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Background: Percutaneous left atrial appendage closure (LAAC) reduces the incidence of stroke/bleeding events in patients with non-valvular atrial fibrillation, high risk of stroke, and contraindication in continuing anticoagulation therapy. Of them, patients with heart failure may remain at high risk of these events after LAAC. Method: Patients who underwent LAAC and were listed for the multi-center, prospectively collected OCEAN-LAAC registry, were eligible. Of them, individuals without baseline plasma B-type natriuretic peptide (BNP) levels and those dependent on hemodialysis were excluded. The prognostic impact of baseline plasma BNP levels on the incidence of death or stroke/bleeding events after LAAC was evaluated. Results: A total of 937 patients (median 78 years, 596 men) were included. The LAAC device was successfully implanted in 934 (98%) patients. Over the 366 (251, 436) days after the LAAC, 148 patients encountered a primary outcome. The common logarithm of baseline plasma BNP was independently associated with the primary outcome with an adjusted hazard ratio of 1.46 (95% confidence interval 1.06–2.18, p = 0.043). A calculated cutoff of 2.12 (equivalent to 133 pg/mL of plasma BNP level) significantly stratified the cumulative incidence of the primary outcome (29% vs. 21% for 2 years, p = 0.004). Conclusions: Using prospectively collected large-scale multi-center Japanese registry data, we demonstrated that a baseline higher plasma BNP level was independently associated with a higher incidence of stroke/bleeding events and mortality after LAAC. Further studies are warranted to understand the optimal therapeutic strategy for LAAC candidates with elevated baseline plasma BNP levels.

Background Limited data on the efficacy and safety of atrial fibrillation (AF) ablation using an ablation index (AI) for octogenarians is available. We aimed to compare the efficacy and safety of AI‐guided AF ablation between AF patients aged ≥80 years (Group 1) and <80 (Group 2). Hypothesis We hypothesized that AI‐guided AF ablation could complete the procedure with comparable efficiency and safety in patients aged ≥80 years and <80. Methods We retrospectively reviewed 2087 AF patients undergoing their first AI‐guided AF ablation in our hospital. We compared the atrial tachyarrhythmia (AT) recurrence and procedure‐related complication rate between Group 1 (n = 193) and Group 2 (n = 1894). Results The mean age was 83.0 (interquartile range [IQR] 81.0, 84.0) years in Group 1 and 67.0 (IQR 60.0, 72.0) in Group 2. AF type was significantly different between the two groups: Of Group 1 patients, 120 (62.2%) had paroxysmal AF, 61 (31.6%) persistent AF, and 12 (6.2%) long‐standing persistent AF, while of Group 2 patients, 1016 (53.6%) paroxysmal AF, 582 (30.7%) persistent AF, and 296 (15.6%) long‐standing persistent AF (p = .001). Unadjusted AT recurrence‐free survival curves showed similar AT recurrence‐free survival between the two groups (p = .67 by log‐rank test). After the adjustment for AF type, the survival curve was similar between them (hazard ratio, 1.24; 95% CI [0.92–1.65]; p = .15, Group 1 vs. Group 2). The rate of procedure‐related complications was similar between the two groups (3.1% vs. 3.0%, respectively, p = .83). Conclusion Catheter ablation guided by AI achieved similar AT recurrence and complication rates between elderly AF patients aged ≥80 years and patients <80 years. Catheter ablation guided by the ablation index achieved a similar AT recurrence rate between elderly AF patients aged ≥80 years and patients <80 years. The overall complication rate was similar among them. However, the percentage of cardiac tamponade in AF patients aged ≥80 years was almost three times as high as those <80 years.

Abstract PurposeLocalization of the esophagus and the left atrium (LA) posterior wall thickness (LAPWT) should be taken into account when delivering radiofrequency energy. To validate the visualization of the esophagus and analyze LAPWT by ICE advanced into the LA in patients with atrial fibrillation (AF) undergoing ablation index (AI)-guided pulmonary vein (PV) isolation.MethodsIn 73 patients (mean age, 68 ± 12; paroxysmal AF in 45), a 3-dimensional (3D) esophagus image was created with CARTO SoundstarⓇ and its location was compared with contrast esophagography saved in Carto UNIVU™. LAPWT adjacent to the esophagus was measured at 4 levels: left superior PV (LSPV), intervenous carina (IC), left inferior PV (LIPV), and LIPV bottom. A target AI value was 260 (25 W power) on the esophagus demonstrated by ICE.ResultsAll patients had the esophagus posterior to the left PV antrum. Creating a 3D esophagus and measurement of LAPWT with ICE was done without any complications. ICE esophagus image was completely overlapped with contrast esophagography. LAPWT (mm) was 2.8 (interquartile range, 2.5–3.2), 2.2 (1.9–2.5), 1.9 (1.8–2.1), and 2.1 (1.9–2.4) for LSPV, IC, LIPV, and LIPV bottom, respectively, while LA roof thickness was 3.2 (2.9–3.6) (P < 0.0001 by ANOVA). No residual conduction gap on the esophagus after the first circumferential PV isolation was found in 64 of 73 (88%) patients.ConclusionsICE inserted into the LA can reliably locate and display the esophagus and its relationship to the LA. LAPWT was the thinnest at the LIPV level. AI-guided ablation targeting at AI value 260 on the esophagus seemed to be effective.

Background High‐power short‐duration (HPSD) ablation is an established therapy for pulmonary vein (PV) isolation (PVI) in atrial fibrillation (AF), aiming to form efficient transmural lesions. Very HPSD (vHPSD) can further shorten ablation time but may increase the risk of acute PVI failure compared with HPSD. A combined HPSD and vHPSD strategy (90 W/50 W combination workflow) potentially balances efficiency and durability, though its clinical feasibility remains unknown. Therefore, this multicenter registry evaluated the acute and long‐term efficacy of a 90 W/50 W combination workflow for PVI in patients with paroxysmal AF. Methods In this prospective study, a total of 101 consecutive patients with paroxysmal AF underwent PVI using radiofrequency ablation with a 90 W/50 W combination workflow. We evaluated acute outcomes, including first‐pass isolation and acute PV reconnection, and monitored atrial tachyarrhythmia recurrences over 12 months. Results Median PVI procedure time was 35 min, with total procedure time at 105 min. First‐pass PVI was achieved in 58.4% of patients, including 74.3% in the right PV and 72.3% in the left PV. Acute PV reconnection occurred in 31.7% (32/101). In multivariate analysis, carina sites independently predicted acute PVI failure in both HPSD and vHPSD groups, while contact force also predicted failure in the HPSD group. After 1 year, 89.9% of patients remained free from documented atrial tachyarrhythmias. Conclusion The 90 W/50 W combination workflow did not notably shorten procedure time or enhance first‐pass success. More standardized strategies, particularly in carina segments with higher contact force and ablation index under HPSD, may be required to ensure optimal lesion durability and favorable outcomes. This multicenter registry evaluated a 90 W/50 W combination workflow for pulmonary vein isolation (PVI) in 101 patients with paroxysmal atrial fibrillation. First‐pass PVI was achieved in 74.3% of right and 72.3% of left PVs. The 1‐year atrial tachyarrhythmia recurrence‐free survival was favorable at 89.9%, suggesting this strategy is a clinically effective option for achieving durable PVI.

Background The Asia‐Pacific Heart Rhythm Society Atrial Fibrillation (APHRS‐AF) Registry is a prospective study in Asian metropolitan cities, which provides important information on the baseline characteristics, therapeutic patterns, and 1‐year clinical outcomes in patients with atrial fibrillation (AF). This report describes data from Japanese patients recruited in this registry. Methods and Results A total of 4666 patients with AF were enrolled. Of these, 794 patients were recruited from 28 large cardiovascular centers in Japan between 2015 and 2017. We analyzed 1‐year follow‐up outcome of these patients. Mean age at recruitment was 65.7 years and 69.0% were males. Major comorbidities were hypertension (37.5%), lipid disorder (29.0%), heart failure (15.9%), and diabetes mellitus (15.0%). Mean CHADS2 score, CHA2DS2‐VASc score, and HAS‐BLED score were 1.0, 2.0, and 1.1, respectively. At baseline, use of oral anticoagulants was 81%, including 7% prescribed a vitamin K antagonist (VKA) and 74% a direct oral anticoagulant (DOAC). Majority of the patients (N = 459, 57.8%) were planned to undergo catheter ablation. One‐year follow‐up was conducted in 743 patients. One‐year all‐cause mortality was 0.1% (n = 1) and the incidence of stroke/thromboembolic events was also 0.1% (n = 1). Major bleeding events were observed in 5 patients (0.7%), including 3 intracranial hemorrhages. Conclusion In this 1‐year analysis, a high prevalence of oral anticoagulant use was recorded. A low mortality rate and a low incidence of stroke/thromboembolic events were observed in Japanese patients of the APHRS‐AF Registry. A total of 794 patients recruited from 28 large cardiovascular centers in Japan were prospectively investigated. Patients were relatively young, had low CHADS2 scores, and relatively few comorbidities such as hypertension. Majority of the patients were scheduled for catheter ablation. Short‐term prognosis was found to be extremely favorable.

Background Confluent inferior pulmonary veins (CIPV) is a rare anatomical variant. There is few evidence in the literature regarding anatomic landmarks consideration to guide radiofrequency application in avoiding complications in the esophagus in CIPV cases. Methods Of 986 consecutive patients undergoing atrial fibrillation (AF) ablation from July 2020 to June 2022, seven (0.7%) had CIPV with a common trunk connecting to the LA diagnosed by 3-dimensional contrast-enhanced computed tomography. Using intracardiac echocardiography (ICE) performed from the left atrium (LA), we measured the posterior wall thickness (PWT) of the CIPV adjacent to the esophagus and compared the measurement with the LA posterior wall thickness (LAPWT) at the left inferior PV level of 25 controls without CIPV. For ablation in CIPV patients, each superior PV was individually isolated, and box isolation of CIPV without ablating the CIPV posterior wall was added (tri-circle ablation technique). Results The CIPV PWT was 0.7 ± 0.1 mm, while non-CIPV LAPWT was 2.0 ± 0.4 mm ( P  < 0.001). In the CIPV group, upper and lower portions of the CIPV were both apart from the esophagus (mean distances, 6.7 ± 3.4 mm and 7.9 ± 2.7 mm, respectively). Individual superior PV isolation and box CIPV isolation resulted in complete isolation of all PVs, with no complications. All CIPV patients except one remained AF recurrence-free for 376 ± 52 days. Conclusions Although CIPV frequency is low, CIPV PWT is very thin and special care is needed during ablation. A “tri-circle” ablation strategy avoids ablating in the thinnest portion of the posterior wall. Further studies are warranted to assess the safety.

BackgroundCoaptation gap (CG) is one of the challenging anatomies of mitral transcatheter edge-to-edge repair (TEER), but its impact on patient outcomes is unclear. This study aimed to evaluate the impact of CG on procedural and clinical outcomes in patients with functional mitral regurgitation (MR).MethodsData from 2140 patients undergoing TEER for functional MR were analysed, focusing on the presence of CG, which is a missing leaflet coaptation between the anterior and posterior leaflets during systole. The primary outcome was a composite of death, heart failure hospitalisation and mitral valve reintervention.ResultsOf the 2140 patients, 219 (10%) had CG and 1921 (90%) did not, as assessed by baseline transoesophageal echocardiography. In patients with CG, baseline MR grade and New York Heart Association (NYHA) functional class were more severe, and long/wide clip types were used more frequently. Post-TEER, patients with CG had significantly lower achievement of MR grade ≤2+ (93%) and ≤1+ (65%) compared with patients without CG (97%, p<0.01; 82%, p<0.01, respectively). NYHA functional class at 1 year was similar in both groups. The cumulative incidence of the primary outcome was comparable between CG and non-CG groups (51% vs 53% at 3 years, p=0.71). While residual MR grade 2+ was associated with the higher primary outcome incidence compared with ≤1+ in patients without CG (p<0.01), no significant difference was found in patients with CG (p=0.51).ConclusionCG was associated with less MR reduction but with no clear difference in adverse clinical outcomes after TEER. Similar outcomes between residual MR grade 2+ and ≤1+ in CG patients highlight the importance of procedural endpoint in anatomically challenging cases.Trial registration numberUMIN000023653.