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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EAtrial fibrillation is a common arrhythmia that presents management challenges to clinicians. Pulmonary vein isolation may help patients with paroxysmal and persistent AF convert to prolonged sinus rhythm. However, patients in need for additional substrate modification will likely require radiofrequency ablation as the preferred ablation technology. For patients with low left ventricular ejection fraction, cardiac resynchronization therapy may be achieved by simultaneously pacing both the left and right ventricles; endocardial pacing is likely superior to epicardial pacing.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eatrial fibrillation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epulmonary vein isolation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eablation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiac resynchronization therapy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecryoballoon\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Econtact force\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EAtrial fibrillation (AF) is the most common heart rhythm abnormality in people aged \u0026gt;\u200565 years. Stasis caused by the lack of organized atrial contraction increases the risk of thrombus formation in the left atrium potentially resulting in embolic stroke. The estimated risk of stroke among all AF patients is 5% per year [Sellers MB, Newby LK. \u003Cem\u003EAm Heart J\u003C\/em\u003E. 2011]. AF is the most common arrhythmia worldwide, with a reported prevalence of 1% to 2% [Camm AJ et al. \u003Cem\u003EEuropace\u003C\/em\u003E. 2010] and it is anticipated that the incidence will increase over the next several decades. One approach to treating AF in symptomatic patients is catheter-based ablation to try to restore and maintain normal sinus rhythm.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EErik Wissner, MD, Asklepios Klinik St Georg, Hamburg, Germany, spoke of challenges in developing novel catheters for isolating the pulmonary veins in patients with paroxysmal atrial fibrillation (PAF). It is well established that the electrical signals from the pulmonary veins initiate some forms of PAF [Ha\u00efssaguerre M et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 1998]; however, isolation of the veins has proven challenging. Since 1998, point-by-point ablation has been used to create a circle around the ipsilateral pulmonary veins, but the data on long-term clinical outcomes have been limited.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EDr Wissner highlighted data from a study showing that among 161 patients with PAF and normal left ventricular (LV) function, pulmonary vein isolation (PVI) resulted in stable sinus rhythm in 47% of patients after the first procedure, which increased to 80% when patients who had recurrent AF underwent additional ablation (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Ouyang F et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2010]. Additionally, patients experienced a low progression to persistent forms of AF during 5 years of follow-up.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/22\/21\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Clinical Outcomes After Each Ablation ProcedureFlowchart detailing the clinical outcome during 5-year follow-up after each ablation procedure.Pts indicates patients; AF, atrial fibrillation; ATa, atrial tachyarrhythmia; FU, follow-up; SR, sinus rhythm.Reprinted from Ouyang F et al, Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up, Circulation. 2010, Vol 122, Issue 23, Pages 2368-77A, with permission from American Heart Association, Inc.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-726557728\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Clinical Outcomes After Each Ablation ProcedureFlowchart detailing the clinical outcome during 5-year follow-up after each ablation procedure.Pts indicates patients; AF, atrial fibrillation; ATa, atrial tachyarrhythmia; FU, follow-up; SR, sinus rhythm.Reprinted from Ouyang F et al, Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up, \u0026amp;lt;em\u0026amp;gt;Circulation\u0026amp;lt;\/em\u0026amp;gt;. 2010, Vol 122, Issue 23, Pages 2368-77A, with permission from American Heart Association, Inc.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/22\/21\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/22\/21\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/22\/21\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16747\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EClinical Outcomes After Each Ablation Procedure\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EFlowchart detailing the clinical outcome during 5-year follow-up after each ablation procedure.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EPts indicates patients; AF, atrial fibrillation; ATa, atrial tachyarrhythmia; FU, follow-up; SR, sinus rhythm.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EReprinted from Ouyang F et al, Long-term results of catheter ablation in paroxysmal atrial fibrillation: lessons from a 5-year follow-up, \u003Cem\u003ECirculation\u003C\/em\u003E. 2010, Vol 122, Issue 23, Pages 2368-77A, with permission from American Heart Association, Inc.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EAccording to Dr Wissner, one of the parameters that may drive the effectiveness of ablation is contact force (CF). CF between the catheter tip and the myocardium is important because too much force can cause perforation whereas too little CF creates a less durable lesion and gaps in the isolation line. Data from the EFFICAS I study [Neuzil P et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E. 2013]\u2014in which the operators were blinded to CF readings\u2014suggest that operators should aim for a target CF of 20 g, an absolute minimum CF of 10 g, and an absolute minimum Force-Time Integral (FTI) of 400 grams\u2005\u00d7\u2005seconds per individual ablation lesion in order to achieve successful isolation of the pulmonary veins.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EThe EFFICAS II study [Kautzner J et al. \u003Cem\u003EEuropace\u003C\/em\u003E. 2015] was a small multicenter study designed to prospectively assess whether CF guidance would reduce PVI gaps. Twenty-four patients in EFFICAS II were compared with 26 patients from EFFICAS I. The key result from EFFICAS II was that maintaining adequate CF levels (20 g, FTI \u2265\u2005400 g\u2005\u00d7\u2005sec) and contiguous deployment of adjacent lesions resulted in a high proportion of durable PVI at 3-month follow-up. At follow-up, 85% of PVs remained isolated, compared with 72% in EFFICAS I (\u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.04), in which the operators were blinded to CF readings.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EDr Wissner also discussed the second-generation cryoballoon, which is relatively easy to use, offers live verification of PVI, and can be used to create a one-shot transmural continuous lesion. In one study, 50 patients underwent PVI using the second-generation cryoballoon [Metzner A et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E. 2014]. Duration of the freeze cycle was 4 minutes plus 1 additional bonus freeze following successful isolation of the pulmonary vein. At a mean duration of 440 days, 80% of patients remained in normal sinus rhythm.\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EThere is a paucity of data as to how to best use PVI in patients with persistent AF. In the STAR AF II study [Verma A et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2015], there was no significant difference in the rate of recurrent AF after 18 months of follow-up among patients who underwent either PVI alone, PVI plus linear ablation, or PVI plus ablation of complex fractionated electrograms (59% vs 46% vs 49%;\u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.15). Hence, PVI alone may be the preferred strategy in patients with persistent AF. One-year clinical follow-up of 49 patients with persistent AF who underwent PVI with the second-generation cryoballoon and a bonus freeze showed that 69% remained in stable sinus rhythm [Lemes C et al. \u003Cem\u003EEuropace\u003C\/em\u003E. 2015].\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EIn closing, Dr Wissner noted that PVI appears to be a viable option for patients with either paroxysmal or persistent AF. However, for patients who may need substrate modification, deployment of linear lesions, or have rotors, radiofrequency ablation is likely to be the better choice.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EAnother topic covered in this session is the use of cardiac resynchronization (CRT) for patients with depressed left ventricular ejection fraction. This therapy utilizes right atrial and ventricular pacing leads, in addition to a left ventricle lead advanced through the coronary sinus into a vein that runs along the ventricular free wall. This permits simultaneous pacing of both ventricles to allow resynchronization of the LV septum and free wall.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003EAngelo Auricchio, MD, PhD, Fondazione Cardiocentro Ticino, Lugano, Switzerland, reviewed the history of CRT. Prof Auricchio traced the roots of CRT to Dr M. Mower, who submitted a patent in 1989 for a \u201cmethod and apparatus for treating hemodynamic function.\u201d Although the patent was issued in May 1990, it took many more years for the concept to influence cardiology practice. According to Prof Auricchio, the feasibility of CRT has improved over the past 20 years, with most clinicians now able to accomplish 90% of CRT implantations in 90 minutes. This is due in part to the introduction of preshaped leads and more effective delivery catheters.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EAnother innovation in LV pacing was the invention of the open-ended and multipolar intravenous cardiac leads. Prof Auricchio then described the development of multifunctional leads, which allow electrophysiologists and cardiac surgeons more flexibility in programming and the ability to track wall motion directly from the implanted lead [Behar JM et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E. 2015; Wecke L et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E. 2012].\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EAnother breakthrough in the understanding of CRT is the use of endocardial pacing, which allows some patients to experience a full recovery of their LV structure and function. Although it is not clear why this mechanism is successful, results from canine models suggest that the benefit might be due to a shorter path length along the endocardium and faster impulse conduction during endocardial pacing of the left ventricle [Strik M et al. \u003Cem\u003ECirc Arrythm Electrophysiol\u003C\/em\u003E. 2012]. Other animal studies have confirmed that endocardial pacing is superior to epicardial pacing [Bordacher P et al. \u003Cem\u003EAm J Physiol Heart Circ Physiol\u003C\/em\u003E. 2012]. Prof Auricchio then focused on new wireless, ultrasound-based CRT systems, which were found to be a safe and viable option in 17 patients who had not previously undergone CRT implantation or who did not respond to CRT [Auricchio A et al. \u003Cem\u003EEuropace\u003C\/em\u003E. 2014]. In these patients, LV ejection fraction significantly increased (\u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.01) at 6 months of follow-up.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EProf Auricchio closed his presentation by urging his colleagues to better understand how the electrical and mechanical differences impact the heart so they can consider strategies to deliver individualized resynchronization therapy.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/22\/21.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzl43q\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzl43q\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}