Pulmonary vein isolation for the treatment of drug-refractory atrial fibrillation in adults with congenital heart disease. A prospective study on safety of catheter ablation procedures: contact force guided ablation could reduce the risk of cardiac perforation. A clinical risk score for atrial fibrillation in a biracial prospective cohort (from the Atherosclerosis Risk in Communities [ARIC] study). A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale.
BACKGROUND Atrial fibrillation ( AF ) is a common arrhythmia in adults with congenital heart disease ( CHD ) .  Long-term antiarrhythmic therapy ( AAT ) in these patients has significant shortcomings . The safety and efficacy of pulmonary vein antrum isolation ( PVAI ) for the treatment of AF in CHD is presently unknown . HYPOTHESIS We hypothesized that PVAI for AF in patients with CHD is effective and safe . METHODS We review ed a prospect i ve cohort of 4315 patients ( age ≥ 18 ) undergoing PVAI for drug refractory AF at a single institution and identified 36 consecutive patients with CHD ( single ventricle physiology , tetralogy of Fallot , coa rct ation of the aorta , ventricular septal defects , atrial septal defects ( ASD ) and cardiomyopathy result ing from anomalous origin of the left main coronary from the pulmonary artery ) . A second cohort of 355 consecutive patients with noncongenital structural heart disease ( NSHD ) ( coronary artery disease , valvular heart disease , ejection fraction < 50 % , or prior noncongenital cardiac surgery ) undergoing PVAI during the same time period was used as a control . Success was defined as freedom from AF starting two months after PVAI in the absence AAT until the end of follow-up . Partial success was defined as freedom from AF in the presence of AAT until the end of follow-up . Combined success was defined as the sum of success and partial success . We compared the outcomes with the use of propensity-score matching in the overall cohort . RESULTS Patients with NSHD were older and had higher prevalence of hypertension ( P < .01 ) , diabetes ( P < .01 ) and hyperlipidemia ( P < .01 ) . The most common CHD lesion was ASD ( 61 % ) and the most common NSHD lesion was valvular heart disease ( 57 % ) . After one PVAI , success was achieved in 42 % and 53 % at 300 days in the CHD and NSHD groups respectively . Four-year success was achieved in 27 % and 36 % in the CHD and NSHD groups , respectively . There were no significant differences in the success rates between patients groups ( P= .46 ) , nor were there any differences in left atrial size or changes in ejection fraction after one or two PVAI in the respective groups . Complication rates between the CHD and NSHD groups were similar ( 15 % vs. 11 % , P= .42 ) except for a higher risk of vascular site complications in patients with CHD ( 8 % vs. 1 % , P < .05 ) . CONCLUSION PVAI is an attractive treatment modality in drug refractory AF in CHD , with combined success rates in excess of 60 % . The maintenance of sinus rhythm after PVAI in CHD appears similar to that of NSHD and warrants prospect i ve validation BACKGROUND Contact force ( CF ) sensing catheters provide advantages with regard to safety and efficacy . This study aim ed to evaluate if CF catheters reduce cardiac perforations and other major complications and offer equal safety compared to the magnetic navigation system ( MNS ) . METHODS Data from 1.517 ablation procedures from our prospect i ve registry was analyzed . Ablations were performed using either CF guided catheters ( CF group , n=248 ) , non-CF catheters ( NCF group , n=813 ) , or MNS ( n=456 ) . Four subgroups were analyzed : atrial fibrillation ( AF , n=557 ) , supraventricular tachycardia ( SVT , n=715 ) , ventricular tachycardia ( VT , n=190 ) and patients with congenital heart defects ( CHD , n=55 ) . The primary endpoint of this study was incidence of cardiac perforation . Secondary endpoints were major and minor complications within 30 days of the procedure . RESULTS Complications occurred in 11.3 % ( n=172 ) of the procedures . In 2.8 % ( n=43 ) a major complication occurred , 0.9 % ( n=13 ) had a perforation , 8.5 % ( n=129 ) had a minor complication and 2 patients died ( 0.1 % ) . No cardiac perforation occurred in the CF group , which was significantly different from NCF procedures ( 0.0 % vs. 1.6 % ; relative risk 0.76 , 95 % CI 0.74 - 0.79 , P=0.031 ) and equal to MNS ( 0.0 % ) . This was also observed in the AF subgroup ( 0.0 % vs. 3.3 % ; RR 0.67 , 95 % CI 0.63 - 0.72 , P=0.021 ) , and the occurrence of major complications was lower for CF versus NCF procedures ( 2.1 % vs. 7.8 % , P=0.010 ) . CONCLUSIONS CF-guided catheter ablation is superior to NCF with regard to procedural safety and avoidance of cardiac perforation . This difference is due to a reduction of cardiac perforation and major complications in the AF subgroup A risk score for atrial fibrillation ( AF ) has been developed by the Framingham Heart Study ; however , the applicability of this risk score , derived using data from white patients , to predict new-onset AF in nonwhites is uncertain . Therefore , we developed a 10-year risk score for new-onset AF  from risk factors commonly measured in clinical practice using 14,546 subjects from the Atherosclerosis Risk In Communities ( ARIC ) study , a prospect i ve community-based cohort of blacks and whites in the United States . During 10 years of follow-up , 515 incident AF events occurred . The following variables were included in the AF risk  score  : age , race , height , smoking status , systolic blood pressure , hypertension medication use , precordial murmur , left ventricular hypertrophy , left atrial enlargement , diabetes , coronary heart disease , and heart failure . The area under the receiver operating characteristics curve ( AUC ) of a Cox regression model that included the previous variables was 0.78 , suggesting moderately good discrimination . The point-based score developed from the coefficients in the Cox model had an AUC of 0.76 . This clinical risk score for AF in the Atherosclerosis Risk In Communities cohort compared favorably with the Framingham Heart Study 's AF ( AUC 0.68 ) , coronary heart disease ( CHD ) ( AUC 0.63 ) , and hard CHD ( AUC 0.59 ) risk scores and the Atherosclerosis Risk In Communities CHD risk score ( AUC 0.58 ) . In conclusion , we have developed a risk score for AF and have shown that the different pathophysiologies of AF and CHD limit the usefulness of a CHD risk score in identifying subjects at greater risk of AF BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence
The complexity of CHD appears to have a significant effect on a study but not in others .
Catheter ablation in ASD and persistent left superior vena cava had a high success rate .
Overall , catheter ablation is safe whichever the type of CHD is .
Conclusion Catheter ablation for AF in CHD had modest efficacy that can be increased by subsequent/repeat ablation and it also has an excellent safety profile .
Abstract Background Prevalence of atrial fibrillation ( AF ) in patients with congenital heart disease ( CHD ) is on the rise .
Anti-arrhythmic drugs are usually the first line of treatment in CHD , however , it is often ineffective and poorly tolerated .
We aim ed to perform a systematic review to assess the efficacy and safety of catheter ablation for AF in CHD .