation: Procedure success and recurrence rate at 12 months follow‐up

Sein Khine, Jemelee Hernandez, Tan Nee Hooi, Tan Boon Yew, Ho Kah Leng, Chong Thuan Tee Daniel, Teo Wee Siong, Chua Chi Ming Kelvin, Lim Chun Yin Paul, Lim Tien Siang Eric, Ching Chi Keong

National Heart Centre Singapore, Singapore

Introduction

Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation in patients with paroxysmal atrial fibrillation. Cryoballoon ablation is recently introduced for PVI with shorter procedural times, lower rates of pulmonary vein stenosis. However, freedom from recurrence atrial fibrillation (AF) after cryoballoon ablation remains a matter of interest. We reported AF free rate at 3 months and 12 months after cryoballoon ablation in this study.

Methods

Patients with paroxysmal atrial fibrillation (PAF) who underwent PVI with cryoballoon ablation at National Heart Centre Singapore between March 2017 and January 2019 were included. Clinical parameters including duration of symptoms, left ventricular function, left atrial volume index and procedure details were reported. Patients were followed for recurrence by means of holter, electrocardiogram, and symptoms at follow up.

Result

A total of 33 patients were recruited with a mean age of 60 ± 9 years and 60% was male. Median duration of symptoms before ablation was 12 months (Interquartile range 3 months to 21 months). Mean left ventricular ejection fraction was 60 ± 6%. Mean left atrium volume index was 33 ± 11 mL/m². 10 patients (30%) presented with AF to cath lab, of which 7 patients were restored to sinus rhythm after PVI. 3 patients needed DC cardioversion. Lowest achieved mean cryoballoon temperature during ablation were ‐52 ± 4C at left superior pulmonary vein (LSPV), ‐46 ± 6C at left inferior pulmonary vein (LIPV), ‐53 ± 3C at right superior pulmonary vein (RSPV), and ‐47 ± 6C at right inferior pulmonary vein (RIPV). Mean number of freeze cycles were 2.5 ± 0.7 cycles for LSPV and LIPV, 2.6 ± 1.1 for RSPV and 2.9 ± 1.1 for RIPV. Acute PVI was achieved in 79% of patients with cryoballoon ablation. With adjuvant radiofrequency ablation, up to 97% of patients achieved acute PVI. In this study, adjuvant radiofrequency ablation was required in 30% (n = 10) for the following: cavotricuspid isthmus ablation (n = 5), complex fractionated atrial electrograms ablation (n = 2), RIPV isolation (n = 1), premature atrial complex ablation (n = 1), and concomitant atrioventricular nodal reentry tachycardia (n = 1). Total ablation time was 2166 ± 1164 seconds. Mean procedure time was 185 ± 59 minutes. Mean fluoroscopy time was 53 ± 20 minutes. There were no phrenic nerve injury in this series. One patient sustained transient ST elevation in inferior lead presumably due to air embolism. This resolved spontaneously without any clinical sequelae. The 3 months AF free rate was 85% and 12 months AF free rate was 60%.

Conclusion

Cryoballoon ablation is a safe and suitable alternative energy for pulmonary vein isolation. Recurrence of AF about 40% at 1 year follow up.

AP19‐01119

Effect of radiofrequency catheter ablation of atrial fibrillation on the clinical outcome in patients with implantable cardioverter defibrillator

Sukkyu Oh

Korea University Medical Center, South Korea

Introduction

Atrial fibrillation (AF) is common trigger for inappropriate shock in implantable cardioverter‐defibrillator (ICD) implant patient well. We aimed to investigate the effect of radiofrequency catheter ablation (RFCA) of AF on clinical outcome and on the parameters of ICD interrogation, i.e., inappropriate shock, anti‐tachycardia pacing (ATP) and misinterpretation as ventricular arrhythmia in AF patients.

Methods

We retrospectively analyzed ICD implanted patients with preexisting AF in a single institute between July 1998 and September 2018. Total 79 ICD implant patients with AF were enrolled. We analyzed ICD interrogation data and compared clinical outcome according to whether RFCA was implemented.

Result

Mean age was 65.4 ± 12.4 years and median follow was 41 months. Secondary prevention of sudden cardiac death was more common (60.8%). In RFCA group, patients were younger than no RFCA group (58.0 ± 12.9 vs 67.9 ± 11.2, P = .005) and paroxysmal AF was more common (70.0% vs 47.5%, P = .081). There was no significant difference in mortality and any hospitalization. However, in RFCA group, there were significant differences after RFCA in any event at interrogation (45.0% vs 76.3%, P = .009) and tendency to decreased inappropriate shock (0% vs 13.6%, P = .082) and misinterpretation as ventricular arrhythmia (10.0% vs 31.5%, P = .089)

Conclusion

In ICD implant patient with AF, RFCA of AF did not improve mortality, but reduced unwanted or inappropriate events in ICD and minimized misinterpretation as ventricular arrhythmia.

TABLE Baseline characteristics and clinical outcome according to RFCA implementation

Total (n=79)	RFCA (n=20)	No RFCA (n=59)	P value
Age (year)	65.4±12.4	58.0±12.9	67.9±11.2	.005
Gender (Male)	56 (70.9%)	17 (85.1%)	39 (66.1%)	.108
Median follow up (month)
All period	41	85	36
After RFCA	37	50	36
AF type	.081
Paroxysmal AF	42 (53.2%)	14 (70.0%)	28 (47.5%)
Persistent AF	37 (46.8%)	6 (30.0%)	31 (52.5%)
Indication	.327
Primary prevention	31 (39.2%)	6 (30.0%)	25 (42.4%)
Secondary prevention	48 (60.8%)	14 (70.0%)	34 (57.6%)
CHA2DS2‐VASc score	2.8 ± 1.7	1.5±1.2	3.25±1.6	<.001
Anti‐arrhythmic drug	44 (55.7%)	11 (55.0%)	33 (55.9%)	.942
Death	13 (16.5%)	2 (10.0%)	11 (18.6%)	.368
Any hospitalization	64 (81.0%)	19 (95.0%)	45 (76.3%)	.065
Any event at interrogation
All period	61 (77.2%)	16 (80.0%)	45 (76.3%)	.731
After RFCA period	54 (68.4%)	9 (45.0%)	45 (76.3%)	.009
Any shock	22 (27.8%)	5 (25%)	17 (28.8%)	.742
Appropriate shock	13 (16.5%)	2 (10.0%)	11 (18.6%)	.368
Inappropriate shock
All period	11 (13.9%)	3 (15.0%)	8 (13.6%)	.872
After RFCA period	8 (12.7%)	0 (0%)	8 (13.6%)	.082
Anti‐tachycardia pacing (ATP)	12 (15.2%)	2 (10.0%)	10 (16.9%)	.454
Appropriate ATP	9 (11.4%)	1 (5.0%)	8 (13.6%)	.298
Inappropriate ATP
All period	6 (7.6%)	1 (5.0%)	5 (8.5%)	.612
After RFCA period	5 (6.3%)	0 (0%)	5 (8.5%)	.179
Misinterpretation as ventricular arrhythmia
All period	23 (31.9%)	6 (33.3%)	17 (31.5%)	.884
After RFCA period	19 (24.1%)	2 (10.0%)	17 (31.5%)	.089

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AP19‐01120

Gender specific long term multiprocedural outcome after catheter ablation for persistent Atrial fibrillation. Time to close the gender gap

Hariharan Sugumar, Shane Nanayakkara, David Chieng, Geoffrey R Wong, Ramanathan Parameswaran, Robert Anderson, Ahmed Al‐Kaisey, Chrishan J Nalliah, Sonia Azzopardi, Geoffrey Lee, Alex J McLellan, Liang‐Han Ling, Joseph Morton, Jonathan M Kalman, Peter M Kistler

Alfred Health , Australia

Introduction

Despite increasing number of ablations performed for persistent atrial fibrillation (AF), even with multiple procedures, arrhythmia outcomes continue to remain suboptimal. Whether repeat ablation procedure improves arrhythmia outcomes in the female population with persistent AF (PsAF) compared to men is not well understood.

Methods

We conducted a large scale multicentre long‐term observational study with prospective follow up evaluating multiprocedural long term arrhythmia outcomes in people with PsAF undergoing catheter ablations.

Result

From a total of 4,089 patients undergoing AF ablation at 4 sites, 281 patients had more than one ablation procedure for PsAF and were included in the analysis. Eighty‐six (30.6%) were women. Female gender (HR 2.16 P < .001) and enduring pulmonary vein isolation (HR 1.66 P = .01) were independently associated with AF recurrence.

Conclusion

Female gender is a strong and independent predictor of arrhythmia recurrence in people with persistent AF despite multiple ablation procedures.

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AP19‐01123

Simplified fluoroless catheter ablation of atrial fibrillation: A single center experience

Ruhong Jiang, Chenyang Jiang

Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China

Introduction

Zero or reduced X‐ray exposure during atrial fibrillation (AF) ablation has been pursued in the 3D era. This study aims to access the feasibility of a simplified fluoroless approach of AF ablation by using intracardiac echocardiography (ICE) and Cartosound™ system (Biosense‐Webster, Diamond Bar, CA, USA).

Methods

All geometries of the right atrium (RA), coronary sinus, left atrium, pulmonary vein, left atrial appendage, and esophagus were constructed via a SOUNDSTAR catheter (Biosense‐Webster). Fluoroless transseptal puncture was performed under ICE guidance. Pulmonary vein isolation (PVI) was performed with a contact‐force sensing catheter in all patients, guided by ablation index.

Result

From January 2019 to July 2019, 86 atrial fibrillation patients with a mean age of 66 ± 12 years, 58% male, 74% paroxysmal AF were included. All geometries were obtained in 23 ± 12 minutes before transseptal puncture. PV isolation was achieved in all patients. Mean total procedure time was 170 ± 44 minutes and mean RF time was 36 ± 16 minutes. No fluoroscopy was used in 51% of patients, while 6.8 (3.8‐14.7) minutes was used in 49% of patients due to the learning curve. One patient was observed with a moderate pericardial effusion that was managed conservatively with pericardiocentesis and drainage.

Conclusion

Simplified fluoroless catheter ablation of AF is safely feasible using a combination of ICE and Cartosound mapping system.

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AP19‐01127

Tailoring of ablation index based on left atrial wall thickness improves efficacy of pulmonary vein isolation in atrial fibrillation

Yuji Motoike, Harada Masahide, Yoshihiro Nomura, Asuka Nishimura, Masayuki Koshikawa, Eiichi Watanabe, Yukio Ozaki

Fujita Health University, Japan

Introduction

Ablation index (AI), incorporates contact force, time, and radiofrequency energy in a weighted formula, and linearly correlated with the lesion depth. Since wall thickness (WT) in the left atrial (LA)/pulmonary vein (PV) surrounding area is anatomically heterogeneous, AI should be tailored in accordance with the WT to yield the best therapeutic performance in catheter ablation for atrial fibrillation (AF). The aim of this study was to evaluate the efficacy of PV isolation (PVI) using AI tailored by individual WT.

Methods

In 43 patients undergoing PVI, regional WTs (anterior, posterior, roof, and bottom) in the LA/PV surrounding area were measured with intra‐cardiac echocardiography (ICE) placed in the LA: average WT was calculated in each region. PVI was performed with the two different AI protocol, fixed AI protocol (FAI) and tailored AI protocol (TAI). In FAI, the maximum AI (530) was applied to the PV anterior wall (the thickest wall) and the values were decreased corresponding to average WT in each region (AI = 480, 420, and 450 for roof, posterior, and bottom, respectively, n = 23). In TAI, AI in each region was tailored by the regional WT measured by ICE in each patient (n = 10); the efficacy of PVI was compared between FAI and TAI.

Result

WTs in the anterior, roof, posterior, and bottom of the left PV were 7.1 ± 0.8, 6.2 ± 1.2, 5.1 ± 0.9, and 5.8 ± 1.3 mm, respectively. Similarly, those of the right‐PV were 6.5 ± 1.8, 6.3 ± 1.5, 5.1 ± 1.3, and 4.3 ± 0.7 mm, respectively. The rate of first‐pass isolation was similar between FAI and TAI (91% and 95% respectively). The percentage of residual PV gap/potential and/or acute PV reconnection after isoproterenol/adenosine triphosphate infusion was also unchanged between TAI and FAI (15% and 15% respectively). Procedure time for PVI significantly decreased in TAI vs FAI (by 19%, P = .02).

Conclusion

WTs in the LA/PV surrounding area were heterogeneous. Tailoring AI by individual WTs improve the efficacy of PVI by shortening the procedure time.

AP19‐01128

Left atrial appendage volume measured by multi‐detector computed tomography predicts long term outcome following atrial fibrillation ablation

Do Young Kim, Jong‐Il Choi, Ha Young Choi, Yun Young Choi, Ki Yung Boo, Yun Gi Kim, Kwang‐No Lee, Dae In Lee, Jaemin Shim, Young‐Hoon Kim

Korea University Anam Hospital, South Korea

Introduction

Left atrial (LA) volume multi‐detector computed tomography (MDCT) is useful in predicting prognosis of atrial fibrillation (AF) following catheter ablation. However, there is limited data regarding role of Left atrial appendage (LAA) volume using MDCT for risk stratification of AF recurrence after catheter ablation.

Methods

Consecutive 287 patients who underwent catheter ablations for AF and MDCT prior to the ablation were retrospectively enrolled from K. Circumferential PV isolation was performed guided by electroanatomical mapping system and additional ablation lesions were made at the discretion of the operators. To determine optimal cut‐off value for predicting recurrence, Receiver operating characteristic (ROC) curve analysis was performed.

Result

During a mean follow‐up of 5.75 years, The AF recurrence was documented in 109 patients (37.9%). LA volume index (LAVI; 46.9[36.8‐55.7] vs 52[41.2‐66.5]; P = .001) and LAA volume index (LAAVI; 4.9[3.5‐6.0] vs, 5.8[4.3‐7.3]; P = .005) were significantly larger in the recurrence group. ROC curve analysis showed that LAAVI of 5.75 mL/m³ and LAVI of 63.35 mL/m³ were optimal cut‐off values for predicting recurrence of AF, respectively. In the Kaplan Meier analysis, Patient who had both LAVI and LAAVI greater than the cut‐off value showed the highest recurrence rate of AF recurrence following catheter ablation. The predicting model using both LAVI and LAAVI yielded time‐dependent C‐index of 0.64 at 1 year after catheter ablation and 0.62 at 3 years following catheter ablation. Multivariate logistic regression showed that LAA volume index was an independent predictor of AF recurrence with an adjusted HR of 1.10 for every 1 mL/m² increase (95% confidence interval 1.01‐1.22).

Conclusion

In corporate with LAVI assessment, LAAVI measurement can be useful for predicting AF recurrence among AF patients who underwent catheter ablation.

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AP19‐01129

Dabigatran bridging therapy during hospitalization for atrial fibrillation ablation is safety

Kentaro Adachi, Shinji Kaneko, Ryota Ito, Yoshinori Shirai, Htomi Hori, Tomoaki Haga, Yosuke Tatami, Masaya Fujita, Taiki Ohashi, Ryuji Kubota, Masanori Shinoda

Toyota Kosei Hospital, Japan

Introduction

Direct oral anticoagulants (DOAC) is essential for patient with atrial fibrillation (Af) ablation, however there is a risk of hemorrhagic complications. Only Dabigatran has antagonist among DOAC. The aim of this study was to investigate the safety of Dabigatran bridging therapy during hospitalization for Af ablation.

Methods

We evaluated consecutive 530 patients who were underwent catheter ablation for Af between May 2017 and October 2018 in our institute. And we exclude 108 patients who were prescribed Dabigatran or Warfarin on an outpatient basis and 75 patients who could not replace prescribed Edoxaban, Rivaroxaban or Apixaban with Dabigatran because of age or creatinine clearance (CCR). We enrolled 347 patients in this study. We divided them into 2 groups (Dabigatran bridging group and non‐ bridging group). Dabigatran bridging group, we replaced Edoxaban, Rivaroxaban or Apixaban with Dabigatran for two days from the operation day (N = 236). And non‐bridging group, we continue Edoxaban, Rivaroxaban or Apixaban (N = 111). The end point was hemorrhagic complication and thromboembolic event including cerebral infarction.

Result

There was no significant difference in Baseline Characteristics. The mean age was 67.8 years in Dabigatran bridging group vs 65.6 years in non‐bridging group (P = .058), CHADS2 score was 1.47 vs 1.39 (P = .500), HAS‐BLED score was 1.63 vs 1.47 (P = .245), operation time was 1.86 h vs 1.81 h (P = .464), atrial diameter was 41.9 mm vs 41.3 mm (P = .471), respectively. In bridging group, 121 patients was prescribed Dabigatran 220 mg (51.3%) and 115 patients was prescribed Dabigatran 300 mg (48.7%). Hemorrhagic complication rate was 2.88% (2 cardiac tamponade, 5 arterial pseudo‐aneurysm, 3 femoral artery hematoma) and 1.69% in Dabigatran bridging group vs 5.40% in non‐bridging group (P = .054), respectively. There was no thromboembolic event in both group.

Conclusion

We demonstrated Dabigatran bridging therapy without increasing thromboembolic complication. Our findings suggest that Dabigatran bridging therapy has the advantage when unexpected adverse bleedings occurred, because of existence rapidly effective antagonist.

AP19‐01132

Transient ST‐T segment depression and its recovery after catheter ablation are associated with lower recurrence rate in persistent atrial fibrillation

Yoshihiro Nomura, Masahide Harada, Ryo Nagasaka, Asuka Nishimura, Yuji Motoike, Masayuki Koshikawa, Eiichi Watanabe, Yukio Ozaki

Fujita Health University, Japan

Seong‐Huan Choi, Yong‐Soo Baek, Jin‐Hee Park, Sung Woo Kwon, Gwang‐Seok Yoon, Seong‐Ill Woo, Dae‐Hyeok Kim, Jun Kwan, Suh Joon LEE, Sang‐Don Park

Inha University Hospital, South Korea

Introduction

Vitamin K antagonist (warfarin) and Non‐Vitamin K antagonist (NOAC) are widely used for anticoagulation. There have been many reports of vasculopathy in Vitamin K antagonist. However data for NOAC is lacking. Our aim is to investigate the incidence of angina, myocardiac infarction (MI) and chronic kidney disease (CKD) in patients who were on either warfarin or NOAC.

Methods

We enrolled 31,721 consecutive patients who were diagnosed with AF and treated for anti‐ coagulation from the national Sample Cohort released by the National Health Insurance Service in Korea. 19,110 patients were on warfarin and 12,611 patients were on NOAC. These two groups were matched using propensity scoring method to adjust relevant risk factors including age, sex, co‐morbidities and CHA2DS2‐VASc score.

Result

We used propensity matched analysis (1:1) to match age, sex, previous history of stoke, diabetes mellitus, hypertension and CHAD2Vasc score. There were no significant difference in baseline characteristics between the two groups. Kaplan‐Meier estimates showed that warfarin group had higher incidence of CKD whereas for angina episodes and MI there were no significant difference between the two groups (Figure. 1). Multivariate analysis adjusted for clinical variables showed that warfarin group were at higher risk of CKD (OR: 0.56, 95% CI, 0.47‐0.67, P < .001).

Conclusion

Warfarin group had higher risk of CKD compared to NOAC group. Our data suggests that NOAC may have contributed beneficially with respect to lowering risk of adverse renal outcome compared to warfarin.

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AP19‐01144

Hadrianus Sinaga Hospital Registry on Atrial Fibrillation

Arthur Monang Kharisma, Blessdova Hutabarat

Indonesian Doctor Association, Indonesia

Introduction

Atrial fibrillation (AF) is the most common arrhythmia of clinical significance. AF is associated with increased morbidity, especially stroke and heart failure, and increased mortality. Thus, with the aging of the population and improved survival after the occurrence of myocardial infarction and CHF, AF is emerging as a major public health concern. Observational study like registry is a very effective tool to observe the course of the disease and evaluate the effectiveness and safety of the treatment and identify other variant of clinic occurrence. Therefore, registry of AF is very important. However, the registry of AF is not available in North Sumatera Province. We started to collect data in Hadrianus Sinaga hospital, located in the remote area of North Sumatera that have limited source of treatment and diagnostic tools. This registry has a purpose to identify AF diagnosis and treatment in this hospital and evaluate the obedience to clinic guideline.

Methods

This was a descriptive observational study in Hadrianus Sinaga Hospital, North Sumatera, Indonesia. This study was done from November 2018 – July 2019. We collect data from patient that willing to be followed up for 24 months. We use CHA2DS2‐VASc score and ATRIA score to evaluate the treatment of AF patients. Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study group described a new bleeding risk scheme for AF, which includes five weighted risk factors: anemia, severe renal disease, age ≥ 75 years, previous hemorrhage, and diagnosed hypertension.

Result

Until July 2019, we had collected data from 25 patients. From 25 patients, all patients (100%) came to hospital with symptom. Most of the symptom was breathlessness (15 patients/60%), followed by palpitation (5 patients/20%), dizziness (3 patients/12%), and chest pain (2 patients/8%). The majority of AF patients that came to hospital was persistent AF (16 patients/64%), followed by long standing persistent (5 patients/20%), permanent AF (2 patients/8%), and paroxysmal type of AF (2 patients/8%). The classification of AF patients based on ATRIA score showed that the biggest proportion is patient with ATRIA score < 4 (18 patients/76,2%), followed score 3 (4 patients/14,3%) and score > 4 (3 patients/9,5%). The proportion of female patients that has CHA2DS2‐VASc score > 3 and got therapy of anticoagulant is 11 patients (91.7%). The proportion of male patients that has CHA2DS2‐VASc score > 2 and got therapy of anticoagulant is 10 patients (76.9%).

Conclusion

Hadrianus Sinaga Hospital registry showed that most of patients that came to the hospital is patient AF with symptomatic with the biggest proportion of persistent AF. Most of the patients that include criteria got therapy according the guideline of AF treatment for stroke prevention.

TABLE 1 Classification of AF patients based on CHA2DS2‐VASc score

CHA2DS2‐VASc	Frequency	Percentage (%)
0	0	0
1	1	4
2	7	28
3	11	44
4	6	24
5	0	0
6	0	0
7	0	0
8	0	0
9	0	0
Total	25	100

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TABLE 2 Classification of AF patients based on ATRIA SCORE CHA2DS2‐VASc score

ATRIA SCORE	Frequency	Percentage (%)
< 4	18	72
4	4	16
>4	3	12
Total	25	100

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TABLE 3 Classification of AF patients based on CHA2DS2‐VASc score and gender

Gender
CHA2DS2‐VASc score	Male		Female
CHA2DS2‐VASc score	Frequency	Percentage (%)	Frequency	Percentage (%)
0	0	0	0	0
1	0	0	1	8,3
2	4	30,7	3	0,25
3	6	46,2	5	41,7
4	3	23,1	3	0,25
5	0	0	0	0
6	0	0	0	0
7	0	0	0	0
8	0	0	0	0
9	0	0	0	0
Total	13	100	12	100

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AP19‐01146

Long‐term follow‐up results of circumferential pulmonary vein isolation plus ganglionated plexus ablation for patients with atrial fibrillation

Ruxia Zhang

Jincheng People's Hospital, China

Introduction

To investigate whether the addition of ganglionated plexus ablation on the basis of circumferential pulmonary vein isolation can improve the long‐term successful rate of catheter ablation in patients with atrial fibrillation (AF).

Methods

From March 2011 to December 2012, 226 patients with paroxysmal or persistent AF who received radiofrequency catheter ablation for the first time in our hospital were reviewed. 123 cases were treated with CPVI (CPVI group)and 103 cases with CPVI plus GP (CPVI+GP group). The date of age, sex, type of atrial fibrillation and left atrial size were collected and compared. All patients were followed up at 3 months, 6 months, 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years and 4 years after operation. To compare the difference of the successful rate of operation between CPVI and CPVI +GP groups.

Result

Among 226 patients with AF undergoing catheter ablation for the first time, persistent AF accounted for 32.7%, hypertension accounted for 62.8%, diabetes accounted for 21.2%, coronary heart disease accounted for 21.7%, stroke history accounted for 7.5%. The successful rate of operation 3 months after operation was 92.7% in CPVI group and 91.3% in CPVI+GP group, respectively, P = 0.807; at 6 months, 75.6% in CPVI group, 89.3% in CPVI +GP group, P = .009; at 1 year, 70.7% in CPVI group, 82.5% in CPVI + GP group,P = .043; at 1.5 years, 65.0% in CPVI group, 77.7% in CPVI + GP group, P = .041; at 2 years, 56.1% in CPVI group, 68.9% in CPVI + GP group, P = .032; at 2.5 years, 48.8% in CPVI group , 66.0% in CPVI + GP group, P = .011; at 3 years, 42.3% in CPVI group, 63.1% in CPVI + GP group, P = .002; at 3.5 years, 39.0% in CPVI group, 61.2% in CPVI + GP group, P = .001; at 4 years, 32.5% in CPVI group, 58.3% in CPVI + GP group, P < .001. The results showed that there was no significant difference in the successful rate of operation between the two groups in 3 months after operation, but the successful rate of operation in CPVI+GP group was significantly higher than that in CPVI+GP group at 6 months, 1 year, 1.5 years, 2 years, 2.5 years, 3 years, 3.5 years, respectively. Subgroup analysis is shown in the attachment.

Conclusion

Compared with simple circumferential pulmonary vein isolation, the long‐term successful rate of single time ablation in patients with paroxysmal or persistent AF can be further improved by circumferential pulmonary vein isolation plus ganglion ablation. Although additional ganglion ablation may prolong ablation time, X‐ray exposure time and total operative time, it does not increase serious ablation‐related complications.

Keywords: atrial fibrillation, pulmonary vein, ganglionated plexus, ablation, isolation

AP19‐01147

Prognostic impact of early sinus rhythm restoration in critically ill patients with atrial fibrillation

JinHee Park

Inha University Hospital, South Korea

Wendy Wiharja

Universitas Pelita Harapan, Indonesia

Introduction

Dengue fever (DF) is highly prevalent in Indonesia as evidenced by 129,650 cases in 2015. Atrial fibrillation (AF) in dengue is exceptionally rare and usually self‐limiting with resolution after recovery of illness. The aim of this case report is to depict two patients with AF in DF which resolves spontaneously in one and persists after infection in the other

Methods

CASE ILLUSTRATION Case 1 was 50 years old male presented with fever since 4 days before admission. NS1 antigen and IgM anti‐Dengue virus were positive. An electrocardiogram (ECG) showed AF with rapid ventricular response (AFRVR). Case 2 was 53 years old male presented with dyspnea and palpitations 1 hour before admission. Patient had fever since 5 days before admission. Laboratory exams showed leukopenia, thrombocytopenia and positive IgM anti‐Dengue virus. An electrocardiogram showed AFRVR. Intravenous fluids (normal saline), paracetamol, and digoxin were administered in both patients. They were admitted for close monitoring. Pre‐discharge ECG of Case 1 showed resolution of AF. However Case 2, AF persists in pre‐discharge ECG.

Result

DISCUSSION The patients with dengue hemorrhagic fever and dengue shock syndrome have higher level of TNF‐α, IL‐6, IL‐13 and IL‐18, and cytotoxic factor which cause direct infection of cardiac muscle and trigger arrhythmias.. The diagnosis of DHF in the first patient was confirmed by evidence of fever, rashes, thrombocytopenia, leucopenia, hemoconcentration, with positive serological tests. While diagnosis of DF in the second patient was established by the presence of fever, leucopenia, thrombocytopenia and positive serological test. Anticoagulant was not given in acute phase in both patients because of high risk of bleeding in DF and DHF. Digoxin was given as a rate control in both patients. Chemical cardioversion was not attempted, preferring observation, hoping spontaneous conversion into sinus rhythm after resolution of DF and avoiding potential embolization that may result from formation of thrombus in left atrium since onset of AF is unknown (may be > 48 hours). Fortunately, AF spontaneously resolve in the first patient indicating that there was no further intervention needed besides a stricter control of blood pressure. However, in second case AF does not resolve by itself, anticoagulation should be continued 3 weeks after discharge with close follow‐up whether the ECG persisted and needs cardioversion by direct current or chemical cardioversion to prevent complications arising from AF. It might not be always as ‘self‐limiting’ as it thought to be.

Conclusion

In conclusion, physicians should be aware that a potentially reversible atrial fibrillation might be caused by this infection. It should be ensured that in those persisting cases, they should not be dismissed as just an ‘irreversible’ AF and progress into full‐blown heart failure

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AP19‐01170

Ablation of Atrial tachycardia with multiple reentrant rings in right Atrial cardiomyopathy without history of surgery or ablation by an ultra‐high‐density mapping system

Kang Li, Jing Zhou, Yansheng Ding

Peking University First Hospital, China

Introduction

There are usually three types of atrial scar: cardiac surgical incision, catheter ablation scar and spontaneous scar. Atrial scarring can lead to scar‐related reentrant atrial tachycardia (AT). Atrial spontaneous scarring combined with reentrant AT can cause atrial cardiomyopathy. Intracardiac mapping can detect scarring and multiple reentrances, and the complex electrophysiological mechanism, ablation and long‐term prognosis of these patients are still few reported.

Methods

A 68 years old Female patient with persistent AT for at least 4 months, who had no history of cardiac surgery or catheter ablation, was found to have spontaneous scars in the right atrium, variable tachycardia circumference and multiple reentry rings using Orion basket catheter and Rhythmia™ system (Boston Scientific, MA, USA).

Result

AT ECGs of the patient are shown in Figure 1. In the process of Orion mapping, The atrial tachycardia changed repeatedly (Figure 2). The substrate of the free wall of the right atrium was complex, and there were many scars. When the catheter touched the free wall of the right atrium, it was easy to change the tachycardia cycle length (TCL). Which strategy to choose: (1) Traditional entrainment?: TCL changed as soon as the catheter touch; (2) Substrate mapping?: large area of low voltage ; (3) Activation mapping?: changeful sequence and TCL, multiple maps alternate; (4) Ablation of tricuspid isthmus?: activation mapping does not accord with the typical atrial flutter. We decided to conduct right atrial substrate modification first ‐‐ linear ablation of right atrial free wall scar to inferior vena cava. After that, the AT tends to be stable, with the TCL of about 300 milliseconds (Figure 3). Activation mapping suggested that there were three small scars in the free wall of right atrium. There was no potential in the scar area. Fragmentation potential could be seen at the edge of the scar area, and a small local reentry was formed around the scar (Figure 4). The tachycardia was terminated by the ablation discharge from the scar to the previous modified ablation line. Continuous ablation to connect the first ablation line constitutes a conduction barrier and verifies the blockade. Then, we continue to ablate the isthmus of tricuspid annulus to prevent typical atrial flutter (Figure 5), and revalidate the block after ablation with proximal coronary sinus pacing. No tachycardia recurrence was found after more than 3 months follow‐up.

Conclusion

The mechanism of persistent atrial tachycardia in patient with right atrial cardiomyopathy is complex. Typical atrial flutter associated with tricuspid annulus isthmus and Large reentry ring related to spontaneous atrial scar, coexist to form complex reentry. Local scar can also lead to micro‐reentry. To locate and ablate the critical isthmus of the reentry ring is most important.

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Conclusion

Warfarin confers stroke prevention in patients with CHA2DS2‐VASc ≥ 1 and non–self‐ limiting AF. In our patient, CHA2DS2‐VASc score was 3 (Hypertension, Female Gender, and DMT2) and HAS‐BLED score was 1 (Hypertension), this condition was a candidate for using of anti‐coagulant for preventing stroke in AF related Hyperthyroidism.

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AP19‐01188

Comparison of AV nodal ablation with pulmonary‐vein isolation ablation as the suggestive rhythm control therapy for patient with atrial fibrillation in heart failure

Jeremiah Suwandi, Bertha Bertha, Nixie Elvaretta Liono, Audrey Hadisurya, Sabrina Agatha Jean Aswan, Wendy Wiharja

Universitas Pelita Harapan, Indonesia

Introduction

Prevalence of Atrial Fibrillation (AF) in modern Heart Failure (HF) ranges from 13%‐27%. AFFIRM investigator showed that the presence of sinus rhythm through rhythm control or rate control was associated with significantly improved survival. The aim of this case report is to give a comparing description between AV‐Node Ablation and Pulmonary‐vein Isolation as alternative rhythm control therapies for the patient with AF in HF.

Methods

A 56 y.o Male presented with shortness of breath, orthopnea, nocturnal dyspnea, and palpitation worsening since 2 days ago. The patient had hypertension since 5 years ago, and consumes oral irbesartan 150 mg regularly. On the physical examination: BP (130/80), Pulse (112x/min‐ irregular), RR (28x/min), bilateral rhonchi on base of the lung, and bilateral pitting edema on ankles. Chest X‐ray showed Cardiomegaly, Echocardiography showed EF 30%, Electrocardiography showed AF Rapid Ventricular Response. The patient was treated with Furosemide, and Digoxin as the initial treatments.

Result

In this case, patient came with symptomatic AF, NYHA Class 3&4, and EF < 40%, rhythm control was advocated. The pathophysiologic changes in patients with HF and AF were alterations in neurohormonal activation, electrophysiologic parameters, and mechanical factors conspire to create an environment in which HF predisposes to AF and AF exacerbates HF. A Radiofrequency ablation therapy can be done using 2 methods; they are AV Node Ablation and Pulmonary‐vein Isolation ablation. A study showed superiority of using Pulmonary‐vein isolation ablation than AV node ablation, with end point of 6 months follow‐up, higher EF (35 ± 9% vs 28 ± 6%, P < .001), better walking distance (340 ± 49 m vs 297 ± 36 m, P < .001), better MLWHF score (60 ± 8 vs 82 ± 14, P < .001), and freedom from atrial fibrillation was seen in 88% of patients regardless of the use of antiarrhythmic medications and in 71% without the use of antiarrhythmic medications and with the use of at least one repeat procedure.

Conclusion

Even though, there were alternatives in treating AF that occurred in HF patient, catheter ablation is considered to have better outcomes than anti‐arrhythmic drugs. A study showed superiority of using Pulmonary‐vein isolation ablation than AV node ablation, made this method could be suggested as a rhythm control therapy for the patient.

Keywords: Atrial Fibrillation, Heart Failure, AV node Ablation, PV Ablation, comparison study

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AP19‐01192

Atrial fibrillation in the patient with acute coronary syndrome: How should it be managed? (case report)

Jeremiah Suwandi, Bertha Bertha, Nixie Elvaretta Liono, Audrey Hadisurya, Sabrina Agatha Jean Aswan, Wendy Wiharja

Universitas Pelita Harapan, Indonesia

Masato Okada, Koji Tanaka, Toshinari Onishi, Takafumi Oka, Yuko Hirao, Nobuaki Tanaka, Issei Yoshimoto, Ryo Kitagaki, Yasushi Koyama, Atsunori Okamura, Katsuomi Iwakura, Kenshi Fujii, Koichi Inoue

Sakurabashi Watanabe Hospital, Japan

Introduction

Successful restoration of sinus rhythm (SR) by catheter ablation (CA) for persistent atrial fibrillation (AF) improves cardiac function, resulting in decrease of plasma brain natriuretic peptide (BNP) level. The exact significance and prognostic implications of this change have yet to be determined. The purpose of this study was to examine the impact of pre‐ and post‐procedural BNP level on the clinical outcome after CA in patients with persistent AF and reduced left ventricular ejection fraction (LVEF).

Methods

Out of 242 patients with LVEF < 50% who underwent first‐time CA for persistent AF between March 2012 and September 2018 at our institute, we enrolled 137 patients (61 ± 10 years, 83% male) whose plasma BNP level was available both at baseline and early after CA (during 1‐3 month). We evaluated the impact of the BNP levels on future AF recurrence 3 months after CA as the primary endpoint. Additional secondary endpoints included heart failure (HF) hospitalization and cardiovascular death.

Result

All patients successfully restored SR at the end of CA. Within 3 months of a blanking period (BP), improvement of LVEF (from 39 ± 10% to 65 ± 12%, P < .001) and reduction of BNP levels (from 178 [107‐332] pg/mL to 42.3 [21.1‐78.6] pg/mL, P < .001) were observed. During the median follow‐up of 21 months after BP, the incidence of AF recurrence, HF hospitalization, and cardiovascular death was 37% (n = 50), 3% (n = 4), and 1% (n = 1), respectively. Cox proportional hazard regression analysis after adjustment for age and gender revealed that post‐procedural BNP level was a significant predictor of the AF recurrence (hazard ratio [HR] per 100‐pg/mL increase, 1.13; 95% confidence interval [CI], 1.02‐1.25; P = .023), but pre‐procedural BNP level was not (1.02; 0.95‐1.09; P = 0.56). Receiver operating curve analysis determined the post‐procedural BNP level of 55.5 pg/mL as the best cut‐off value for predicting the AF recurrence, with area under the curve of 0.620 (95%CI, 0.534‐0.702; P = .018). The incidence of AF recurrence was significantly higher in patients with post‐procedural BNP level > 55.5 pg/mL (n = 50) than the others (50% vs 29%; HR, 3.99; 95% CI, 2.07‐7.68; P < .001). No patients with post‐ procedural BNP level ≤ 55.5 pg/mL experienced HF hospitalization and cardiovascular death (8% vs 0% and 2% vs 0%, P = .006 and P = 0.17, respectively).

Conclusion

Not pre‐procedural but post‐procedural BNP level early after CA predicted the future clinical outcome in patients with persistent AF and reduced LVEF. Decreased but still elevated BNP level after restoration of SR would identify the residual risk for developing unfavorable outcome.

AP19‐01214

Extent of self‐adjustment to atrial fibrillation determines suitability of an aggressive sinus maintenance therapy in long‐persistent atrial fibrillation patients.

Toka Hamaguchi, Tetsuya Haruna, Tomoari Kuriyama, Mitsuki Kimura, Shuji NIshiwaki, Moriaki Inoko

Kitano Hospital, Japan

Introduction

Lately, catheter ablation (RFCA) was performed even for persistent atrial fibrillation (AF). However, sinus rhythm (SR) maintenance rate of RFCA for persistent AF varied. Accordingly, the suitability of RFCA for persistent‐AF remained to be studied. Perpetuation of AF can lead to deterioration in heart condition. However, a large number of persistent‐AF patients become less symptomatic even though AF continues. Furthermore, the adverse impact of new onset AF on congestive heart failure is reported to cease in approximately 2 years. This suggests that some suitable self‐ adjustment to AF exists. We investigated the extent of the self‐adjustment to AF by measuring exercise capacity (EC) before and after SR maintenance by RFCA. We sought to clarify whether the extent of self‐adjustment could help in determining the suitability of RFCA for persistent‐AF.

Methods

Two hundred consecutive persistent‐AF patients (>6 months) referred for catheter ablation and evaluated for EC before the procedure (male: 155, female: 45). Cardiopulmonary exercise test (CPX) was performed to measure peak Oxygen intake (PVO) at baseline. %PVO was calculated by standardizing PVO to age and gender. During catheter ablation, a Swan‐Ganz catheter study was performed before and after defibrillation. Four PVI with or without additional procedures were performed. After > 6 months SR‐maintenance, CPX was repeated.

Result

%PVO varied from 38 to 175% before RFCA. Out of 200 patients, 156 obtained > 6 months SR‐maintenance and undertook CPX again. Changes in %PVO2 ranged from ‐28% to 126% (median: 8.3%). According to multi‐regression analysis of relationship between changes in %PVO and clinical parameters, persistent‐AF patients with lower %PVO before RFCA (t = ‐4.92, P < .001) and greater difference in heart rate (HR) from at rest to peak during repeated CPX (t = 5.92, P < .001), obtained larger improvement in EC through SR‐maintenance. In particular, %PVO before RFCA was the sole predictor of change in EC after SR‐maintenance. Accordingly, we considered %PVO before RFCA as the most reliable indicator of extent of self‐adjustment to AF in persistent‐AF patients. Furthermore, when we determined the suitability of RFCA for long persistent‐AF patients, we need to recognize that chronotropic incompetence in SR can lead to insufficient recovery of EC after SR‐maintenance in long persistent‐AF patients.

Conclusion

The extent to which persistent‐AF patients could or could not adjust to AF helps in evaluating the significance of SR‐maintenance and determining the suitability of aggressive SR‐ maintenance therapy by RFCA.

AP19‐01220

Nonspecific intraventricular conduction delay is associated with future occurrence of atrial fibrillation in patients with structurally normal heart and sinus rhythm

Jae‐Sun Uhm, Moo‐Nyun Jin, In‐Soo Kim, Min Kim, Hee Tae Yu, Tae‐Hoon Kim, Jong‐Youn Kim, Boyoung Joung, Hui‐Nam Pak, Moon‐Hyoung Lee

Severance Hospital, South Korea

Introduction

We aimed to elucidate the long‐term prognosis of nonspecific intraventricular conduction delay (NIVCD) in patients with structurally normal heart.

Methods

We included 107,838 patients (age, 52.1 ± 15.5 years; men, 46.8%) who underwent electrocardiography in outpatient clinics (unmatched cohort). NIVCD was defined as QRS duration ≥ 110 milliseconds without meeting the criteria for bundle branch block. Five hundred ninety‐eight patients with structurally normal heart and sinus rhythm were assigned to the NIVCD and normal QRS groups according to propensity score with matching variables of age, sex, hypertension, diabetes, and PR interval (matched cohort). Baseline characteristics, electrocardiographic parameters, and clinical outcomes were compared in the cohorts.

Result

In the unmatched cohort, the NIVCD group exhibited the significantly higher frequencies of male sex and preexisting atrial fibrillation (AF), slower sinus rate and longer PR interval than the normal QRS group. In the matched cohort, the cumulative incidence of AF was significantly higher in the NIVCD group than in the normal QRS group during a follow‐up period of 8.8 ± 2.9 years. NIVCD significantly increased the risk for AF (hazard ratio, 2.571; 95% confidence interval, 1.074–6.156; P = .034).

Conclusion

NIVCD is associated with future occurrence of AF in patients with structurally normal heart.

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AP19‐01228

Identification of critical isthmus by coherence map in atypical atrial flutter with multiple reentrant circuits

Shin‐Huei Liu, Jennifer Jeanne B. Vicera, Po ‐ Tseng Lee, Yenn‐Jiang Lin, Shih‐Lin Chang, Li‐Wei Lo, Yu‐Feng Hu, Fa‐Po Chung, Tze‐Fan Chao, Jo‐Nan Liao, Ting‐Yung Chang, Chin‐Yu Lin, Da‐Chyuan Duan, Cheng‐I Wu, Chih‐Min Liu, Wen‐Han Cheng, Shih‐Ann Chen

Taipei Veterans General Hospital, Taiwan

Introduction

Identifying the critical isthmus of atypical atrial flutter (AFL) in standard activation map is difficult, especially with substrate disease. The Coherence map excludes the limitations of early meets late in standard activation map in cases with non‐conducting scars. Objective: This study aimed to investigate and compare the difference of critical isthmus between the novel Coherence map and standard activation map.

Methods

Twenty‐one patients with clinically documented atypical AFL were investigated, including 9 patients with structural heart disease and 18 patients underwent previous ablation (Table 1). Standard activation map and Coherence map were complete using PentaRay mapping catheter and Carto 3.0 System Version 7 (Biosense Webster, Inc.). Conduction barriers were defined by velocity = 0 m/s and critical isthmus (CI) was defined by concealed entrainment (post‐pacing interval < 20 milliseconds), conduction velocity < 0.3 m/s and local fractionated electrograms.

Result

A total of 29 CIs were identified from 21 patients (58.6 ± 8.96y/o; 16 male) (Table 1, Figure 1). Eleven patients had single loop reentry and 10 patients had multiple loop reentry. The length of the isthmus showed no difference between activation and Coherence map, but the width of the isthmus was narrower measured by the Coherence map than by standard activation map (16.37 ± 10.17 mm vs 22.68 ± 7.80 mm, P = 0.552) (Table 2). The TCL was significantly longer in multiple loop reentry AFL in comparison with single loop reentry (291.00 ± 49.90 vs 281.33 ± 28.98, P = .045) (Table 3). The isthmus velocity between single and multiple loop reentry showed no difference (0.68 ± 0.24 vs 0.33 ± 0.21, P = 0.878). The isthmus length showed no difference between single and multiple loop reentry, but the isthmus width in the multiple loop reentry was significantly narrower than the single loop reentry (10.68 ± 1.17 vs 17.80 ± 9.69, P = .039) (Table 3).

Conclusion

The Coherence map identifies the CI more clearly which enables less extensive ablation in comparison with standard activation map in scar‐related reentrant tachycardias. By eliminating the limitations of early‐meets‐late in standard activation map, the scar‐related circuits can be precisely terminated.

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TABLE 1 Critical isthmus characteristics

Case	Isthmus Voltage(mV)	Isthmus in Coherence Map			EntranceVelocity (m/s)	Isthmus Velocity(m/s)	Exit Velocity(m/s)
Case	Isthmus Voltage(mV)	Length (mm)	Width (mm)	Area (cm2)	EntranceVelocity (m/s)	Isthmus Velocity(m/s)	Exit Velocity(m/s)
1	0.85	19.7	11.1	2.6	0.95	0.55	1.375
2	0.61	11.2	9.6	1	1.05	0.625	1.87
3	0.17	15.2	7.2	1.1	1.33	0.426	1.21
4	0.15	7	28.3	1.3	1.01	0.72	0.86
5	0.34	17.8	13.1	2.3	1.26	0.149	2.21
6	0.49	12.6	5.4	0.68	1.56	0.16	0.23
7	0.15	23.9	11.6	2.7	0.32	0.18	0.19
8	0.85	12.5	9.6	1.2	0.21	0.12	0.51
9	2.62	52.3	35	18.3	1.11	0.88	0.58
10	0.54	26	13.7	3.5	0.50	0.12	1.71
11	0.04	15.6	13.3	20.7	0.25	0.16	0.35
12	0.23	72	39.4	28.3	1.85	0.23	0.76
13	0.22	23.1	18.4	4.2	0.36	0.3	0.7
14	0.12	35	6.4	2.2	1.93	0.11	1.96
15	1.87	15.9	14.7	2.3	0.61	0.19	0.46
16	0.52	33	21.4	7.0	1.7	0.33	0.63
17	0.1	21.1	15.3	3.2	1.23	0.58	3.7
18	0.84	24.3	15.4	3.7	0.38	0.29	1.55
19	0.35	21.1	7.7	1.6	1.98	0.13	0.79
20	0.42	20.3	10.1	2.0	0.78	0.19	0.73
21	0.34	33.1	37	12.2	0.72	0.42	2.5

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TABLE 2 Measurement of isthmus in conventional activation map and coherence map

Activation	Coherence	P value
Length (mm)	17.78 ±11.16	24.41 ±14.84	0.608
Width (mm)	22.68 ±7.80	16.37 ±10.17	0.552

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TABLE 3 Measurement of isthmus in single and multiple loop reentry

Single loop	Multiple loop	P value
Cycle Length (ms)	281.33 ±28.98	291.00 ±49.90	.045
Velocity (m/s)	0.68 ±0.24	0.33 ±0.21	.878
Length (mm)	12.07 ±4.43	17.15 ±4.08	.800
Width (mm)	17.80 ±9.69	10.68 ±1.17	.039

High density mapping using HD Grid catheters can identify specific conduction gaps between left atrium and pulmonary veins. When pacing at different sites and cycle lengths, anisotropic conduction gaps could be revealed. It has a notable value in planning ablation approach to eliminate conduction gaps after PVI.

TABLE 1 Patient characteristics and ablation results

Cases	Age	Gender	AF types	Ablation sites	Conduction gaps	Final inducibility
1	60	male	Paroxysmal	PVI	Presence	Negative
2	61	male	Paroxysmal	PVI and CTI	Absence	Negative
3	32	male	Paroxysmal	PVI and CTI	Presence	Negative
4	45	male	Persistent	PVI, roof line, mitral isthmus line,LA posterior box isolation and CTI	Presence	Positive(non‐sustained AF)
5	55	male	Persistent	PVI and CFAE ablation atantero‐septum of LA, posterior wall near RIPV and posterior wall near mitral isthmus	Presence	Negative
6	66	female	Paroxysmal	PVI and CTI	Presence	Negative
7	58	male	Paroxysmal	PVI and CTI	Presence	Negative
8	70	female	Paroxysmal	PVI and CTI	Presence	Negative
9	57	female	Paroxysmal	PVI and CTI	Absence	Negative
10	63	male	Paroxysmal	PVI and CTI	Presence	Negative

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AF: atrial fibrillation, CFAE: complex fractionated atrial electrogram, CTI: cavo‐tricuspid isthmus, LA: left atrium, PVI: pulmonary vein isolation, RIPV: right inferior pulmonary vein.

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AP19‐01243

Results of atrial fibrillation screening in primary care setting in an urban cohort in north India

Wasim Rashid, Vipul Gupta, Aparna Jaswal, Anil Saxena, Amitesh Chakravarty

Fortis Escorts Heart Institute, India

Introduction

Atrial fibrillation (AF) is the most common sustained clinical arrhythmia with immense public health importance. There is paucity of prevalence data about AF in India. This study aimed to screen the presence of AF in patients presenting to a primary care clinic.

Methods

This was a prospective, observational study conducted over a period of one year from June 2018 to May 2019. 1500 consecutive patients were presenting to a primary care clinic in New Delhi were screened for presence of AF using 12 lead ECG after obtaining proper informed consent. Baseline data like height, weight, age, sex and presence of comorbidities like hypertension, diabetes and presence of known rheumatic heart disease (RHD) was taken after a comprehensive history and physical examination. The data was compiled in Microsoft Excel and statistics was done using SPSS V 19 (IBM).

Result

The mean age of patients screened was 53.8 ± 14.98 years and a mean BMI of 25.7 ± 5.63 kg/m². 823 (54.9%) patients were male. Out of 1500 patients screened 25 had ECG documented AF (prevalence of 1.7%). The mean age of patients with AF was 61.8 ± 15.80 years. 94 (6.3%) patients had known RHD, 703 (46.9%) were diabetics and 1043 (69.3%) had hypertension. Out of 25 patients with AF, 9 (36%) had history of rheumatic heart disease and 21 (84%) had hypertension. The mean age of patients with RHD was 51.8 ± 16.29 years compared to 63.9 ± 14.9 years in those with non‐valvular AF.

Conclusion

AF prevalence in this primary care cohort was 1.7%. Hypertension was the most common comorbidity followed by rheumatic heart disease. Valvular AF presented a decade earlier than valvular AF.

AP19‐01246

Is transesophageal echocardiography the “Gold Standard” to guide LAAO? The feasibility and benefits of LAAO workflow with CartoSound versus TEE: a pilot study

Fang‐Yi Xiao, Yi‐He Chen, Liang‐Guo Wang, Wei‐Jian Huang

The First Affiliated Hospital of Wenzhou Medical University, China

Introduction

Transesophageal echocardiography (TEE) plays an important role in left atrial appendage occlusion (LAAO) procedure which is considered as the “gold standard” to assess the implant device position and peri‐device flow currently. In recent years, the efficacy and safety has been demonstrated in clinical trials that LAAO can be performed under local anesthesia guided by intracardiac echocardiography (ICE). However, there's no standard workflow for comprehensive measurement and assessment using ICE technology. This study is intended to develop an optimized manipulation workflow for ICE use in LAAO procedure, compared with TEE.

Methods

This was a single‐center, cohort study. 80 patients undergoing LAAO with LAmbre device in the First Affiliated Hospital of Wenzhou Medical University from January 2018 to July 2019 were enrolled. CartoSound (CS) guided LAAO (CS group)were performed under the local anesthesia (n = 40 including 23 cases with combined catheter ablation and LAAO). TEE guided LAAO ( TEE group) were also performed under the local anesthesia (n = 40, including 23 cases with combined catheter ablation and LAAO) . Another 10 more procedures were guided by CS and TEE simultaneously. CS guided LAAO from left atrium applied “FLAVOR” approach (Four Long Axis Views Surround Orifice) under Carto3 navigation system.

Result

Clinical characteristics were comparable between the 2 groups. In TEE group, 40% of the cases could not show satisfactory long axis view of device at 135°, while in CS group, the long axis views with four angles of device were successfully gained in all the cases. Of the other 10 cases, simultaneously evaluated by both CS and TEE during procedure, 2‐dimensional TEE failed to identify the leak due to inability to display the long axis view at 135° in 2 cases, however, the leak was clearly showed by CS at 45°. All procedures were successfully completed. There were no statistically significant differences in device exchange rate and periprocedural complications. The fluoroscopic time, radiation dose and contrast usage in CS group were significantly reduced compared with TEE group (P < .01). There was no statistical difference in procedure time between the two groups. There was no significant difference in peri‐device flow ratio between the two groups in 45 days follow‐up with TEE examination.

Conclusion

Compared with TEE, ICE guided LAAO appears to be effective and safe and without increased procedure‐related complications. ICE with “ FLAVOR” approach can be more accurately to evaluate the location of implant device and peri‐device flow. It also significantly reduces radiation dose, fluoroscopic time , contrast usage. ICE may be a promising imaging tool to guide LAAO under local anesthesia.

AP19‐01249

Catheter ABlation of LOw VOltage regions in the treatment of persistent Atrial Fibrillation (ABLOVO‐AF study) – A single centre experience

Dimitrios Panagopoulos, Szabolcs Z. Nagy, Steven Kim, Chris Cantwell, Vishal Luther, Louisa Malcolme‐Lawes, Kevin Leong, David C. Lefroy, Nick F. Linton, Zachary I. Whinnett, Fu Siong Ng, Michael Koa‐Wing, Wyn Davies, Prapa Kanagaratnam, Nicholas S. Peters, Norman A. Qureshi, Phang Boon Lim, Smaragda Lampridou

Imperial College, UK

Introduction

Treatment of Persistent Atrial Fibrillation (PsAF) remains challenging with the optimal ablative approach unclear, largely due to poor understanding of mechanistic triggers and propagators of AF maintenance. Emerging evidence suggests that targeting arrhythmogenic substrate in areas of atrial fibrosis may be beneficial, as AF drivers may be harboured within these regions. DECAAF II will be assessing a MRI‐DE guided approach to identifying and ablating these areas of fibrosis. We have recently described a novel evaluation of AF voltage which correlates better with MRI‐DE defined scar than sinus rhythm voltage. We evaluated the clinical efficacy of additional ablation of low voltage regions mapped in AF, in conjunction with PVI, in patients undergoing catheter ablation for PsAF and present a single centre case series.

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Introduction

The first‐in‐human RADIANCE study demonstrated feasibility of a novel multielectrode RF balloon catheter (RFB) with 10 irrigated, flexible gold surface electrodes to directionally‐tailor energy delivery for PVI. The aim of the multicenter single‐arm SHINE study was to evaluate safety and clinical efficacy of the RFB when used in conjunction with a circular mapping catheter.

Methods

95 patients (age 60.3 ± 9,81 yrs, 64.2% male) underwent PVI at 6 centres using the RFB, in conjunction with the 10‐pole 3Fr circular catheter to provide real‐time PV electrograms (Figure). Eight subjects were enrolled as part of the roll‐in phase. Main population consisted of 87 subjects of whom two were considered ineligible, resulting in an evaluable cohort of 85 subjects. The primary safety endpoint was the occurrence of primary AEs within 7 days of the procedure. Acute success, the primary effectiveness endpoint, was defined as sustained PV entrance block upon Adenosine/Isoproterenol challenge. Single‐shot success (SSS) was defined as PVI before adenosine challenge with one valid 60 sec ablation, or with up to 2 additional invalid ablation shots (less than 30 sec RF delivery or less than 5 active electrodes) to reach PV isolation. Time to isolation was the observed RF ablation time to reach a pure SSS; a pure SSS was achieved by one initial ablation shot, regardless of RF duration or number of activated electrodes. Recurrence of symptomatic AF/AT/AFL was documented with weekly transtelephonic monitoring from 3‐6 months, and Holter monitoring at 6 months.

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Result

Ablation procedures were performed under general anesthesia in 47/85 (55.3%) subjects, and under conscious sedation in 40/85 (47.1%) subjects. One primary AE (retroperitoneal bleed) occurred in 1/85 (1.2%) patient. Acute success was achieved in all 82 evaluable pts (100%) undergoing Aden/Iso challenge; 3 pts did not receive Aden/Iso challenge and were excluded from this analysis. Single‐shot successes were 74.7%, 57.9%, 72.3%, and 68.7% for the LIPV, LSPV, RIPV, and RSPV. Time to isolation (for pure SSS) per vein was 8.2 ± 4.95, 10.6 ± 7.71, 8.7 ± 4.70 and 8.8 ± 6.45 sec for the LIPV, LSPV, RIPV, and RSPV, respectively. Touch‐up with focal catheter was required in 1/85 (1.2%) pt. Ablations were performed with procedure time 87.6 ± 22.25 min, RF time 6.1 ± 2.37 min, with 7.5 ± 3.25 RF applications, RFB LA dwell time 40.3 ± 16.69 min, and fluoroscopy time 10.9 ± 9.12 min. After the first roll‐in cases, the total procedure and fluoroscopy times decreased to 76.0 min and 10.5 min. The Kaplan‐Meier estimate of freedom from documented symptomatic AF/AT/AFL recurrence at 6 months was 80.9% (standard error [SE], 4.3%; Figure).

Conclusion

This study demonstrated acute safety and short term effectiveness of the new RFB with high procedural efficiencies and a short learning curve.

AP19‐01302

Baseline demographics and characteristics of 2,959 atrial fibrillation patients from Asia (Korea and Taiwan) on edoxaban comparing recommended vs non‐recommended dosing

Tze‐Fan Chao, Keun‐Sik Hong, Byung‐Chul Lee, Raffaele De Caterina, Paulus Kirchhof, Paul‐Egbert Reimitz, Heiko Rauer, Hiroshi Higashiyama, Cathy Chen, Martin Unverdorben, Chun‐Chieh Wang

Taipei Veterans General Hospital, Taiwan

Introduction

Edoxaban is approved for stroke prevention in patients with atrial fibrillation (AF) based on the phase III ENGAGE AF‐TIMI 48 trial. Baseline data of patients with recommended and non‐ recommended dosing may help to understand the reasons of deviation from the dosing recommended as per local approved prescribing information.

Methods

Between 2017 and 2019, 3,008 patients were enrolled from 47 hospitals and medical practices in Korea and Taiwan in the global Edoxaban Treatment in routiNe clinical prActice in patients with nonvalvular Atrial Fibrillation (ETNA‐AF) programme. We analyzed data of 2,959 patients with baseline information available (67% from Korea and 33% from Taiwan).

Result

Mean age was 71.5 ± 9.5 years and mean BMI 25.0 ± 3.7 kg/m². The most frequent stroke risk factors and comorbidities were hypertension (71.3%), diabetes mellitus (29.3%), history of ischemic stroke (14.1%), valvular heart disease (11.0%), congestive heart failure (7.7%), and myocardial infarction (1.4%). Edoxaban 60 mg was used in 48.6% and 30 mg in 51.4% of patients. According to the approved local labels, 70.4% of patients received the recommend doses and 29.6% received non‐ recommended doses (19.4% received non‐recommended 30 mg and 10.2% non‐recommended 60 mg). Compared with patients receiving recommended 60 mg edoxaban, patients on non‐recommended edoxaban 30 mg were older, had a lower creatinine clearance (CrCl), and had more prior history of major or clinically relevant non‐major (CRNM) bleedings. Compared with patients on recommended 30 mg dose, those on non‐recommended 60 mg dose were younger, had a higher CrCl, had less prior history of major or CRNM bleedings, and had more prior history of ischemic stroke.

Conclusion

Over 70% patients received recommended dose of edoxaban in the Asian countries of Korea and Taiwan of the global ETNA program. It appears that the sickest population is the one on recommended 30 mg whereas the least sick population is the one on recommended 60 mg. Age, history of major bleeding/CRNM bleeding and ischemic stroke seem to be among the factors that influence non‐ recommended dosing. Long‐term follow‐up is needed to assess the impact of non‐recommended edoxaban dosing on clinical events.

TABLE Baseline characteristic of South Korean and Taiwanese patients combined by dosing appropriateness

Recommended 60 mg N=1,136	Nonrecommended 30 mg N=573	Recommended 30 mg N=948	Nonrecommended 60 mg N=302
Age, median (IQR)	68.0 (62.0, 74.0)	72.0 (66.0, 78.0)	77.0 (72.0, 83.0)	72.0 (67.0, 77.0)
Age, ≥75 years (%)	21.0	40.5	63.7	39.7
Gender, male (%)	78.7	64.6	38.8	47.4
Weight [kg], median (IQR)	72.0 (66.0, 78.0)	70.0 (65.0, 77.0)	56.0 (51.0, 60.0)	58.0 (54.0, 60.0)
Body mass index, mean (SD)Type of AF (%)	26.4 (3.2)	26.7 (3.4)	23.1 (3.4)	23.2 (2.8)
paroxysmal,	41.3	44.8	45.4	47.2
persistent,	28.1	24.0	21.9	16.6
long lasting AF	13.6	18.9	12.4	15.0
permanent	17.0	12.4	20.3	21.3
CHA2DS2‐VASc, mean (SD)	2.5 (1.34)	2.9 (1.32)	3.7 (1.36)	3.1 (1.30)
HAS‐BLED§, mean (SD)	2.1 (1.02)	2.3 (1.01)	2.4 (1.06)	2.1 (1.06)
CrCl [mL/min],	74.8	68.7	44.1	50.5
median (IQR)	(63.6, 88.3)	(59.0, 83.3)	(34.7, 54.2)	(43.9, 65.1)
Medical History
Hypertension, %	70.4	72.4	73.3	66.6
Myocardial infarction, %	1.4	0.7	1.7	1.3
Congestive heart failure, %	4.8	6.8	11.8	7.3
Diabetes mellitus, %	31.1	30.5	28.4	23.2
Major or CRNM bleeding, %	1.4	2.4	4.3	1.7
Major GI bleeding	0.0	0.3	0.9	0.0
Intracranial hemorrhage	1.0	1.6	1.6	1.7
Ischemic stroke, %	14.3	12.0	13.8	18.5
Transient ischemic attack, %	1.8	1.2	2.1	2.0
Peripheral artery disease, %	0.6	0.5	1.4	0.0
Chronic obstructive
pulmonary disease, %	4.0	4.0	6.1	5.0

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§Modified HAS‐BLED: without “labile INR”

AP19‐01303

The safety and effectiveness of pulmonary vein isolation with standardized ablation index workflow

Mattias Duytschaever, Johan Vijgen, Tom De Potter, Daniel Scherr, Hugo Van Herendael, Sebastien Knecht, Richard Kobza, Benjamin Berte, Niels Sandgaard, Jean‐Paul Albenque, Gabor Szeplaki, Yorick Stevenhagen, Phillippe Taghji, Matthew Wright, Dhiraj Gupta

AZ Sint Jan, Belgium

Introduction

Pulmonary Vein Isolation (PVI) is the cornerstone of atrial fibrillation ablation. Novel automated ablation lesion tagging technology based on real‐time catheter CF stability (Visitag) and incorporating Force‐Power‐Time Integral formula (Ablation Index [AI]) have been shown to improve clinical success. The Vistax study evaluated 12 month clinical outcome of PVI using a standardized AI ablation workflow with the aim of creating contiguous and durable lesions.

Methods

The VISTAX study is a prospective, non‐randomized multicenter study conducted across 17 European sites. PVI of paroxysmal atrial fibrillation patients was performed by point‐by‐point ablation to obtain a contiguous lesion set for ipsilateral PV isolation. Visitag settings were : location stability: 2‐3 mm, minimum time: 3‐5 s, Force Over Time (FOT): 25%, minimum force: 3 g, inter tag distance: ≤ 6 mm, and tag size of 3 mm (radius). The AI target values were 550 for anterior and 400 for posterior, and may be reduced due to safety reason per investigators’ discretion. Patients were followed‐up at 3, 6, and 12 months post‐ablation. Atrial arrhythmia recurrence was stringently monitored (weekly and symptomatically) and documented via transtelephonic monitor, holter monitor, and electrocardiogram (ECG).

Result

Between 27JAN2017 to 05MAR2018, a total of 340 paroxysmal AF subjects were enrolled; 329 met all eligibility criteria and underwent ablation using AI (evaluable cohort); 281 patients met all AI workflow recommendations including patients in whom for safety measures the ablation was proactively stopped prior to reaching the AI target (per protocol [PP] cohort). Majority of the patients were male (61.5%), with a mean age of 61.3 ± 10.1 years, and mean CHA2DS2‐VASc of 1.6 ± 1.42. General anesthesia was used in majority of evaluable subjects (84.2%). Average procedure (inclusive of adenosine‐proof isolation at 30 minutes), RF application, and fluoroscopy times in the evaluable cohort were 156.2 ± 37.0 min, 35.1 ± 11.2 min, and 7.9 ± 6.9 min, respectively. Primary adverse event rate was 3.6% in the evaluable cohort. First pass PVI after the waiting period and adenosine challenge were 82.4% (95% CI: 77.4%, 86.7%) in the evaluable cohort and 82.2% (95% CI: 76.7%, 86.9%) in the PP cohort (Table). Per Kaplan Meier analysis, the freedom from documented all or symptomatic atrial arrhythmia rate at 12 month follow‐up in the evaluable cohort were 78.3% (90% CI: 73.8%, 82.8%) and 82.9% (90% CI: 78.8%, 87.0%), respectively.

Conclusion

The VISTAX trial demonstrates the reproducibility of AI‐guided PAF ablation workflow with low procedure and fluoroscopy times, low primary adverse events, and high acute first pass isolation. High single procedure freedom from arrhythmia recurrence (in the setting of a multicenter study with stringent monitoring) suggests that this approach leads to more durable isolation.

TABLE Summary of Acute Effectiveness

Evaluable		PP
Statistic n/N (%)	95% CI	Statistic n/N (%)	95% CI
Primary AcuteEffectiveness*	229/278 (82.4)	77.4, 86.7	194/236 (82.2)	76.7, 86.9
Secondary AcuteEffectiveness**	283/329 (86.0)	81.8, 89.6	240/281 (85.4)	80.7, 89.3
Acute ProceduralSuccess at the End of Procedure***	325/329 (98.8)	96.9, 99.7	279/281 (99.3)	97.5, 99.9

Conclusion

Trans‐thoracoscopic LAAE plus AF ablation is an innovative and effective approach for secondary thromboprophylaxis in AF patients. Our findings merit further prospective RCTs in this high‐ risk cohort, and may be highly relevant to healthcare systems where OAC management remains challenging.

TABLE 1 Summary of surgical LAA intervention studies

Studies	Ohtsuka T, et al .J Am Coll Cardiol.2013; 9;62:103‐107.	Inoue T, et al.Eur J CT Surg. 2018;1;54:78‐83.	Friedman DJ, et al.JAMA. 2018;23;319:365‐374.	Yao X, et al.JAMA. 2018,22;319:2116‐2126.	Our study
Study design	• Observational• Single arm	• Observational• Single arm	• Retrospective largecohort study• Two arms• Adjust vs. No adjust	• Retrospective largecohort study• Two arms• Propensity scorematching	• Prospective cohortstudy• Two arms• Propensity scorematching
Population	AF patients	AF patients	AF patients withconcomitant cardiacSurgery	Patients withconcomitant cardiacSurgery	AF patients withprevious TE (Secondaryprevention)
Number	30	87	10524	75782(4374 LAAO)	474
Mean age (y)	74±?	68±?	76±?	? ±?	67±9
Median CHA2DS2‐ VASc score	4.5	2.9	4.0	3.9	4.0
Bleeding risk	High risk of bleeding	HASBLED: 2.57
Procedure Type	• Thoracoscopicstand‐alone appendectomy • No AF ablation	• Thoracoscopic stand‐alone LAA resection • No AF ablation	• CABG or valve surgery • With LAA occlusion vs. no LAA occlusion	• CABG or valve surgery • With LAA occlusion vs. no LAA occlusion	• Thoracoscopic left appendectomy • Plus AF ablation
Surgical LAA Intervention	Totally endoscopic LAA excision	Thoracoscopic linear cutter	Surgical LAA occlusion during cardiac surgery	Surgical LAA occlusion during cardiac surgery	Totally endoscopic LAA excision
Post‐procedureAnticoagulation	No	No	No	No data	No
Clinical Outcomes	No thromboembolism	No thromboembolism	Concomitant surgical LAAO reduces strokerate and all causemortality	LAAO was associated with a reduced risk of stroke (1.14 vs 1.59events per 100 person‐years	The composite primary endpoint of`thromboembolism,major bleeding, or all‐cause mortalitysignificantly reduced
Median follow‐up time	16 months	3 months	2.6 years	2.1 years	951 days

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PERMALINK

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AP19‐­00001

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AP19‐­00002

Efficacy and safety of the second generation cryoballoon ablation for atrial fibrillation in patients over 75 years

AP19‐­00006

Bleeding outcome of peri‐­procedural anticoagulation in patients of atrial fibrillation undergoing catheter ablation: A network meta‐­analysis

AP19‐­00008

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AP19‐­00010

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AP19‐­00035

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Haplotype analysis of phagocytic NADPH oxidase polymorphisms in Korean atrial fibrillation patients: effect on the systemic oxidative stress burden

AP19‐­00054

Mid‐­term clinical outcome after catheter ablation for atrial fibrillation guided by ablation index at relatively low target value

AP19‐­00058

Prevention of serious air embolism during cryoballoon ablation, risk assessment of air intrusion into the sheath by catheter selection, and change in intrathoracic pressure: an ex vivo study

AP19‐­00059

Effectiveness and safety of reduced dose non‐­vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: A nationwide population‐­based study in Korea

AP19‐­00060

How to approach for atrial fibrillation case post amplatzer implantation

AP19‐­00064

Persistent atypical atrial flutter after device closure of atrial septal defect in a young male—A rare case scenario

AP19‐­00065

Feasibility and safety of his bundle pacing and left bundle branch area pacing in atrial fibrillation patients in need of pacing

AP19‐­00066

Efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonist (VKA) among patients with atrial fibrillation and hypertrophic cardiomyopathy: A systematic review and meta‐­analysis

AP19‐­00067

Fentanyl facilitate intraoperative sedation during expansion pulmonary vein isolation.

AP19‐­00068

Left atrial volume index as a predictor of non‐­pulmonary vein foci in patients with atrial fibrillation

AP19‐­0070

Implantable loop recorders: Sensitive but not specific

AP19‐­00076

Comparison of an uninterrupted rivaroxaban strategy vs uninterrupted warfarin strategy in patients undergoing catheter ablation of atrial fibrillation

AP19‐­00079

Atrial fibrillation first detected during admission for ischemic stroke: In‐­hospital and 1 year outcomes

AP19‐­00081

Preoperative multidetector computed tomography is adequate enough to detect intracardiac thrombi at atrial fibrillation ablation

AP19‐­00084

Catheter ablation of atrial fibrillation prevents cardiovascular events and death in over 80‐­year‐­old patients

AP19‐­00087

Significance of advanced coronary atherosclerosis in development of atrial fibrillation

AP19‐­00089

Factors related to clinically low dose direct oral anticoagulant use in real‐­world practice

AP19‐­00090

Clinical profile and adherence to guidelines directed stroke prevention therapy in patient with atrial fibrillation in Department of Cardio Vascular Medicine, Mandalay General Hospital

AP19‐­00095

Uninterrupted vs interrupted dabigatran. Uninterrupted dabigatran is associated with optimal ACT control during catheter ablation

AP19‐­00097

The incidence and origin of atrial tachycardia after cryoballoon ablation

AP19‐­00101

Thoracoscopic left atrial appendage excision plus atrial fibrillation ablation as a secondary prevention strategy against stroke: Initial experience and two year outcome data

AP19‐­00127

AF anticoagulation—DOACs breaking the bank?

AP19‐­00128

Locations of recovery of conduction with the high power short duration approach in radiofrequency catheter ablation for atrial fibrillation

AP19‐­00129

Proper precautionary measures can prevent thermal injury to esophagus during ablation of coronary sinus in patients with atrial fibrillation

AP19‐­00130

Best ablation strategy in patients with coexistent metabolic syndrome and long‐­standing persistent atrial fibrillation: Results from a propensity‐­matched population

AP19‐­00131

Pain at the puncture site and back pain in patients undergoing electrophysiology procedures with venous access site closure utilizing vascular closure device vs manual compression

AP19‐­00132

Stroke risk in paroxysmal and persistent atrial fibrillation treated with anti‐­arrhythmic drugs vs catheter ablation

AP19‐­00134

A case report of an effective ethanol infusion to vein of marshall for peri‐­mitral flutter patient after AF ablation

AP19‐­00138

The increased risk of stroke and systemic embolism in hyperthyroidism related atrial fibrillation: A Korean nationwide cohort study

AP19‐­00144

Participation of posterior wall for strategy of atrial fibrillation ablation

AP19‐­00146

Heart rate control resistant minor allele of GJA‐­1 gene polymorphism in patients with persistent atrial fibrillation

AP19‐­00148

Home‐­based cardiac rehabilitation versus conventional care for patients with atrial fibrillation treated with catheter ablation: A randomized controlled trial

AP19‐00001

AP19‐00002

AP19‐00006

Bleeding outcome of peri‐procedural anticoagulation in patients of atrial fibrillation undergoing catheter ablation: A network meta‐analysis

AP19‐00008

AP19‐00010

Association between acute hepatitis B flare and long‐term clinical outcomes in patients with atrial fibrillation

AP19‐00013

AP19‐00035

AP19‐00046

AP19‐00054

Mid‐term clinical outcome after catheter ablation for atrial fibrillation guided by ablation index at relatively low target value

AP19‐00058

AP19‐00059

Effectiveness and safety of reduced dose non‐vitamin K antagonist oral anticoagulants in Asian patients with atrial fibrillation: A nationwide population‐based study in Korea

AP19‐00060

AP19‐00064

AP19‐00065

AP19‐00066

Efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonist (VKA) among patients with atrial fibrillation and hypertrophic cardiomyopathy: A systematic review and meta‐analysis

AP19‐00067

AP19‐00068

Left atrial volume index as a predictor of non‐pulmonary vein foci in patients with atrial fibrillation

AP19‐0070

AP19‐00076

AP19‐00079

Atrial fibrillation first detected during admission for ischemic stroke: In‐hospital and 1 year outcomes

AP19‐00081

AP19‐00084

Catheter ablation of atrial fibrillation prevents cardiovascular events and death in over 80‐year‐old patients

AP19‐00087

AP19‐00089

Factors related to clinically low dose direct oral anticoagulant use in real‐world practice

AP19‐00090

AP19‐00095

AP19‐00097

AP19‐00101

AP19‐00127

AP19‐00128

AP19‐00129

AP19‐00130

Best ablation strategy in patients with coexistent metabolic syndrome and long‐standing persistent atrial fibrillation: Results from a propensity‐matched population

AP19‐00131

AP19‐00132

Stroke risk in paroxysmal and persistent atrial fibrillation treated with anti‐arrhythmic drugs vs catheter ablation

AP19‐00134

A case report of an effective ethanol infusion to vein of marshall for peri‐mitral flutter patient after AF ablation

AP19‐00138

AP19‐00144

AP19‐00146

Heart rate control resistant minor allele of GJA‐1 gene polymorphism in patients with persistent atrial fibrillation

AP19‐00148

Home‐based cardiac rehabilitation versus conventional care for patients with atrial fibrillation treated with catheter ablation: A randomized controlled trial

AP19‐00150

AP19‐00151

AP19‐00152

The independent effect of insulin resistance on incidence of atrial fibrillation in non‐diabetics

AP19‐00153

AP19‐00154

AP19‐00158

AP19‐00161

AP19‐00163

Uninterrupted peri‐procedural anticoagulation with new oral anticoagulants in atrial fibrillation ablation: Insights from an updated meta‐analysis

AP19‐00164

Comparison between cyroballoon and radiofrequency ablation for persistent atrial fibrillation: A meta‐analysis of observational studies

AP19‐00166

Alterations of resting heart rate and coefficient of variation of R‐R interval after cryoballoon ablation in the patients with paroxysmal atrial fibrillation

AP19‐00167

AP19‐00171

Comparison of prevalence and mechanism between right ventricular apical pacing and non‐right ventricular apical pacing induced tricuspid regurgitation: Insight from 3D echocardiography

AP19‐00174

AP19‐00179

AP19‐00180

AP19‐00181

AP19‐00184

Diagnostic performance of a wearable ring‐type device with deep learning analysis of photoplethysmography for detecting atrial fibrillation

AP19‐00187

AP19‐00189

AP19‐00193

Electrocardiogram predictors of new‐onset atrial fibrillation after typical atrial flutter ablation