Study procedures
thrombi, atrial tachycardias
THROMBI, ATRIAL TACHYCARDIAS, EXIT BLOCK, ATRIAL FLUTTER
Transesophageal echocardiography and/or contrast CT will be performed before the CA procedure in all patients to exclude the presence of any thrombi in the left atrial appendage (LAA) and left atrium (LA). All antiarrhythmic drugs except for amiodarone will be discontinued for at least five half‐lives. All patients will receive oral anticoagulants for at least 3 weeks before the CA procedure. Warfarin will be continued throughout the pre‐ and postprocedural period. Direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, dabigatran, or edoxaban will be continued throughout the pre‐ and postprocedural period, or the dose will be withheld on the day of the ablation procedure and will be resumed on the evening of the CA procedure or on the morning of the next day according to the hospital's standard strategy. The levels of the coagulation markers such as the prothrombin time, activated partial thromboplastin time, During the CA procedure, intravenous heparin will be introduced to maintain an activated clotting time (ACT) of 300–400 s during the procedure. The ACT will be monitored every 15 min. The esophageal temperature will be monitored with a temperature probe (SensiTherm Multi, Abbott; Esophastar, Japan Lifeline; Circa, Boston Scientific). A PVI will be mandatorily performed in both groups. Confirmation of LA to the pulmonary vein (PV) electrical connection and PVI will be conducted with a circular (Achieve, Medtronic, Lasso, Biosense Webster; Advisor, AFocus, Optima, Abbott; EP star Libero, Japan Lifeline), PentaRay (Biosense Webster), or HD grid (Abbott) catheter at a proximal site in the ostium in each vein before and after the ablation. Exit block from each PV is also confirmed after PVI by pacing from the circular, PentaRay, or HD grid catheter within the PV.A cavotricuspid isthmus ablation will be performed in patients who have clinical or inducible cavotricuspid isthmus‐dependent atrial flutter. Other adjunctive ablation lesion sets targeting sites outside the PVs will be conducted when non‐PV AF triggers are detected and/or atrial tachycardias are induced.