Background:Esophageal fistula (EF) is a rare but devastating complication following atrial fibrillation (AF) ablation. Data regarding the impact of age on EF are scarce. Objective:To study the impact of age on the management and prognosis of EF following catheter ablation for AF. Methods:The POTTER-AF study is a worldwide registry on EF following catheter ablation for AF. A total of 553,729 patients underwent AF ablation in 214 centers between 1996 and 2022. Of them, 138 patients experienced EF, and data regarding age, management, and prognosis were available in 113 patients. The population was divided based on the median age. Results:The median age was 63 years; 54 patients were <63 years old (Group 1), and 59 patients were ≥63 years old (Group 2). The groups were similar regarding procedural characteristics. The older population had a shorter time to symptom onset [15.0 (6.0, 21.0) vs. 21.0 (10.0, 25.3) days; p = 0.031]. Group 2 was less likely to receive a brain CT or MRI for diagnosis (25.9% vs. 45.3%; p = 0.046). The older population was more likely to undergo endoscopic treatment without surgery (27.6% vs. 11.3%; p = 0.035). Conservative and surgical treatments were used in similar proportions. A trend toward higher fatality was noted in the older patients (72.9% vs. 56.6%; p = 0.078). Conclusion:The older population had a shorter time to symptom onset, was less likely to receive a brain CT or MRI, and more likely to be treated by an endoscopic approach only. The older patient group showed a trend toward a higher fatality.

BACKGROUND:Heart failure (HF) patients who exhibit improvement in systolic function following atrial fibrillation (AF) ablation may experience better outcomes than those who do not. However, the prognostic significance of such improvement compared to originally preserved systolic function remains unclear. METHODS:Among 1538 patients undergoing AF ablation, those meeting HF criteria were included. Patients with systolic dysfunction (n = 272) and those with a high likelihood of HF with preserved ejection fraction (HFA-PEFF score ≥ 5; pEF group, n = 293) were analyzed. The former were further subdivided based on post-procedural left ventricular ejection fraction (LVEF) into improved EF (imp-EF, LVEF ≥50 %) and non-improved EF (non-imp-EF, LVEF <50 %) groups. The primary endpoint was a composite of all-cause mortality and HF hospitalization, comparing the imp-EF and pEF groups. RESULTS:Among 272 patients with systolic dysfunction, 127 were categorized as imp-EF. After propensity-score matching (101 per group), the imp-EF group had comparable risk of the primary endpoint as the pEF group [HR 0.40 (0.13-1.16), p = 0.09] and similar atrial tachyarrhythmia (ATA) recurrence rates [HR 0.70 (0.37-1.30), p = 0.26] over a median follow-up of 41 (24-71) months. ATA recurrence after the last procedure was associated with adverse events in the imp-EF group, whereas E-wave velocity was the only predictor in the pEF group in univariate analysis. CONCLUSIONS:Patients in both the imp-EF and pEF groups demonstrated comparable prognoses.

BACKGROUND:Evidence regarding the benefits of catheter ablation in patients aged ≥80 years with nonvalvular atrial fibrillation (AF) remains limited. OBJECTIVES:This study sought to evaluate the clinical effectiveness of catheter ablation compared with conservative management in elderly patients (age ≥80 years) with nonvalvular AF. METHODS:This prospective, registry-based, multicenter observational study involved 703 patients aged ≥80 years with nonvalvular AF enrolled from 47 hospitals in Japan (June 2022-December 2023). Among them, 249 underwent catheter ablation and 454 received nonablation management. RESULTS:The nonablation group was slightly older, with more comorbidities and modestly worse baseline characteristics; however, most were potential ablation candidates, and the differences were small. During a median follow-up of 504 days (Q1-Q3: 375-667 days), the primary outcome (a composite of stroke, transient ischemic attack, systemic embolism, cardiovascular events, bleeding, or all-cause death) did not differ between groups in the unmatched (HR: 0.78; P = 0.30) or matched (HR: 0.65; P = 0.21) cohorts. However, in the matched cohort, multivariable adjustment for log-N-terminal pro-B-type natriuretic peptide and albumin levels showed a significant benefit of ablation (adjusted HR: 0.44; P = 0.029). At 1 year, ablation improved symptoms, quality of life, N-terminal pro-B-type natriuretic peptide levels, and left atrial diameter, as well as better preservation of Mini-Mental State Examination and frailty scores. These benefits remained significant after adjustment. CONCLUSIONS:The REHEALTH AF Study (Registry for Evaluating Healthy Life Expectancy and Long-Term Outcomes After Catheter Ablation of Atrial Fibrillation in the Very Elderly) study is the first prospective comparison of ablation vs nonablation in patients aged ≥80 years with AF. Although ablation improved functional and structural outcomes, its prognostic benefit was limited without adjustment but emerged after multivariable correction. Ablation may offer meaningful advantages in well-selected elderly patients, supporting individualized treatment strategies. (Registry for Evaluating Healthy Life Expectancy and Long-Term Outcomes After Catheter Ablation of Atrial Fibrillation in the Very Elderly [REHEALTH AF]; UMIN000047023).

Background and Objective:Treatment for atrial fibrillation (AF) has evolved significantly, with pulmonary vein isolation (PVI) becoming an established treatment. However, the outcomes following catheter ablation for persistent AF remain unsatisfactory. Hybrid catheter-surgical ablation has emerged as a therapeutic approach for persistent AF, combining the strengths of both interventions. The purpose of this narrative review is to comprehensively examine the current state of knowledge regarding hybrid ablation for AF.Methods:A thorough PubMed search using the terms "hybrid ablation", "atrial fibrillation", "catheter ablation", and "guideline on cardiology" within the timeframe of 1980 to 2024 resulted in 138,969 articles. Consensus on the selected articles was reached through a series of structured meetings and discussions.Key Content and Findings:PVI has demonstrated higher sinus rhythm maintenance rates, especially for paroxysmal AF. However, the efficacy is not as high for persistent AF. Additional ablation strategies, such as linear ablation, complex fractionated atrial electrogram ablation, low voltage zone ablation as well as posterior wall isolation, lack consistent evidence of effectiveness. Hybrid ablation, involving collaboration between cardiac surgeons and electrophysiologists, presents a promising alternative for hard-to-treat AF. Recent studies report favorable outcomes of hybrid ablation, with atrial arrhythmia-free rates ranging from 53.5% to 76%, surpassing those of catheter ablation alone, which might result from better lesion durability or intervention for non-PV foci and left atrial appendage excision or closure during hybrid ablation. The rate of complications associated with hybrid ablation is higher than catheter ablation alone.Conclusions:While favorable outcomes of hybrid ablation for persistent AF have been reported, it is not recommended for all AF patients due to its invasiveness compared to catheter ablation. Additionally, some patients with persistent AF maintain sinus rhythm with catheter ablation alone. More clinical data are needed to determine which patients are suitable candidates for hybrid ablation.

Atrial fibrillation (AF) is a common cardiac arrhythmia, with structural and electrical remodeling being significant risk factors for recurrence post-catheter ablation. The advent of high-power short-duration pulmonary vein isolation (HPSD-PVI) presents a novel approach, potentially enhancing procedural success rates through the creation of transmural lesions without overheating. This study investigates the predictors of atrial tachyarrhythmia (ATA) recurrence and compares outcomes between HPSD-PVI and conventional PVI techniques. A total of 1005 patients undergoing radiofrequency catheter ablation (RFA) for AF were retrospectively analyzed in this study. The cohort was divided based on the ablation strategy: conventional PVI from February 2013 to September 2018, and HPSD-PVI from October 2018 onwards. The primary objective was to compare the predictors of ATA recurrence and the outcome between the two groups. Among 969 patients analyzed after exclusions, independent predictors of recurrence differed between groups; higher CHADS(2)/CHA(2)DS(2)-VASc scores and lower left ventricular ejection fraction (LVEF) were significant in the HPSD-PVI group, while non-paroxysmal AF, larger left atrial volume index (LAVI), and longer AF history were predictors in the conventional PVI group. The HPSD-PVI group showed a trend toward lower ATA recurrence rates compared to the conventional PVI group in the propensity-score-matched (PSM) cohort (log-rank test, p = 0.06). Higher CHADS(2)/CHA(2)DS(2)-VASc scores and lower LVEF were also independent predictors of ATA recurrence in the PSM cohort.

Introduction Data are lacking on the extent to which patients with non-valvular atrial fibrillation (AF) who are aged ≥80 years benefit from ablation treatment. The question pertains especially to patients’ postablation quality of life (QoL) and long-term clinical outcomes. Methods and analysis We are initiating a prospective, registry-based, multicentre observational study that will include patients aged ≥80 years with non-valvular AF who choose to undergo treatment by catheter ablation and, for comparison, such patients who do not choose to undergo ablation (either according to their physician’s advice or their own preference). Study subjects are to be enrolled from 52 participant hospitals and three clinics located throughout Japan from 1 June 2022 to 31 December 2023, and each will be followed up for 1 year. The planned sample size is 660, comprising 220 ablation group patients and 440 non-ablation group patients. The primary endpoint will be the composite incidence of stroke/transient ischaemic attack (TIA) or systemic embolism (SE), another cardiovascular event, major bleeding and/or death from any cause. Other clinical events such as postablation AF recurrence, a fall or bone fracture will be recorded. We will collect standard clinical background information plus each patient’s Clinical Frailty Scale score, AF-related symptoms, QoL (Five-Level Version of EQ-5D) scores, Mini-Mental State Examination (optional) score and laboratory test results, including measures of nutritional status, on entry into the study and 1 year later, and serial changes in symptoms and QoL will also be secondary endpoints. Propensity score matching will be performed to account for covariates that could affect study results. Ethics and dissemination The study conforms to the Declaration of Helsinki and the Ethical Guidelines for Clinical Studies issued by the Ministry of Health, Labour and Welfare, Japan. Results of the study will be published in one or more peer-reviewed journals. Trial registration number UMIN000047023.

A 63-year-old man was admitted to the hospital due to ventricular tachycardia (VT) undersensing, caused by decreased R-wave amplitude in a cardiac resynchronization therapy defibrillator. The R-wave amplitude of VT sensed by the left ventricular (LV) lead was markedly higher than that by the right ventricular (RV) lead; therefore, we reconnected the IS-1 RV lead to the LV IS-1 port and the IS-1 LV lead to the RV IS-1 port to resolve this issue. After discharge, it was confirmed that VT was successfully terminated by the second sequence of intrinsic ATP (iATP, Medtronic, Minneapolis, MN, USA) from the LV lead.

AIMS:Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse. METHODS AND RESULTS:This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001]. CONCLUSION:Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

Background:The long-term relationship between fracture-prone implantable cardioverter-defibrillator (ICD) leads and poor prognosis remains unclear in Japanese patients. Methods:We conducted a retrospective review of the records of 445 patients who underwent implantation of advisory/Linox leads (Sprint Fidelis, 118; Riata, nine; Isoline, 10; Linox S/SD, 45) and non-advisory leads (Endotak Reliance, 33; Durata, 199; Sprint non-Fidelis, 31) between January 2005 and June 2012 at our hospital. The primary outcomes were all-cause mortality and ICD lead failure. The secondary outcomes were cardiovascular mortality, heart failure (HF) hospitalization, and the composite outcome of cardiovascular mortality and HF hospitalization. Results:During the follow-up period (median, 8.6 [4.1-12.0] years), there were 152 deaths: 61 (34%) in patients with advisory/Linox leads and 91 (35%) in those with non-advisory leads. There were 32 ICD lead failures: 27 (15%) in patients with advisory/Linox leads and five (2%) in those with non-advisory leads. Multivariate analysis for ICD lead failure demonstrated that the advisory/Linox leads had a 6.65-fold significantly greater risk of ICD lead failure than non-advisory leads. Congenital heart disease (hazard ratio 2.51; 95% confidence interval 1.08-5.83; p = .03) could also independently predict ICD lead failure. Multivariate analysis for all-cause mortality demonstrated no significant association between advisory/Linox leads and all-cause mortality. Conclusions:Patients who have implanted fracture-prone ICD leads should be carefully followed up for ICD lead failure. However, these patients have a long-term survival rate comparable with that of patients with non-advisory ICD leads in Japanese patients.

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AbstractBackgroundReports of long‐term outcomes after atrial fibrillation (AF) ablation for tachycardia‐bradycardia syndrome (TBS) are limited. This study aimed to investigate the impact of radiofrequency catheter ablation (RFCA) on clinical outcomes in patients with TBS.MethodsAmong 1669 patients who underwent AF ablation between January 2010 and April 2020, we retrospectively enrolled 53 patients (62.3% males; age, 67.1 ± 7.0 years) who had been diagnosed with TBS before RFCA for paroxysmal AF (TBS group). After 1:2 propensity score‐matching based on age, gender, AF type, and left atrial dimension, 106 patients were assigned to the control group (non‐TBS group). The atrial tachyarrhythmia (ATA) recurrence rate and rate of avoidance of permanent pacemaker implantation (PMI) were examined.ResultsDuring a median follow‐up period of 37.7 months, the ATA recurrence rate after a single ablation procedure was significantly higher in the TBS group than in the non‐TBS group (51.0% vs. 38.5%; log‐rank p = .008); however, the ATA recurrence rate after the final ablation procedure did not significantly differ between groups. In the TBS group, the rate of PMI avoidance after AF ablation was 92.5%. A Cox‐regression multivariate analysis revealed that the presence of non‐pulmonary vein/superior vena cava premature atrial contractions (odds ratio, 3.38; 95% confidence interval, 1.49–7.66; p = .004) was an independent predictor of ATA recurrence in the TBS group.ConclusionsPatients with TBS had higher ATA recurrence rates after the first ablation procedure compared to those without TBS. However, ATA recurrence after AF ablation did not necessarily result in PMI for TBS patients.

BACKGROUND A recent randomized trial demonstrated that catheter ablation for atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (EF) is associated with a reduction in death or heart failure. However, the effect of catheter ablation for AF in patients with heart failure with mid-range or preserved EF is unclear.Methods and Results: We screened 899 AF patients (72.4% male, mean age 68.4 years) with heart failure and left ventricular EF ≥40% from 2 Japanese multicenter AF registries: the Atrial Fibrillation registry to Follow the long-teRm Outcomes and use of aNTIcoagulants aftER Ablation (AF Frontier Ablation Registry) as the ablation group (525 patients who underwent ablation) and the Hokuriku-Plus AF Registry as the medical therapy group (374 patients who did not undergo ablation). Propensity score matching was performed in these 2 registries to yield 106 matched patient pairs. The primary endpoint was a composite of cardiovascular death and hospitalization for heart failure. At 24.6 months, the ablation group had a significantly lower incidence of the primary endpoint (hazard ratio 0.32; 95% confidence interval 0.13-0.70; P=0.004) than the medical therapy group. CONCLUSIONS Compared with medical therapy, catheter ablation for AF in patients with heart failure and mid-range or preserved EF was associated with a significantly lower incidence of cardiovascular death or hospitalization for heart failure.

Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with < 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine [SCr] ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF > 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF > 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (P = 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.