Background/Objectives: Alcohol septal ablation (ASA) is an established interventional therapy for patients with obstructive hypertrophic cardiomyopathy (OHCM) who remain symptomatic despite optimal medical treatment. Nevertheless, 10-20% of patients fail to achieve a satisfactory hemodynamic or clinical response, highlighting the need for improved patient selection. Given that mitral valve (MV) morphology plays a central role in left ventricular outflow tract (LVOT) obstruction, we aimed to evaluate the impact of MV anatomical parameters on ASA outcomes. Methods: We retrospectively analyzed 38 OHCM patients who underwent ASA and had complete echocardiographic data before and at 6-month follow-up. Patients were stratified into responders (n = 32, defined as >50% reduction in LVOT pressure gradient and/or residual LVOT gradient < 50 mmHg) and non-responders (n = 6, <50% reduction or persistent gradient ≥ 50 mmHg), consistent with criteria used in previous ASA outcome studies. MV parameters-including redundant anterior mitral leaflet (AML) length, posterior mitral leaflet (PML) projection, and anterior displacement of the coaptation point (AML/PML projection ratio)-were compared between groups. Results: Non-responders demonstrated significantly greater AML redundancy (13.16 ± 1.72 vs. 9.96 ± 1.99 mm, p < 0.001), larger PML projection (18.5 ± 3.78 vs. 13.65 ± 3.8 mm, p = 0.006), and lower AML/PML projection ratio (0.80 ± 0.15 vs. 1.34 ± 0.45, p = 0.007). These parameters were associated with reduced post-procedural LVOT gradient reduction in univariate logistic regression (p = 0.01, p = 0.027, p = 0.015, respectively). Multivariate modeling was not pursued due to collinearity among MV parameters and the limited number of non-responder events, which precluded robust adjustment. Conclusions: Mitral valve morphological features-particularly redundant AML, greater PML projection, and anterior displacement of the coaptation point-were associated with suboptimal ASA outcomes in univariate analysis. These data emphasize the need for comprehensive MV imaging in pre-procedural assessment. Integrating MV morphology into current selection algorithms may refine ASA patient selection and improve long-term success rates.

Background: Sacubitril/valsartan is a cornerstone of guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF), yet data regarding reverse remodeling after ARNI initiation in patients previously treated with cardiac resynchronization therapy (CRT) remain limited. This study evaluated echocardiographic reverse remodeling following sacubitril/valsartan initiation in a real-world cohort of CRT-treated patients and explored the association between treatment timing and remodeling response. Methods: This single-center retrospective pilot study included 188 patients with HFrEF treated with CRT who subsequently initiated sacubitril/valsartan. Patients were categorized into early (≤12 months after CRT, n = 112) and late (>12 months, n = 76) initiation groups. Echocardiographic parameters and functional status were assessed at baseline and at approximately 12 months. Reverse remodeling was evaluated using changes in left ventricular ejection fraction (LVEF), ventricular volumes, and clinical status. Multivariable logistic regression was used to explore factors associated with reverse remodeling (ΔLVEF ≥ 10%). Results: Sacubitril/valsartan therapy was associated with significant improvements in LVEF, left ventricular end-diastolic volume, left atrial volume, and NYHA functional class in both groups. The magnitude of improvement in echocardiographic parameters was similar between early and late initiation groups. In exploratory multivariable analyses, earlier ARNI initiation was associated with clinically meaningful reverse remodeling (ΔLVEF ≥ 10%) (OR 6.36, 95% CI 1.59–25.50, p = 0.009). SGLT2 inhibitor therapy was also associated with reverse remodeling (OR 5.76, 95% CI 1.86–17.87, p = 0.002), while a longer CRT-to-ARNI interval was associated with lower odds of response (OR 0.77 per year, 95% CI 0.62–0.96, p = 0.018). Analysis of CRT-to-ARNI interval as a continuous variable showed only a weak association with reverse remodeling, while receiver operating characteristic analysis did not identify a meaningful temporal threshold (AUC 0.497). Conclusions: Sacubitril/valsartan initiation after CRT was associated with significant reverse remodeling, including in patients who initiated therapy several years after CRT implantation, although the late-initiation subgroup was of limited size, and treatment intervals beyond the interquartile range (4.0–7.0 years) were sparsely represented. Absolute echocardiographic improvements were broadly similar between groups, and receiver operating characteristic analysis did not identify a discriminative temporal threshold (AUC 0.497), indicating no discriminative ability beyond chance. Exploratory multivariable analysis identified an association between earlier initiation and clinically meaningful reverse remodeling, but this finding was not supported by a clinically meaningful temporal threshold.

The direct oral anticoagulants (DOACS) such as dabigatran (D), rivaroxaban (R), apixaban (A), and edoxaban (E) have become the leading anticoagulation strategy in atrial fibrillation (AF). Many studies have shown that the safety of DOACS is similar or better than warfarin (W) periprocedural pre- and post AF ablation. It is unclear if they fare the same compared to vitamin K antagonists (VKA) other than W, if individual DOACS have the same benefits, or if interrupted or uninterrupted regimens are better. Since complication rates of AF ablation are low, individual studies preclude an ability to answer this issue with certainty, and a meta-analysis would provide a better estimation.

INTRODUCTION:Strategies beyond pulmonary vein isolation (PVI) in persistent atrial fibrillation (persAF) are debated. A novel mapping tool provides algorithmic detection of ablation targets based on electrogram (EGM) properties specific to stable localized rotational activations. METHODS:The mapping tool was used on 31 patients (20 de novo). The algorithm was used to optimize PVI line placement and guide additional ablations. Targets were detected by calculating local cycle length (L-CL) and local spread of activation within that L-CL (Duty Cycle; DC) for EGMs with consistent morphology and activation. At least two left atrial (LA) maps (pre-PVI and post-PVI) were acquired in atrial fibrillation (AF) in all patients (except those with AF termination during PVI). Extra-pulmonary vein (PV) targets were compared between the two LA maps in each patient. Follow-up included Holter monitoring every 3 months. RESULTS:Patients had a median of 3 extra-PV drivers/targets. The majority (81%) were localized in the same areas between the two LA maps. All patients had progressive AF organization demonstrated by global activation slowing: histogram peak L-CL increased from 162 to 171 ms (post-PVI; p = .0003) than to 175 ms (posttarget ablation; p = .04). Moreover, L-CL dispersion was reduced by ablation; in 50% their values tended to cluster around two dominant cycles. In de novo patients AF terminated to sinus rhythm or atrial tachycardia (AT) within 48 h postprocedure in 88% of cases, and at 18 months mean follow-up recurrence occurred in only five (25%) patients (three persAF, two AT). There were no complications. CONCLUSION:The algorithmic detection of EGMs consistent with localized reentry during sequential mapping of persAF provided reproducible targets for ablation. This allowed personalized PVI and limited, highly-selective, extra-PV ablation. Results of this initial experience included progressive organization of AF with ablation and a low recurrence rate after a single procedure.

Abstract Funding Acknowledgements Type of funding sources: None. Background Developing ablation strategies beyond pulmonary vein isolation (PVI) in persistent atrial fibrillation (persAF) is still a challenge. To date, few diagnostic tools have allowed identification of potential drivers during AF, with questionable results. There is a need for a tool that allows to consistently display and detect EGMs and identify optimal ablations targets. A novel mapping tool can provide algorithmic detection of ablation targets based on EGM properties specific to relatively stable localized rotational activations. Objective Describing an initial series of patients (pts) where Ockham mapping was used during AF to identify ablation targets and treat PersAF. Methods PersAF pts presenting in AF for were mapped using an ultra-high density mapping system (RHYTHMIA). A novel PersAF mapping feature (Ockham) was used to detect ablation targets by calculating local cycle length (LCL) and local spread of activation time within that LCL (Duty Cycle) for consistent EGMs. A scatterplot tool (F1 A) was used to identify regions of consistent (relatively stable) local activation. Among these areas, those with fast CL and high DC (>90%) were used to guide the optimal PVI line placement. Additionally, during remapping the same approach was used to target ablation beyond PVI.RF was delivered at 40-45 W via a StablePointTM IntallaNav OI catheter aiming at the maximum impedance drop (30 ohms).Durable PVI was verified by EGM visualization. In case of ongoing AF at the end of the procedure patients were monitored for 48 h before eventual cardioversion. Follow-up was by Holter every 3 months (more if symptoms). Data are median [IQR]. Results The novel mapping tool was used on 31 PersAF pts (68±9.5 years, 71% male, 20 De Novo).A median of 41228 [32789-46512] EGMs was collected before PVI. After PVI, 3 de novo pts had AF terminate into AT. Additional targets were identified in the other ones from a second post-PVI map. 81% of the extra-venous potential drivers identified on the post-PVI maps were already present on the pre-PVI map, supporting the reproducibility of the tool. Pts had a median of 3 [1-4.25] extra-PV drivers targets. Across all pts, following PVI and targeted ablation, there was progressive AF organization demonstrated by global activation slowing (a rightward shift of CL; F1 B), which in approximately half of the patients formed bi-modal curves clustered around 2 discrete CL values. Acutely, 88% of patients had AF terminate to SR or AT. At 10 months [5.75-13] follow-up, 3 (15%) patients had recurrence of persAF, and 2 (10%) patients had AT recurrences. No complication occurred. Discussion This clinical experience demonstrates that this tool can identify limited, but highly selective, reproducible extra-PV AF drivers. Since PersAF pts have high variability in arrhythmogenic sites, this novel tool allows efficient identification of ablation targets based on EGM properties for an individualized approach to ablation beyond PVI.

The risk of atrial fibrillation (AF) recurrence after ablation in persistent AF is significant, but predictive factors of recurrence are disputed. The aim of our study is to determine clinical, anatomical (trans-thoracic echocardiography and computed tomography), and electrophysiological factors predictive of arrythmia recurrence after a first radiofrequency (RF) ablation procedure in patients with persistent AF. Consecutive patients with RF ablation for persistent AF were prospectively included. Patients in sinus rhythm (SR) or atrial tachycardia (AT) were excluded. Lack of spontaneous SR resumption during RF/post-procedural follow up (FU within 48 h) was defined as acute failure. Any sustained (> 30 s) AF or AT episode after a 3-month blanking period was labelled recurrence. FU was performed with a 24-h Holter monitoring every 3 months. Clinical (e.g., age, gender, BMI, sleep apnea, AF disease duration), anatomical (e.g., left atrial (LA) diameter/surface/volume) and electrophysiological parameters (e.g., LA map volume, total surface, low left atrial voltage surfaces (range 0–0.5 mV), surface of organized areas) were tested for the prediction of acute failure and recurrence. In this series, 51 patients (64.8 ± 8.3 years, 70% males) had a first ablation for persistent AF using ultrahigh density (UHD) contact mapping. The procedure was performed in spontaneous AF. Clinical parameters had no prognostic value. Only the antero-posterior diameter of the LA was higher in patients with post procedural atrial arrhythmia (52.17 mm vs. 42.75 mm, P = 0.034). Two range of low-voltage areas (< 0.05 mV and < 0.5 mV) were significantly larger in patients with acute failure (90.37 cm2 vs. 60.05 cm2, P = 0.029 respectively, 20.53 cm2 vs. 3.71 cm2, P = 0.012). During a mean FU of 15 ± 7.3 months, 46.7% of patients had a recurrence, predicted only by larger low-voltage areas: absolute values (< 0.5 mV: 104.87 cm2 vs. 67.36 cm2, P = 0.001 and < 0.05 mV: 25.30 cm2 vs. 10.20 cm2, P = 0.007 respectively); and percentages (< 0.5 mV: 76.52% vs. 50.91%, P = 0.0001 and < 0.05 mV: 20.67% vs. 7.65%, P = 0.014 respectively); predictive cut-offs of recurrence are depicted in panel C of the Fig. 1. We identify for the first time that low left atrial voltage area surface is stronger than any other classical factor identified up to now to predict acute failure and recurrence of atrial arrhythmia.

OBJECTIVES This study aimed to evaluate the progression of electrophysiotogicat phenomena in a cohort of patients with paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PsAF). BACKGROUND Electrical remodeling has been conjectured to determine atrial fibrillation (AF) progression. METHODS High-density electroanatomic maps during sinus rhythm of 20 patients with AF (10 PAF, 10 PsAF) were compared with 5 healthy control subjects (subjects undergoing ablation of a left-sided accessory pathway). A computational postprocessing of electroanatomic maps was performed to identify specific electrophysiological phenomena: stow conductions corridors, defined as discrete areas of conduction velocity <50 cm/s, and pivot points, defined as sites showing high wave-front curvature documented by a curt module >2.5 1/s. RESULTS A progressive decrease of mean conduction velocity was recorded across the groups (111.6 +/- 55.5 cm/s control subjects, 97.1 +/- 56.3 cm/s PAF, and 84.7 +/- 55.7 cm/s PsAF). The number and density of slow conduction corridors increase in parallel with the progression of AF (8.6 +/- 2.2 control subjects, 13.3 +/- 3.2 PAF, and 20.5 +/- 4.5 PsAF). In PsAF the atrial substrate is characterized by a higher curvature of wave-front propagation (0.86 +/- 0.71 1/s PsAF vs 0.74 +/- 0.63 1/s PAF; P = 0.003) and higher number of pivot points (25.1 +/- 13.8 PsAF vs 9.5 +/- 6.7 PAF; P < 0.0001). Slow conductions: corridors were mostly associated with pivot sites tending to cluster around pulmonary veins antra. CONCLUSIONS The electrical remodeling hinges mainly on corridors of slow conduction and higher curvature of wave-front propagation. Pivot points associated to SC corridors may be the major determinants for functional localized re-entrant circuits creating the substrate for maintenance of AF. (C) 2022 by the American College of Cardiology Foundation.

Depuis le début des années 2010, les technologies numériques ont trouvé une large application en cardiologie. La médecine connectée, ou santé digitale, qui en résulte utilise les technologies de l’information et de la communication pour colliger partager et analyser les informations à visée médicale. La fibrillation atriale qui est l’arythmie la plus fréquente est une des plus grandes pourvoyeuses de complications emboliques et à type d’insuffisance cardiaque. Dans presque la moitié des cas, elle est cependant asymptomatique et ces technologies ont grandement aidé à son diagnostic. Cet article passe en revue l’historique récent des technologies utilisées, et montre qu’elles sont à fort pouvoir diagnostique et influencent de la prise en charge thérapeutique. L’introduction récente de l’intelligence artificielle augmente fortement la puissance diagnostique des technologies classiques et influencera dans un avenir proche considérablement les processus de décision.

Since the beginning of the last decade, digital technologies are widely applied in cardiology. Connected medicine or digital health uses information and communication technologies to collect, share, and analyse medical data. Atrial fibrillation which is the most frequent arrhythmia is one of the major sources of emboli complication and of heart failure. However, in almost half of the cases it remains under diagnosed as asymptomatic, and these technologies have greatly helped its diagnosis. This article reviews their recent history and emphasises their major diagnostic and management power. The recent introduction of artificial intelligence strongly increases the diagnostic power of classical technologies and in a very near future, will considerably influence the decision-making processes. (c) 2021 l'Academie nationale de medecine. Published by Elsevier Masson SAS. All rights reserved.

Experimental data suggest that shifts in the site of origin of the sinus node (SN) correlate with changes in heart rate and P wave morphology. The direct visualization of the effect of respiration on SN electrical activation has not yet been reported in humans. We aimed to measure the respiratory shifting of the SN activation using ultra-high-density mapping. Sequential right atrial (RA) activation mapping during sinus rhythm (SR) was performed. Three maps were acquired for each patient: basal end-expiratory (Ex), end-inspiratory (Ins), and end-expiratory under isoproterenol (Iso). The earliest activation site (EAS) was defined as the earliest unipolar electrograms (EGM) with a QS pattern and was localized with respect to the ostium of the superior vena cava (SVC; negative values if EAS inside the SVC). In 20 patients, 49 maps in SR were acquired (20 Ex, 19 Ins, and 10 Iso). Expiratory (944 ± 227 ms) and inspiratory (946 ± 227 ms) SR cycle lengths were similar, but shortened under isoproterenol (752 ± 302 ms). Activation was unicentric in 33 maps and multicentric in 16: 4 during Ins, 10 during Ex, and 2 Iso. EAS location was significantly more cranial in expiration than in inspiration (0.27 ± 12.1 vs 5 ± 11.51 mm, p = 0.01). Iso infusion tends to induce a supplemental cranial shift (−4.07 ± 15.83 vs 0.27 ± 12.7 mm, p = 0.21). EAS were found in SVC in 22.7% of maps (30% Ex, 21% Ins, and 8% Iso). Inspiration induces a significant caudal shift of the earliest sinus activation. In one-third of the cases, sinus rhythm earliest activation is inside the SVC.

(1) Background: Cardiac resynchronization therapy (CRT) systems can be simplified by excluding the atrial lead and using a Ventricular-Dual-Dual (VDD) pacing lead. Possible disadvantages might include atrial undersensing and Ventricular-Ventricular-Inhibition (VVI) pacing. Because literature data concerning these systems are scarce, we analyzed their benefits and technical safety. (2) Methods: this retrospective study compared 50 patients implanted with VDD–CRT systems (group A), mainly because of unfavorable venous anatomy concerning the complication rate, with 103 subjects with Dual-Dual-Dual (DDD)–CRT systems (group B) implanted during 2000–2016 and 49 (group C) during 2016–2020. To analyze the functional parameters of the devices, we selected subgroups of 27 patients (subgroup A) and 47 (subgroup B) patients with VDD–CRT in 2000–2016, and 36 subjects (subgroup C) with DDD–CRT implanted were selected in 2017–2020. (3) Results: There was a trend of a lower complication rate with VDD–CRT systems, especially concerning infections during 2000–2016 (p = 0.0048), but similar results were obtained after rigorous selection of patients and employment of an upgraded design of devices/leads. With a proper device programing, CRT pacing had similar results, atrial undersensing being minimal (p = 0.65). For VDD-systems, VVI pacing was recorded only 1.7 ± 2.24% of the time. (4) Conclusions: In patients with a less favorable venous anatomy, VDD–CRT systems may represent a safe alternative regarding complications rates and functional parameters.

Active fixation leads for acute complete atrioventricular block (AVB 3) have recently been introduced in the last international guidelines for cardiac pacing. To describe the routine management of acute AVB 3 in France, with emphasis on the organisational aspects. From September 2019 to November 2019, a prospective national survey including 29 questions was electronically sent to 100 physicians (Google Form). The answers were collected from 93 physicians (response rate 93%). A temporary active fixation lead for AVB 3 has already been implanted by 50.5% of the operators. Eighty (86%) have already observed a dislocation of the temporary pacing lead (TPL), a cardiac perforation already occurred in 57 (61.3%), a groin hematoma in 35 (37.6%), and this technique was proscribed for 4.3% of the operators. Definitive pacemaker implantation during weekends and nights (after 8PM) is possible for 48.9% of the operators (< 5 times a year), for 15.2% (> 5 times a year), impossible for 35.9% of the operators. For AVB3 non-responsive to isoproterenol occurring during the night (Fig. 1), a TPL is implanted by: the on-site medical staff on-duty (27.2%), the on-call interventional cardiologist (20.7%), the on-call electrophysiologist (18.5%), a permanent pacemaker is implanted by the electrophysiologist (12%), the strategy is not standardised (15.2%). Our survey shows important disparities in terms of management of acute AVB3 among the different centres, and a high incidence of complications with temporary passive pacing leads. An active fixation lead with an external pacemaker was used by half of the centres.

BACKGROUND:Complete atrioventricular block (AVB3) may be an urgent potentially lifethreatening situation. Our objective was to describe the routine management of AVB 3, with emphasis on the organizational aspects. METHODS:From September 2019 to November 2019, a prospective national survey including 28 questions was electronically sent to 100 physicians (Google Form). RESULTS:The answers were collected from 93 physicians (response rate 93%). Permanent pacemaker implantation during weekends and nights (after 8PM) is possible for 49% of the operators (<5 times a year), for 15% (>5 times a year), impossible for 36% of the operators. For AVB3 nonresponsive to isoproterenol occurring during the night, a temporary pacing lead (TPL) is implanted by: the on-site medical staff on-duty (27%), the on-call interventional cardiologist (21%), the on-call electrophysiologist (19%), a permanent pacemaker is implanted by the electrophysiologist (12%), the strategy is not standardized (15%). An externalized active fixation lead (AFL) for AVB3 has already been implanted by 50% of the operators. 80 (86%) have already observed a dislocation of the TPL, a cardiac perforation already occurred in 57 (61%), a groin hematoma in 35 (38%), and this technique was proscribed for 4% of the operators. CONCLUSION:Our survey shows important disparities in terms of management of AVB3 among the different centers. An externalized AFL with a reusable generator was used by half of the centers.

Objective: To review adverse events reports for the subcutaneous implantable cardioverter defibrillator (S-ICD) device and understand challenges in its application. Background: The S-ICD is an increasingly popular alternative to transvenous ICD (TV-ICD) devices since FDA approval in 2012. Although we have the benefit of professional guidelines, there are no high-quality trials showing mortality benefit. There are concerns about higher rates of inappropriate shocks with use of S-ICD, which prompted a ‘Smartpass’ firmware upgrade in 2016. The impact of this upgrade on rates of inappropriate shocks remains ill-defined. Methods: Narrative reports of adverse events associated with the S-ICD reported to the FDA MAUDE database were reviewed for reason for reporting and outcomes. These were compared with the total number of devices found on shareholder reports as of October 2020. Results: Of 35,000 S-ICD devices in the US, 9,349 adverse events and 2,521 inappropriate shocks were reported in MAUDE. There were 108 deaths, 21 of which were due to a failure to convert a ventricular arrhythmia. Rates of inappropriate shocks comprised an increasing proportion of adverse events year over year with no decline following the ‘Smartpass’ upgrade. Conclusion: The multiple instances of death following S-ICD failure are alarming as these fatal events are thought to be rare for TV-ICDs. Additionally, even with the introduction of Smartpass, inappropriate shocks have not declined. These findings, taken in conjunction with the lack of data for mortality benefit of the S-ICD and safety concerns surrounding the recent lead recall, should be considered by clinicians in future decisions about S-ICD use.

Introduction – The current scientific literature suggests similar or even better catheter contact on caval regions of the cavo-tricuspid isthmus (CTI) compared to the more medial or annular part. Yet CTI ablation can be challenging owing to instability at the inferior vena cava (IVC) edge. No study specifically addressed the issue of catheter-tissue contact on caval/mid/annular regions of the CTI. Methods – Twenty-seven patients (22 men, 67±12 years) underwent typical atrial flutter ablation with a contact force (CF) sensing catheter (Tacticath 75, Abott) and were prospectively included. Operators aimed at optimizing CF for all RF pulses. The product of CF, time (force-time integral; FTI) and delivered power (FTPI) has been proposed as an estimate of lesion size. In a subset of 8 consecutive pts, electrograms (EGM) of all RF lesions were analyzed. Annular CTI was defined as sites showing both atrial and ventricular near-field bipolar EGM. Mid CTI sites had only atrial near field bipolar EGM on both distal and proximal dipoles (or distal only in case of superior-to-inferior approach). Caval sites had near-field bipolar EGM only in distal dipole, while the proximal one was inferiorly located. Results – Complete persistent (at 30 min) CTI block was obtained in all patients. A steerable sheath was used in 12 pts (44%). Procedure duration was 93±30 min, RF delivery time 10±6 min, fluoroscopy time 14±8 min. Mean CF was 15.8±5.9 g. CF was significantly lower (11.1±9.7 g) at the caval CTI than at mid CTI (19.9±11.8 g) and annular CTI (20±12.2 g; p=0.001). CF and FTI were higher during sinus rhythm than during Fl (23.2±15.3 vs 18.5±15.4 g, p=0.04 and 677±432 vs 532±357 gs, p=0.03). Use of a sheath improved mean CF (24.4±12.5 vs 18.4±14.9 g, p=0.01) but this was not significant at caval sites (17.5±11.4 vs 12.6±10.7 g, p=0.31). Conclusion – Applied forces are significantly lower at the IVC edge during CTI ablation. This supports the use of a steerable sheath in challenging cases.

INTRODUCTION:Literature supports the existence of drivers as maintainers of atrial fibrillation (AF). Whether ultrahigh density (UHD) contact mapping may detect them is unknown.METHODS:We sequentially mapped the left atrial (LA) activation during spontaneous persistent AF and performed circumferential pulmonary vein isolation (CPVI), followed by remapping and ablation of potential drivers (rotational and focal propagation sites) with Rhythmia™ in 90 patients. The time reference was an LA appendage (LAA) electrogram (EGM). Regions with uniform color were defined as "organized." Only patients (51) with no previous ablation were considered for acute results and follow-up reporting.RESULTS:LA maps (175 ± 28 ml, 43578 ± 18013 EGM) were acquired in 23 ± 7 min. In all post-CPVI maps potential drivers (7.3 ± 3.2/patient) were visualized: 85% with rotational propagation and continuous low voltage in the center; the remaining with focal propagation and an organized EGM at the site of earliest activation. The RF delivery time for extra-PV driver ablation was 12.2 ± 7.9 min. There was a progressive increase of AF organization: the LAA cycle length prolonged, the number of potential drivers decreased, and the organized LA surface in AF increased from 14 ± 6% to 28 ± 16% (p = .0007). Termination of AF without cardioversion was obtained in 67%. AF recurrence rate at 15 ± 7.3 months was 17.6% after the first procedure.CONCLUSIONS:Sequential UHD contact activation mapping of persistent AF allows visualization of potential drivers. A sequential strategy of CPVI followed by ablation of potential drivers with limited RF time resulted in an increasing organization of AF and good acute and long-term results.

Abstract Introduction More and more patients undergoing atrial fibrillation (AF) ablation are anticoagulated with direct oral anticoagulants (DOAC). In order to balance the peri-procedural risk of bleeding with the risk of stroke, an important clinical question is whether to continue an interrupted DOAC administration or minimal interrupt by skipping the last one or two doses before the procedure. Dealing with rare events, the randomized controlled trials (RCTs) looking at this question have not been sufficiently powered to give a definitive answer. Purpose To do a systematic review of the literature comparing an uninterrupted DOAC strategy to minimally interrupted (1-2 doses) strategy in the setting of AF ablation in terms of peri-procedural stroke and bleeding. Methods PubMed, EMBASE, and Cochrane databases were searched for RCTs comparing a strategy of uninterrupted versus minimally interrupted DOAC administration for atrial fibrillation ablation. The primary endpoint was a composite of clinically significant adverse events: ischemic stroke, transient ischemic attack (TIA), systemic embolism, and major or minor bleeding events. A random-effects meta-analysis was performed on the resulting trials. The systematic review protocol was pre-registered in the PROSPERO database. The study selection process followed the PRISMA statement. Results After checking and removing duplicates, 188 articles were screened by reading the title and abstract. 8 of them were selected for a full text screening. Because 3 were not randomized, finally, 5 RCTs met the inclusion criteria. A total of 1 769 patients were included in the meta-analysis, and the sample size of the individual RCTs ranged from 97 to 846 patients. The overall prevalence of paroxysmal AF varied from 54% to 100%. The mean age of patients ranged from 63,5 to 70 years, and 21,6% to 32,8% of the trial populations were women. Comorbidities, such as hypertension, dyslipidemia, and diabetes, were common. Most patients had CHA2DS2-VASc < 3; range from 1,7 to 2,7We found consistently low rates of strokes, TIAs, systemic embolisms and bleedings across all trials and both arms (RR = 0.98, 95% CI 0.69 – 1.38, I-squared = 0%, p = 0.874). Conclusion We found no evidence in favor of a difference between uninterrupted and interrupted administration of NOACs regarding the primary outcome of clinical thromboembolic and bleeding. Abstract Figure. Meta-analysis of the primary outcome