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BACKGROUND: Global longitudinal strain (GLS) and atrial voltage are acknowledged markers for worse rhythm outcome after ablation of persistent atrial fibrillation (PeAF). The majority of research efforts have been directed towards the left atrium (LA), with relatively fewer studies focusing on the right atrium (RA). The aim of this study was to investigate the effect of the biatrial substrate on the outcome following radiofrequency catheter ablation (RFCA).
METHODS: All patients underwent two-dimensional speckle tracking echocardiography (2D-STE) and high-density mapping (HDM) on LA and RA in preoperative and postoperative stages of RFCA. Atrial substrate was assessed by GLS, average voltage, and low voltage zone (LVZ).
RESULTS: This retrospective study enrolled 48 patients. With a follow-up of 385.98 ± 161.78 days, 22.92% (11/48) of all patients had AF recurrence and 63.64% in low strain group. Left atrial-low voltage zone (LA-LVZ) prior to RFCA was 67.52 ± 15.27% and 54.21 ± 20.07%, respectively, in the recurrence group and non-recurrence group. Multivariate regression analysis showed that preoperative LA-GLS (OR 0.047, 95%CI 0.002-0.941, p = .046) was independent predictors of AF recurrence. Biatrial average voltage in preoperative and postoperative stages were positively correlated (preoperative: r = 0.563 p < .001; postoperative: r = 0.464 p = .002). There was no significant difference in the proportion of RA in the recurrence group except the septum in preoperative and postoperative stages.
CONCLUSIONS: Low LA-GLS and high LA-LVZ may be predictors of RFCA recurrence in PeAF patients. Biatrial average voltage were positively correlated in preoperative and postoperative stages.

BACKGROUND: Although radiofrequency ablation of the cavotricuspid isthmus (CTI), responsible for sustaining atrial flutter, is a highly effective procedure, in extended patients\' observations following this procedure, more than every tenth becomes unsuccessful. Therefore, this study aimed to provide helpful information about the anatomy of the CTI in transthoracic echocardiography, which can aid in better planning of the CTI radiofrequency ablation in patients with typical atrial flutter.
METHODS: 56 patients with typical atrial flutter after radiofrequency ablation were evaluated at the end of the 24-month observation period. With substernal modified transthoracic echocardiographic (mTTE) evaluation, we identified four main anatomical obstacles impeding radiofrequency ablation. These obstacles were tricuspid annular plane systolic excursion, cavotricuspid isthmus length, cavotricuspid isthmus morphology, and the presence of a prominent Eustachian ridge/Eustachian valve. All intraprocedural radiofrequency ablation data were collected for analysis and correlated with anatomical data.
RESULTS: In the 24-month observation period, freedom from atrial flutter was 67.86%. The mean length of the isthmus was 30.34 ± 6.67 mm. The isthmus morphology in 56 patients was categorized as flat (n = 27; 48.2%), concave (n = 10; 17.85%), and pouch (n = 19, 33.9%). A prominent Eustachian ridge was observed in 23 patients (41.1%). Lack of anatomical obstacles in mTTE evaluation resulted in 100% efficacy, while the presence of at least two obstacles significantly increased the risk of unsuccessful ablation with more than two (OR 12.31 p = 0.01). Generally, 8 mm electrodes were the most effective for non-difficult CTI, while 3.5 mm electrodes used with a 3D system had highest performance for complex CTI. Notably, aging was the only factor that worsened the long-term outcome (OR 1.07 p = 0.044).
CONCLUSIONS: Preoperative usage of mTTE evaluation helps predict difficulty in cavotricuspid isthmus radiofrequency ablation, thus allowing better planning of the radiofrequency ablation strategy using the most accurate radiofrequency ablation electrode.

BACKGROUND: Radiofrequency catheter ablation (RFA) targets the left atrial appendage isthmus (LAA isthmus) and mitral isthmus for treatment of atrial fibrillation. However, proximity of left circumflex artery (LCxA) and great cardiac vein (GCV) in the isthmuses poses fatal risks during ablation.
METHODS: This study investigated relationships of LCxA and GCV across three lines in the LAA and mitral isthmus, using 15 human cadaveric hearts. Distances between the vessels and the endocardium, myocardium, and perivascular fat thickness were measured.
RESULTS: The results showed that LCxA was mostly consistently located in lower atrial segments and GCV was in lower/upper atrial segments, with change of course mainly observed in the middle of the LAA. The LCxA was found as close as 3-5 mm from the lower border of the LAA isthmus in 80% of specimens, at a depth of 2-3 mm within the LAA isthmus, where 1 mm consisted of myocardium and the remainder was fat, which may not provide adequate protection due to the possibility of liquefaction of fat with heat application. The effective myocardial thickness was consistently 1 mm across all cases in both isthmuses. LCxA was 2 mm in second and third sections of LAA isthmus (\"careful segment\"). LCxA distances from left inferior pulmonary vein opening was 5 to 12 mm, occasionally dangerously close as <1 mm in 16% of cases.
CONCLUSIONS: This study measured LCxA and GCV in the LAA and mitral isthmus across three lines for the first time in the Indian population, aiding surgeons in RFA planning.

UNASSIGNED: Atrial fibrillation is the most common tachyarrhythmia, while catheter ablation is an effective therapy for atrial fibrillation. However, pain and nervousness may occur during the procedure. Moreover, a consensus has still not been reached on which is the best kind of analgesic and sedative to use in these procedures. Therefore, we conducted a network meta-analysis to evaluate the efficacy and safety of analgesics and sedatives used in catheter ablation for atrial fibrillation.
UNASSIGNED: We searched PubMed, Cochrane Library, Web of Science, EMBASE, China National Knowledge Infrastructure, and Baidu Wenku document download website for randomized controlled trials from their inception to February 26, 2023. Only studies that made comparisons among analgesics or sedatives and involved patients with atrial fibrillation undergoing radiofrequency catheter ablation were included. The efficacy endpoints were Ramsay sedation scores and visual analog scale scores during the radiofrequency catheter ablation for atrial fibrillation. The safety endpoints were the incidence of respiratory depression, hypotension, nausea, and vomiting. Pairwise comparisons and frequency method analyses were conducted. Results were reported as odds ratio (OR), mean difference (MD), and corresponding 95% confidence intervals (CIs). We assessed the risk bias of the studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions.
UNASSIGNED: Out of the 709 articles initially retrieved, 14 studies, with a total of 1156 participants, were included. In terms of efficacy, patients receiving dexmedetomidine during radiofrequency ablation for atrial fibrillation had higher Ramsay sedation scores than those receiving midazolam plus fentanyl, or its derivatives (MD -0.88, 95% CI [-0.04 to -0.72]). Compared with morphine, dezocine (MD 1.88, 95% CI [1.16 to 2.60]), hydromorphone (MD 4.07, 95% CI [3.56 to 4.58]), butorphanol (MD 3.18, 95% CI [2.38 to 3.96]), and fentanyl or its derivatives (MD 1.57, 95% CI [1.25 to 1.89]) had a better analgesic effect. In terms of safety, propofol (OR 16.46; 95% CI [1.54 to 175.95]) and midazolam plus fentanyl or its derivatives (OR 7.02; 95% CI [1.33 to 36.99]) significantly increased the incidence of respiratory depression compared with dexmedetomidine plus fentanyl or its derivatives. Dexmedetomidine plus fentanyl or its derivatives reduced the incidence of nausea and vomiting compared with fentanyl alone (OR 4.74; 95% CI [1.01 to 22.22]). Propofol was associated with a lower incidence of nausea and vomiting than hydromorphone (OR 0.01; 95% CI [0.00 to 0.59]) and fentanyl or its derivatives (OR 0.01; 95% CI [0.00 to 0.51]). There was no statistically significant difference in the incidence of hypotension between any two strategies.
UNASSIGNED: Hydromorphone and butorphanol had better analgesic effects than fentanyl or its derivates. Dexmedetomidine had better sedative effects. In terms of safety, dexmedetomidine, oxymorphone, and butorphanol were superior. It is necessary to explore the regimen that can consider both the effectiveness and safety during radiofrequency catheter ablation for atrial fibrillation (AF).
UNASSIGNED: This study was registered with PROSPERO, number: CRD42023403661.

UNASSIGNED: Abnormal respiration during radiofrequency catheter ablation (RFCA) with deep sedation in patients with atrial fibrillation (AF) can affect the procedure\'s success. However, the respiratory pattern during RFCA with deep sedation remains unclear. This study aimed to investigate abnormal respiration during RFCA and its relationship with sleep apnea in patients with AF.
UNASSIGNED: We included patients with AF who underwent RFCA with cardiorespiratory monitoring using a portable polygraph both at night and during RFCA with deep sedation. The patients were divided based on the administered sedative medicines.
UNASSIGNED: We included 40 patients with AF. An overnight sleep study revealed that 27 patients had sleep apnea; among them, 9 showed central predominance. During RFCA with deep sedation, 15 patients showed an abnormal respiratory pattern, with 14 patients showing obstructive predominance. Further, 17 and 23 patients were administered with propofol alone and dexmedetomidine plus propofol, respectively. There was no significant between-group difference in the respiratory event index (REI) at night (7.9 vs. 9.3, p = 0.744). However, compared with the group that received dexmedetomidine plus propofol, the propofol-alone group showed a higher REI during RFCA (5.4 vs. 2.6, p = 0.048), more frequent use of the airway (47% vs. 13%, p = 0.030), and a higher dose of administered propofol (3.9 mg/h/kg vs. 1.2 mg/h/kg, p < 0.001). Multivariable analysis revealed that only the propofol amount was associated with REI during RFCA (p = 0.007).
UNASSIGNED: Our findings demonstrated that respiratory events during RFCA with deep sedation were mainly obstructive. Propofol should be administered with dexmedetomidine rather than alone to reduce the propofol amount and avoid respiratory instability.

Background and Objectives: Radiofrequency catheter ablation (RFCA) is a highly successful intervention. By comparing the lesion changes in prostate parenchymal and striated muscle tissues after RFCA with and without cooling, it was possible to assess the correlation between the shape regularity, area, and perimeter of the thermal lesion, and to predict the geometric shape changes of the lesions. Materials and Methods: A standard prostate and striated muscle RFCA procedure was performed on 13 non-purebred dogs in two sessions: no cooling and cooling with 0.1% NaCl solution. Microtome-cut 2-3 µm sections of tissue samples were stained with haematoxylin and eosin and further examined. The quotient formula was employed to evaluate the geometric shape of the damage zones at the ablation site. Results: The extent of injury following RFCA in striated muscle tissue was comparable to that in prostate parenchymal tissue. Regression analysis indicated a strong and positive relationship between area and perimeter in all experimental groups. In the experimental groups of parenchymal tissues with and without cooling, an increase in the area or perimeter of the damage zone corresponded to an increase in the quotient value. A similar tendency was observed in the striated muscle group with cooling. However, in the striated muscle group without cooling, an increase in lesion area or perimeter lowered the quotient value. Standardised regression coefficients demonstrated that in the striated muscle with cooling, the damage zone shape was more determined by area than perimeter. However, in the parenchymal tissue, the perimeter had a more substantial impact on the damage zone shape than the area. Conclusions: The damage area and perimeter have predictive power on the overall shape regularity of damage zone geometry in both striated muscles and parenchymal tissue. This approach is employed to achieve a balance between the need for tumour eradication and the minimisation of ablation-induced complications to healthy tissue.

BACKGROUND: High-frequency-low-tidal-volume (HFLTV) ventilation increases the efficacy and efficiency of radiofrequency catheter-ablation (RFCA) of paroxysmal atrial fibrillation (PAF). Whether those benefits can be extrapolated to RFCA of persistent AF (PeAF) is undetermined.
OBJECTIVE: To evaluate whether using HFLTV ventilation during RFCA in patients with PeAF, is associated with improved procedural and clinical outcomes when compared to standard ventilation (SV).
METHODS: In this prospective-multicenter registry (REAL-AF) patients who underwent PVI+PWI for PeAF using either HFLTV-ventilation or SV were included. The primary efficacy outcome was freedom from all-atrial arrhythmias at 12 months. Secondary outcomes included procedural and long-term clinical outcomes, and complications.
RESULTS: A total of 210 patients were included (HFLTV=95 vs. SV=115) in the analysis. There was no difference in baseline characteristics between groups. Procedural time (80 [63-103.5] vs.110 [85-141], p<0.001), total RF time (18.73 [13.93-26.53] vs. 26.15 [20.30-35.25], p<0.001), and PV RF time (11.35 [8.78-16.69] vs. 18 [13.74-24.14], p<0.001) were significantly shorter using HFLTV ventilation when compared with SV. Freedom from all-atrial arrhythmias was significantly higher with HFLTV ventilation when compared with SV (82.1% vs. 68.7%; HR 0.41, 95% CI [0.21-0.82], p=0.012), indicating a 43% relative risk reduction and a 13.4% absolute risk reduction in all-atrial arrhythmias recurrence. There was no difference in long-term procedural-related complications between the groups (p=0.270).
CONCLUSIONS: In patients undergoing RFCA with PVI+PWI for PeAF, the use of HFLTV ventilation was associated with a higher freedom from all-atrial arrhythmias at 12-month follow-up with significantly shorter procedural and RF times compared to SV, while reporting a similar safety profile.

UNASSIGNED: Patients with atrial fibrillation (AF) who undergo radiofrequency catheter ablation (RFCA) necessitate the administration of antiarrhythmic drugs to prevent early recurrence. The clinical outcomes among these patients may be influenced by varying antiarrhythmic regimens.
UNASSIGNED: To identify the risk factors associated with early recurrence and compare the clinical outcomes among different antiarrhythmic regimens in elderly patients with AF following radiofrequency catheter ablation (RFCA) during a 3-month period.
UNASSIGNED: A retrospective observational study encompassed 420 elderly patients with AF following RFCA. Baseline data were collected during the initial postoperative visit and clinical outcomes were carefully monitored over a 3-month follow-up period. Logistic regression and Cox-proportional hazard regression analyses were performed to investigate the relationship between various antiarrhythmic regimens and the clinical outcomes.
UNASSIGNED: Multivariate logistic regression analysis revealed that age (p = 0.001), left atrial diameter (p < 0.001), left ventricular diameter (p = 0.015), reactive hyperemia index (RHI) (p < 0.001), antiarrhythmic drug (p < 0.001) and hs-cTnI (p = 0.017) were independent risk factors of early recurrence. Furthermore, in cox survival regression analysis model, survival rate of early recurrence in the amiodarone group was higher than in the propafenone group (HR 2.30, 95%CI 1.17-4.53, p = 0.016) and in the sotalol group (HR 3.60, 95%CI 2.17-5.95, p < 0.001). Compared to the amiodarone group, the incidence of liver dysfunction was lower in the dronedarone group (p = 0.046) and the propafenone group (p = 0.021). The incidence of bradyarrhythmia (p = 0.003), QT interval prolongation (p = 0.035) and atrioventricular transmission block (p = 0.021) were higher in the sotalol group than in the amiodarone group.
UNASSIGNED: RHI was identified as an independent risk factor for early recurrence among elderly AF patients after RFCA. Compared to amiodarone, propafenone and sotalol exhibited an elevated risk of early recurrence. Although there was no significant difference in early recurrence between amiodarone and dronedarone, dronedarone emerged as the preferred option due to its lower frequency of adverse drug reactions than amiodarone.

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