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Pulmonary vein isolation using "contact force" ablation: the effect on dormant conduction and long-term freedom from recurrent atrial fibrillation--a prospective study. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. Efficacy of three different ablative procedures to treat atrial fibrillation in patients with valvular heart disease: a randomised trial. Circumferential pulmonary vein ablation: does use of a circular mapping catheter improve results? A prospective randomized study. 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Cryoballoon vs. radiofrequency contact force ablation for paroxysmal atrial fibrillation: a propensity score analysis Neuropsychological Effects of MRI-Detected Brain Lesions After Left Atrial Catheter Ablation for Atrial Fibrillation: Long-Term Results of the MACPAF Study A Randomized Controlled Trial of the Efficacy and Safety of Electroanatomic Circumferential Pulmonary Vein Ablation Supplemented by Ablation of Complex Fractionated Atrial Electrograms Versus Potential-Guided Pulmonary Vein Antrum Isolation Guided by Intracardiac Ultrasound Surgical ablation of atrial fibrillation during mitral-valve surgery. Cryoballoon vs. open irrigated radiofrequency ablation for paroxysmal atrial fibrillation: long-term FreezeAF outcomes Technique and Results of Linear Ablation at the Mitral Isthmus Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation.
Background —The Cox Maze procedure for treatment of medically refractory atrial fibrillation ( AF ) is limited by its complexity and requirement for cardiopulmonary bypass . Long-term follow-up and success using criteria established by the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society consensus statement have not been reported for surgical AF ablation . We describe the results of using a thorascopic approach and radiofrequency energy to perform bilateral pulmonary vein isolation and left atrial ganglionic plexi ablation for treatment of AF . Methods and Results —Forty-five ( 33 paroxysmal ; 12 persistent ) consecutive patients underwent thorascopic bilateral radiofrequency pulmonary vein isolation , ganglionic plexi ablation , ligament of Marshall ablation , and left atrial appendage exclusion by a single surgeon . Forty-three patients were prospect ively followed without antiarrhythmic drugs for a minimum of 1 year with a 30-day continuous event monitor or pacemaker interrogation at 6 and 12 months . Failure was defined as any atrial tachyarrhythmia of > 30 seconds ’ duration occurring > 90 days after surgery . Mean follow-up was 516±181 days ( 202 to 858 days ) . Twenty-eight ( 65 % ) patients had no atrial tachyarrhythmia > 30 seconds by 1 year , and 15 ( 35 % ) patients had atrial tachyarrhythmia recurrences by 1 year . Eight of 15 patients with recurrent AF had catheter ablation result ing in elimination and /or reduction of AF episodes in 7 of 8 patients . Four of 15 patients had AF elimination or reduction with antiarrhythmic drugs alone . Three patients did not benefit from surgery and received rate control only . There were no deaths ; 1 phrenic nerve injury and 2 pleural effusions were the only major complications . Conclusions —The single procedure success at 1-year follow-up for surgical pulmonary vein isolation and ganglionic plexi ablation is 65 % . Atrial tachyarrhythmia recurrences after surgery are usually responsive to catheter ablation and /or antiarrhythmic drugs OBJECTIVES This study sought to determine whether ablation of complex fractionated atrial electrograms ( CFAEs ) after antral pulmonary vein isolation ( APVI ) further improves the clinical outcome of APVI in patients with long-lasting persistent atrial fibrillation ( AF ) . BACKGROUND Ablation of CFAEs has been reported to eliminate persistent AF . However , residual pulmonary vein arrhythmogenicity is a common mechanism of recurrence . METHODS In this r and omized study , 119 consecutive patients ( mean age 60 + /- 9 years ) with long-lasting persistent AF underwent APVI with an irrigated-tip radiofrequency ablation catheter . Antral pulmonary vein isolation result ed in termination of AF in 19 of 119 patients ( Group A , 16 % ) . The remaining 100 patients who still were in AF were r and omized to no further ablation and underwent cardioversion ( Group B , n = 50 ) or to ablation of CFAEs in the left atrium or coronary sinus for up to 2 additional hours of procedure duration ( Group C , n = 50 ) . RESULTS Atrial fibrillation terminated during ablation of CFAEs in 9 of 50 patients ( 18 % ) in Group C. At 10 + /- 3 months after a single ablation procedure , 18 of 50 ( 36 % ) in Group B and 17 of 50 ( 34 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.84 ) . In Group A , 15 of 19 patients ( 79 % ) were in sinus rhythm . A repeat ablation procedure was performed in 34 of 100 r and omized patients ( for AF in 30 and atrial flutter in 4 ) . At 9 + /- 4 months after the final procedure , 34 of 50 ( 68 % ) in Group B and 30 of 50 ( 60 % ) in Group C were in sinus rhythm without antiarrhythmic drugs ( p = 0.40 ) . CONCLUSIONS Up to 2 h of additional ablation of CFAEs after APVI does not appear to improve clinical outcomes in patients with long-lasting persistent AF Background —An anatomic approach of left atrial radiofrequency circumferential ablation ( LACA ) to encircle the pulmonary veins is often effective in eliminating  paroxysmal atrial fibrillation ( AF ) .  However , no electrophysiological end points other than voltage abatement and /or conduction slowing or block across ablation lines have been used . It has been unclear whether noninducibility of AF is a clinical ly useful end point . Methods and Results —In 100 patients with paroxysmal AF ( mean age , 55±10 years ) , LACA to encircle the left- and right-sided pulmonary veins was performed during AF , with additional ablation lines in the posterior left atrium and mitral isthmus , with an 8-mm-tip catheter . After completion of this lesion set , sinus rhythm was present , and AF lasting > 60 seconds was not inducible in 40 patients ( 40 % ; group 1 ) . The 60 patients in whom AF was still present or who still had inducible AF were r and omly assigned to no further ablation ( group 2 ; 30 patients ) or to additional ablation lines along the left atrial septum , roof , and /or anterior wall where there were fractionated electrograms ( group 3 ; 30 patients ) . In group 3 , AF was rendered noninducible in 27 of 30 patients ( 90 % ) . At a 6-month follow-up , 67 % of patients in group 2 were free of AF without drug therapy compared with 86 % of patients in group 3 . ( P=0.05 , log-rank test ) . Left atrial flutter occurred in 17 % and 27 % of patients in each group , respectively ( P=0.3 ) . Conclusions —After LACA in patients with paroxysmal AF , AF usually can be rendered noninducible by additional ablation at sites of fractionated electrograms . Noninducibility of AF attained by additional electrogram-guided left atrial ablation may be associated with a better midterm clinical outcome than when AF is still inducible after LACA alone The limited efficacy and proarrhythmic risks of antiarrhythmia agents have result ed in alternative therapeutic approaches . Radiofrequency ablation has been reported to be an effective treatment of patients with atrial fibrillation . However , there is no r and omized clinical trial comparing drug and radiofrequency ablation . The authors r and omized 30 patients with chronic atrial fibrillation refractory to medication into amiodarone and radiofrequency ablation .  The primary objective of this study was to compare the efficacy of amiodarone and radiofrequency ablation in the maintenance of sinus rhythm at 1 year after r and omization . Pulmonary vein isolation and linear ablation of right atrium was the technique used for radiofrequency ablation . There were no significant differences in baseline patient characteristics between the 2 groups . The results of this study showed that the probability of free from atrial fibrillation was better in the radiofrequency ablation group compared to amiodarone ( 78.6 % in the ablation group and 40 % in the amiodarone group , p = 0.018 ) . Radiofrequency ablation results in a significant reduction in symptoms relating to atrial fibrillation and a significant improvement in quality of life , whereas amiodarone had no significant effect on symptoms and quality of life . There was an ischemic stroke as a major complication related to radiofrequency ablation . Amiodarone was associated with adverse effects in 46.7 per cent of patients and needed discontinuation in 1 patient . In conclusion , radiofrequency ablation is an effective alternative treatment in patients with atrial fibrillation refractory to medication OBJECTIVES The aim of this study was to compare -- in patients with persistent and permanent atrial fibrillation (AF)--the  efficacy and safety of left atrial ablation with that of a biatrial approach . BACKGROUND Left atrium-based catheter ablation of AF , although very effective in the paroxysmal form of the arrhythmia , has an insufficient efficacy in patients with persistent and permanent AF . METHODS Eighty highly symptomatic patients ( age , 58.6 + /- 8.9 years ) with persistent ( n = 43 ) and permanent AF ( n = 37 ) , refractory to antiarrhythmic drugs , were r and omized to two different ablation approaches guided by electroanatomical mapping . A procedure including circumferential pulmonary vein , mitral isthmus , and cavotricuspid isthmus ablation was performed in 41 cases ( left atrial ablation group ) . In the remaining 39 patients ( biatrial ablation group ) , the aforementioned approach was integrated by the following lesions in the right atrium : intercaval posterior line , intercaval septal line , and electrical disconnection of the superior vena cava . RESULTS During follow-up ( mean duration 14 + /- 5 months ) , AF recurred in 39 % of patients in the left atrial ablation group and in 15 % of patients in the biatrial ablation group ( p = 0.022 ) . Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up . CONCLUSIONS In patients with persistent and permanent AF , circumferential pulmonary vein ablation , combined with linear lesions in the right atrium , is feasible , safe , and has a significantly higher success rate than left atrial and cavotricuspid ablation alone Background —Segmental ostial catheter ablation ( SOCA ) to isolate the pulmonary veins ( PVs ) and left atrial catheter ablation ( LACA ) to encircle the PVs both may eliminate paroxysmal atrial fibrillation ( PAF ) .  The relative efficacy of these 2 techniques has not been directly compared . Methods and Results —Of 80 consecutive patients with symptomatic PAF ( age , 52±10 years ) , 40 patients underwent  PV isolation by SOCA and 40 patients underwent LACA to encircle the PVs . During SOCA , ostial PV potentials recorded with a ring catheter were targeted . LACA was performed by encircling the left- and right-sided PVs 1 to 2 cm from the ostia and was guided by an electroanatomic mapping system ; ablation lines also were created in the mitral isthmus and posterior left atrium . The mean procedure and fluoroscopy times were 156±45 and 50±17 minutes for SOCA and 149±33 and 39±12 minutes for LACA , respectively . At 6 months , 67 % of patients who underwent SOCA and 88 % of patients who underwent LACA  were free of symptomatic PAF when not taking antiarrhythmic drug therapy ( P = 0.02 ) . Among the variables of age , sex , duration and frequency of PAF , ejection fraction , left atrial size , structural heart disease , and the ablation technique , only an increased left atrial size and the SOCA  technique were independent predictors of recurrent PAF . The only complication was left atrial flutter in a patient who underwent LACA . Conclusions —In patients undergoing catheter ablation for PAF  , LACA to encircle the PVs is more effective than SOCA BACKGROUND Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation . Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation . METHODS We r and omly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone ( 67 patients  ) , pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity ( 263 patients  ) , or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus ( 259 patients ) . The duration of follow-up was 18 months . The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure . RESULTS Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures ( P<0.001 ) . After 18 months , 59 % of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation , as compared with 49 % of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46 % of patients assigned to pulmonary-vein isolation plus linear ablation ( P=0.15 ) . There were also no significant differences among the three groups for the secondary end points , including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia . Complications included tamponade ( three patients ) , stroke or transient ischemic attack ( three patients ) , and atrioesophageal fistula ( one patient ) . CONCLUSIONS Among patients with persistent atrial fibrillation , we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation . ( Funded by St. Jude Medical ; Clinical Trials.gov number , NCT01203748 . ) Background — Several approaches have been developed for radiofrequency catheter ablation of atrial fibrillation , but the correct intraprocedural end point is still under debate , and few data exist about the destiny of ablation lesions over time . The aim of the present study was to evaluate the long-term maintenance of intraprocedural end points of ablation procedures . Methods and Results — Inclusion criteria were ( 1 ) a previous ablation procedure of pulmonary vein ( PV ) encircling performed for drug-refractory persistent atrial fibrillation ; ( 2 ) a “ complete ” intraprocedural end point , which consisted of voltage abatement inside the lesions , PV disconnection , and exit-block pacing from inside the lesions , attained in all PVs ; and ( 3 ) stable sinus rhythm documented during a minimum follow-up of 2.5 years after the procedure . Twenty volunteers were selected ( 12 males , mean age 59±7 years ) and underwent a repeat electrophysiological study . After a follow-up of 36.4±4.7 months , complete voltage abatement was maintained around 32 PVs ( 40.0 % ) , PV disconnection persisted in 12 ( 37.5 % ) of the previously isolated PVs , and exit block was present in 39 PVs ( 48.7 % ) . Ten patients who underwent a redo ablation procedure because of recurrences of atrial fibrillation were used as the control group . Differences in intraprocedural end-point maintenance between the 2 groups were not statistically significant . Conclusions — Common intraprocedural end points such as voltage abatement , PV disconnection , and exit block persist only in a limited number of patients , even when the outcome is favorable during follow-up . Further investigation will be required to determine whether such data will have implication s for ablation strategies BACKGROUND Several studies have provided details of left atrial anatomy by means of the image integration techniques , particularly focusing on the atypical patterns of the pulmonary veins . OBJECTIVE To compare , in a prospect i ve , r and omized fashion , the conventional method of pulmonary vein disconnection and the image integration-guided approach . METHODS Two hundred and ninety consecutive patients ( 290 patients , mean age 55 + /- 11 years ) with drug-refractory paroxysmal or persistent atrial fibrillation were enrolled in the study and were divided into two treatment groups : group 1 ( 145 patients ) undergoing an imaging integration-guided ( CartoMerge TM ) ablation ; group 2 ( 145 patients ) treated by a conventional radiofrequency catheter ablation procedure .  The arrhythmia was refractory to at least two antiarrhythmic drugs ( IC , amiodarone )  . RESULTS Electrical disconnection of all identified pulmonary veins was obtained in all patients of both groups . Bidirectional block of the cavotricuspid isthmus was achieved in 34 group 1 patients and in 40 group 2 patients . Left mitral isthmus ablation was attempted in 52 group 1 patients and in 56 group 2 patients . At a mean follow-up of 14 + /- 12 months , the atrial fibrillation-free survival rate was significantly higher in group 1 patients compared with group 2 patients ( 88 % vs 69 % , P = 0.017 ) . The analysis for the subset of patients with previously ineffective ablation ( 98 patients : 52 group 1 patients and 46 group 2 patients ) showed a significantly lower recurrence rate in group 1 versus group 2 ( 19 % vs 48 % , P < 0.01 ) . CONCLUSIONS Our data indicate a superior efficacy of the image-integration guided catheter ablation of atrial fibrillation over the long term INTRODUCTION Intraoperative left atrial radiofrequency ( RF ) ablation recently has been suggested as an effective surgical treatment for atrial fibrillation ( AF ) . The aim of this study was to verify the outcome of this technique in a controlled multicenter trial . METHODS AND RESULTS One hundred three consecutive patients ( 39 men and 65 women ; age 62 + /- 11 years ) affected by AF underwent cardiac surgery and RF ablation in the left atrium ( RF group ) . The control group consisted of 27 patients ( 6 men and 21 women ; age 64 + /- 7 years ) with AF who underwent cardiac surgery during the same period and refused RF ablation .  Mitral valve disease was present in 89 ( 86 % ) and 25 ( 92 % ) patients , respectively ( P = NS ) . RF endocardial ablation was performed in order to obtain isolation of both right and left pulmonary veins , a lesion connecting the previous lines , and a lesion connecting the line encircling the left veins to the mitral annulus . Upon discharge from the hospital , sinus rhythm was present in 65 patients ( 63 % ) versus 5 patients ( 18 % ) in the control group ( P < 0.0001 ) . Mean time of cardiopulmonary bypass was longer in the RF group ( 148 + /- 50 min vs 117 + /- 30 min , P = 0.013 ) . The complication rate was similar in both groups , but RF ablation-related complications occurred in 4 RF group patients ( 3.9 % ) . After a mean follow-up of 12.5 + /- 5 months ( range 4 - 24 ) , 83 ( 81 % ) of 102 RF group patients were in stable sinus rhythm versus 3 ( 11 % ) of 27 in the control group ( P < 0.0001 ) . The success rate was similar among the four surgical centers . Atrial contraction was present in 66 ( 79.5 % ) of 83 patients in the RF group in sinus rhythm . CONCLUSION Endocardial RF left atrial compartmentalization during cardiac surgery is effective in restoring sinus rhythm in many patients . This technique is easy to perform and reproducible . Rare RF ablation-related complications can occur . During follow-up , sinus rhythm persistence is good , and biatrial contraction is preserved in most patients Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA AIMS A detailed appreciation of the left atrial/pulmonary venous ( LA/PV ) anatomy may be important in improving the safety and success of catheter ablation for AF . The aim of this r and omized study was to determine the impact of computed tomographic ( CT ) integration into an electroanatomic mapping ( EAM ) system on clinical outcome in patients undergoing catheter ablation for atrial fibrillation ( AF ) . METHODS AND RESULTS Eighty patients with AF were r and omized to undergo first-time wide encirclement of ipsilateral PV pairs using EAM alone ( 40 patients ) or with CT ( 40 patients , Cartomerge ) . Wide encirclement of the pulmonary veins was performed using irrigated radiofrequency ablation with the electrophysiological endpoint of electrical isolation ( EI ) . The primary endpoint was single-procedure success at 6 month follow up . Acute and long-term procedural outcomes were also determined . There was no significant difference in single procedure success between EAM ( 56 % ) and cavotricuspid isthmus image ( CTI ) ( 50 % ) groups ( P = 0.9 ) . Acute procedural outcomes ( EI , PV reconnection , sinus rhythm restored by ablation in persistent AF ) , fluoroscopy , and procedure duration s ( EI of right PVs , EI of left PVs , total ) did not differ significantly between EAM and CTI groups . CONCLUSION Image integration to guide catheter ablation for AF did not significantly improve the clinical outcome . Achieving PV EI is the critical determinant of procedural success rather than the mapping tools used to achieve it BACKGROUND In our previous prospect i ve and r and omized study , we have demonstrated that the concomitant surgical ablation using saline-irrigated cooled tip radiofrequency ablation ( SICTRA ) system is more effective than subsequent circumferential pulmonary vein isolation ( CPVI ) combined with substrate modification in treating patients with long-st and ing persistent atrial fibrillation ( LS-AF ) and rheumatic heart disease ( RHD ) undergoing cardiac surgery during middle-term follow-up . Whether this strategy also decreases longer-term arrhythmia recurrence is unknown . This study describes the 4-year efficacy of SICTRA for these patients . Furthermore , we seek to compare the electrophysiological characteristics for recurrent atrial tachyarrhythmia ( ATa ) at the session of catheter ablation between two groups . METHODS Long-term follow-up was performed in 95 patients who underwent the catheter ablation strategy ( n=47 , Group A ) or SICTRA ( n=48 , Group B ) combined with valvular surgery for symptomatic LS-AF patients with RHD . RESULTS After one procedure , Group B had a significantly higher freedom from ATa compared with Group A ( 29/48 vs 15/47 , P=0.005 ) after a mean follow-up of 54 months ( range 48 to 63 months ) . Catheter-based mapping and ablation of recurrent ATa showed larger amounts of macro-reentrant atrial tachycardias ( ATs ) in Group B and higher incidence of pulmonary vein ( PV ) recovery in Group A. After multiple catheter ablations for recurrent ATa , sinus rhythm ( SR ) could be maintained equally between two groups . CONCLUSIONS Single procedure success seems to be higher with SICTRA but repeated catheter ablation potentially results in comparable outcomes in treating patients with LS-AF and RHD during long-term follow-up . More macro-reentrant ATs and more PV recoveries are identified to be responsible for ATa in SICTRA and catheter ablation group , respectively Background —The pulmonary veins ( PVs ) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to the genesis of atrial fibrillation ( AF ) . We developed an anatomic approach aim ed at isolating each PV from the left atrium ( LA ) by circumferential radiofrequency ( RF ) lesions around their ostia . Methods and Results —We selected 26 patients with resistant AF , either paroxysmal ( n=14 ) or permanent ( n=12 ) . A nonfluoroscopic mapping system was used to generate 3D electroanatomic LA maps and deliver RF energy . Two maps were acquired during coronary sinus and right atrial pacing to vali date the lateral and septal PV lesions , respectively . Patients were followed up closely for ≥6 months . Procedures lasted 290±58 minutes , including 80±22 minutes for acquisition of all maps , and 118±16 RF pulses were deployed . Among 14 patients in AF at the beginning of the procedure , 64 % had sinus rhythm restoration during ablation . PV isolation was demonstrated in 76 % of 104 PVs treated by low peak-to-peak electrogram amplitude ( 0.08±0.02 mV ) inside the circular line and by disparity in activation times ( 58±11 ms ) across the lesion . After 9±3 months , 22 patients ( 85 % ) were AF-free , including 62 % not taking and 23 % taking antiarrhythmic drugs , with no difference ( P = NS ) between paroxysmal and permanent AF . No thromboembolic events or PV stenoses were observed by transesophageal echocardiography . Conclusions —Radiofrequency PV isolation with electroanatomic guidance is safe and effective in either paroxysmal or permanent AF BACKGROUND This r and omized prospect i ve study compared three ablation strategies in patients with long-st and ing persistent atrial fibrillation ( LPeAF ) . It also explored the best procedural endpoint from among the following : circumferential pulmonary vein isolation ( PVI ) + left atrial ( LA ) linear lesions ( roofline , mitral isthmus ) + complex fractionated atrial electrogram ( CFAE ) ablation , PVI + LA linear lesions + cavotricuspid isthmus ( CTI ) ablation + CFAE ablation , and PVI + CFAE ablation . METHODS AND RESULTS A total of 210 patients with LPeAF referred for catheter ablation were enrolled and r and omized into three ablation groups . The patients in group A ( n = 70 ) underwent PVI followed by LA linear and CFAE ablation ; in 93 % of patients the primary endpoint was achieved ( five patients with incomplete linear lesions ) . Of the 70 patients in group B who were subjected to PVI followed by LA linear , CFAE , and CTI ablations , in 94 % of patients the primary endpoint was achieved ( four patients with incomplete linear lesions ) . All patients in group C ( n = 70 ) successfully underwent PVI and CFAE ablation . Direct current cardioversion was performed upon PVI , CFAE elimination , and completion of linear lesions . Patients were followed-up for atrial tachyarrhythmia recurrence for at least 24 months . After a single ablation procedure , group C ( 36 % ) exhibited the lowest success compared with group A ( 54 % ) and group B ( 51 % ) ( P = 0.06 ) . At the mean follow-up of 32 ± 9 months after the final ablation procedure , 53 patients ( 76 % ) in group A , 53 ( 76 % ) in group B , and 41 ( 59 % ) in group C were in sinus rhythm without antiarrhythmic drugs ( P = 0.03 ) . CONCLUSIONS In LPeAF , linear lesions in the LA help improve outcome of ablation , additional CTI ablation does not Background —Pulmonary veins ( PVs ) play a pivotal role in initiating and perpetuating  atrial fibrillation ( AF ) . We investigated if PV electrical isolation from the left atrium is required for curing AF . Methods and Result —Fifty-one patients with paroxysmal or persistent AF underwent circumferential radiofrequency ablation of PV ostia performed with an anatomic approach . The end point of the ablation procedure was the recording of low peak-to-peak bipolar potentials ( < 0.1 mV ) inside the lesions . Left atrium pacing was used to assess the conduction between the PVs and the left atrium . During a mean follow-up period of 16.6±3.9 months , 41 patients ( 80.4 % ) were free of atrial arrhythmias . When patients with and without AF recurrence were analyzed , no significant difference was observed in the mean number of PVs in which the ablation end point was reached ( 3.4±1.2 versus 3.7±0.87 ) and PVs isolated ( 1.5±1.4 versus 1.6±1 ) . We noted that , although in 29 of 41 patients ( 71 % ) without AF recurrence , the ablation end point was reached in all PVs mapped , it was only possible to demonstrate the isolation of all PVs mapped in 2 patients . On the other h and , in 7 of 10 patients ( 70 % ) with AF recurrence , the ablation end point was reached in all PVs mapped , whereas one patient had all PVs isolated . Conclusions —Our findings show that with the use of a pure anatomic approach , it is possible to prevent AF in > 80 % of patients undergoing catheter ablation . Moreover , the isolation of PVs is not crucial for curing AF Background —Electric isolation of the pulmonary veins and posterior left atrium with a single ring of radiofrequency lesions ( single-ring isolation [ SRI ] ) may result in fewer atrial fibrillation ( AF ) recurrences than wide antral pulmonary vein isolation ( wide antral isolation [ WAI ] ) by abolishing extravenous AF triggers . The effect of mitral isthmus line ( MIL ) ablation on outcomes after SRI has not previously been assessed . Methods and Results —We r and omly assigned 220 consecutive patients ( 58±10 years old ; 82 % men ) with highly symptomatic AF ( 61 % paroxysmal , 39 % persistent/longst and ing persistent ) to undergo either SRI or WAI .  Half of each cohort was also r and omly allocated to have left lateral MIL ablation ( 2 × 2 factorial study design ) . Patients were followed clinical ly and with 7-day Holter studies for arrhythmia recurrences . The primary end points were recurrence of AF and organized atrial tachyarrhythmias . AF-free survival at 2 years was better after SRI ( 74 % [ 95 % CI , 65%–82 % ] ) than WAI ( 61 % [ 51%–70 % ] ; P=0.031 ) . Organized atrial tachyarrhythmia – free survival was similar after SRI and WAI ( 67 % [ 57%–75 % ] ersus 64 % [ 54%–72 % ] , respectively , at 2 years ; P=0.988 ) . MIL ablation result ed in better 2-year organized atrial tachyarrhythmia – free survival ( 71 % [ 62%–79 % ] versus 60 % [ 50%–69 % ] ; P=0.07 ) , which approached statistical significance . Survival free of any atrial arrhythmia after one procedure was not significantly affected by isolation technique or MIL ablation . Conclusions —SRI result ed in fewer AF recurrences compared with WAI on long-term follow-up but did not reduce the recurrence of all atrial arrhythmias . MIL ablation may reduce organized atrial tachyarrhythmia recurrences . Clinical Trial Registration —http://www.anzctr.org.au ; ACTRN12606000467538 BACKGROUND We conducted a r and omized , controlled trial of circumferential pulmonary-vein ablation for the treatment of chronic atrial fibrillation . METHODS A total of 146 patients with a mean ( + /-SD ) age of 57+/-9 years who had chronic atrial fibrillation were r and omly assigned to receive amiodarone and undergo two cardioversions during the first three months alone ( the control group ) or in combination with circumferential pulmonary-vein ablation . Cardiac rhythm was assessed with daily telephonic transmissions for one year . The left atrial diameter and the severity of symptoms were assessed at 12 months . RESULTS Among the 77 patients assigned to undergo circumferential pulmonary-vein ablation , ablation was repeated because of recurrent atrial fibrillation in 26 percent of patients and atypical atrial flutter in 6 percent . An intention-to-treat analysis showed that 74 percent of patients in the ablation group and 58 percent of those in the control group were free of recurrent atrial fibrillation or flutter without antiarrhythmic-drug therapy at one year ( P=0.05 ) . Among the 69 patients in the control group , 53 ( 77 percent ) crossed over to undergo circumferential pulmonary-vein ablation for recurrent atrial fibrillation by one year and only 3 ( 4 percent ) were in sinus rhythm without antiarrhythmic-drug therapy or ablation . There were significant decreases in the left atrial diameter ( 12+/-11 percent , P<0.001 ) and the symptom severity score ( 59+/-21 percent , P<0.001 ) among patients who remained in sinus rhythm after circumferential pulmonary-vein ablation . Except for atypical atrial flutter , there were no complications attributable to circumferential pulmonary-vein ablation . CONCLUSIONS Sinus rhythm can be maintained long term in the majority of patients with chronic atrial fibrillation by means of circumferential pulmonary-vein ablation independently of the effects of antiarrhythmic-drug therapy , cardioversion , or both . The maintenance of sinus rhythm is associated with a significant decrease in both the severity of symptoms and the left atrial diameter Background — Catheter ablation ( CA ) and minimally invasive surgical ablation ( SA ) have become accepted therapy for antiarrhythmic drug – refractory atrial fibrillation . This study describes the first r and omized clinical trial comparing their efficacy and safety during a 12-month follow-up . Methods and Results — One hundred twenty-four patients with antiarrhythmic drug – refractory atrial fibrillation with left atrial dilatation and hypertension ( 42 patients , 33 % ) or failed prior CA ( 82 patients , 67 % ) were r and omized to CA ( 63 patients ) or SA ( 61 patients ) . CA consisted of linear antral pulmonary vein isolation and optional additional lines . SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein , ganglionated plexi ablation , and left atrial appendage excision with optional additional lines . Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording . The primary end point , freedom from left atrial arrhythmia > 30 seconds without antiarrhythmic drugs after 12 months , was 36.5 % for CA and 65.6 % for SA ( P=0.0022 ) . There was no difference in effect for subgroups , which was consistent at both sites . The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA ( n=21 [ 34.4 % ] versus n=10 [ 15.9 % ] ; P=0.027 ) , driven mainly by procedural complications such as pneumothorax , major bleeding , and the need for pacemaker . In the CA group , 1 patient died at 1 month of subarachnoid hemorrhage . Conclusion — In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA , SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up , although the procedural adverse event rate is significantly higher for SA than for CA . Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00662701 Background — Together with pulmonary veins , many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation . The left atrial appendage ( LAA ) is an underestimated site of initiation of atrial fibrillation . Here , we report the prevalence of triggers from the LAA and the best strategy for successful ablation . Methods and Results — Nine hundred eighty-seven consecutive patients ( 29 % paroxysmal , 71 % nonparoxysmal ) undergoing redo catheter ablation for atrial fibrillation were enrolled . Two hundred sixty-six patients ( 27 % ) showed firing from the LAA and became the study population . In 86 of 987 patients ( 8.7 % ; 5 paroxysmal , 81 nonparoxysmal ) , the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection . Ablation was performed either with focal lesion ( n=56 ; group 2 ) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography ( 167 patients ; group 3 ) . In the remaining patients , LAA firing was not ablated ( n=43 ; group 1 ) . At the 12±3-month follow-up , 32 patients ( 74 % ) in group 1 had recurrence compared with 38 ( 68 % ) in group 2 and 25 ( 15 % ) in group 3 ( P<0.001 ) . Conclusions — The LAA appears to be responsible for arrhythmias in 27 % of patients presenting for repeat procedures . Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated BACKGROUND This prospect i ve multicenter r and omized study aim ed to compare the efficacy of 3 common ablation methods used for longst and ing permanent atrial fibrillation ( AF ) . METHODS A total of 144 patients with longst and ing permanent AF ( median duration 28 months ) were r and omly assigned to circumferential pulmonary vein ablation ( CPVA , group 1 , n = 47 ) , to pulmonary vein antrum isolation ( PVAI , group 2 , n = 48 ) or to a hybrid strategy combining ablation of complex fractionated or rapid atrial electrograms ( CFAE ) in both atria followed by a pulmonary vein antrum isolation ( CFAE + PVAI , group 3 , n = 49 ) . RESULTS Scarring in the left atrium and structural heart disease/hypertension were present in most patients ( 65 % ) . After a mean follow-up of 16 months , 11 % of patients in group 1 , 40 % of patients in group 2 and 61 % of patients in group 3 were in sinus rhythm after one procedure and with no antiarrhythmic drugs ( P < .001 ) . Sinus rhythm maintenance would increase respectively to 28 % ( group 1 ) , 83 % ( group 2 ) , and 94 % ( group 3 ) after 2 procedures and with antiarrhythmic drugs ( AADs , P < .001 ) . The AF terminated during ablation , either by conversion to sinus rhythm or organization into an atrial tachyarrhythmia , in 13 % of patients ( group 1 ) , 44 % ( group 2 ) , and 74 % ( group 3 ) respectively . CFAE alone , performed as the first step of the ablation in group 3 , organized AF in only 1 patient . CONCLUSION In this study , the hybrid AF ablation strategy including antrum isolation and CFAE ablation had the highest likelihood of maintaining sinus rhythm in patients with longst and ing permanent AF . Electrical isolation of the PVs , although inadequate if performed alone , is relevant to achieve long-term sinus rhythm maintenance after ablation . Bi-atrial CFAE ablation had a minimal impact on AF termination during ablation BACKGROUND Persistent and long-st and ing persistent atrial fibrillation ( AF ) often requires extensive and /or repeat radiofrequency ( RF ) ablation procedures . OBJECTIVE The Tailored Treatment of Persistent Atrial Fibrillation ( TTOP-AF ) study assessed the effectiveness and safety of the phased RF system in a r and omized controlled comparison of medical therapy against phased RF ablation for the management of persistent and long-st and ing persistent AF . METHODS Patients who had failed at least 1 antiarrhythmic drug ( AAD ) were r and omized ( 2:1 ) to ablation management ( AM ) or medical management ( MM ) . AM patients were allowed up to 2 ablations . Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated atrial electrograms . MM patients received AAD changes and /or cardioversion . The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation . RESULTS At 6 months , a greater proportion of AM patients achieved effectiveness off AAD ( 77 of 138 [ 55.8 % ] ) compared to MM patients ( 19 of 72 [ 26.4 % ] ) ( P < .0001 ) . Acutely , 92.8 % ( 128/138 ) of the procedures were successful while 12.3 % ( 17/138 ) experienced a serious procedure and /or device-related adverse event . The predefined acute safety end point was not met . The proportion of patients with chronic safety events did not differ significantly between groups . CONCLUSIONS Catheter ablation of persistent/long-st and ing persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM . More intense anticoagulation strategies , careful attention to catheter placement relative to the pulmonary vein ostia , and elimination of electrode interaction are expected to reduce the risk of stroke , pulmonary vein stenosis , and asymptomatic cerebral emboli Summary Background Evidence from animal and human studies suggests that cryoablation might be associated with a lesser inflammatory response and activation of coagulation compared with radiofrequency ablation . The study was aim ed at comparing the effect of cryoballoon and radiofrequency catheter ablation of paroxysmal atrial fibrillation on markers of myocardial damage , inflammation , and activation of coagulation . Methods Forty-one patients received either cryoballoon  ( n = 23 ) or radiofrequency ( n = 18 ) ablation of atrial fibrillation .  We measured troponin I , high-sensitivity CRP , and interleukin 6 at baseline from the cubital vein , and from the right and left atrium before and after ablation , and from the cubital vein the following day . Prothrombin fragments 1 + 2 , soluble P‑selectin , and D‑dimer were measured before and after ablation from both atria . Results We observed higher troponin I release in the cryoballoon than in the radiofrequency group ( 7.01 mcg/l ( interquartile range [ IQR ] : 5.30–9.09 ) vs 2.32 mcg/l ( IQR : 1.45–2.98 ) , p < 0.001 ) . The levels of inflammatory markers ( high-sensitivity CRP and interleukin 6 ) in the two groups were comparable , as were the levels of markers of coagulation activation . Procedure duration , fluoroscopy times , and mid-term success ( 23 months , IQR 7–32 ) of the two groups were also comparable . Conclusions Cryoballoon ablation of atrial fibrillation causes more significant myocardial damage , that is , more extensive ablation lesions , compared with radiofrequency catheter ablation . However , no major differences between these two ablation techniques with regard to the inflammatory response and activation of the coagulation system were observed Background —The objective of this study was to assess the incidence and impact of asymptomatic arrhythmia in patients with highly symptomatic atrial fibrillation ( AF ) who qualified for radiofrequency ( RF ) catheter ablation .  Methods and Results —In this prospect i ve study , 114 patients with at least 3 documented AF episodes together with corresponding symptoms and an ineffective trial of at least 1 antiarrhythmic drug were selected for  RF ablation .  With the use of CARTO , circumferential lesions around the pulmonary veins and linear lesions at the roof of the left atrium and along the left atrial isthmus were placed . A continuous , 7-day , Holter session was recorded before ablation , right after ablation , and after 3 , 6 , and 12 months of follow-up . During each 7-day Holter monitoring , the patients recorded quality and duration of any complaints by using a detailed symptom log . More than 70 000 hours of ECG recording were analyzed . In the 7-day Holter records before ablation , 92 of 114 patients ( 81 % ) had documented AF episodes . All episodes were symptomatic in 35 patients ( 38 % ) . In 52 patients ( 57 % ) , both symptomatic and asymptomatic episodes were recorded , whereas in 5 patients ( 5 % ) , all documented AF episodes were asymptomatic . After ablation , the percentage of patients with only asymptomatic AF recurrences increased to 37 % ( P<0.05 ) at the 6-month follow-up . An analysis of patient characteristics and arrhythmia patterns failed to identify a specific subset who were at high risk for the development of asymptomatic AF . Conclusions —Even in patients presenting with highly symptomatic AF , asymptomatic episodes may occur and significantly increase after catheter ablation . A symptom-only – based follow-up would substantially overestimate the success rate . Objective measures such as long-term Holter monitoring are needed to identify asymptomatic AF recurrences after ablation OBJECTIVES The purpose of this study was to investigate the efficacy safety of the novel cryoballoon device ( A rct ic Front , Cryocath , Quebec , Canada ) . BACKGROUND Antral pulmonary vein ( PV ) ablation with radiofrequency energy is widely used as a strategy for catheter ablation of paroxysmal atrial fibrillation ( PAF ) . A novel double lumen cryoballoon catheter was design ed for circumferential pulmonary vein isolation ( PVI ) with the cryoablation technique . METHODS We consecutively enrolled 346 patients with symptomatic , drug refractory paroxysmal ( n = 293 ) or persistent ( n = 53 ) atrial fibrillation ( AF ) . In all patients , PVI of all targeted PVs was the therapeutic aim . The primary end points of this nonr and omized study were : 1 ) acute isolation rate of targeted PV ; and 2 ) first electrocardiogram-documented recurrence of AF . The secondary end point was occurrence of PV stenosis or atrio-esophageal fistula . RESULTS The 1,360 of 1,403 PVs ( 97 % ) were targeted with balloons or balloons in combination with the use of Freezor Max ( Cryocath ) . We found that ablation with the cryoballoon result ed in maintenance of sinus rhythm in 74 % of patients with PAF and 42 % of patients with persistent AF . No PV narrowing occurred . The most frequent complication was right phrenic nerve palsy observed during cryoballoon ablation at the right superior PV . CONCLUSIONS Pulmonary vein isolation with a new cryoballoon technique is feasible . Sinus rhythm can be maintained in the majority of patients with PAF by circumferential PVI using a cryoballoon ablation system . Cryoablation was less effective in patients with persistent AF than in patients with PAF Background — Contact force ( CF ) is a major determinant of lesion size and transmurality and has the potential to improve efficacy of atrial fibrillation ablation . This study sought to evaluate the safety and effectiveness of a novel irrigated radiofrequency ablation catheter that measures real-time CF in the treatment of patients with paroxysmal atrial fibrillation . Methods and Results — A total of 300 patients with symptomatic , drug-refractory , paroxysmal atrial fibrillation were enrolled in a prospect i ve , multicenter , r and omized , controlled trial and r and omized to radiofrequency ablation with either a novel CF-sensing catheter or a non-CF catheter ( control ) . The primary effectiveness end point consisted of acute electrical isolation of all pulmonary veins and freedom from recurrent symptomatic atrial arrhythmia off all antiarrhythmic drugs at 12 months . The primary safety end point included device-related serious adverse events . End points were powered to show noninferiority . All pulmonary veins were isolated in both groups . Effectiveness was achieved in 67.8 % and 69.4 % of subjects in the CF and control arms , respectively ( absolute difference , −1.6 % ; lower limit of 1-sided 95 % confidence interval , −10.7 % ; P=0.0073 for noninferiority ) . When the CF arm was stratified into optimal CF ( ≥90 % ablations with ≥10 g ) and nonoptimal CF groups , effectiveness was achieved in 75.9 % versus 58.1 % , respectively ( P=0.018 ) . The primary safety end point occurred in 1.97 % and 1.40 % of CF patients and control subjects , respectively ( absolute difference , 0.57 % ; upper limit of 1-sided 95 % confidence interval , 3.61 % ; P=0.0004 for noninferiority ) . Conclusions — The CF ablation catheter met the primary safety and effectiveness end points . Additionally , optimal CF was associated with improved effectiveness . Clinical Trial Registration — http://www . clinical trials.gov . Unique identifier : NCT01278953 INTRODUCTION This study examines the feasibility of atrial fibrillation ( AF ) ablation using registered three-dimensional computed tomography ( CT ) images of the left atrium with fluoroscopy . METHODS AND RESULTS A total of 50 consecutive patients with symptomatic AF refractory to medical therapy ( 32 paroxysmal , 18 persistent , age 55 + /- 10 years ) were r and omized to undergo a catheter-based AF ablation procedure with or without the CT-fluoroscopy guidance system . All patients underwent preprocedural contrast-enhanced CT imaging and segmentation of the left atrium . For the CT-fluoroscopy group , circumferential lesions encompassing the pulmonary vein ( PV ) antrum and linear lesions along the roof of the left atrium between the superior PVs and the mitral isthmus were created on the CT image , which was registered with real-time fluoroscopy . The registered images were then used to navigate the ablation catheters to the sites of planned ablation . After the ablation sites were completed , any remaining PV potentials were isolated with electrophysiological guidance . In the control patients , the same technique was performed without using the CT-fluoro guidance system . CT scans were accurately registered to fluoroscopic images with minimal manual correction . Operators could navigate catheters on the registered images to preplanned , extraostial sites for ablation . CT-fluoroscopy guidance decreased procedure duration and fluoro times ( P < 0.05 ) . At a mean follow-up of 9 + /- 2 months , 21 patients ( 84 % ) in the CT-fluoro guidance group and 16 patients ( 64 % ) in the control group have had no recurrence of AF . CONCLUSION CT-fluoroscopic-guided left atrial ablation is feasible and allows appropriate catheter manipulation in the left atrium Background Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation ( AF ) . We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus ( PVAI + CS ) to pulmonary vein antral isolation ( PVAI ) alone in patients with paroxysmal AF . Methods Forty-two consecutive patients with paroxysmal AF were prospect ively r and omized to PVAI vs. PVAI + CS . All patients were seen 3 , 6 , 12 , and 18 months after ablation and underwent 24-h ambulatory Holter monitoring . Results Following a single procedure , 17 out of 22 patients ( 77 % ) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 ( 50 % ) after PVAI + CS ( p < 0.01 ) . After PVAI , three patients had recurrent paroxysmal AF , and two had atrial tachycardia , whereas after PVAI + CS , three patients had recurrent paroxysmal AF , and seven had atrial tachycardia . All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism . Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80 % after 1.35 procedures in the PVAI + CS group ( p < 0.01 ) . Conclusion The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia Background —Circumferential radiofrequency ablation around pulmonary vein ( PV ) ostia has recently been described as a new anatomic approach for atrial fibrillation ( AF ) . Methods and Results —We treated 251 consecutive patients with paroxysmal ( n=179 ) or permanent ( n=72 ) AF .  Circular PV lesions were deployed transseptally during sinus rhythm ( n=124 ) or AF ( n=127 ) using 3D electroanatomic guidance . Procedures lasted 148±26 minutes . Among 980 lesions surrounding individual PVs ( n=956 ) or 2 ipsilateral veins with close openings or common ostium ( n=24 ) , 75 % were defined as complete by a bipolar electrogram amplitude < 0.1 mV inside the lesion and a delay > 30 ms across the line . The amount of low-voltage encircled area was 3594±449 mm2 , which accounted for 23±9 % of the total left atrial ( LA ) map surface . Major complications ( cardiac tamponade ) occurred in 2 patients ( 0.8 % ) . No PV stenoses were detected by transesophageal echocardiography . After 10.4±4.5 months , 152 patients with paroxysmal AF ( 85 % ) and 49 with permanent AF ( 68 % ) were AF-free . Patients with and without AF recurrence did not differ in age , AF duration , prevalence of heart disease , or ejection fraction , but the LA diameter was significantly higher ( P < 0.001 ) in permanent AF patients with recurrence . The proportion of PVs with complete lesions was similar between patients with and without recurrence , but the latter had larger low-voltage encircled areas after radiofrequency ( expressed as percent of LA surface area;P < 0.001 ) . Conclusions —Circumferential PV ablation is a safe and effective treatment for AF . Its success is likely due to both PV trigger isolation and electroanatomic remodeling of the area encompassing the PV ostia AIMS Early recurrences of atrial arrhythmia after wide electrically isolating ablation for atrial fibrillation ( AF ) are well described , but the long-term risk of recurrence for patients with persistent and permanent AF has not been studied in detail . METHODS AND RESULTS Fifty-six consecutive patients [ 45 men ( 80.4 % ) , age 55.9 + /- 8.7 years ] with persistent [ 39(69.6 % ) ] or permanent [ 17(30.4 % ) ] AF were followed for 21.6 + /- 8.8 months after ablation . Atrial fibrillation duration prior to ablation was 6.4 + /- 5.6 years .  Electrically isolating lesions encircling the left and right pulmonary veins ( PVs ) in pairs were created . After 1.5 + /- 0.7 procedures , 48 ( 85.7 % ) had sinus rhythm ( SR ) at 21.6 + /- 8.8 months of follow-up : achieved with 1 procedure in 27 ( 56.3 % ) and without anti-arrhythmics in 30 ( 62.5 % ) . Atrial fibrillation recurrence was observed in 69.6 % after the first and 46.4 % after the last procedure . Of those with late recurrences ( > 90 days ) following the last procedure , most [ 18 ( 69.2 % ) ] did not have early recurrences . Pre-procedural AF duration ( P = 0.007 ) and female gender ( P = 0.005 ) were independent predictors of recurrence following the last procedure . CONCLUSION Circumferential PV isolation is effective in most patients with persistent or permanent AF . However , repeat procedures are frequently required . Late recurrences are common and not precluded by the absence of early post-procedural arrhythmias BACKGROUND A detailed appreciation of left atrial/pulmonary vein ( LA/PV ) anatomy may be important in improving the safety and success of catheter ablation ( CA ) for atrial fibrillation ( AF ) . OBJECTIVES The aim of this nonr and omized study was to determine the impact of computerized tomography ( CT ) image integration into a 3-dimensional ( 3D ) mapping system on the clinical outcome of patients undergoing CA for AF . METHODS Ninety-four patients ( age : 56 + /- 10 years ) with AF ( paroxysmal 46 , persistent 48 ) underwent wide encirclement of ipsilateral PV pairs using irrigated radiofrequency ablation with the endpoint of electrical isolation . Ablation was guided by 3D mapping alone ( electroanatomic 24 , noncontact 23 ) in 47 ( 3DM group ) patients and by CT image integration ( Cartomerge ) in 47 ( CT group ) . In persistent AF , a combination of linear ablation and targeted ablation of complex fractionated electrograms was also performed . RESULTS Successful PV electrical isolation did not differ between the two groups . A significant reduction in fluoroscopy times was demonstrated in the CT group ( 49 + /- 27 minutes vs 3DM group 62 + /- 26 minutes , P = 0.03 ) . Arrhythmia recurrence was reduced in the CT group ( 32 % vs 51 % in the 3DM group , P < 0.01 ) . In 30 symptomatic patients ( 12 CT and 18 3DM ) , repeat procedures for AF ( 13 in 3DM and 5 CT , P < or = 0.10 ) and AT ( 5 in 3DM and 7 CT , P = NS ) were performed . Overall success on 7-day monitor off antiarrhythmic drugs was achieved in 60 % in the 3DM group when compared with 83 % in the CT group ( P < 0.05 ) at a follow-up of 25 + /- 5 weeks . CONCLUSION CA for AF guided by CT integration was associated with reduced fluoroscopy times , arrhythmia recurrence , and increased restoration of sinus rhythm . Improved visualization of complex LA geometries might improve the safety and success of CA for AF Abstract Background : Catheter ablation of atrial fibrillation is a rapidly evolving art . There is currently no consensus as to optimal methodology . We report a sequential experience , during which three distinct ablation techniques were utilized . Methods : A cohort of 112 patients in whom atrial fibrillation onset was precipitated by ectopy arising solely from myocardium investing the pulmonary veins underwent catheter ablation using one of three techniques : focal ( Group A ) ; individual vein encircling ( Group B ) ; vestibule encircling ( Group C ) . In each group , non-fluoroscopic guidance of the mapping and ablation process was provided by the t and em use of CARTORM and intracardiac echocardiography . Results : In all groups , endocardial topography was complex , and ablation electrode-endocardial contact was often unstable . Maximal electrode temperatures were low , despite frequent echocardiographic evidence of myocardial boiling . A significant progression in the number of radiofrequency energy applications between groups A and C was observed . Although acute suppression of atrial fibrillation inducibility was observed uniformly , chronic suppression rates were significantly different : Group A = 47 % ; Group B ; 69 % ; Group C = 87 % . Conclusions : In this non-concurrent cohort , the rate of chronic suppression of atrial fibrillation correlated with the amount of myocardium ablated or electrically isolated . Prospect i ve data will be required to further evaluate whether “ more is better . AIM To investigate the impact of using computed tomography ( CT ) and contact force ( CF ) technology on recurrence of atrial tachyarrhythmia after atrial fibrillation ( AF ) ablation . METHODS This non-r and omized study included 2 groups of patients . All patients had symptomatic recurrent paroxysmal or persistent AF and were treated with at least 1 anti arrhythmic medication or intolerant to medication . The first group included 33 patients who underwent circumferential pulmonary veins isolation ( PVI ) for AF during 2012 and 2013 guided by CT image integration ( Cartomerge , Biosense Webster , Diamond Bar , CA , United States ) of left atrium and pulmonary veins into an electroanatomic mapping ( EAM ) system ( CT group ) using st and ard irrigated radiofrequency catheter ( ThermoCool , Carto , Biosense Webster , Diamond Bar , CA , United States ) or irrigated catheter with integrated CF sensor ( Smart Touch , Carto , Biosense Webster , Diamond Bar , CA , United States ) . The second group included immediately preceding 32 patients who had  circumferential PVI by st and ard irrigated catheter ( ThermoCool ) using only EAM ( Carto ) system ( EAM group ) . Linear lesions were performed according to the discretion of operator . RESULTS Sex , age , and persistent AF were not different between groups . PVI was achieved in all patients in both groups . Linear ablations including cavo-tricuspid isthmus and or roof line ablation were not different between groups . Free of atrial tachyarrhythmia during follow-up of 24 mo was significantly higher among CT group compared to EAM group ( 81 % vs 55 % ; respectively ; P = 0.027 ) . When 11 patients from CT group who had ablation using Smart Touch catheter were excluded , the difference between CT group and EAM became non significant ( 73 % vs 55 % ; respectively ; P = 0.16 ) . Sub analysis of CT group showed that patients who had ablation using Smart Touch catheter tend to be more free of atrial tachyarrhythmia compared to patients who had ablation using st and ard irrigated catheter during follow-up ( 100 % vs 73 % ; respectively ; P = 0.07 ) . Major complications ( pericardial effusion , cerebrovascular accident/transient ischemic attack , vascular access injury requiring intervention ) did not occurred in both groups . CONCLUSION These preliminary results suggest that CT image integration and CF technology may reduce the recurrence of atrial tachyarrhythmia after catheter ablation for AF BACKGROUND Atrial fibrillation ( AF ) recurrence after pulmonary vein isolation ( PVI ) is associated with PV to left atrium reconduction . Effective lesion creation necessitates adequate contact force between the ablation catheter and myocardium . OBJECTIVE The purpose of this study was to study the utility of contact force-guided ablation on immediate and long-term outcomes . METHODS Seventy-five patients with highly symptomatic paroxysmal AF underwent wide circumferential PVI using an irrigated-tip radiofrequency catheter . In 25 patients , ablation was guided by real-time contact force measurements ( CF group ; SmartTouch , Biosense Webster ) . A control group of 50 patients underwent  PVI using a st and ard nonforce sensing catheter ( st and ard group ; ThermoCool , Biosense Webster ) . After PVI , all patients underwent adenosine testing to unmask dormant conduction . Patients were followed up at 3 , 6 , and 12 months and by transtelephonic monitoring as well . RESULTS Dormant conduction was unmasked and subsequently eliminated in 4 PV pairs ( 8 % ; 16 % of patients ) in the CF group and 35 PV pairs ( 35 % ; 52 % of patients ) in the st and ard group ( P = .0004 per PV pair ; P = .0029 per patient ) . The single-procedure , off-antiarrhythmic drug freedom from recurrent atrial arrhythmias at 1 year was 88 % in the CF group vs 66 % in the st and ard group ( P = .047 ) . Procedure duration and fluoroscopy time were significantly longer in the CF group ( P = .0038 and P = .0001 , respectively ) . CONCLUSION The use of real-time contact force guidance results in a significant reduction in the prevalence of dormant conduction with improved long-term freedom from recurrent arrhythmias . The utility of a contact force-guided approach requires evaluation in a long-term prospect i ve r and omized study ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on BACKGROUND Advances in technology such as epicardial bipolar radiofrequency pulmonary vein isolation , ganglionated plexi identification , and isolation and thoracoscopic left atrial appendage exclusion have enabled less invasive surgical options for management of atrial fibrillation . METHODS We performed a prospect i ve , nonr and omized study of consecutive patients with symptomatic paroxysmal atrial fibrillation undergoing a video-assisted , minimally invasive surgical ablation procedure .  The procedure consisted of bilateral , epicardial pulmonary vein isolation with bipolar radiofrequency , partial autonomic denervation , and selective excision of the left atrial appendage . Minimum follow-up was 1 year with long-term monitoring ( 24-hour continuous , 14-day event or pacemaker interrogation ) . RESULTS Between March 2005 and January 2008 , 52 patients ( 35 male ) , mean age 60.3 years ( range , 42 - 79 years ) underwent the procedure . The left atrial appendage was isolated in 88.0 % ( 44/50 ) . Average hospital stay was 5.2 days ( range 3 - 10 days ) . There were no operative deaths or major adverse cardiac events . On long-term monitoring , freedom from atrial fibrillation/flutter/tachycardia was 86.3 % ( 44/51 ) and 80.8 % ( 42/52 ) at 6 and 12 months , respectively . Antiarrhythmic drugs were stopped in 33 of 37 patients and warfarin in 30 of 37 of the patients in whom ablation was successful at 12 months . Freedom from symptoms attributed to atrial fibrillation/flutter/tachycardia was 78.0 % ( 39/50 ) at 6 months and 63.8 % ( 30/47 ) at 12 months . CONCLUSIONS Minimally invasive surgical ablation is effective in the management of paroxysmal atrial fibrillation as evidence d by freedom from atrial arrythmias by long-term monitoring at 12 months . Measuring success using clinical symptoms underestimated clinical success as compared with long-term monitoring OBJECTIVES Various modifications have been proposed to the original Cox 's Maze procedure due to concerns about the long bypass and cross clamp times . The efficacy of these procedures has been studied and reported . We conducted a r and omised prospect i ve study to compare three procedures , differing in extent , of ablation in patients in atrial fibrillation who were undergoing surgery for rheumatic valvular heart disease . These procedures utilised radiofrequency in the bipolar mode . The extent of ablation was ( 1 ) biatrial ( replication of the Cox Maze ) ( 2 ) left atrial portion of the Cox Maze and ( 3 ) pulmonary vein isolation along with a control group ( the No Maze group ) . Conversion rate to sinus rhythm was studied over a mid-term follow-up period . METHODS A total of 160 patients were studied with 40 patients in each group .  Antiarrhythmic drugs were not used in the three months preceding surgery and for seven days postoperatively . The patients underwent surgery for their valve disease along with the ablative procedure as per r and omisation using radiofrequency microbipolar coagulation and cryoablation . They were followed up and were evaluated for symptomatic improvement , rhythm with ECG documentation and 2D echocardiography . RESULTS Follow-up was available for 133 patients . Mid-term results showed that sinus rhythm was restored in 62.5 % patients of Biatrial Maze group and 57.5 % in the Left Atrial Maze . In the Pulmonary Vein Isolation Maze group , 67.5 % patients converted to NSR whereas in the No Maze group only 20 % patients were in sinus rhythm ( p value for all the groups was 0.001 when compared to the No Maze group ) . The incidence of other arrhythmias was not significant and there were no other major complications . All the patients in sinus rhythm at follow-up were in NYHA functional class I-II and showed good effort tolerance . CONCLUSIONS Results achieved with the three ablative procedures are comparable . Therefore lesser procedures viz . Left Atrial Maze and the Pulmonary Vein Isolation Maze procedures must be studied further with the additional use of antiarrhythmic drugs BACKGROUND The best method for performing atrial fibrillation ( AF ) ablation is still under debate . The importance of using a circular mapping ( CM ) catheter for assessing isolation of the pulmonary vein ( PV ) antrum on the outcome of the procedure has not been clearly established . OBJECTIVE The purpose of this study was to evaluate whether use of a CM catheter improves the arrhythmia-free proportion after circumferential pulmonary vein ablation ( CPVA ) . METHODS A series of 146 consecutive patients ( 83 % males , age 53 + /- 10 years , 53 % paroxysmal AF ) were r and omized to two ablation strategies . In both groups , ipsilateral PV encirclement was performed until disappearance or dissociation of the local electrogram within the surrounded area . In the first group , only the radiofrequency catheter was used to both map and ablate ( CPVA group , n = 73 ) . In the other group , a CM catheter was added to assess the electrical activity of the PV antrum ( CPVA-CM group , n = 73 ) . An ablation line along the left atrial roof was also created in all patients . RESULTS Procedural and fluoroscopic times were longer in the CPVA-CM group ( P < .05 ) . Severe procedure-related complications occurred in 1 ( 1.4 % ) patient in the CPVA group and in 3 ( 4.1 % ) patients in the CPVA-CM group ( P = .317 ) . After mean follow-up of 9 + /- 3 months , 31 ( 42.5 % ) patients in the CPVA group and 47 ( 64.4 % ) patients in the CPVA-CM group were arrhythmia-free without antiarrhythmic medication ( P = .008 ) . CONCLUSION Use of a CM catheter to ensure isolation of the PV antrum improved the success of CPVA but increased some procedural requirements Background —Ablation of persistent atrial fibrillation can be challenging , often involving not only pulmonary vein isolation ( PVI ) but also additional linear lesions and ablation of complex fractionated electrograms ( CFE ) . We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure . Methods and Results —In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ⩽35 % , high-density CFE maps were recorded biatrially at baseline , in the left atrium ( LA ) after PVI and linear lesions ( roof and mitral isthmus ) , and biatrially after LA CFE ablation . Surface area of CFE ( mean cycle length ⩽120 ms ) remote to PVI and linear lesions , defined as CFE area , was reduced after PVI ( 18.3±12.03 to 10.2±7.1 cm2 ; P<0.001 ) and again after linear lesions ( 7.7±6.5 cm2 ; P=0.006 ) . Complete mitral isthmus block predicted greater CFE reduction ( P=0.02 ) . Right atrial CFE area was reduced by LA ablation , from 25.9±14.1 to 12.9±11.8 cm2 ( P<0.001 ) . Estimated 1-year arrhythmia-free survival was 72 % after a single procedure . Incomplete linear lesion block was an independent predictor of arrhythmia recurrence ( hazard ratio , 4.69 ; 95 % confidence interval , 1.05–21.06 ; P=0.04 ) . Conclusions —Remote LA CFE area was progressively reduced following PVI and linear lesions , and LA ablation reduced right atrial CFE area . Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena . Nevertheless , in an advanced atrial fibrillation substrate , linear lesions after PVI diminished the target area for CFE ablation , and complete lesions result ed in a favorable clinical outcome CONTEXT Although left atrial radiofrequency ablation ( RFA ) is increasingly used for the treatment of chronic atrial fibrillation during mitral valve surgery , its efficacy to restore sinus rhythm and any result ing benefits have not been examined in the context of an adequately powered r and omized trial . OBJECTIVE To determine whether intraoperative RFA of the left atrium increases the long-term restoration of sinus rhythm and improves exercise capacity . DESIGN , SETTING , AND PATIENTS R and omized , double-blind trial performed in a single UK tertiary referral center with enrollment between December 2001 and November 2003 . A total of 101 patients referred for mitral valve surgery with at least 6 months ' history of uninterrupted atrial fibrillation were assessed for eligibility ; 97 were enrolled . Patients were followed up for 12 months . INTERVENTION Patients were r and omly assigned to undergo mitral valve surgery and RFA of the left atrium ( n = 49 ) or mitral valve surgery alone ( controls ; n = 48 ) . MAIN OUTCOME MEASURES The primary outcome measure was presence of sinus rhythm at 12 months ; secondary measures were patient functional status and exercise capacity ( assessed by shuttle-walk test ) , left atrial contractility , and left atrial and left ventricular dimension and function and plasma levels of B-type natriuretic peptide . RESULTS At 12 months , sinus rhythm was present in 20 ( 44.4 % ) of 45 RFA patients and in 2 ( 4.5 % ) of 44 controls ( rate ratio , 9.8 ; 95 % CI , 2.4 - 86.3 ; P<.001 ) . Restoration of sinus rhythm in the RFA group was accompanied by a greater improvement in mean ( SD ) shuttle-walk distance compared with controls ( + 94 [ 102 ] m vs + 48 [ 82 ] m ; P = .003 ) and a greater reduction in the plasma level of B-type natriuretic peptide ( -104 [ 87 ] fmol/mL vs -51 [ 82 ] fmol/mL ; P = .03 ) . Patients r and omized to receive RFA had similar rates of postoperative complications and deaths as control patients . CONCLUSIONS Radiofrequency ablation of the left atrium during mitral valve surgery for continuous atrial fibrillation significantly increases the rate of sinus rhythm restoration 1 year postoperatively , improving patient exercise capacity . On the basis of its efficacy and safety , routine use of RFA of the left atrium during mitral valve surgery may be justified . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00238706 BACKGROUND Both segmental ostial and circumferential extraostial pulmonary vein ( PV ) isolation have been proven effective in the treatment of atrial fibrillation ( AF ) . However , the recurrence of AF and PV conduction after the 2 ablation strategies has never been compared in a r and omized study . METHODS A total of 100 consecutive patients ( age 56 + /- 10 ; 71 men ) with symptomatic AF ( paroxysmal , 51 ; persistent , 49 ) were r and omized to segmental ostial ( n = 54 ) or circumferential extraostial ( n = 46 ) PV isolation . A circular catheter positioned at the ostium of each target PV guided the ostial PV isolation . Extraostial PV isolation was performed by encircling the paired left and right PVs , respectively , guided by an electroanatomic mapping system . RESULTS A total of 84 % of the patients had recurrent AF after the first PV isolation procedure , showing 72 % with AF and 12 % with organized left atrial tachycardia . In patients undergoing reablation , all but 2 patients had recurrence of left atrium PV conduction ( > 95 % ) . During a mean follow-up of 12 months without antiarrhythmic medication , 57 % of patients who underwent extraostial PV isolation were free of arrhythmia symptoms compared with 31 % of patients who underwent ostial PV isolation ( P < .05 ) . This difference in success rate between the 2 ablation strategies was mainly seen in patients known with persistent AF ( 52 % and 15 % , respectively ; P = .02 ) as opposed to patients with paroxysmal AF ( 65 % and 46 % , respectively ; P = .26 ) . CONCLUSIONS Overall , the more proximal , extraostial PV isolation was found to be superior to ostial PV isolation , especially in patients known with persistent AF . A high recurrence rate of 84 % after a single complete PV isolation procedure was seen . At reablation , more than 95 % had recurrence of left atrium PV conduction regardless of the procedure used , supporting the idea that complete PV isolation seems essential to prevent arrhythmia recurrences AIMS The urge to facilitate the atrial fibrillation ( AF ) ablation procedure has led to the development of new ablation catheters specifically design ed as ' one-shot tools ' for pulmonary vein isolation ( PVI ) . The purpose of this study was to compare the efficacy , safety , and procedure times for two such catheters using different energy sources . METHODS AND RESULTS One hundred and ten patients , referred for ablation of paroxysmal or persistent AF , were r and omized to treatment with either the cryoballoon or the circular multipolar duty-cycled radiofrequency-based pulmonary vein ablation catheter ( PVAC ) .  Complete PVI was achieved in 98 vs. 93 % patients in the cryoballoon and PVAC group , respectively , with complication rates of 8 vs. 2 % ( P = 0.2 ) . Complete freedom from AF , without antiarrhythmic drugs , after one single ablation procedure was seen in 46 % in the cryoballoon vs. 34 % after 12 months ( P = 0.2 ) . Procedure times were comparable , but fluoroscopy time was shorter for the cryoballoon ( 32 ± 16 min ) than for the PVAC procedures ( 47 ± 17 min ) ( P < 0.001 ) . A significant improvement of quality of life ( QoL ) and arrhythmia-related symptoms was seen in both groups after ablation . CONCLUSION Both catheters proved comparably effective and safe in achieving acute PVI , apart from the shorter fluoroscopy times achieved with the cryoballoon . At follow-up , there was no statistically significant difference between the groups regarding freedom from AF and clinical success . The QoL increased to the same levels as for the general Swedish population in both groups AIMS The aim of the study was to investigate the feasibility of performing segmental pulmonary vein ( PV ) isolation guided by the NavX ( Endocardial Solutions , St Jude Medical , Inc. , St Paul , MN , USA ) system without the three-dimensional ( 3D ) geometric reconstruction option and whether the use of NavX system will reduce the radiation exposure and procedure duration . METHODS AND RESULTS The study included 64 patients with symptomatic paroxysmal or permanent atrial fibrillation , in whom PV isolation was performed using fluoroscopic guidance ( n=32 ) or the NavX system ( n=32 ) . Pulmonary vein mapping with a circular mapping catheter allowed the identification and localization of myocardial connections between the PV and the left atrium . PV isolation was performed by radiofrequency ablation of these connections at the atrial aspect of the PV ostium . Primary success rate for isolated PVs did not differ significantly in patients ablated under fluoroscopic guidance vs. those ablated under guidance of NavX system [ 100/107 PVs ( 93.5 % ) vs. 120/124 PV ( 96.8 % ; P = n.s . ) ] . Compared with fluoroscopy guided procedures , NavX-guided procedures showed a significant reduction in the fluoroscopy time ( 75.8+/-24.5 vs. 38.9+/-19.3 min , P<0.05 ) , total X-ray exposure ( 93.2+/-51.6 vs. 56.6+/-37.9 Gy cm(2 ) , P=0.03 ) , and total procedural time ( 237.7+/-65.4 vs. 188.6+/-62.7 min , P=0.01 ) . The mean follow-up was 9.5+/-3.0 months . One patient in each group was lost to follow-up . Seven-day Holter monitoring showed that 23 of 31 patients ( 74.2 % ) in the NavX-guided group and 21 of 31 patients ( 67.7 % ) in the fluoroscopy-guided group were in sinus rhythm ( P=0.57 ) . CONCLUSION The 3D visualization of the catheters by NavX system allows a rapid and precise visualization of the mapping and ablation catheters at the PV ostia and markedly reduces fluoroscopy time , total X-ray exposure , and procedural duration during PV isolation compared with ablation performed under fluoroscopy guidance AIM Catheter ablation of paroxysmal atrial fibrillation ( PAF ) is associated with an important risk of early and late recurrence , necessitating repeat ablation procedures . The aim of this prospect i ve r and omized patient-blind study was to compare the efficacy and safety of cryoballoon ( Cryo ) versus radiofrequency ( RF ) ablation of PAF after failed initial RF ablation procedure . METHODS Patients with a history of symptomatic PAF after a previous failed first RF ablation procedure were eligible for this study . Patients were r and omized to Cryo or RF redo ablation . The primary endpoint of the study was recurrence of atrial tachyarrhythmia , including AF and left atrial flutter/tachycardia , after a second ablation procedure at 1 year of follow-up . All patients were implanted with a cardiac monitor ( Reveal XT , Medtronic ) to continuously track the cardiac rhythm . Patients with an AF burden ( AF% ) ≤ 0.5 % were considered AF-free ( Responders ) , while those with an AF% > 0.5 % were classified as patients with AF recurrences ( non-Responders ) . RESULTS Eighty patients with AF recurrences after a first RF pulmonary vein isolation ( PVI ) were r and omized to Cryo ( N = 40 ) or to RF ( N = 40 ) . Electrical potentials were recorded in 77 mapped PVs ( 1.9 ± 0.8 per patient ) in Cryo Group and 72 PVs ( 1.7 ± 0.8 per patient ) in RF Group ( P = 0.62 ) , all of which were targeted . In Cryo group , 68 ( 88 % ) of the 77 PVs were re-isolated using only Cryo technique ; the remaining 9 PVs were re-isolated using RF . In RF group , all 72 PVs were successfully re-isolated ( P = 0.003 vs Cryo ) . By intention-to-treat , 23 ( 58 % ) RF patients were AF-free vs 17 ( 43 % ) Cryo patients on no antiarrhythmic drugs at 1 year ( P = 0.06 ) . Three patients had temporary phrenic nerve paralysis in the Cryo group ; the RF group had no complications . Of the 29 patients who had only Cryo PVI without any RF ablation , 11 ( 38 % ) were AF-free vs 20 ( 59 % ) of the 34 patients who had RF only ( P = 0.021 ) . CONCLUSION When patients require a redo pulmonary vein isolation ablation procedure for recurrent PAF , RF appears to be the preferred energy source relative to Cryo Background Various strategies have been used for atrial fibrillation ( AF ) ablation . It is unclear whether adding linear lesions to pulmonary vein ( PV ) isolation has significant advantages . Objectives We assessed the clinical benefit of adding linear lesions in patients undergoing PV isolation for AF . Methods One hundred patients ( 63 male and 37 female ; mean age of 59 ± 11 years ) with documented paroxysmal AF were included in the study . Patients were r and omized into two groups . The first group underwent PV isolation alone . The second group underwent PV isolation and had two linear lesions created ; one line between the superior PVs , and a second line from the left inferior PV to the mitral valve annulus . Patients ’ clinical progress after the ablation was evaluated and compared at 1 , 3 , and 9 months after their respective ablation procedures . Results The linear lesions group maintained sinus rhythm and had fewer symptoms than the lone PV isolation group ( 86 vs. 58 % , respectively ) ( p < 0.05 ) at 1 month . At 9 months , when patients who reverted to AF underwent additional management to regain sinus rhythm ( 90 vs. 82 % , respectively ) ( p = NS ) , there was no statistical difference between the groups regarding the use of antiarrhythmics , the need for electrical cardioversion , and subjective improvement . Conclusion The addition of linear lesions to PV isolation more effectively achieved sinus rhythm initially and fewer patients required additional management to maintain their rhythm when compared to patients who underwent lone PV isolation . However , at 9 months , the overall results were similar in both groups BACKGROUND Left atrial ( LA ) circumferential ablation has been reported to eliminate atrial fibrillation ( AF ) . Whether an ablation without encirclement of the pulmonary veins ( PVs ) is as effective as LA circumferential ablation is not clear . OBJECTIVES The purpose of this study was to compare the efficacy of LA circumferential ablation and nonencircling linear ablation in patients with chronic AF . METHODS Eighty patients with chronic AF were r and omized to undergo LA circumferential ablation ( n = 40 ) or nonencircling linear ablation ( n = 40 ) . In LA circumferential ablation , the PVs were encircled , with additional lines made in the mitral isthmus and posterior wall or roof . In nonencircling linear ablation , 4 + /- 1 ablation lines were created through areas of complex electrograms , with lines in the roof ( 38 ) , anterior wall ( 36 ) , septum ( 40 ) , mitral isthmus ( 32 ) , and posterior annulus ( 6 ) . The endpoint of LA circumferential ablation and nonencircling linear ablation was voltage abatement . RESULTS LA flutter occurred in 15 % after LA circumferential ablation and in 18 % after nonencircling linear ablation ( P = .8 ) . A repeat ablation procedure was performed for recurrent AF in 7 and 11 patients or for atrial flutter in 6 and 4 patients after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .8 ) . At 9 + /- 4 months , the prevalence of AF was 28 % in the LA circumferential ablation and 25 % in the nonencircling linear ablation group ( P = .8 ) . Sixty-eight percent and 60 % of patients were in sinus rhythm and free of AF and atrial flutter in the absence of antiarrhythmic drug therapy after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .5 ) . There were no complications . CONCLUSION Nonencircling linear ablation and LA circumferential ablation are equally efficacious in eliminating chronic AF . However , the advantage of nonencircling linear ablation is that it eliminates the need for ablation along the posterior wall of the LA . Therefore , nonencircling linear ablation may avoid the small but real risk of atrioesophageal fistula formation associated with LA circumferential ablation BACKGROUND Residual gaps due to incomplete ablation lines are known to be the most common cause of recurrent atrial fibrillation ( AF ) after catheter ablation . We hypothesized that any residual potentials at the junction of the left atrium and pulmonary vein ( PV ) , inside the circumferential PV ablation ( CPVA ) lines , would contribute to the recurrence of AF or post-AF ablation atrial flutter ( AFL ) ; therefore , the elimination of these potentials increases AF-/AFL-free survival rates . METHODS AND RESULTS One hundred and two patients with paroxysmal AF ( PAF ) were enrolled and prospect ively r and omized to a group with  ablation of residual potentials  as add-on therapy to  CPVA + PV electrical isolation ( PVI ) ( group 1 , n = 49 ) , or a group without ablation of the residual potentials ( group 2 , n = 53 ) . Post-CPVA residual potentials , inside the ablation lines , were identified by contact bipolar electrode mapping catheter and a detailed 3-dimensional voltage map . Twenty-three patients in group 1 and 18 patients in group 2 had post-CPVA residual potentials ( 46.9 % vs 34.0 % , P = 0.182 ) . The AF-/AFL-free survival rate during follow-up of 23.3 ± 7.9 months was not different in comparisons between the 2 groups ( P = 0.818 ) , and 79.6 % and 81.1 % of the patients in groups 1 and 2 maintained a sinus rhythm ( P = 0.845 ) , respectively . CONCLUSIONS Residual potentials inside CPVA were commonly found in the patients with PAF after CPVA + PVI . Further ablation of residual potentials did not increase the efficacy of catheter ablation in patients with PAF AIMS We conducted a multi-centre , prospect i ve , controlled , r and omized trial to investigate the adjunctive role of ablation therapy to antiarrhythmic drug therapy in preventing  atrial fibrillation ( AF )  relapses in patients with paroxysmal or persistent AF in whom antiarrhythmic drug therapy had already failed . METHODS AND RESULTS One hundred and thirty seven patients were r and omized to ablation and antiarrhythmic drug therapy ( ablation group ) or antiarrhythmic drug therapy alone ( control group ) . In the ablation group , patients underwent cavo-tricuspid and left inferior pulmonary vein (PV)-mitral isthmus ablation plus circumferential PV ablation . The primary end-point of the study was the absence of any recurrence of atrial arrhythmia lasting > 30 s in the 1-year follow-up period , after 1-month blanking period . Three ( 4.4 % ) major complications were related to ablation : one patient had a stroke during left atrium ablation , another suffered transient phrenic paralysis , and the third had a pericardial effusion which required pericardiocentesis . After 12 months of follow-up , 63/69 ( 91.3 % ) control group patients had at least one AF recurrence , whereas 30/68 ( 44.1 % ) ( P<0.001 ) ablation group patients had atrial arrhythmia recurrence ( four patients had atrial flutter , 26 patients AF ) . CONCLUSION Ablation therapy combined with antiarrhythmic drug therapy is superior to antiarrhythmic drug therapy alone in preventing atrial arrhythmia recurrences in patients with paroxysmal or persistent AF in whom antiarrhythmic drug therapy has already failed AIMS Ablation of complex fractionated atrial electrograms ( CFAEs ) is a new approach for the treatment of atrial fibrillation ( AF ) . The purpose of the study was to assess the efficacy of CFAE ablation as a st and -alone strategy in patients with persistent AF and to compare it with a combined approach of CFAE ablation and pulmonary vein isolation ( PVI ) . METHODS AND RESULTS The study included 77 consecutive patients with persistent AF who underwent radiofrequency ( RF ) ablation of CFAE as a sole ablation procedure ( CFAE group , n = 23 patients ) or a combined approach of CFAE ablation and PVI ( CFAE plus PVI group , n = 54 patients ) . Procedures were guided by three-dimensional mapping systems . After the procedure , AF recurrences were evaluated with 7-day Holter recordings at 1 , 3 , and 6 months and every 6 months thereafter . Treatment failure was defined as > or=1 AF episode lasting > 30 s on Holter recordings during follow-up . After a mean follow-up time of 13 + /- 10 months , 2 of 23 patients ( 9 % ) with CFAE ablation and 22 of 54 patients ( 41 % ) with CFAE plus PVI were in sinus rhythm after a single ablation procedure without anti-arrhythmic medication ( P = 0.008 ) . CONCLUSION Ablation of CFAE as a st and -alone ablation strategy seems insufficient for the treatment of patients with persistent AF . Pulmonary vein isolation plus CFAE ablation significantly increases the mid-term success rate Background —Atrial flutter ( AFL ) and atrial fibrillation ( AF ) frequently coexist in the same patient . Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins ( PVs ) . We hypothesized that in patients with both AF and typical AFL , pulmonary vein – left atrial junction ( PV-LAJ ) disconnection may eliminate both arrhythmias . Methods and Results —Consecutive patients with documented symptomatic AF and typical AFL were r and omly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus ( CTI ) ablation ( group 1 , n=49 ) or PV-LAJ disconnection alone ( group 2 , n=59 ) . Within the first 8 weeks after ablation , 32 of the group 2 patients had typical AFL documented , whereas none was seen in group 1 . Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs ( AADs ) . Twelve were cardioverted , and AADs were started . After 8 weeks , all AADS were stopped , and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation . Beyond 8 weeks of follow-up , 7 patients in group 1 and 6 patients in group 2 ( 14 % and 11 % , respectively ) continued to have AF . Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured . The remaining 3 remained in normal sinus rhythm while taking AADs . Conclusions —In patients with both AFL and AF , PV-LAJ disconnection alone may be sufficient to control both arrhythmias . CTI block reduced early postablation recurrence of arrhythmias , which in the majority of patients reflects a short-term clinical problem BACKGROUND Catheter ablation is important for treatment of paroxysmal atrial fibrillation ( PAF ) . Limited animal and human studies suggest a correlation between electrode-tissue contact and radiofrequency lesion generation . OBJECTIVES The study sought to assess the safety and effectiveness of an irrigated , contact force (CF)-sensing catheter in the treatment of drug refractory symptomatic PAF . METHODS A prospect i ve , multicenter , nonr and omized study was conducted . Enrollment criteria included : ≥3 symptomatic episodes of PAF within 6 months of enrollment and failure of ≥1 antiarrhythmic drug ( Class I to IV ) . Ablation included pulmonary vein isolation with confirmed entrance block as procedural endpoint . RESULTS A total of 172 patients were enrolled at 21 sites , where 161 patients had a study catheter inserted and 160 patients underwent radiofrequency application . Procedural-related serious adverse events occurring within 7 days of the procedure included tamponade ( n = 4 ) , pericarditis ( n = 3 ) , heart block ( n = 1 , prior to radiofrequency application ) , and vascular access complications ( n = 4 ) . By Kaplan-Meier analyses , 12-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 72.5 % . The average CF per procedure was 17.9 ± 9.4 g. When the CF employed was between investigator selected working ranges ≥80 % of the time during therapy , outcomes were 4.25 times more likely to be successful ( p = 0.0054 ; 95 % confidence interval : 1.53 to 11.79 ) . CONCLUSIONS The SMART-AF trial demonstrated that this irrigated CF-sensing catheter is safe and effective for the treatment of drug refractory symptomatic PAF , with no unanticipated device-related adverse events . The increased percent of time within investigator-targeted CF ranges correlates with increased freedom from arrhythmia recurrence . Stable CF during radiofrequency application increases the likelihood of 12-month success . ( THERMOCOOL ® SMARTTOUCH ® Catheter for Treatment of Symptomatic Paroxysmal Atrial Fibrillation ; NCT01385202 ) INTRODUCTION Congestive heart failure ( CHF ) and atrial fibrillation ( AF ) are frequently linked , and when associated produce additive deleterious effects . In this prospect i ve study , the effects of catheter ablation for AF  in patients with impaired left ventricular ( LV ) function are presented . METHODS Baseline data and clinical outcome have been prospect ively collected in 105 consecutive patients who underwent pulmonary vein ablation for the control of AF .  We evaluated 40 patients affected by LV dysfunction with ejection fraction (EF)<40 % and compared them to the remaining 65 patients with normal ventricular function in terms of changes in LV function , maintenance of sinus rhythm , and quality of life during follow-up . RESULTS After a mean follow-up of 14+/-2 months , 87 % of patients with impaired LV function and 92 % of patients with normal ventricular function were in sinus rhythm , with or without antiarrhythmic therapy ( P = NS ) . A significant improvement in LVEF and fractional shortening was documented in patients with CHF ( 33+/-2 % vs 47+/-3 % , and 19+/-4 % vs 30+/-3 % , P<0.01 for both comparisons ) . Evaluation of exercise capacity and quality of life documented better improvements in patients with CHF compared to patients without CHF . CONCLUSIONS Catheter ablation in patients with LV dysfunction is feasible , not associated with higher procedural complications , and provides a significant improvement in LV performance , symptoms , and quality of life during follow-up BACKGROUND Congestive heart failure and atrial fibrillation often coexist , and each adversely affects the other with respect to management and prognosis . We prospect ively evaluated the effect of catheter ablation for atrial fibrillation on left ventricular function in patients with heart failure . METHODS We studied 58 consecutive patients with congestive heart failure and a left ventricular ejection fraction of less than 45 percent who were undergoing catheter ablation for atrial fibrillation .  We selected as controls 58 patients without congestive heart failure who were undergoing ablation for atrial fibrillation , matched according to age , sex , and classification of atrial fibrillation . We evaluated the patients ' left ventricular function and dimensions , symptom score , exercise capacity , and quality of life at baseline and at months 1 , 3 , 6 , and 12 . RESULTS After a mean ( + /-SD ) of 12+/-7 months , 78 percent of the patients with congestive heart failure and 84 percent of the controls remained in sinus rhythm ( P=0.34 ) ( 69 percent and 71 percent , respectively , were in sinus rhythm without the administration of antiarrhythmic drugs ) . The patients with congestive heart failure had significant improvement in left ventricular function ( increases in the ejection fraction and fractional shortening of 21+/-13 percent and 11+/-7 percent , respectively ; P<0.001 for both comparisons ) , left ventricular dimensions ( decreases in the diastolic and systolic diameters of 6+/-6 mm and 8+/-7 mm , respectively ; P=0.03 and P<0.001 , respectively ) , exercise capacity , symptoms , and quality of life . The ejection fraction improved significantly not only in patients without concurrent structural heart disease ( 24+/-10 percent , P<0.001 ) and those with inadequate rate control before ablation ( 23+/-10 percent , P<0.001 ) , but also in those with coexisting heart disease ( 16+/-14 percent , P<0.001 ) and adequate rate control before ablation ( 17+/-15 percent , P<0.001 ) . CONCLUSIONS Restoration and maintenance of sinus rhythm by catheter ablation without the use of drugs in patients with congestive heart failure and atrial fibrillation significantly improve cardiac function , symptoms , exercise capacity , and quality of life BACKGROUND The optimal ablation technique for persistent and long-st and ing persistent atrial fibrillation ( AF ) is unclear . Both linear lesion ( LL ) and ganglionated plexus ( GP ) ablation have been used in addition to pulmonary vein isolation ( PVI ) , but no direct comparison of the 2 methods exists . OBJECTIVE The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-st and ing persistent AF . METHODS Two hundred sixty-four consecutive patients with persistent/long-st and ing persistent AF were r and omly assigned to 2 different ablation schemes : PVI+LL ( n = 132 ) and PVI+GP ( n = 132 ) ablation . Consistent sinus rhythm ( SR ) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device . RESULTS All procedural end points were acutely achieved . At 12 months after a single procedure , 47 % of the patients treated with PVI+LL were in SR compared to 54 % of the patients treated with PVI+GP ( P = .29 ) . At 3 years , 34 % of the patients with PVI+LL and 49 % of the patients with PVI+GP maintained SR ( P = .035 ) . Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group ( 18 % vs 6 % ; P = .002 ) . After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group , the long-term overall success rate was 52 % and 68 % , respectively ( P = .006 ) . CONCLUSIONS PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up BACKGROUND The efficacy of ablation of complex fractionated atrial electrograms ( CFEs ) in the single ablation procedure for nonparoxysmal atrial fibrillation ( AF ) patients is not well demonstrated . The aim of this study was to compare the ablation strategies of pulmonary vein isolation ( PVI ) plus linear ablation with and without additional ablation ofCFEs in these patients . METHODS Consecutive 60 patients ( 49 + /- 11 years old , 50 male , 10 female ) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system .  A stepwise approach included a circumferential PVI and left atrial ( LA ) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus ( the first 30 patients ) or not ( the second 30 patients ) , detected by an automatic algorithm . RESULTS There was no difference in the baseline characteristics between the two groups . Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs . Following PVI and linear ablation , the remaining continuous CFEs were identified in 7.9 + /-10 % mapping sites of the LA and CS , and were ablated successfully with a procedural AF termination rate of 53 % . With a follow-up of 19 + /-11 months , a Kaplan-Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance . Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS . CONCLUSIONS Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure AIMS The Atrial Fibrillation Ablation Pilot Study is a prospect i ve , multinational registry conducted by the European Heart Rhythm Association of the European Society of Cardiology that has been design ed to describe the clinical epidemiology of patients undergoing an atrial fibrillation ( AFib ) ablation procedure  , and the diagnostic/therapeutic processes applied in these patients across Europe . We present the results of the short-term ( in-hospital ) analysis . METHODS AND RESULTS A total of 72 centres in 10 European countries were asked to enrol 20 consecutive patients scheduled for a first AFib ablation procedure . Between October 2010 and May 2011 , 1410 patients were included , of which 1391 underwent an AFib ablation ( 98.7 % ) . The median age was 60 years [ inter-quartile range ( IQR ) 52 - 66 ] , and 28 % were females . Two-thirds presented paroxysmal AFib and 38 % lone AFib . Symptoms were present in 86 % . The indications for ablation were mostly symptomatic AFib , but in over a third of patients there was also a desire for a drug-free lifestyle and the maintenance of sinus rhythm . Pulmonary vein isolation was attempted in 98.4 % of patients , the roof line in 21.3 % and the mitral isthmus line in 12.8 % . Complex-fractionated atrial electrograms were targeted in 17.9 % and the ganglionated plexi in 3.3 % . Complications occurred in 7.7 % , of which 1.7 % was major ( i.e. cardiac perforation , myocardial infraction , endocarditis , cardiac arrest , stroke , hemothorax , pneumothorax , and sepsis ) . The median duration of hospitalization was 3 days ( IQR 2 - 4 ) . At discharge , 91.4 % of patients were in sinus rhythm , 88.3 % of patients were given vitamin K antagonists , and 67 % antiarrhythmic medication . There was one death after the ablation procedure . CONCLUSION The AFib Ablation Pilot Study provides crucial information on AF ablation in clinical practice across Europe . These data are relevant for further improvement of the management strategies of patients suffering from atrial fibrillation Background — Information on comparative outcome between radiofrequency catheter ablation ( RFA ) and antiarrhythmic drugs ( AADs ) > 1 year after r and omization is important for clinical decision-making . Methods and Results — A total of 198 patients ( age , 56±10 years ) with paroxysmal atrial fibrillation were r and omly assigned to RFA ( 99 patients ) or to AADs ( 99 patients ) . We evaluated efficacy of RFA or AADs in a comparable 48-month follow-up period according to intention-to-treat analysis . Cardiac rhythm was assessed with daily transtelephonic transmissions . Quality of life was also analyzed . At 4 years , among the 99 patients first assigned to RFA , the procedure was repeated because of recurrent atrial fibrillation/atrial tachycardia in 27 patients ( 27.3 % ) . Among the 99 patients r and omly assigned to AADs , 87 ( 87.9 % ) crossed over to undergo RFA and 4 years after r and om assignment only 12 ( 12.1 % ) were in sinus rhythm with AAD alone without ablation . Despite the high level of crossovers , at 4 years the intention-to-treat analysis showed that 72.7 % of patients in the ablation arm and 56.5 % of those initially r and omly assigned to AADs were free of recurrent atrial fibrillation/atrial tachycardia ( P=0.017 ) . During the follow-up , 19.2 % of AAD patients progressed to persistent atrial fibrillation before switching to RFA . RFA significantly improved quality of life ( P<0.001 ) , whereas before crossing over to RFA , patients receiving AADs showed poorer quality of life . Except for new left atrial tachycardia , there were no serious complications caused by RFA . Conclusions — With follow-up extended to 4 years after r and omly assigned , ablation remains superior to antiarrhythmic drug in these patients with paroxysmal atrial fibrillation . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00340314 BACKGROUND The relationship between the applied techniques and clinical outcomes after radiofrequency ( RF ) ablation of atrial fibrillation ( AF ) remains unclear . We compared the results of ablation by RF delivered via a point-by-point versus catheter dragging technique for the treatment of AF . METHODS This study included 66 patients with drug-refractory AF who underwent circumferential pulmonary vein ( PV ) ablation .  A point-by-point technique was used in 35 ( 53 % ) patients ( Group I ) , and catheter dragging technique in the remaining 31 ( 47 % ) patients ( Group II ) . If AF persisted or remained inducible after the PV isolation , additional ablation of complex fractionated atrial electrograms and linear ablation were performed . RESULTS Significantly , fewer RF applications were delivered in Group II than in Group I. The total RF energy duration delivered was comparable between the two groups ( P = 0.55 ) . However , the total energy of RF deliveries was significantly greater in Group II than in Group I ( P = 0.02 ) . Despite a longer fluoroscopic exposure time ( P = 0.01 ) , the total procedural duration was significantly shorter in Group II than in Group I ( P = 0.005 ) . Within 3 months after a single ablation procedure , 24 patients ( 69 % ) in Group I versus 13 patients ( 42 % ) in Group II had ≥1 recurrence(s ) of atrial tachyarrhythmias ( P = 0.03 ) . A multivariate analysis showed that a point-by-point ablation was the only independent predictor of early atrial tachyarrhythmia recurrences . CONCLUSIONS The catheter dragging technique for ablation of AF was associated with a lower early recurrence rate of atrial tachyarrhythmias than the point-by-point technique BACKGROUND There are limited data comparing radiofrequency catheter ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation . METHODS We r and omly assigned 294 patients with paroxysmal atrial fibrillation and no history of antiarrhythmic drug use to an initial treatment strategy of either  radiofrequency catheter ablation  ( 146 patients ) or therapy with class IC or class III antiarrhythmic agents ( 148 patients ) . Follow-up included 7-day Holter-monitor recording at 3 , 6 , 12 , 18 , and 24 months . Primary end points were the cumulative and per-visit burden of atrial fibrillation ( i.e. , percentage of time in atrial fibrillation on Holter-monitor recordings ) . Analyses were performed on an intention-to-treat basis . RESULTS There was no significant difference between the ablation and drug-therapy groups in the cumulative burden of atrial fibrillation ( 90th percentile of arrhythmia burden , 13 % and 19 % , respectively ; P=0.10 ) or the burden at 3 , 6 , 12 , or 18 months . At 24 months , the burden of atrial fibrillation was significantly lower in the ablation group than in the drug-therapy group ( 90th percentile , 9 % vs. 18 % ; P=0.007 ) , and more patients in the ablation group were free from any atrial fibrillation ( 85 % vs. 71 % , P=0.004 ) and from symptomatic atrial fibrillation ( 93 % vs. 84 % , P=0.01 ) . One death in the ablation group was due to a procedure-related stroke ; there were three cases of cardiac tamponade in the ablation group . In the drug-therapy group , 54 patients ( 36 % ) underwent supplementary ablation . CONCLUSIONS In comparing radiofrequency ablation with antiarrhythmic drug therapy as first-line treatment in patients with paroxysmal atrial fibrillation , we found no significant difference between the treatment groups in the cumulative burden of atrial fibrillation over a period of 2 years . ( Funded by the Danish Heart Foundation and others ; MANTRA-PAF Clinical Trials.gov number , NCT00133211 . ) AIMS Clinical benefit from ablation for long-st and ing persistent atrial fibrillation has remained unknown . We hypothesized that successful ablation of long-st and ing persistent atrial fibrillation would improve haemodynamics , functional status , and quality of life . METHODS AND RESULTS A total of 160 patients ( aged 59 ± 9 years , 23 % females ) undergoing ablation of long-st and ing ( median of 28 months ) persistent atrial were enrolled in this prospect i ve study . Morphological and functional echocardiographic parameters , N-terminal prohormone of brain natriuretic peptide ( NT-proBNP ) , maximum oxygen consumption during exercise test ( VO2 max ) , and quality of life were assessed at baseline and 1 year after the ablation . At the 1-year follow-up visit , 81 % patients were examined in sinus rhythm ( after repeat ablation in 38 % patients ) . Left atrial appendage outflow velocity increased from 44 ± 20 to 58 ± 23 cm/s , left ventricular ejection fraction from 54 ± 9 to 59 ± 5 % , and VO2 max from 20.4 ± 6.4 to 23.7 ± 8.1 mL/kg/min ; NT-proBNP decreased from median 897 ( interquartile range 603 - 1424 ) to 230 ( interquartile range 120 - 420 ) pg/mL ( all P < 0.0001 ) . These beneficial effects of ablation were predominantly associated with the presence of sinus rhythm . Quality of life ( range 0 - 100 ) increased significantly ( EQ-5D index : from 68.8 ± 12.5 to 75.4 ± 14.4 ; EQ-VAS score : from 62.8 ± 13.2 to 70.6 ± 13.8 ; both P < 0.0001 ) . CONCLUSION Ablation of long-st and ing persistent atrial fibrillation was associated with significant recovery of haemodynamics and exercise capacity that projected onto the long-term improvement in quality of life BACKGROUND High-frequency stimulation ( HFS ) of the atria induces atrial fibrillation ( AF ) when applied during sinus rhythm and elicits a parasympathetic response when delivered at sites where ganglionated plexi ( GPs ) are located . However , little is known about its impact after an electrophysiological study . OBJECTIVE To evaluate the impact of HFS on the short-term and long-term outcomes after the ablation of persistent AF . METHODS Thirty consecutive patients with persistent or long-st and ing persistent AF were r and omly assigned to either receive HFS of the left atrium ( n = 15 ) or not ( n = 15 ) during their electrophysiological studies . Patients receiving HFS were examined to determine whether or not a vagal response was elicited by the HFS at sites where GPs were located before and after conventional pulmonary vein isolation without any ablation targeting the GPs . Patients not receiving the HFS underwent the ablation procedure alone . The rate of recurrence of AF within 3 months of the procedure ( early recurrence [ ER ] ) and the frequency of that occurring after that period ( late recurrence ) were compared between the patient groups . RESULTS The incidence of ER occurred more frequently in patients with HFS than in those without ( 80 % vs 40 % ; P = .015 ) , whereas the occurrence of late recurrence was similar between the 2 groups ( 27 % vs 33 % ; P = .73 ) . In the HFS group , the number of GPs decreased from 3.4 ± 1.1 to 1.5 ± 0.8 after the pulmonary vein isolation ( P < .0001 ) , and the decrease was smaller in the patients experiencing ER than in those without . CONCLUSION HFS increases the incidence of ER in patients with persistent AF despite a partial GP modification result ing from the pulmonary vein isolation Purpose Recent data show no benefit of additional ablation beyond pulmonary vein isolation ( PVI ) in persistent atrial fibrillation ( AF ) . Evidence suggests that radiofrequency energy ( RF ) and cryoballoon ( CRYO ) have comparable efficacy for PVI . We aim ed to assess the outcomes after a single catheter ablation procedure , comparing PVI using CRYO vs. RF ablation for PVI plus additional ablation in a cohort of patients with persistent AF . Methods In this prospect i ve multicenter propensity score-matched comparison , 59 consecutive patients undergoing CRYO ablation of persistent AF were matched to 59 patients treated with RF from November 2010 to June 2012 . Results During a mean follow-up of 15.6 ± 11.5 months , 43.2 % of patients presented atrial arrhythmia relapse after a blanking period of 3 months , which was comparable between the two groups ( 40.7 % in CRYO vs. 45.8 % in RF , Log rank P = 0.14 ; HR = 0.67 , 95 % CI 0.38–1.16 , P = 0.15 ) , despite the fact that 52.5 % of RF patients add additional complex fractionated atrial electrogram ablation , as well as left atrial linear ablation in over two-thirds ( roof line in 67.8 % and mitral isthmus in 32.2 % ) . On multivariate Cox regression , only AF duration in years ( HR = 1.10 , 95 % CI 1.01–1.10 , P = 0.04 ) was a predictor of relapse . Patients undergoing RF ablation presented a numerically , but non-significantly , lower complication rate ( 6.8 vs 10.2 % , P = 0.51 ) . Conclusion In our multicenter experience , freedom from atrial arrhythmias was comparable among matched patients treated with CRYO and RF , despite non-significant trends in favor of RF in terms of complications , at the cost of longer procedure times AIMS To investigate the effectiveness of additional substrate modification ( SM ) by left atrial ( LA ) linear lesions as compared with pulmonary vein isolation ( PVI ) alone in patients with persistent atrial fibrillation ( AF ) in a prospect i ve r and omized study . Percutaneous PVI has evolved as an accepted treatment for paroxysmal AF but seemed to be less effective in patients with persistent AF . The benefit of PVI alone and additional linear lesions has not been vali date d in a r and omized study so far . METHODS AND RESULTS Sixty-two patients with persistent AF ( median duration 7 , range 1 - 18 months ) were r and omly assigned to either PVI alone ( n = 30 ) or additional SM ( n = 32 ) consisting of a roof line connecting both left superior and right superior PV and LA isthmus ablation between left inferior PV and mitral annulus . Procedures including SM were performed using a three-dimensional mapping system ( EnSite NavX , St Jude Medical , St Paul , MN , USA ) . Anti-arrhythmic drugs were discontinued within 8 weeks after ablation in both groups . Follow-up included daily trans-telephonic ECG transmitted irrespective of the patient 's symptoms . PVI was successful in 98 % of all targeted veins in both groups . Additional SM did not increase fluoroscopy time ( 72.1+/-18.7 vs. 72.9+/-17.3 min , P=0.92 ) because of the use of three-dimensional navigation in the PVI+SM group . AF recurrences within the first 4 weeks following ablation were more common after PVI alone ( 77 % ) than additional SM ( 44 % , P=0.002 ) . After a follow-up time of 487 ( 429 - 570 ) days , only 20 % of patients undergoing st and alone PVI  remained in sinus rhythm when compared with 69 % following PVI combined with SM ( P=0.0001 ) . Two patients assigned to PVI+SM experienced procedure-related complications ( cardiac tamponade and minor stroke ) which resolved without sequelae . CONCLUSION PVI alone is insufficient in the treatment of persistent AF . However , additional left linear lesions increase the success rate significantly . Early AF-relapses are associated with a negative outcome after PVI alone but not following additional SM AIMS Cerebral embolism is a possible serious complication during catheter ablation of atrial fibrillation ( AF ) .  The purpose of this prospect i ve pilot study was to analyse the incidence and possible impact of cryo ablation on cerebral lesions and possible differences to radiofrequency ( RF ) ablation during pulmonary vein isolation ( PVI ) . METHODS AND RESULTS Pulmonary vein isolation was performed in 89 patients , either with the cryoballoon technique ( n = 45 ) or with RF ablation ( n = 44 ) .  Phenprocoumon was stopped 3 days before intervention and replaced by subcutaneous low-molecular-weight heparin . During the catheter procedure , an infusion of unfractionated heparin was maintained to achieve an activated clotting time ( ACT ) of > 300 s. Cerebral magnetic resonance imaging scans were performed 1 day before and after PVI , and at 3-month follow-up . Chronic lesions were observed in 11 patients ( 12.3 % ) before PVI without statistically significant difference between the two groups . None of the patients had neurological symptoms during or following the procedure . Seven patients ( 7.9 % ) developed acute lesions 1 day after PVI , without statistically significant difference between the group treated by cryoenergy ( 8.9 % ) and RF ablation ( 6.8 % ) . Patients with acute lesions were significantly older compared with those without acute cerebral lesions . No additional cerebral lesions during follow-up were observed . CONCLUSION A considerable portion of patients with AF but without any neurological symptoms had chronic cerebral lesions before PVI . Additional acute lesions could be added after the procedure . Both ablation techniques showed additional cerebral acute lesions with no neurological symptoms after PVI Background Radiofrequency and cryoballoon pulmonary vein isolation are common approaches for paroxysmal atrial fibrillation treatment , showing similar results in recent multicenter studies , including heterogeneous tools and protocol s. The aim of this study is to compare prospect ively in a single , high-volume center the outcome of paroxysmal atrial fibrillation ablation performed specifically by second-generation cryoballoon or contact force radiofrequency ablation . Methods Consecutive patients scheduled for paroxysmal atrial fibrillation transcatheter ablation have been included and prospect ively followed up . Aim ing to reduce potential bias deriving from baseline characteristics , a propensity score matching analysis has been performed to analyze safety and efficacy outcomes . Results Out of consecutive patients undergoing atrial fibrillation transcatheter ablation between January 2015 and December 2016 , 46 patients approached by cryoablation  were matched 1 : 1 by propensity score to a similar population treated by last-generation radiofrequency ablation .  Freedom from atrial fibrillation after 12 months ( 76 vs. 78 % , P = 0.804 ) and incidence of complications ( 4 vs. 6 % , P = 0.168 ) did not differ between the two groups . Radiological exposure was higher for the cryoballoon group ( 11 vs. 4 min , P < 0.001 ) , whereas procedural duration did not differ ( P = 0.174 ) . Aim ing to assess the potential impact of a learning curve in patients undergoing cryoablation , the first-third of patients ( n = 15 ) were compared with the remaining , reporting longer radiological exposure ( P < 0.001 ) , but similar safety and efficacy . Conclusion In this propensity score analysis , last-generation cryoballoon and radiofrequency catheters for atrial fibrillation ablation present similar efficacy and safety .  Cryoablation requires longer fluoroscopy exposure compared with radiofrequency , although this is reduced by increased experience Background — MRI-detected brain lesions are common after  left atrial catheter ablation for symptomatic atrial fibrillation . The clinical relevance of these acute ischemic lesions is not fully understood , but ablation-related cerebral injury could contribute to cognitive dysfunction . Methods and Results — In the prospect i ve Mesh Ablator versus Cryoballoon Pulmonary Vein Ablation of Symptomatic Paroxysmal Atrial Fibrillation ( MACPAF ) study , serial 3-T brain MRIs and neuropsychological assessment were performed to analyze the rate of ablation-related brain lesions and their effect on cognitive function .  Thirty-seven patients with paroxysmal atrial fibrillation ( median age , 63.0 [ interquartile range , 57–68 ] years ; 41 % female ; median CHA2DS2VASc score 2 [ interquartile range , 1–3 ] ) underwent 41 ablation procedures according to study criteria . None of these patients had overt neurological deficits after ablation . High-resolution diffusion-weighted imaging , performed within 48 hours after ablation , showed that new brain lesions ( range , 1–17 ) were present in 16 ( 43.2 % ) patients after 18 ( 43.9 % ) left atrial catheter ablation procedures . Follow-up MRI at 6 months ( median , 6.5 ; interquartile range , 6–7 ) revealed that 7 ( 12.5 % ) of the 56 total acute brain lesions after ablation formed a persistent glial scar in 5 ( 31.3 % ) patients . Large diffusion-weighted imaging lesions and a corresponding fluid-attenuated inversion recovery lesion 48 hours after ablation predicted lesion persistence on 6-month follow-up . Neither persistent brain lesions nor the ablation procedure itself had a significant effect on attention or executive functions , short-term memory , or verbal and nonverbal learning after 6 months . Conclusions — Ablation-related acute ischemic brain lesions persist to some extent but do not cause cognitive impairment 6 months after the ablation procedure . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01061931 Background —The study was conducted to compare relative safety and efficacy of pulmonary vein antrum isolation ( PVAI ) using intracardiac echocardiographic guidance and circumferential pulmonary vein ablation ( CPVA ) for atrial fibrillation ( AF ) using radiofrequency energy . Methods and Results —Sixty patients ( 81 % men ; 81 % paroxysmal ; age , 56±8 years ) failing 2±1 antiarrhythmic drugs were r and omly assigned to undergo CPVA ( n=30 ) or PVAI ( n=30 ) at 5 centers between December 2004 and October 2007 .  CPVA patients had circular lesions placed at least 1 cm outside of the veins . Ipsilateral veins were ablated en block with the end point of disappearance of potentials within the circular lesion . Left atrial roof line and mitral isthmus line were ablated without verification of block . For patients in AF postablation or with AF induced with programmed stimulation , complex fractionated electrograms were mapped and ablated to the end point of AF termination or disappearance of complex fractionated electrograms . PVAI did not include complex fractionated electrogram ablation . Esophageal temperature was monitored and kept within 2 ° C of baseline or under 39 ° C . Success was defined as absence of atrial tachyarrhythmias ( AF/AT ) off antiarrhythmic drugs . There was no difference between CPVA and PVAI regarding to baseline variables , catheter used , duration of the procedure , or RF delivery . Fluoroscopy time was longer with PVAI ( 54±17 minutes versus 77±18 minutes , P=0.0001 ) . No significant complications occurred in either arm . PVAI was more likely to achieve control of AF/AT off antiarrhythmic drugs ( 57 % versus 27 % , P=0.02 ) at 2±1 years of follow-up . Conclusions —A single PVAI procedure is more likely to result in freedom from AF/AT off antiarrhythmic drugs than CPVA supplemented by complex fractionated electrogram ablation in select patients BACKGROUND Among patients undergoing mitral-valve surgery , 30 to 50 % present with atrial fibrillation , which is associated with reduced survival and increased risk of stroke .  Surgical ablation of atrial fibrillation has been widely adopted , but evidence regarding its safety and effectiveness is limited . METHODS We r and omly assigned 260 patients with persistent or long-st and ing persistent atrial fibrillation who required mitral-valve surgery  to undergo either surgical ablation ( ablation group ) or no ablation ( control group ) during the mitral-valve operation . Patients in the ablation group underwent further r and omization to pulmonary-vein isolation or a biatrial maze procedure . All patients underwent closure of the left atrial appendage . The primary end point was freedom from atrial fibrillation at both 6 months and 12 months ( as assessed by means of 3-day Holter monitoring ) . RESULTS More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months ( 63.2 % vs. 29.4 % , P<0.001 ) . There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure ( 61.0 % and 66.0 % , respectively ; P=0.60 ) . One-year mortality was 6.8 % in the ablation group and 8.7 % in the control group ( hazard ratio with ablation , 0.76 ; 95 % confidence interval , 0.32 to 1.84 ; P=0.55 ) . Ablation was associated with more implantations of a permanent pacemaker than was no ablation ( 21.5 vs. 8.1 per 100 patient-years , P=0.01 ) . There were no significant between-group differences in major cardiac or cerebrovascular adverse events , overall serious adverse events , or hospital readmissions . CONCLUSIONS The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-st and ing persistent atrial fibrillation , but the risk of implantation of a permanent pacemaker was also increased . ( Funded by the National Institutes of Health and the Canadian Institutes of Health Research ; Clinical Trials.gov number , NCT00903370 . ) Background Effective treatment of paroxysmal atrial fibrillation ( AF ) is essential for reducing the risk of stroke and heart failure .  Cryoballoon ( CB ) ablation has been developed as an alternative to the use of radiofrequency ( RF ) energy for electrical isolation of the pulmonary veins . Herein , we provide long-term data regarding the efficacy of CB ablation in comparison to RF . Methods FreezeAF was a r and omised non-inferiority study comparing CB ablation with RF ablation for the treatment of patients with drug-refractory paroxysmal AF . Procedural success for the long-term follow-up ( 30 months ) was defined as freedom from AF with an absence of persistent complications . Results Of the 315 patients that were r and omised and received catheter ablation , 292 ( 92.7 % ) completed the 30-month follow-up ( 147 in the RF group and 145 in the CB group ) . The baseline characteristics of the RF and CB groups were similar . Single-procedure success was achieved by 40 % of patients in the RF group and 42 % of the CB group ( p < 0.001 for non-inferiority ) . When including re-do procedures in the analysis , the multiple procedure success rate was 72 % in the RF group and 76 % in the CB group . Conclusion The data provide long-term evidence that CB ablation is non-inferior to RF ablation , with high proportions of patients reporting freedom from AF 30 months after the index procedure . Trial registration Clinical Trials.gov Identifier : NCT00774566 ; first registered October 16 , 2008 ; first patient included October 20 , 2008 Background —This prospect i ve clinical study evaluates the feasibility and efficacy of combined linear mitral isthmus ablation and pulmonary vein ( PV ) isolation in patients with paroxysmal atrial fibrillation ( AF ) . Methods and Results —One hundred consecutive patients ( 13 women ; age 55±10 years ) with drug-refractory , symptomatic paroxysmal AF underwent PV isolation and linear ablation of the cavotricuspid isthmus and the mitral isthmus ( lateral mitral annulus to the left inferior PV ) . They were compared with 100 consecutive patients ( 14 women ; age , 52±10 years ) undergoing PV isolation and cavotricuspid ablation without mitral isthmus ablation .  Bidirectional mitral isthmus block was confirmed by demonstrating ( 1 ) a parallel corridor of double potentials during coronary sinus ( CS ) pacing , ( 2 ) an activation detour by pacing either side of the line , and ( 3 ) differential pacing techniques . Isolation of all PVs and cavotricuspid isthmus ablation were performed successfully in all . Mitral isthmus block was achieved in 92 patients after 20±10 minutes of endocardial radiofrequency application and an additional 5±4 minutes of epicardial radiofrequency application from within the CS in 68 , result ing in a conduction delay of 151±26 ms during CS pacing . Thirty-two patients with mitral isthmus ablation compared with 49 without had recurrent atrial arrhythmia ( P=0.02 ) requiring further ablation . At 1 year after the last procedure , 87 patients with mitral isthmus ablation and 69 without ( P=0.002 ) were arrhythmia free without antiarrhythmic drugs , mitral isthmus ablation being the only factor associated with long-term success ( RR for AF recurrence , 0.2 ; CI , 0.1 to 0.4 ; P<0.001 ) . Conclusions —Catheter ablation of the mitral isthmus results consistently in demonstrable conduction block and is associated with a high cure rate for paroxysmal AF BACKGROUND Current guidelines recommend pulmonary-vein isolation by means of catheter ablation as treatment for drug-refractory paroxysmal atrial fibrillation .  Radiofrequency ablation is the most common method , and cryoballoon ablation is the second most frequently used technology . METHODS We conducted a multicenter , r and omized trial to determine whether cryoballoon ablation was noninferior to radiofrequency ablation in symptomatic patients with drug-refractory paroxysmal atrial fibrillation . The primary efficacy end point in a time-to-event analysis was the first documented clinical failure ( recurrence of atrial fibrillation , occurrence of atrial flutter or atrial tachycardia , use of antiarrhythmic drugs , or repeat ablation ) following a 90-day period after the index ablation . The noninferiority margin was prespecified as a hazard ratio of 1.43 . The primary safety end point was a composite of death , cerebrovascular events , or serious treatment-related adverse events . RESULTS A total of 762 patients underwent r and omization ( 378 assigned to cryoballoon ablation and 384 assigned to radiofrequency ablation ) . The mean duration of follow-up was 1.5 years . The primary efficacy end point occurred in 138 patients in the cryoballoon group and in 143 in the radiofrequency group ( 1-year Kaplan-Meier event rate estimates , 34.6 % and 35.9 % , respectively ; hazard ratio , 0.96 ; 95 % confidence interval [ CI ] , 0.76 to 1.22 ; P<0.001 for noninferiority ) . The primary safety end point occurred in 40 patients in the cryoballoon group and in 51 patients in the radiofrequency group ( 1-year Kaplan-Meier event rate estimates , 10.2 % and 12.8 % , respectively ; hazard ratio , 0.78 ; 95 % CI , 0.52 to 1.18 ; P=0.24 ) . CONCLUSIONS In this r and omized trial , cryoballoon ablation was noninferior to radiofrequency ablation with respect to efficacy for the treatment of patients with drug-refractory paroxysmal atrial fibrillation , and there was no significant difference between the two methods with regard to overall safety . ( Funded by Medtronic ; FIRE AND ICE Clinical Trials.gov number , NCT01490814 . )
Contribution This systematic review found that radiofrequency ablation after a failed drug course maintained sinus rhythm more often than continuation of drug therapy alone .
The benefits of maintaining sinus rhythm with antiarrhythmic drugs appeared to be offset by the serious adverse effects of the drugs .
Context Is radiofrequency catheter ablation a better alternative than medical therapy for patients with atrial fibrillation ?
The Editors Atrial fibrillation is the most common sustained arrhythmia in clinical practice ( 1 ) .
Its prevalence increases with age , from 0.1 % in people younger than 55 years to more than 9 % by 80 years of age ( 2 ) .
The heavy burden of atrial fibrillation on morbidity , mortality , and health care re sources creates a pressing need for novel approaches to management .
In some patients , adequate pharmacologic slowing of the ventricular response rate ( a rate-control strategy ) is sufficient to control symptoms .
However , many patients remain symptomatic from the lack of organized atrial contraction and the persistent irregularity of the ventricular response in atrial fibrillation .
In such patients , the appropriate treatment is restoration of normal sinus rhythm , achieved electrically or chemically ( a rhythm-control strategy ) ( 2 ) .
Radiofrequency catheter ablation is a promising approach that offers the benefits of maintaining sinus rhythm without the adverse effects of antiarrhythmic drugs .
Catheter ablation for atrial fibrillation is based on the underst and ing that electrical activity emanating from the pulmonary veins frequently serves as a trigger for atrial fibrillation .
In the late 1990s , Hassaguerre and colleagues ( 5 ) observed that elimination of local electrograms at these foci with radiofrequency energy reduced the risk for recurrence of atrial fibrillation .
Currently , the foundation of most atrial fibrillation ablation procedures is to target and electrically isolate the pulmonary veins ( 6 ) .
This may be achieved by delivering lesions immediately outside the ostia of the pulmonary veins or along a wider area in the left atrium encircling the veins .
Additional lesion sets have been used to ablate nonpulmonary vein triggers of atrial fibrillation and to target atrial areas thought to be responsible for maintaining atrial fibrillation ( 6 ) .
These linear lesions may be created in the posterior left atrium , the roof of the left atrium , the interatrial septum , and the isthmus formed between the mitral annulus and the pulmonary vein or left atrial appendage .
At present , the Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation , put forth by the Heart Rhythm Society and endorsed by several professional organizations , states that the foundation of most atrial fibrillation ablation procedures is to target the pulmonary veins , pulmonary vein antra , or both ( 6 ) .
The panel advised us that 8-mmtip and irrigated-tip catheters are now the catheters of choice for radiofrequency ablation of atrial fibrillation in the United States .
The conventional 4-mmtip catheter is rapidly being phased out of use for this indication .
The following 3 key questions were formulated : 1 .
What is the effect of radiofrequency catheter ablation on short-term ( 6 to 12 months ) and long-term ( > 12 months ) rhythm control ; rates of congestive heart failure ; changes in the size of the left atrium and ventricle ; rates of stroke ; quality of life ; avoiding anticoagulation ; and readmissions for paroxysmal , persistent , and long-st and ing persistent ( chronic ) atrial fibrillation ?
2 .
How does the effect of radiofrequency ablation  on rhythm control differ among the various techniques used ?
3 .
What are the short- and long-term complications and harms associated with radiofrequency ablation ?