Background: Atrial fibrillation (AF) recurrence following catheter ablation remains high. Recent studies have shown a relation between epicardial adipose tissue and AF. epicardial adipose tissue secretes several proinflammatory and anti-inflammatory adipokines that directly interact with the adjacent myocardium. The aim of the current study was to evaluate whether posterior left atrial (LA) adipose tissue attenuation, as marker of inflammation, is related to AF recurrences after catheter ablation. Methods: Consecutive patients with symptomatic AF referred for first AF catheter ablation who underwent computed tomography were included. The total epicardial adipose tissue and posterior LA adipose tissue were manually traced and adipose tissue was automatically recognized as tissue with Hounsfield units (HU) between −195 and −45. The attenuation value of the posterior LA adipose tissue was assessed, and the population was divided according to the mean HU value (−96.4 HU). Results: In total, 460 patients (66% male, age 61±10 years) were included in the analysis. After a median follow-up of 18 months (interquartile range, 6–32), 168 (37%) patients had AF recurrence. Patients with higher attenuation (≥−96.4 HU) of the posterior LA adipose tissue showed higher AF recurrence rates compared with patients with lower attenuation (<−96.4 HU; log-rank test P =0.046). Univariate analysis showed an association between AF recurrence and higher posterior LA adipose tissue attenuation (≥−96.4 HU; P <0.05). On multivariable analysis, posterior LA adipose tissue attenuation (hazard ratio, 1.26 [95% CI, 0.90–1.76]; P =0.181) remained a promising predictor of AF recurrence following catheter ablation. Conclusions: Posterior LA adipose tissue attenuation is a promising predictor of AF recurrence in patients who undergo catheter ablation. Higher adipose tissue attenuation might signal increased local inflammation and serve as an imaging biomarker of increased risk of AF recurrence. Graphic A graphic abstract is available for this article.

Atrial fibrillation (AF) ablation has made huge progress with respect to innovation, efficacy, and safety, however, complications are still present. Recent studies examined various predictors of complications. However, limited data exist regarding the role of a repeat procedure. Our aim was the prospective evaluation of the incidence and predictors of complications related to AF ablation procedures in consecutive patients, including repeat procedures. All ablation procedures for AF between January 2013 and December 2015 were analysed in our electrophysiology laboratory. During the study period 1243 procedures were analysed [394 female, median age 62 (55–69)]. Overall complication rate was 6.84%, major complication rate was 2.82%. Major complications were the following: 18 pericardial tamponades; 5 pseudoaneurysms; 1 arteriovenous fistula; 6 thromboembolic cerebrovascular events; 3 pulmonary vein stenosis; and 2 atrioventricular blocks. No atrio-oesophageal fistula or procedure related death occurred. Univariate analysis for overall complications showed that age ≥ 65 years (P = 0.0231), female gender (P = 0.0438), hypertension (P = 0.0488), CHA₂DS₂-VASc score ≥ 2 (P = 0.0156), and previous AF ablation procedure (P < 0.0001) is associated with higher risk for adverse events. Multivariate analysis showed that the only independent predictor of overall complications was previous AF ablation procedure (P < 0.0001). Similarly, the only predictor of major complications was previous AF ablation procedure (P < 0.0001). Incidence of complications associated with AF ablation in our high volume electrophysiology laboratory is similar to other cohorts. The only independent predictor of complications was previous AF ablation procedure in our series.

Introduction: The role of the spatial relationship between the left superior pulmonary vein (LSPV) and left atrial appendage (LAA) is unknown. We sought to evaluate whether an abutting LAA and LSPV play a role in AF recurrence after catheter ablation for paroxysmal AF.Methods: Consecutive patients, who underwent initial point-by-point radiofrequency catheter ablation for paroxysmal AF at the Heart and Vascular Center of Semmelweis University, Budapest, Hungary, between January of 2014 and December of 2017, were enrolled in the study. All patients underwent pre-procedural cardiac CT to assess left atrial (LA) and pulmonary vein (PV) anatomy. Abutting LAA-LSPV was defined as cases when the minimum distance between the LSPV and LAA was less than 2 mm.Results: We included 428 patients (60.7 ± 10.8 years, 35.5% female) in the analysis. AF recurrence rate was 33.4%, with a median recurrence-free time of 21.2 (8.8–43.0) months. In the univariable analysis, female sex (HR = 1.45; 95%CI = 1.04–2.01; p = 0.028), LAA flow velocity (HR = 1.01; 95%CI = 1.00–1.02; p = 0.022), LAA orifice area (HR = 1.00; 95%CI = 1.00–1.00; p = 0.028) and abutting LAA-LSPV (HR = 1.53; 95%CI = 1.09–2.14; p = 0.013) were associated with AF recurrence. In the multivariable analysis, abutting LAA-LSPV (adjusted HR = 1.55; 95%CI = 1.04–2.31; p = 0.030) was the only independent predictor of AF recurrence.Conclusion: Abutting LAA-LSPV predisposes patients to have a higher chance for arrhythmia recurrence after catheter ablation for paroxysmal AF.

The aim of our study was to investigate the long-term efficacy and safety of transseptal endocardial left ventricular lead implantation (TELVLI). Transseptal endocardial left ventricular lead implantation was performed in 54 patients (44 men, median age 69, New York Heart Association III–IV stage) between 2007 and 2017 in a single centre. In 36 cases, the transseptal puncture (TP) was performed via the femoral vein, and in 18 cases, the TP and also the left ventricular (LV) lead placement were performed via the subclavian vein. An electrophysiological deflectable catheter was used to reach the LV wall through the dilated TP hole. The LV lead implantation was successful in all patients. A total of 54 patients were followed up for a median of 29 months [interquartile range (IQR) 8–40 months], the maximum follow-up time was 94 months. Significant improvement in the LV ejection fraction was observed at the 3-month visit, from the median of 27% (IQR 25–34%) to 33% (IQR 32–44%), P < 0.05. Early lead dislocation was observed in three cases (5%), reposition was performed using the original puncture site in all. The patients were maintained on anticoagulation therapy with a target international normalized ratio between 2.5 and 3.5. Four thromboembolic events were noticed during follow-up. A total of 27 patients died, with a median survival of 15 months (IQR 6–40). The TELVLI is an effective approach for cardiac resynchronization therapy (CRT) however it is associated with a substantial thromboembolic risk (7%).

Background. The burden and persistence of atrial fibrillation (AF) have been associated with the presence and extent of left atrial (LA) fibrosis. Recent reports have implicated an association between the extent of LA fibrosis and the outcome of pulmonary vein isolation (PVI). We aimed to analyse the value of an automated scar quantification method in the prediction of success following PVI. Methods. One hundred and nine consecutive patients undergoing PVI for paroxysmal or persistent AF were included in our observational study with a 2-year follow-up. Prior to PVI, patients underwent high-definition LA electroanatomical mapping, and scar burden was quantified by automated software (Voltage Histogram Analysis, CARTO 3, Biosense Webster), then classified into 4 subgroups (Dublin Classes I-IV). Recurrence rates were analysed on and off antiarrhythmic drug therapy (AAD), respectively. Results. The overall success rate was 74% and 67% off AAD at 1- and 2-year follow-up, respectively. Patients with Dublin Class IV had significantly lower success rates ( $p=0.008$ , off AAD). Dublin Class IV ( $\text{OR}=2.27$ , $p=0.022$ , off AAD) and the presence of arrhythmia in the blanking period ( $\text{OR}=3.28$ , $p=0.001$ , off AAD) were the only significant predictors of recurrence. The use of AAD did not affect these results. Conclusions. We propose a classification of low voltage areas based on automated quantification by software during 3D mapping prior to PVI. Patients with high burden of low voltage areas (>31% of <0.5 mV, Dublin Class IV) have a higher risk of recurrence following PVI. Information gathered during electroanatomical mapping may have important prognostic value.