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      3D Myocardial Scar Prediction Model Derived from Multimodality Analysis of Electromechanical Mapping and Magnetic Resonance Imaging

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          Abstract

          Many cardiac catheter interventions require accurate discrimination between healthy and infarcted myocardia. The gold standard for infarct imaging is late gadolinium–enhanced MRI (LGE-MRI), but during cardiac procedures electroanatomical or electromechanical mapping (EAM or EMM, respectively) is usually employed. We aimed to improve the ability of EMM to identify myocardial infarction by combining multiple EMM parameters in a statistical model. From a porcine infarction model, 3D electromechanical maps were 3D registered to LGE-MRI. A multivariable mixed-effects logistic regression model was fitted to predict the presence of infarct based on EMM parameters. Furthermore, we correlated feature-tracking strain parameters to EMM measures of local mechanical deformation. We registered 787 EMM points from 13 animals to the corresponding MRI locations. The mean registration error was 2.5 ± 1.16 mm. Our model showed a strong ability to predict the presence of infarction ( C-statistic = 0.85). Strain parameters were only weakly correlated to EMM measures. The model is accurate in discriminating infarcted from healthy myocardium. Unipolar and bipolar voltages were the strongest predictors.

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          The online version of this article (10.1007/s12265-019-09899-w) contains supplementary material, which is available to authorized users.

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          2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary

          Table of Contents Abbreviations159 Section 1: Introduction159 Section 2: Definitions, Mechanisms, and Rationale for AF Ablation163 Section 3: Modifiable Risk Factors for AF and Impact on Ablation163 Section 4: Indications163 Section 5: Strategies, Techniques, and Endpoints166 Section 6: Technology and Tools166 Section 7: Technical Aspects of Ablation to Maximize Safety and Anticoagulation166 Section 8: Follow-up Considerations167 Section 9: Outcomes and Efficacy176 Section 10: Complications176 Section 11: Training Requirements182 Section 12: Surgical and Hybrid AF Ablation182 Section 13: Clinical Trial Design182 Unanswered Questions in AF Ablation182 Section 14: Conclusion186  Acknowledgments198 Appendix A187 Appendix B196  References198 Abbreviations AAD antiarrhythmic drug AF atrial fibrillation AFL atrial flutter CB cryoballoon CFAE complex fractionated atrial electrogram LA left atrial LAA left atrial appendage LGE late gadolinium-enhanced LOE level of evidence MRI magnetic resonance imaging OAC oral anticoagulation RF radiofrequency Section 1: Introduction During the past three decades, catheter and surgical ablation of atrial fibrillation (AF) have evolved from investigational procedures to their current role as effective treatment options for patients with AF. Surgical ablation of AF, using either standard, minimally invasive, or hybrid techniques, is available in most major hospitals throughout the world. Catheter ablation of AF is even more widely available, and is now the most commonly performed catheter ablation procedure. In 2007, an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Cardiac Arrhythmia Society (ECAS). 1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC). This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim. 2 The rate of advancement in the tools, techniques, and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms, outcomes, and treatment of AF. For this reason, the HRS initiated an effort to rewrite and update this Consensus Statement. Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is charged with defining the indications, techniques, and outcomes of AF ablation procedures. Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes, including definitions relevant to this topic. The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardíacas [SOBRAC]). All the members of the writing group, as well as peer reviewers of the document, have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest. All author and peer reviewer disclosure information is provided in Appendix A and Appendix B. In writing a consensus document, it is recognized that consensus does not mean that there was complete agreement among all the writing group members. Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation. These recommendations were systematically balloted by the 60 writing group members and were approved by a minimum of 80% of these members. The recommendations were also subject to a 1-month public comment period. Each partnering and collaborating organization then officially reviewed, commented on, edited, and endorsed the final document and recommendations. The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA. 3 , 4 It is important to state, however, that this document is not a guideline. The indications for catheter and surgical ablation of AF, as well as recommendations for procedure performance, are presented with a Class and Level of Evidence (LOE) to be consistent with what the reader is familiar with seeing in guideline statements. A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks, and that AF ablation should be performed; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks, and that it is reasonable to perform AF ablation; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks, and that AF ablation may be considered; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended. The writing group reviewed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high-quality evidence from more than one randomized clinical trial, meta-analyses of high-quality randomized clinical trials, or one or more randomized clinical trials corroborated by high-quality registry studies. The writing group ranked available evidence as Level B-R when there was moderate-quality evidence from one or more randomized clinical trials, or meta-analyses of moderate-quality randomized clinical trials. Level B-NR was used to denote moderate-quality evidence from one or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies. This designation was also used to denote moderate-quality evidence from meta-analyses of such studies. Evidence was ranked as Level C-LD when the primary source of the recommendation was randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies of human subjects. Level C-EO was defined as expert opinion based on the clinical experience of the writing group. Despite a large number of authors, the participation of several societies and professional organizations, and the attempts of the group to reflect the current knowledge in the field adequately, this document is not intended as a guideline. Rather, the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies. 5 , 6 This consensus document is specifically focused on catheter and surgical ablation of AF, and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience. It is directed to all health care professionals who are involved in the care of patients with AF, particularly those who are caring for patients who are undergoing, or are being considered for, catheter or surgical ablation procedures for AF, and those involved in research in the field of AF ablation. This statement is not intended to recommend or promote catheter or surgical ablation of AF. Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient. The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF. A second major objective is to provide recommendations for designing clinical trials and reporting outcomes of clinical trials of AF ablation. It is recognized that this field continues to evolve rapidly. As this document was being prepared, further clinical trials of catheter and surgical ablation of AF were under way. Section 2: Definitions, Mechanisms, and Rationale for AF Ablation This section of the document provides definitions for use in the diagnosis of AF. This section also provides an in-depth review of the mechanisms of AF and rationale for catheter and surgical AF ablation (Table 1 , Figures 1–6 ). Table 1 Atrial fibrillation definitions AF episode An AF episode is defined as AF that is documented by ECG monitoring or intracardiac electrogram monitoring and has a duration of at least 30 seconds, or if less than 30 seconds, is present throughout the ECG monitoring tracing. The presence of subsequent episodes of AF requires that sinus rhythm be documented by ECG monitoring between AF episodes. Chronic AF Chronic AF has variable definitions and should not be used to describe populations of AF patients undergoing AF ablation. Early persistent AF Early persistent AF is defined as AF that is sustained beyond 7 days but is less than 3 months in duration. Lone AF Lone AF is a historical descriptor that is potentially confusing and should not be used to describe populations of patients with AF undergoing AF ablation. Long-standing persistent AF Long-standing persistent AF is defined as continuous AF of greater than 12 months’ duration. Paroxysmal AF Paroxysmal AF is defined as AF that terminates spontaneously or with intervention within 7 days of onset. Permanent AF Permanent AF is defined as the presence of AF that is accepted by the patient and physician, and for which no further attempts to restore or maintain sinus rhythm will be undertaken. The term permanent AF represents a therapeutic attitude on the part of the patient and physician rather than an inherent pathophysiological attribute of AF. The term permanent AF should not be used within the context of a rhythm control strategy with antiarrhythmic drug therapy or AF ablation. Persistent AF Persistent AF is defined as continuous AF that is sustained beyond 7 days. Silent AF Silent AF is defined as asymptomatic AF diagnosed with an opportune ECG or rhythm strip. AF, atrial fibrillation; ECG, electrocardiogram. Figure 1 Anatomical drawings of the heart relevant to AF ablation. This series of drawings shows the heart and associated relevant structures from four different perspectives relevant to AF ablation. This drawing includes the phrenic nerves and the esophagus. (A) The heart viewed from the anterior perspective. (B) The heart viewed from the right lateral perspective. (C) The heart viewed from the left lateral perspective. (D) The heart viewed from the posterior perspective. (E) The left atrium viewed from the posterior perspective. Illustration: Tim Phelps © 2017 Johns Hopkins University, AAM. Figure 2 This figure includes six CT or MR images of the left atrium and pulmonary veins viewed from the posterior perspective. Common and uncommon variations in PV anatomy are shown. (A) Standard PV anatomy with 4 distinct PV ostia. (B) Variant PV anatomy with a right common and a left common PV. (C) Variant PV anatomy with a left common PV with a short trunk and an anomolous PV arising from the right posterior left atrial wall. (D) and (E) Variant PV anatomy with a common left PV with a long trunk. (F) Variant PV anatomy with a massive left common PV. Figure 3 Schematic drawing showing various hypotheses and proposals concerning the mechanisms of atrial fibrillation. (A) Multiple wavelets hypothesis. (B) Rapidly discharging automatic foci. (C) Single reentrant circuit with fibrillatory conduction. (D) Functional reentry resulting from rotors or spiral waves. (E) AF maintenance resulting from dissociation between epicardial and endocardial layers, with mutual interaction producing multiplying activity that maintains the arrhythmia. Figure 4 Structure and mechanisms of atrial fibrillation. (A) Schematic drawing of the left and right atria as viewed from the posterior perspective. The extension of muscular fibers onto the PVs can be appreciated. Shown in yellow are the five major left atrial autonomic ganglionic plexi (GP) and axons (superior left GP, inferior left GP, anterior right GP, inferior right GP, and ligament of Marshall). Shown in blue is the coronary sinus, which is enveloped by muscular fibers that have connections to the atria. Also shown in blue is the vein and ligament of Marshall, which travels from the coronary sinus to the region between the left superior PV and the left atrial appendage. (B) The large and small reentrant wavelets that play a role in initiating and sustaining AF. (C) The common locations of PV (red) and also the common sites of origin of non-PV triggers (shown in green). (D) Composite of the anatomic and arrhythmic mechanisms of AF. Adapted with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21. 2 Figure 5 Schematic drawing showing mechanisms of atrial flutter and atrial tachycardia. (A) Isthmus-dependent reverse common (clockwise) atrial flutter. (B) Isthmus-dependent common (counter clockwise) atrial flutter. (C) Focal atrial tachycardia with circumferential spread of activation of the atria (can arise from multiple sites within the left and right atrium). (D) Microreentrant atrial tachycardia with circumferential spread of activation of the atria. (E) Perimitral atrial flutter. (F) Roof-dependent atrial flutter. Figure 6 Schematic of common lesion sets employed in AF ablation. (A) The circumferential ablation lesions that are created in a circumferential fashion around the right and the left PVs. The primary endpoint of this ablation strategy is the electrical isolation of the PV musculature. (B) Some of the most common sites of linear ablation lesions. These include a “roof line” connecting the lesions encircling the left and/or right PVs, a “mitral isthmus” line connecting the mitral valve and the lesion encircling the left PVs at the end of the left inferior PV, and an anterior linear lesion connecting either the “roof line” or the left or right circumferential lesion to the mitral annulus anteriorly. A linear lesion created at the cavotricuspid isthmus is also shown. This lesion is generally placed in patients who have experienced cavotricuspid isthmus-dependent atrial flutter clinically or have it induced during EP testing. (C) Similar to 6B, but also shows additional linear ablation lesions between the superior and inferior PVs resulting in a figure of eight lesion sets as well as a posterior inferior line allowing for electrical isolation of the posterior left atrial wall. An encircling lesion of the superior vena cava (SVC) directed at electrical isolation of the SVC is also shown. SVC isolation is performed if focal firing from the SVC can be demonstrated. A subset of operators empirically isolates the SVC. (D) Representative sites for ablation when targeting rotational activity or CFAEs are targeted. Modified with permission from Calkins et al. Heart Rhythm 2012; 9:632–696.e21. 2 Section 3: Modifiable Risk Factors for AF and Impact on Ablation Management of patients with AF has traditionally consisted of three main components: (1) anticoagulation for stroke prevention; (2) rate control; and (3) rhythm control. With the emergence of large amounts of data, which have both defined and called attention to the interaction between modifiable risk factors and the development of AF and outcomes of AF management, we believe it is time to include risk factor modification as the fourth pillar of AF management. This section of the document reviews the link between modifiable risk factors and both the development of AF and their impacts on the outcomes of AF ablation. Section 4: Indications Shown in Table 2 , and summarized in Figures 7 and 8 of this document, are the Consensus Indications for Catheter and Surgical Ablation of AF. As outlined in the introduction section of this document, these indications are stratified as Class I, Class IIa, Class IIb, and Class III indications. The evidence supporting these indications is provided, as well as a selection of the key references supporting these levels of evidence. In making these recommendations, the writing group considered the body of published literature that has defined the safety and efficacy of catheter and surgical ablation of AF. Also considered in these recommendations is the personal lifetime experience in the field of each of the writing group members. Both the number of clinical trials and the quality of these trials were considered. In considering the class of indications recommended by this writing group, it is important to keep several points in mind. First, these classes of indications only define the indications for catheter and surgical ablation of AF when performed by an electrophysiologist or a surgeon who has received appropriate training and/or who has a certain level of experience and is performing the procedure in an experienced center (Section 11). Catheter and surgical ablation of AF are highly complex procedures, and a careful assessment of the benefit and risk must be considered for each patient. Second, these indications stratify patients based only on the type of AF and whether the procedure is being performed prior to or following a trial of one or more Class I or III antiarrhythmic medications. This document for the first time includes indications for catheter ablation of select asymptomatic patients. As detailed in Section 9, there are many other additional clinical and imaging-based variables that can be used to further define the efficacy and risk of ablation in a given patient. Some of the variables that can be used to define patients in whom a lower success rate or a higher complication rate can be expected include the presence of concomitant heart disease, obesity, sleep apnea, left atrial (LA) size, patient age and frailty, as well as the duration of time the patient has been in continuous AF. Each of these variables needs to be considered when discussing the risks and benefits of AF ablation with a particular patient. In the presence of substantial risk or anticipated difficulty of ablation, it could be more appropriate to use additional antiarrhythmic drug (AAD) options, even if the patient on face value might present with a Class I or IIa indication for ablation. Third, it is important to consider patient preference and values. Some patients are reluctant to consider a major procedure or surgery and have a strong preference for a pharmacological approach. In these patients, trials of antiarrhythmic agents including amiodarone might be preferred to catheter ablation. On the other hand, some patients prefer a nonpharmacological approach. Fourth, it is important to recognize that some patients early in the course of their AF journey might have only infrequent episodes for many years and/or could have AF that is responsive to well-tolerated AAD therapy. And finally, it is important to bear in mind that a decision to perform catheter or surgical AF ablation should only be made after a patient carefully considers the risks, benefits, and alternatives to the procedure. Table 2 Indications for catheter (A and B) and surgical (C, D, and E) ablation of atrial fibrillation Recommendation Class LOE References Indications for catheter ablation of atrial fibrillation A. Indications for catheter ablation of atrial fibrillation Symptomatic AF refractory or intolerant to at least one Class I or III antiarrhythmic medication Paroxysmal: Catheter ablation is recommended. I A 7–18 Persistent: Catheter ablation is reasonable. IIa B-NR 8 , 16–26 Long-standing persistent: Catheter ablation may be considered. IIb C-LD 8 , 16–26 Symptomatic AF prior to initiation of antiarrhythmic therapy with a Class I or III antiarrhythmic medication Paroxysmal: Catheter ablation is reasonable. IIa B-R 27–35 Persistent: Catheter ablation is reasonable. IIa C-EO Long-standing persistent: Catheter ablation may be considered. IIb C-EO B. Indications for catheter atrial fibrillation ablation in populations of patients not well represented in clinical trials Congestive heart failure It is reasonable to use similar indications for AF ablation in selected patients with heart failure as in patients without heart failure. IIa B-R 36–52 Older patients (>75 years of age) It is reasonable to use similar indications for AF ablation in selected older patients with AF as in younger patients. IIa B-NR 53–59 Hypertrophic cardiomyopathy It is reasonable to use similar indications for AF ablation in selected patients with HCM as in patients without HCM. IIa B-NR 60–62 Young patients (  65% – 70% on warfarin. Table 5 Signs and symptoms following AF ablation Differential Suggested evaluation Signs and symptoms of complications within a month postablation Back pain Musculoskeletal, retroperitoneal hematoma Physical exam, CT imaging Chest pain Pericarditis, pericardial effusion, coronary stenosis (ablation related), pulmonary vein stenosis, musculoskeletal (after cardioversion), worsening reflux Physical exam, chest X-ray, ECG, echocardiogram, stress test, cardiac catheterization, chest CT Cough Infectious process, bronchial irritation (mechanical, cryoballoon), pulmonary vein stenosis Physical exam, chest X-ray, chest CT Dysphagia Esophageal irritation (related to transesophageal echocardiography), atrioesophageal fistula Physical exam, chest CT or MRI Early satiety, nausea Gastric denervation Physical exam, gastric emptying study Fever Infectious process, pericarditis, atrioesophageal fistula Physical exam, chest X-ray, chest CT, urinalysis, laboratory blood work Fever, dysphagia, neurological symptoms Atrial esophageal fistula Physical exam, laboratory blood work, chest CT or MRI; avoid endoscopy with air insufflation Groin pain at site of access Pseudoaneurysm, AV fistula, hematoma Ultrasound of the groin, laboratory blood work; consider CT scan if ultrasound negative Headache Migraine (related to anesthesia or transseptal access, hemorrhagic stroke), effect of general anesthetic Physical exam, brain imaging (MRI) Hypotension Pericardial effusion/tamponade, bleeding, sepsis, persistent vagal reaction Echocardiography, laboratory blood work Hemoptysis PV stenosis or occlusion, pneumonia Chest X-ray, chest CT or MR scan, VQ scan Neurological symptoms Cerebral embolic event, atrial esophageal fistula Physical exam, brain imaging, chest CT or MRI Shortness of breath Volume overload, pneumonia, pulmonary vein stenosis, phrenic nerve injury Physical exam, chest X-ray, chest CT, laboratory blood work Signs and symptoms of complications more than a month postablation Fever, dysphagia, neurological symptoms Atrial esophageal fistula Physical exam, laboratory blood work, chest CT or MRI; avoid endoscopy with air insufflation Persistent cough, atypical chest pain Infectious process, pulmonary vein stenosis Physical exam, laboratory blood work, chest X-ray, chest CT or MRI Neurological symptoms Cerebral embolic event, atrial esophageal fistula Physical exam, brain imaging, chest CT or MRI Hemoptysis PV stenosis or occlusion, pneumonia CT scan, VQ scan AF, atrial fibrillation; ECG, electrocardiogram; CT, computed tomography; MRI, magnetic resonance imaging; VQ, ventilation-perfusion. Section 8: Follow-up Considerations AF ablation is an invasive procedure that entails risks, most of which are present during the acute procedural period. However, complications can also occur in the weeks or months following ablation. Recognizing common symptoms after AF ablation and distinguishing those that require urgent evaluation and referral to an electrophysiologist is an important part of follow-up after AF ablation. The success of AF ablation is based in large part on freedom from AF recurrence based on ECG monitoring. Arrhythmia monitoring can be performed with the use of noncontinuous or continuous ECG monitoring tools (Table 6 ). This section also discusses the important topics of AAD and non-AAD use prior to and following AF ablation, the role of cardioversion, as well as the indications for and timing of repeat AF ablation procedures. Table 6 Types of ambulatory cardiac monitoring devices Type of recorder Typical monitoring duration Continuous recording Event recording Auto trigger Unique features Holter monitor 24–48 hours, approximately 7–30 days Yes Yes N/A Short term, provides quantitative data on arrhythmia burden Patch monitor 1–3 weeks Yes Yes N/A Intermediate term, can provide continuous data for up to several weeks; improved patient compliance without lead wires External loop recorder 1 month Yes Yes Variable Good correlation between symptoms and even brief arrhythmias External nonloop recorder Months No Yes No May be used long term and intermittently; will not capture very brief episodes Smartphone monitor Indefinite No Yes No Provides inexpensive long-term intermittent monitoring; dependent on patient compliance; requires a smartphone Mobile cardiac telemetry 30 days Yes Yes Yes Real time central monitoring and alarms; relatively expensive Implantable loop recorder Up to 3 years Yes Yes Yes Improved patient compliance for long-term use; not able to detect 30-second episodes of AF due to detection algorithm; presence of AF needs to be confirmed by EGM review because specificity of detection algorithm is imperfect; expensive Pacemakers or ICDs with atrial leads Indefinite Yes Yes Yes Excellent AF documentation of burden and trends; presence of AF needs to be confirmed by electrogram tracing review because specificity of detection algorithms is imperfect; expensive Wearable multisensor ECG monitors Indefinite Yes Yes Yes ECG 3 leads, temp, heart rate, HRV, activity tracking, respiratory rate, galvanic skin response AF, atrial fibrillation; ICD, implantable cardioverter defibrillator; ECG, electrocardiogram; HRV, heart rate variability. Section 9: Outcomes and Efficacy This section provides a comprehensive review of the outcomes of catheter ablation of AF. Table 7 summarizes the main findings of the most important clinical trials in this field. Outcomes of AF ablation in subsets of patients not well represented in these trials are reviewed. Outcomes for specific ablation systems and strategies (CB ablation, rotational activity ablation, and laser balloon ablation) are also reviewed. Table 7 Selected clinical trials of catheter ablation of atrial fibrillation and/or for FDA approval Trial Year Type N AF type Ablation strategy Initial time frame Effectiveness endpoint Ablation success Drug/ Control success P value for success Ablation complications Drug/ Control complications Comments Clinical Trials Performed for FDA Approval JAMA 2010; 303: 333-340 (ThermoCool AF) 14 2010 Randomized to RF ablation or AAD, multicenter 167 Paroxysmal PVI, optional CFAEs and lines 12 months Freedom from symptomatic paroxysmal atrial fibrillation, acute procedural failure, or changes in specified drug regimen 66% 16% 24h 70% 44% 0.002 6.1% 4.20% NEJM 2015; 372: 1812-1822 19 2015 Randomized ablation strategies, multicenter 589 Persistent PVI alone versus PVI & CFAEs or PVI & lines 18 months Freedom from afib with or without drugs 59% (PVI alone) 49% & 46% NS 6% 4.3% & 7.6% Other Mixed Paroxysmal and Persistent AF Ablation Trials J Med Assoc Thai 2003; 86 (Suppl 1): S8-S16 24 2003 Randomized to RF ablation or amiodarone 30 Paroxysmal (70%), Persistent (30%) PVI, mitral line, CTI, SVC to IVC 12 months Freedom from AF 79% 40% 0.018 6.70% 47% EHJ 2006; 27: 216-221 17 2006 Randomized to RF ablation or drug, multicenter 137 Paroxysmal (67%), Persistent (33%) PVI, mitral line, CTI 12 months Freedom from AF, flutter, tachycardia 66% 9% QOL and 6 min walk increase with abl 38 °C), in combination with either purulent discharge from the mediastinum or an organism isolated from blood culture or culture of mediastinal drainage. Esophageal injury Esophageal injury is defined as an erosion, ulceration, or perforation of the esophagus. The method of screening for esophageal injury should be specified. Esophageal injury can be a mild complication (erosion or ulceration) or a major complication (perforation). Gastric motility/pyloric spasm disorders Gastric motility/pyloric spasm disorder should be considered a major complication of AF ablation when it prolongs or requires hospitalization, requires intervention, or results in late disability, such as weight loss, early satiety, diarrhea, or GI disturbance. Major complication A major complication is a complication that results in permanent injury or death, requires intervention for treatment, or prolongs or requires hospitalization for more than 48 hours. Because early recurrences of AF/AFL/AT are to be expected following AF ablation, recurrent AF/AFL/AT within 3 months that requires or prolongs a patient's hospitalization should not be considered to be a major complication of AF ablation. Mediastinitis Mediastinitis is defined as inflammation of the mediastinum. Diagnosis requires one of the following: (1) an organism isolated from culture of mediastinal tissue or fluid; (2) evidence of mediastinitis observed during surgery; (3) one of the following conditions: chest pain, sternal instability, or fever (>38 °C), in combination with either purulent discharge from the mediastinum or an organism isolated from blood culture or culture of mediastinal drainage. Myocardial infarction in the context of AF ablation The universal definition of myocardial infarction 395 cannot be applied in the context of catheter or surgical AF ablation procedures because it relies heavily on cardiac biomarkers (troponin and CPK), which are anticipated to increase in all patients who undergo AF ablation as a result of the ablation of myocardial tissue. Similarly, chest pain and other cardiac symptoms are difficult to interpret in the context of AF ablation both because of the required sedation and anesthesia and also because most patients experience chest pain following the procedure as a result of the associated pericarditis that occurs following catheter ablation. We therefore propose that a myocardial infarction, in the context of catheter or surgical ablation, be defined as the presence of any one of the following criteria: (1) detection of ECG changes indicative of new ischemia (new ST-T wave changes or new LBBB) that persist for more than 1 hour; (2) development of new pathological Q waves on an ECG; (3) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. Pericarditis Pericarditis should be considered a major complication following ablation if it results in an effusion that leads to hemodynamic compromise or requires pericardiocentesis, prolongs hospitalization by more than 48 hours, requires hospitalization, or persists for more than 30 days following the ablation procedure. Phrenic nerve paralysis Phrenic nerve paralysis is defined as absent phrenic nerve function as assessed by a sniff test. A phrenic nerve paralysis is considered to be permanent when it is documented to be present 12 months or longer following ablation. Pulmonary vein stenosis Pulmonary vein stenosis is defined as a reduction of the diameter of a PV or PV branch. PV stenosis can be categorized as mild 25 mm Hg or during exercise >30 mm Hg), and large V waves ≥10 mm Hg or higher) on PCWP or left atrial pressure tracings in the absence of significant mitral valve disease or PV stenosis. Stroke or TIA postablation Stroke diagnostic criteria Rapid onset of a focal or global neurological deficit with at least one of the following: change in level of consciousness, hemiplegia, hemiparesis, numbness or sensory loss affecting one side of the body, dysphasia or aphasia, hemianopia, amaurosis fugax, or other neurological signs or symptoms consistent with stroke Duration of a focal or global neurological deficit ≥24 hours; OR   7 days but no more than 1 year and (2) a 24-hour Holter within 90 days of the ablation procedure showing continuous AF. Minimum documentation for early persistent AF The minimum AF documentation requirement for persistent AF is (1) physician's note indicating continuous AF > 7 days but no more than 3 months and (2) a 24-hour Holter showing continuous AF within 90 days of the ablation procedure. Minimum documentation for long-standing persistent AF The minimum AF documentation requirement for long-standing persistent AF is as follows: physician's note indicating at least 1 year of continuous AF plus a 24-hour Holter within 90 days of the ablation procedure showing continuous AF. The performance of a successful cardioversion (sinus rhythm >30 seconds) within 12 months of an ablation procedure with documented early recurrence of AF within 30 days should not alter the classification of AF as long-standing persistent. Symptomatic AF/AFL/AT AF/AFL/AT that results in symptoms that are experienced by the patient. These symptoms can include but are not limited to palpitations, presyncope, syncope, fatigue, and shortness of breath. For patients in continuous AF, reassessment of symptoms after restoration of sinus rhythm is recommended to establish the relationship between symptoms and AF. Documentation of AF-related symptoms Documentation by a physician evaluating the patient that the patient experiences symptoms that could be attributable to AF. This does not require a time-stamped ECG, Holter, or event monitor at the precise time of symptoms. For patients with persistent AF who initially report no symptoms, it is reasonable to reassess symptom status after restoration of sinus rhythm with cardioversion. Minimum effectiveness endpoint for patients with symptomatic and asymptomatic AF The minimum effectiveness endpoint is freedom from symptomatic and asymptomatic episodes of AF/AFL/AT recurrences at 12 months following ablation, free from antiarrhythmic drug therapy, and including a prespecified blanking period. Minimum chronic acceptable success rate: paroxysmal AF at 12-month follow-up If a minimum chronic success rate is selected as an objective effectiveness endpoint for a clinical trial, we recommend that the minimum chronic acceptable success rate for paroxysmal AF at 12-month follow-up is 50%. Minimum chronic acceptable success rate: persistent AF at 12-month follow-up If a minimum chronic success rate is selected as an objective effectiveness endpoint for a clinical trial, we recommend that the minimum chronic acceptable success rate for persistent AF at 12-month follow-up is 40%. Minimum chronic acceptable success rate: long-standing persistent AF at 12-month follow-up If a minimum chronic success rate is selected as an objective effectiveness endpoint for a clinical trial, we recommend that the minimum chronic acceptable success rate for long-standing persistent AF at 12-month follow-up is 30%. Minimum follow-up screening for paroxysmal AF recurrence For paroxysmal AF, the minimum follow-up screening should include (1) 12-lead ECG at each follow-up visit; (2) 24-hour Holter at the end of the follow-up period (e.g., 12 months); and (3) event recording with an event monitor regularly and when symptoms occur from the end of the 3-month blanking period to the end of follow-up (e.g., 12 months). Minimum follow-up screening for persistent or long-standing AF recurrence For persistent and long-standing persistent AF, the minimum follow-up screening should include (1) 12-lead ECG at each follow-up visit; (2) 24-hour Holter every 6 months; and (3) symptom-driven event monitoring. Requirements for transesophageal echocardiogram It is recommended that the minimum requirement for performance of a TEE in a clinical trial should be those requirements set forth in ACC/AHA/HRS 2014 Guidelines for AF Management pertaining to anticoagulation at the time of cardioversion. Prior to undergoing an AF ablation procedure a TEE should be performed in all patients with AF of > 48 hours' duration or of unknown duration if adequate systemic anticoagulation has not been maintained for at least 3 weeks prior to AF ablation. If a TEE is performed for this indication, it should be performed within 24 hours of the ablation procedure. AF, atrial fibrillation; DW-MRI, diffusion-weighted magnetic resonance imaging; CHF, congestive heart failure; QOL, quality of life; ECG, electrocardiogram; CABG, coronary artery bypass grafting; PV, pulmonary vein; SVC, superior vena cava; IVC, inferior vena cava; CFAE, complex fractionated atrial electrogram; PVI, pulmonary vein isolation; AFL, atrial flutter; AT, atrial tachycardia; ACC, American College of Cardiology; AHA, American Heart Association; HRS, Heart Rhythm Society. ∗When reporting outcomes of AF ablation, the development of atrial tachycardia or atrial flutter should be included in the broad definition of recurrence following AF ablation. All studies should report freedom from AF, atrial tachycardia, and atrial flutter. These endpoints can also be reported separately. All studies should also clearly specify the type and frequency of ECG monitoring as well as the degree of compliance with the prespecified monitoring protocol. Table 11 Quality-of-life scales, definitions, and strengths Scale Definition/Details Strengths/Weaknesses Short Form (36) Health Survey (SF36)38 (General) Consists of 8 equally weighted, scaled scores in the following sections: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, mental health. Each section receives a scale score from 0 to 100. Physical component summary (PCS) and mental component summary (MCS) is an average of all the physically and mentally relevant questions, respectively. The Short Form (12) Health Survey (SF12) is a shorter version of the SF-36, which uses just 12 questions and still provides scores that can be compared with SF-36 norms, especially for summary physical and mental functioning. Gives more precision in measuring QOL than EQ-5D but can be harder to transform into cost utility analysis. Advantages: extensively validated in a number of disease and health states. Might have more resolution than EQ-50 for AF QOL. Disadvantages: not specific for AF, so might not have resolution to detect AF-specific changes in QOL. EuroQol Five Dimensions Questionnaire (EQ-5D)39 (General) Two components: Health state description is measured in five dimensions: mobility, self-care, usual activities, pain/discomfort, anxiety/depression. Answers may be provided on a three-level (3L) or five-level (5L) scale. In the Evaluation section, respondents evaluate their overall health status using a visual analogue scale (EQ-VAS). Results can easily be converted to quality-adjusted life years for cost utility analysis. Advantages: extensively validated in a number of disease and health states. Can easily be converted into quality-adjusted life years for cost-effectiveness analysis. Disadvantages: might not be specific enough to detect AF-specific changes in QOL. Might be less specific than SF-36. AF effect on Quality of Life Survey (AFEQT)40 (AF specific) 20 questions: 4 targeting AF-related symptoms, 8 evaluating daily function, and 6 assessing AF treatment concerns. Each item scored on a 7-point Likert scale. Advantages: brief, simple, very responsive to AF interventions. Good internal validity and well validated against a number of other global and AF-specific QOL scales. Used in CABANA. Disadvantages: validation in only two published studies (approximately 219 patients). Quality of Life Questionnaire for Patients with AF (AF-QoL)41 (AF specific) 18-item self-administered questionnaire with three domains: psychological, physical, and sexual activity. Each item scores on a 5-point Likert scale. Advantages: brief, simple, responsive to AF interventions; good internal validity; used in SARA trial. Disadvantages: external validity compared only to SF-36; formal validation in 1 study (approximately 400 patients). Arrhythmia-Related Symptom Checklist (SCL)42 (AF specific) 16 items covering AF symptom frequency and symptom severity. Advantages: most extensively validated in a number of arrhythmia cohorts and clinical trials. Disadvantages: time-consuming and uncertain generalizability. Mayo AF Specific Symptom Inventory (MAFSI)43 (AF specific) 10 items covering AF symptom frequency and severity. Combination of 5- point and 3-point Likert scale responses. Used in CABANA trial. Advantages: validated in an AF ablation population and responsive to ablation outcome; used in CABANA trial. Disadvantages: external validity compared only to SF-36; 1 validation study (approximately 300 patients). University of Toronto Atrial Fibrillation Severity Scale (AFSS) (AF specific)44 10 items covering frequency, duration, and severity. 7-point Likert scale responses. Advantages: validated and reproducible; used in CTAF trial. Disadvantages: time-consuming and uncertain generalizability. Arrhythmia Specific Questionnaire in Tachycardia and Arrhythmia (ASTA)45 (AF specific) Records number of AF episodes and average episode duration during last 3 months. 8 symptoms and 2 disabling symptoms are recorded with scores from 1–4 for each. Advantages: validated in various arrhythmia groups; external validity compared with SCL, EQ5D, and SF-36; used in MANTRA-PAF; brief; simple. Disadvantages: one validation study (approximately 300 patients). European Heart Rhythm Association (EHRA)46 (AF specific) Like NYHA scale. I = no symptoms, II = mild symptoms not affecting daily activity, III = severe symptoms affecting daily activity, and IV = disabling symptoms terminating daily activities. Advantage: very simple, like NYHA. Disadvantages: not used in studies and not well validated; not very specific; unknown generalizability. Canadian Cardiovascular Society Severity of Atrial Fibrillation Scale (CCS-SAF)47 (AF specific) Like NYHA scale. O = asymptomatic, I = AF symptoms have minimal effect on patient's QOL, II = AF symptoms have minor effect on patient QOL, III = symptoms have moderate effect on patient QOL, IV= AF symptoms have severe effect on patient QOL. Advantages: very simple, like NYHA; validated against SF-36 and University of Toronto AFSS. Disadvantages: poor correlation with subjective AF burden; not very specific. AF, atrial fibrillation; QOL, quality of life; CABANA, Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation; SARA, Study of Ablation Versus antiaRrhythmic Drugs in Persistent Atrial Fibrillation; CTAF, Canadian Trial of Atrial Fibrillation; MANTRA-PAF, Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation; NYHA, New York Heart Association; AFSS, atrial fibrillation severity scale. Table 12 Non-AF recurrence–related endpoints for reporting in AF ablation trials Stroke and bleeding endpoints Definitions/Details Stroke (2014 ACC/AHA Key Data Elements) An acute episode of focal or global neurological dysfunction caused by brain, spinal cord, or retinal vascular injury as a result of hemorrhage or infarction. Symptoms or signs must persist ≥24 hours, or if documented by CT, MRI or autopsy, the duration of symptoms/signs may be less than 24 hours. Stroke may be classified as ischemic (including hemorrhagic transformation of ischemic stroke), hemorrhagic, or undetermined. Stroke disability measurement is typically performed using the modified Rankin Scale (mRS). Transient ischemic attack (2014 ACC/AHA Key Data Elements) Transient episode of focal neurological dysfunction caused by brain, spinal cord, or retinal ischemia without acute infarction and with signs and symptoms lasting less than 24 hours. Major bleeding (ISTH definition) Fatal bleeding AND/OR symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal, intraarticular, pericardial, or intramuscular with compartment syndrome AND/OR bleeding causing a fall in hemoglobin level of 2 g/dL (1.24 mmol/L) or more, or leading to transfusion of two or more units of blood. Clinically relevant nonmajor bleed (ISTH definition) An acute or subacute clinically overt bleed that does not meet the criteria for a major bleed but prompts a clinical response such that it leads to one of the following: hospital admission for bleeding; physician-guided medical or surgical treatment for bleeding; change in antithrombotic therapy (including interruption or discontinuation). Minor bleeding (ISTH definition) All nonmajor bleeds. Minor bleeds are further divided into clinically relevant and not. Incidence and discontinuation of oral anticoagulation The number of patients receiving oral anticoagulation and the type of oral anticoagulation should be documented at the end of follow-up. If patients have their oral anticoagulation discontinued, the number of patients discontinuing, the timing of discontinuation, and the reasons for discontinuation of oral anticoagulation, as well as the clinical characteristics and stroke risk profile of the patients should be reported. AF, atrial fibrillation; CT, computed tomography; MRI, magnetic resonance imaging. Table 13 Advantages and disadvantages of AF-related endpoints in AF ablation trials Endpoint Advantages Disadvantages Relevance and Comments Freedom from AF/AFL/AT recurrence “gold standard” is 30 seconds - Has been in use for many years - Can be used to compare results of new trials with historical trials - Sets a high bar for AF elimination - Can systematically underestimate the efficacy of AF ablation, particularly for persistent AF, if 30-second cutoff is used - Particularly well suited for paroxysmal AF outcomes - Reporting of cutoffs other than 30 seconds encouraged as secondary endpoints to better contextualize results - May be reported as proportion of patients free from arrhythmia or time to recurrence Freedom from stroke-relevant AF/AFL/AT-duration cutoff of 1 hour - Useful for trials in which interest is more for prognostic change conferred by ablation rather than elimination of all arrhythmias - No consistent definition of what a stroke-relevant duration of AF is: ranges from 6 minutes to 24 hours in literature - More than 1 hour could be a useful cutoff based on results of 505 trial - May be reported as proportion of patients free from arrhythmia or time to recurrence Freedom from AF/AFL/AT requiring intervention (emergency visits, cardioversion, urgent care visit, reablation, etc.) - Can provide an endpoint more relevant to systemic costs of AF recurrence - Clinically relevant - Will overestimate efficacy of ablation by ignoring shorter episodes not requiring intervention that still might be important to quality of life or stroke - Determination of what is an “intervention” must be prespecified in protocol and biases mitigated to avoid over- or underintervention in the trial Freedom from persistent AF/AFL/AT-duration cutoff of 7 days - Useful for trials assessing additional substrate modification in persistent AF - Can systematically overestimate the efficacy of AF ablation, particularly for persistent AF - Can require continuous monitoring to definitively assess if episode is > 7 days Freedom from AF/AFL/AT on previously ineffective antiarrhythmic therapy - If patient maintains sinus rhythm on previously ineffective drug therapy, this may be considered a clinically relevant, successful outcome - Will increase the success rate compared with off-drug success - May not be relevant to patients hoping to discontinue drug therapy - Postablation drug and dosage of drug should be identical to preablation drug and dosage Significant reduction in AF burden: >75% reduction from pre- to postablation and/or total postablation burden 7 days) - Does not assume that total elimination of AF is required - Well suited for paroxysmal or “early” AF studies in which goal is to prevent progression to persistent AF - Prevention in progression might be irrelevant for stroke or thromboembolic outcomes - Long follow-up time might be required unless population is “enriched” - Can ideally require continuous implantable monitoring - Might be useful for specific populations such as heart failure or hypertrophic cardiomyopathy, in which progression to persistent AF can lead to increased hospitalization Regression of AF: reduction in burden to a given threshold or conversion of persistent to paroxysmal AF - Does not assume that total elimination of AF is required - Well suited for persistent “late” AF studies in which goal is to regress to paroxysmal AF, which might be easier to control with drug therapy - Regression endpoint will overestimate efficacy of AF ablation - Might ideally require continuous implantable monitoring - Patients will require ongoing drug therapy - Could be particularly useful for long-standing persistent AF populations with structural heart disease, heart failure, etc. Acute AF termination during ablation procedure - Could provide indication of successful modification of substrate responsible for maintaining AF, most relevant to persistent or long-standing persistent AF - Limited studies have linked acute AF termination to long-term success - Relevance of acute AF termination has not consistently been shown to correlate to long-term success - Endpoint might not be relevant to paroxysmal AF patients in whom AF might terminate spontaneously - Some studies employ administration of intravenous or oral antiarrhythmics during ablation that could cause spontaneous termination - Studies consider termination as reversion to sinus rhythm, whereas others consider reversion to any regular tachycardia as termination - Intraprocedural administration of preprocedural oral antiarrhythmics or intraprocedural intravenous antiarrhythmics are discouraged - If antiarrhythmics are used, their use and dosage before and during the ablation should be clearly documented - Termination to sinus rhythm and termination to another regular tachycardia (AT or AFL) should be separately reported AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia. Unanswered Questions in AF Ablation There is still much to be learned about the mechanisms of AF, techniques of AF ablation, and long-term outcomes. The following are unanswered questions for future investigation: AF ablation and modification of stroke risk and need for ongoing oral anticoagulation (OAC): The CHA2DS2-VASc score was developed for patients with clinical AF. If a patient has received a successful ablation such that he/she no longer has clinical AF (subclinical, or no AF), then what is the need for ongoing OAC? Are there any patients in whom successful ablation could lead to discontinuation of OAC? Substrate modification in catheter-based management of AF—particularly for persistent AF: What is the proper lesion set required beyond pulmonary vein isolation? Do lines and complex fractionated atrial electrogram (CFAE) have any remaining role? Are these approaches ill-advised or simply discouraged? What is the role of targeting localized rotational activations? How do we ablate a localized rotational activation? How can scar be characterized and targeted for ablation? Do we need to replicate the MAZE procedure? Does the right atrium need to be targeted as well as the left atrium? Autonomic influence in AF: Is clinical AF really an autonomic mediated arrhythmia? Is elimination of ganglionated plexi required? Is there a role for autonomic modulation, for example, spinal cord or vagal stimulation? Contribution and modulation of risk factors on outcomes of AF ablation: Obesity reduction has been shown to reduce AF burden and recurrence in patients undergoing ablation. What is the role of bariatric surgery? Does the modulation of other risk factors influence outcome such as hypertension, sleep apnea, and diabetes? Outcomes in ablation of high-risk populations: Do high-risk populations benefit from AF ablation? Congestive heart failure has been assessed in smaller trials, but larger trials are required. Outcome data are needed in patients with very enlarged LAs, hypertrophic cardiomyopathy, patients with renal failure on dialysis, and the very elderly. Surgical vs catheter-based vs hybrid ablation: There should be more comparative work between percutaneous and minimally invasive surgical approaches. Both report similar outcomes, but there is a dearth of comparative data. Is there any patient benefit to hybrid procedures? How do we characterize patients who are optimal candidates for ablation? Preablation late gadolinium-enhanced (LGE)-magnetic resonance imaging (MRI) might identify patients with heavy burdens of scar who are unlikely to respond to ablation. These techniques must become reproducible and reliable and must be assessed in multicenter trials. Other markers need to be investigated, including genetic markers, biochemical markers, and clinical markers based on aggregated risk scores. The incremental role of new technologies: As newer and often more expensive technologies are produced for AF ablation, their definitive incremental value must be determined in order to justify change in practice or case cost. These technologies include global (basket) mapping techniques, newer ablation indices for assessing lesion durability, advanced imaging for viewing lesions in the myocardium, etc. New energy sources, including laser, low-intensity ultrasound, photonic particle therapy, external beam ablation, and MRI-guided ablation, must be assessed in comparative fashion. Outcomes of AF ablation: We need to better understand the clinical relevance of ablation outcomes. What is the significance of time to recurrence of 30 seconds of arrhythmia? How do we best quantify AF burden? How do these outcomes relate to quality of life and stroke risk? What is the role of surgical LA reduction? Does left atrial appendage (LAA) occlusion or obliteration improve outcome of persistent AF ablation with an accompanying reduction in stroke? Does ablation work through atrial size reduction? What is the incidence of “stiff atrial” syndrome and does this mitigate the clinical impact of ablation? Working in teams: What is the role of the entire heart team in AF ablation? Does a team approach achieve better outcomes than a “silo” approach? Improving the safety of catheter ablation: As ablation extends to more operators and less experienced operators, the statistical occurrence of complications will increase. We need newer techniques to minimize complications and institute standards for operators to improve the reproducibility of ablation results and safety profiles at a variety of centers worldwide. How does catheter ablation affect mortality, stroke, and hospitalization in broad and selected patient populations receiving catheter ablation for AF? Management of patients who fail initial attempts at catheter ablation: Should there be specific criteria for repeat ablations (e.g., atrial size, body mass index)? Should patients be referred for surgery for repeat ablation? In order to address these and other important questions in the field of catheter and surgical AF ablation, we urge investigators to create and participate in multisite collaborations and electrophysiology research networks with involvement of senior and junior investigators on the steering committees to push forward the next phase of AF research. We also urge funding bodies to support these important initiatives. Section 14: Conclusion Catheter ablation of AF is a very commonly performed procedure in hospitals throughout the world. This document provides an up-to-date review of the indications, techniques, and outcomes of catheter and surgical ablation of AF. Areas for which a consensus can be reached concerning AF ablation are identified, and a series of consensus definitions have been developed for use in future clinical trials of AF ablation. Also included within this document are recommendations concerning indications for AF ablation, technical performance of this procedure, and training. It is our hope to improve patient care by providing a foundation for those involved with care of patients with AF as well as those who perform AF ablation. It is recognized that this field continues to evolve rapidly and that this document will need to be updated. Successful AF ablation programs optimally should consist of a cooperative team of cardiologists, electrophysiologists, and surgeons to ensure appropriate indications, procedure selection, and follow-up. The full article HRS/EHRA/APHRS/ECAS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation can be read in full online. When referencing please cite the full article [10.1093/europace/eux274].
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            2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

            Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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              Is Open Access

              Cardiovascular magnetic resonance feature-tracking assessment of myocardial mechanics: Intervendor agreement and considerations regarding reproducibility

              Aim To assess intervendor agreement of cardiovascular magnetic resonance feature tracking (CMR-FT) and to study the impact of repeated measures on reproducibility. Materials and methods Ten healthy volunteers underwent cine imaging in short-axis orientation at rest and with dobutamine stimulation (10 and 20 μg/kg/min). All images were analysed three times using two types of software (TomTec, Unterschleissheim, Germany and Circle, cvi42, Calgary, Canada) to assess global left ventricular circumferential (Ecc) and radial (Err) strains and torsion. Differences in intra- and interobserver variability within and between software types were assessed based on single and averaged measurements (two and three repetitions with subsequent averaging of results, respectively) as determined by Bland–Altman analysis, intraclass correlation coefficients (ICC), and coefficient of variation (CoV). Results Myocardial strains and torsion significantly increased on dobutamine stimulation with both types of software (p<0.05). Resting Ecc and torsion as well as Ecc values during dobutamine stimulation were lower measured with Circle (p<0.05). Intra- and interobserver variability between software types was lowest for Ecc (ICC 0.81 [0.63–0.91], 0.87 [0.72–0.94] and CoV 12.47% and 14.3%, respectively) irrespective of the number of analysis repetitions. Err and torsion showed higher variability that markedly improved for torsion with repeated analyses and to a lesser extent for Err. On an intravendor level TomTec showed better reproducibility for Ecc and torsion and Circle for Err. Conclusions CMR-FT strain and torsion measurements are subject to considerable intervendor variability, which can be reduced using three analysis repetitions. For both vendors, Ecc qualifies as the most robust parameter with the best agreement, albeit lower Ecc values obtained using Circle, and warrants further investigation of incremental clinical merit.
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                Author and article information

                Contributors
                S.A.J.Chamuleau@umcutrecht.nl
                Journal
                J Cardiovasc Transl Res
                J Cardiovasc Transl Res
                Journal of Cardiovascular Translational Research
                Springer US (New York )
                1937-5387
                1937-5395
                23 July 2019
                23 July 2019
                2019
                : 12
                : 6
                : 517-527
                Affiliations
                [1 ]GRID grid.7692.a, ISNI 0000000090126352, Department of Cardiology, , University Medical Center Utrecht, ; Utrecht, The Netherlands
                [2 ]GRID grid.411737.7, Netherlands Heart Institute, ; Utrecht, The Netherlands
                [3 ]GRID grid.413762.5, CMH, ; Utrecht, Netherlands
                Author notes

                Associate Editor Enrique Lara-Pezzi oversaw the review of this article

                Author information
                http://orcid.org/0000-0002-9952-6701
                Article
                9899
                10.1007/s12265-019-09899-w
                6854049
                31338795
                8c90a327-c9ca-4985-9bf1-dbbf93889210
                © The Author(s) 2019

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                : 18 March 2019
                : 1 July 2019
                Funding
                Funded by: University Medical Center Utrecht
                Categories
                Original Article
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                © Springer Science+Business Media, LLC, part of Springer Nature 2019

                Cardiovascular Medicine
                heart failure,myocardial infarction,noga,mri,electromechanical mapping,feature tracking,late gadolinium–enhanced mri

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