title: Mortality After Atrioventricular Nodal Radiofrequency Catheter Ablation With Permanent Ventricular Pacing in Atrial Fibrillation: Outcomes From a Controlled Nonrandomized Study Prolonged PR Interval Predicts Clinical Recurrence of Atrial Fibrillation After Catheter Ablation No Benefit of Complex Fractionated Atrial Electrogram Ablation in Addition to Circumferential Pulmonary Vein Ablation and Linear Ablation: Benefit of Complex Ablation Study Does a blanking period after pulmonary vein isolation impact long-term results? Results after 55 months of follow-up. A novel risk prediction score in atrial fibrillation for a net clinical outcome from the ENGAGE AF-TIMI 48 randomized clinical trial Predicting atrial fibrillation ablation outcome: The CAAP-AF score. Usefulness of serum uric acid level to predict atrial fibrillation recurrence after cryoballoon-based catheter ablation. Clinical predictors of arrhythmia recurrences following pulmonary vein antrum isolation for atrial fibrillation: predicting arrhythmia recurrence post-PVAI. Efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation in women. Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following radiofrequency catheter ablation of atrial fibrillation: clinical impact of continuous positive airway pressure therapy. Impact of chronic obstructive pulmonary disease on procedural outcomes and quality of life in patients with atrial fibrillation undergoing catheter ablation. Primary Persistent Atrial Fibrillation: A Distinct Arrhythmia Subentity of an Ablation Population. Experience matters: long-term results of pulmonary vein isolation using a robotic navigation system for the treatment of paroxysmal atrial fibrillation Assessment of clinical factors associated with a successful catheter ablation outcome in younger patients with atrial fibrillation. Repeated catheter ablation of atrial fibrillation: how to predict outcome?
abstract: Background —Atrioventricular nodal radiofrequency ablation ( AVNA ) with permanent ventricular pacing can be used to control rate in patients with atrial fibrillation ( AF ) . However , long-term outcomes after AVNA are uncertain , especially in light of irreversible pacemaker dependence . Methods and Results —We examined 9122 consecutive patients with AF . The outcomes in 453 patients with AVNA ( 26 % of whom underwent an implantable cardiac defibrillator implant and 37 % underwent cardiac resynchronization therapy implant ) were compared with AF patients without AVNA after propensity score 1:1 matching . During follow-up in the propensity-matched cohort ( 2.41±3.23 years , median 1.23 , quartiles 0.33–3.12 ) , 100 patients died ( yearly rate of death 6.6 % ) . Mode of death was available in 86 % of patients , which was cardiovascular in 67 % of the patients ( related to heart failure in 38 % , sudden death in 5 % , and other cardiovascular reason in 24 % ) and noncardiovascular in 33 % . AVNA in patients with AF was associated with a lower risk of mortality ( odds ratio 0.47 , 95 % confidence interval , 0.29–0.77 ; P=0.003 ) , a lower risk of cardiovascular mortality ( odds ratio = 0.41 , 95 % confidence interval 0.23–0.73 ; P=0.003 ) , and nonsignificant lower risk of stroke and thromboembolic events ( odds ratio = 0.61 , 95 % confidence interval 0.36–1.06 ; P=0.08 ) . Conclusions —In sick AF patients with multiple comorbidities  , AVNA with permanent ventricular pacing for rate control seems safe during follow-up and may be associated with lower mortality Background A prolonged PR interval is known to be a poor prognostic factor in cardiovascular disease . The aim of this study was to investigate the association between PR interval and clinical outcome in patients undergoing radiofrequency catheter ablation ( RFCA ) of atrial fibrillation ( AF ) . Methods and Results We prospect ively included 576 patients with AF ( 75.5 % male , 57.8±11.6 years old , 68.8 % paroxysmal AF ) who underwent RFCA .  We analyzed preprocedural sinus rhythm ECGs obtained in the absence of antiarrhythmic drug , and all enrolled patients were categorized into 4 groups based on the quartile values of the PR interval ( 166 , 182 , and 202 ms ) , and were analyzed according to the left atrium ( LA ) volume ( CT ; Computed tomography ) , LA voltage ( NavX ) , and clinical outcome of AF ablation . Based on quartile value of PR interval , the highest quartile of PR interval ( Q4 ; PR ≥202 ms ) was oldest ( P<0.001 ) , and most likely to have persistent AF ( P<0.001 ) and hypertension ( P=0.013 ) compared with the other groups . However , there was no significant difference in LA conduction velocity and atrial effective refractory period . Q4 had the greatest LA dimension ( P<0.001 ) and volume index ( P<0.001 ) , and lowest LA appendage‐emptying velocity ( P<0.032 ) and LA voltage ( P<0.001 ) compared with the others . For 13.1±7.5 months , the classification based on the PR interval was a significant predictor of AF recurrence after RFCA of AF ( HR=1.969 , 95 % CI 1.343 to 2.886 , P=0.001 ) . Conclusions The PR interval was closely associated with advanced LA remodeling due to AF , and had a noninvasive significant predictive value of clinical recurrence of AF after RFCA Background —The optimal ablation strategy for persistent atrial fibrillation ( AF ) remains unclear . Methods and Results —This multicentre r and omized study compared circumferential pulmonary vein ablation+linear ablation ( control arm ) versus circumferential pulmonary vein ablation+linear ablation+complex fractionated atrial electrogram ( CFAE ) ablation ( CFAE arm ) in patients with persistent AF .  Circumferential pulmonary vein ablation was performed followed by roof and mitral isthmus ablation , before CFAE ablation in the CFAE arm . Ablation strategy was maintained at the first redo procedure . Sixty-five patients were recruited in each arm . The mean age was 61±10 years , 75 % were men , median AF duration was 2 years , 42 % had long-lasting persistent AF , 68 % had associated cardiovascular disease , mean left atrial dimension was 46±6 mm , and median CHA2DS2-VASc score was 2 .  Ablation and procedure times were significantly longer in the CFAE arm ( 70±20 versus 55±17 ; 201±35 versus 152±45 minutes ; P<0.005 ) . After a mean follow-up of 35±5 months , single-procedural success off antiarrhythmic drugs at 12 months ( CFAE : 30/65 [ 46 % ] versus control : 37/65 [ 57 % ] ; P=0.29 ) and multiprocedural success ( CFAE : 51/65 [ 78 % ] versus control : 52/65 [ 80 % ] ; P=1.0 ) were not significantly different . At the first redo procedure , patients in the CFAE arm had a higher incidence of organized atrial tachycardia/flutter ( 24/33 [ 73 % ] versus 11/31 [ 35 % ] ; P=0.005 ) and gap-related macro – re-entrant flutter ( 8/33[24 % ] versus 1/31[3 % ] ; P=0.03 ) . Early recurrence of atrial arrhythmia was an independent predictor of late recurrence . Conclusions —CFAE ablation did not confer incremental benefit when performed in addition to circumferential pulmonary vein ablation and linear ablation . It was associated with a higher incidence of gap-related flutter . Clinical Trial Registration —URL : http://www . clinical trials.gov . Unique identifier : NCT01711047 BACKGROUND The aims of the study are 1 ) to assess antiarrhythmic prophylaxis efficacy during the first 2 months after  radiofrequency ablation ( ARF ) due to AF ; 2 ) to define risk factors for early AF recurrence ( EAFR ) after ARF ; 3 ) to determine the long-term follow-up results and risk factors for late AF recurrence ( LAFR ) . METHODS A total number of 210 consecutive patients who had undergone ARF due to AF were analyzed . Patients were r and omized into three groups : Group 1 ( G1 ) , without any anti-arrhythmic drug ( AAD ) ; Group 2 ( G2 ) , with amiodarone or sotalol ; Group 3 ( G3 ) , with last ineffective AAD . The study was design ed to analyze two periods : short-term observation , the first 2 months after ARF ; and at least 2 years of long-term follow-up . RESULTS After 2 months , clinical data were collected from 171 patients ( 123 males , mean age of 50.3 years ; persistent AF in 19.8 % ; lone AF in 36.6 % ) .  Sinus rhythm ( SR ) was maintained in 84 ( 49.1 % ) patients ; 35 ( 20.4 % ) patients presented with a single episode of AF , 39 ( 23 % ) patients experienced a reduction in number of AF episodes , and 13 ( 7.5 % ) patients showed no improvement . No predisposing factor for early recurrence was found . After a mean follow-up of 55 months , clinical data were collected in 137 patients , of which 47 ( 34 % ) maintained SR . Those more likely to sustain SR were : males ( 82.9 % vs. 62.2 % ; p = 0.018 ) , younger patients ( 44.8 ± 12.7 vs. 52.5 ± 9.9 ; p = 0.0001 ) , patients with smaller left atrium diameter ( 4.05 ± ± 0.49 cm vs. 4.25 ± 0.51 cm ; p = 0.04 ) , and those without any AF recurrence during the first 2 months after ARF ( 78.7 % vs. 35.6 % ; p < 0.0001 ) . In the multivariable analysis , the independent risk factors for LAFR were hypertension ( p < 0.001 ) and persistent AF ( p = 0.014 ) . CONCLUSIONS Antiarrhythmic prophylaxis does not affect the number of AF recurrences during the first 2 months after ablation . SR maintenance during a blanking period after AF ablation is a positive prognostic factor in long-term follow-up . Persistent AF and hypertension are independent risk factors for late AF recurrence after pulmonary vein isolation Aims The choice between initiating a non-vitamin K antagonist oral anticoagulant ( NOAC ) and a vitamin K antagonist ( VKA ) in patients with atrial fibrillation ( AF ) may be challenging . To assist in this decision , we developed a risk score to identify patients for whom a therapeutic benefit of NOACs over VKA is predicted . Methods and results ENGAGE AF-TIMI 48 was a r and omized clinical trial of edoxaban vs. warfarin in 21 105 patients with AF . Cox proportional hazard models identified factors associated with a serious net clinical outcome ( NCO ) of disabling stroke , life-threatening bleeding , and all-cause mortality in VKA naïve patients from the warfarin arm . These were used to develop an integer risk score . Performance was assessed by C-indices and validation by bootstrapping . Kaplan-Meier analyses were stratified by three score categories and treatment arm . Over a median of 2.7 years , 457  NCO events occurred in 2898 patients with a total person-time of 7549.5 years ( 6.05%/year ) . The risk prediction model ( C = 0.693 ) for the NCO was translated into a 17-point integer score , with annualized event rates for the low , intermediate , and high-risk categories in the warfarin arm of 3.5 % , 9.9 % , and 20.8 % , respectively . Therapeutic benefit of higher- and lower-dose edoxaban over warfarin was demonstrated in the high- and intermediate-risk , with equal benefit in the low-risk categories ( P-interaction 0.008 and 0.014 , respectively ) . Conclusion In VKA naive patients with AF , the TIMI-AF score can assist in the prediction of a poor composite outcome and guide selection of anticoagulant therapy by identifying a differential clinical benefit with a NOAC or VKA BACKGROUND Patients with a variety of clinical presentations undergo atrial fibrillation ( AF ) ablation .  Long-term ablation success rates can vary considerably . OBJECTIVE The purpose of this study was to develop a clinical scoring system to predict long-term freedom from AF after ablation . METHODS We retrospectively derived the scoring system on a development cohort ( DC ) of 1125 patients undergoing AF ablation  and tested it prospect ively in a test cohort ( TC ) of 937 patients undergoing AF ablation .  RESULTS The demographics of the DC patients were as follows : age 62.3 ± 10.3 years , male sex 801 ( 71.2 % ) , left atrial size 4.30 ± 0.69 cm , paroxysmal AF 348 ( 30.9 % ) , number of drugs failed 1.3 ± 1.1 , hypertension  525 ( 46.7 % ) , diabetes 100 ( 8.9 % ) , prior stroke/transient ischemic attack 78 ( 6.9 % ) , prior cardioversion 528 ( 46.9 % ) , and CHADS2 score 0.87 ± 0.97 . Multivariate analysis showed 6 independent variables predicting freedom from AF after final ablation : coronary artery disease ( P = .021 ) , atrial diameter ( P = .0003 ) , age ( P = .004 ) , persistent or long-st and ing AF ( P < .0001 ) , number of antiarrhythmic drugs failed ( P < .0001 ) , and female sex ( P = .0001 ) . We created a scoring system ( CAAP-AF ) using these 6 variables , with scores ranging from 0 to 13 points . The 2-year AF-free rates by CAAP-AF scores were as follows : 0 = 100 % , 1 = 95.7 % , 2 = 96.3 % , 3 = 83.1 % , 4 = 85.5 % , 5 = 79.9 % , 6 = 76.1 % , 7 = 63.4 % , 8 = 51.1 % , 9 = 53.6 % , and ≥10 = 29.1 % . Ablation success decreased as CAAP-AF scores increased ( P < .0001 ) . The CAAP-AF score also predicted freedom from AF in the TC . The 2-year Kaplan-Meier AF-free rates by CAAP-AF scores were as follows : 0 = 100 % , 1 = 87.0 % , 2 = 89.0 % , 3 = 91.6 % , 4 = 90.5 % , 5 = 84.4 % , 6 = 70.1 % , 7 = 71.0 % , 8 = 60.7 % , 9 = 68.9 % , and ≥10 = 51.3 % . As CAAP-AF scores increased , 2-year freedom from AF in the TC decreased ( P < .0001 ) . CONCLUSION An easily determined clinical scoring system was derived retrospectively and applied prospect ively . The CAAP-AF score predicted freedom from AF after ablation in both a DC and a TC of patients undergoing AF ablation . The CAAP-AF score provides a realistic AF ablation outcome expectation for individual patients AIMS Catheter-based atrial fibrillation ( AF ) ablation has become an important therapeutic option in AF patients . Although there has been significant improvent in procedural success , post-procedural AF recurrences are continuing to be a major clinical problem . To the best of our knowledge , the impact of pre-procedural serum uric acid ( SUA ) level , as a pro-oxidant and pro-inflammatory marker , on AF recurrence following cryoballoon-based AF ablation has never been studied before . The objective of this study was to establish whether there is a relationship between levels of SUA and recurrence of paroxysmal AF after catheter ablation . METHODS AND RESULTS A total of 363 patients ( mean age 53.5 ± 11.2 years , 52.6 % male ) with symptomatic paroxysmal AF underwent initial cryoablation procedure .  Patients were categorized into quartiles on the basis of their pre-procedural SUA assays and follow-up , and the Kaplan-Meier estimation with a log-rank test was used for the analysis of the influence of SUA on the recurrence of AF . Post-ablation blanking period was observed for 3 months . At a mean follow-up of 19.2 ± 6.1 months , 68 patients ( 18.7 % ) had developed AF recurrence . Atrial fibrillation recurrence rates from the lowest to the highest SUA quartiles were 2.9 , 7.4 , 11.8 , and 77.9 % , respectively ( P < 0.001 ) . On multivariate Cox regression analysis , pre-ablation SUA level ( HR : 1.96 , 95 % CI : 1.49 - 2.59 , P < 0.001 ) , left atrial diameter ( HR : 1.11 , 95 % CI : 1.04 - 1.19 , P = 0.002 ) and early AF recurrence ( HR : 4.34 , 95 % CI : 1.9 - 9.95 , P = 0.001 ) were independent predictors of AF recurrence after cryoablation . Using a cut-off level of 6.37 , the pre-ablation SUA level predicted AF recurrence during follow-up with a sensitivity of 85.7 % and a specificity of 83.7 % . CONCLUSION In this prospect i ve study of patients with paroxysmal AF undergoing cryoablation , increased pre-ablation SUA levels were associated with a higher rate of AF recurrence . Our results support the role of a pre-ablation pro-inflammatory and pro-oxidant environment in the development of AF recurrence after ablation therapy but suggest that other factors are also important INTRODUCTION Pulmonary vein antrum isolation ( PVAI ) is an accepted treatment for atrial fibrillation ( AF ) refractory to medical therapy . The purpose of this study was to identify the patient , procedural , and follow-up factors associated with arrhythmia recurrences following PVAI . METHODS AND RESULTS Clinical data were prospect ively collected on all 385 consecutive patients who had 530 PVAI ( age 58 ± 11 years , 63 % paroxysmal AF-PAF , follow-up 2.8 ± 1.2 years ) between February 2004 and March 2009 .  ECGs  were recorded at each follow-up visit with Holter monitoring 1 , 3 , 6 , and 12 months following PVAI and every 6 months thereafter . Recurrences < 3 months post-PVAI were defined as early , 3 months-1 year post-PVAI as late , and > 1 year post-PVAI as very late . Relationship between predictor variables and outcomes was modeled using Cox proportional hazards analysis . Late recurrences occurred in 42 % with a lower rate among PAF versus non-PAF patients ( 39 % vs 56 % , P = 0.001 ) . Of the 256 patients with ≥ 1-year follow-up , 121 ( 47 % ) had no arrhythmia off antiarrhythmic drugs ( AADs ) 1 year post-PVAI ; 36 ( 30 % ) of these had a very late recurrence . In multivariate analysis , non-PAF , hypertension , and prior AAD failure predicted recurrence . When entered into the model , early recurrences remained the only predictor of late recurrences . CONCLUSION Patients with non-PAF , hypertension , and prior failure of multiple AAD were more likely to experience arrhythmia recurrence post-PVAI . Early recurrences were the strongest predictor of late recurrences . Late and very late recurrences following PVAI were common and should be considered when planning long-term AF patient management OBJECTIVES It is uncertain whether gender affects the outcomes of catheter ablation ( CA ) for atrial fibrillation ( AF ) . The objective of the study is to evaluate the efficacy and safety of CA for long-st and ing persistent AF in women . METHODS Between January 2010 and May 2011 , 220 consecutive patients ( 73 females , 33.2 % ) , with long-st and ing persistent AF who underwent CA were prospect ively recruited . Gender-related differences in clinical presentation , periprocedural complications , and outcomes were compared . RESULTS Women were less likely to have lone AF than men ( 27.4 % vs 47.6 % ; P = 0.004 ) . The incidence of rheumatic heart disease was higher in women ( 19.2 % in women vs 1.4 % in men ; P < 0.001 ) . Women had a lower initial ablation success rate than men ( 35.6 % vs 57.1 % ; P = 0.003 ) . Hematomas occurred more often in women ( 6.8 % in women vs 0.7 % in men ; P = 0.027 ) . A Cox regression analysis demonstrated total duration of AF ( per month , hazard ratio [ HR ] 1.003 , confidence interval [ CI ] 1.001 - 1.006 ; P = 0.006 ) and gender ( HR 1.663 , CI 1.114 - 2.485 ; P = 0.013 ) as the independent predictors for recurrence after the first CA . CONCLUSIONS Women and long AF duration were closely related to the recurrence of AF after the first ablation in patients with long-st and ing persistent AF . Women also had a higher risk of vascular complications BACKGROUND Recent studies have suggested an emerging link between obstructive sleep apnea ( OSA ) and  atrial fibrillation ( AF ) . Patients with OSA are less likely to remain in sinus rhythm after radiofrequency catheter ablation of AF . OBJECTIVE To evaluate the efficacy of appropriate treatment with continuous positive airway pressure ( CPAP ) on recurrences of AF after ablation . METHODS This study prospect ively included 153 patients ( 128 men ; 60 ± 9 years ) who underwent extensive encircling pulmonary vein isolation for drug refractory AF .  The st and ard overnight polysomnographic evaluation  was performed 1 week after ablation , and the total duration and the number of central or obstructive sleep apnea or hypopnea episodes were examined . RESULTS Of 153 patients , 116 patients were identified as having OSA . Data regarding the use of CPAP and recurrences of AF were obtained in 82 patients . The remaining 34 patients with OSA were defined as the no-CPAP group . Polysomnography revealed no sleep-disordered breathing in 37 patients . During a mean follow-up period of 18.8 ± 10.3 months , 51 ( 33 % ) patients experienced AF recurrences after ablation . A Cox regression analysis revealed that the left atrial volume ( hazard ratio [ HR ] 1.11 ; 95 % confidence interval [ CI ] 1.01 - 1.23 ; P<.05 ) , concomitant OSA ( HR 2.61 ; 95 % CI 1.12 - 6.09 ; P<.05 ) , and usage of CPAP therapy ( HR 0.41 ; 95 % CI 0.22 - 0.76 ; P<.01 ) were associated with AF recurrences during the follow-up period . CONCLUSIONS Patients with untreated OSA  have a higher recurrence of AF after ablation . Appropriate treatment with CPAP in patients with OSA is associated with a lower recurrence of AF BACKGROUND Chronic obstructive pulmonary disease ( COPD ) is a risk factor for atrial fibrillation ( AF ) . The aim of this study was to investigate the impact of COPD on outcomes of catheter ablation in patients with AF in terms of recurrence and quality of life ( QoL ) . METHODS In this prospect i ve study , 550 consecutive patients with symptomatic , medication-refractory AF underwent first catheter ablation .  Patients were classified into those with COPD ( group 1 , n = 54 ) and those without COPD ( group 2 , n = 496 ) . Patients were followed up for atrial tachyarrhythmia ( ATa ) recurrence for at least 24 months . The Medical Outcomes Study SF-36 Health Survey was used to assess QoL at baseline and 24 months after ablation . RESULTS After a single ablation , 24 patients in group 1 ( 44.4 % ) and 142 in group 2 ( 28.6 % ) had ATa recurrence during a mean follow-up of 31.4 ± 4.8 months ( P = 0.016 ) . The second ablation was performed in 19 patients ( 35.2 % ) from group 1 and in 109 patients ( 22.0 % ) from group 2 ( P = 0.029 ) . Multivariate logistic analysis showed that nonparoxysmal AF ( P = 0.013 , OR = 1.767 , 95 % CI : 1.129 - 2.765 ) as well as the presence of COPD ( P = 0.029 , OR = 1.951 , 95 % CI : 1.070 - 3.557 ) was the independent predictor for higher ATa recurrence . Moreover , patients in group 1 had significantly lower baseline scores on all SF-36 Health Survey subscales . At 24-month follow-up , both mental component summary and physical component summary scores improved markedly in group 1 and 2 . CONCLUSIONS Although the presence of COPD predicted higher recurrence  after single-catheter ablation in AF patients , significant improvements in QoL were observed in the postablation COPD population INTRODUCTION  Persistent atrial fibrillation ( persAF ) can occur either as a sustained arrhythmia that has progressed from initially paroxysmal AF or as primary persAF without a history of any spontaneously terminated episode . There is a paucity of data differentiating between the 2 different persAF entities . Thus , we prospect ively evaluated baseline characteristics , electrophysiological features , and ablation outcome in these 2 patient cohorts . METHODS AND RESULTS A total number of 154 consecutive persAF patients ( 63 ± 10 years , f = 42 , longst and ing persAF = 60 ) were characterized in terms of having  primary persAF ( P-persAF group ) or persAF that secondarily progressed from paroxysmal AF ( S-persAF group ) . All patients underwent de novo catheter ablation using the stepwise approach . PersAF entities were characterized by detailed patient history , sequential Holter monitoring , and reports of documented modes of AF conversion , respectively . The P-persAF group had a higher number of  young patients ( < 50 years ) , a shorter AF history , and a higher number of congestive heart failure . The HATCH score did not differ between the groups . Procedural AF termination rate was significantly higher in S-persAF than in P-persAF patients ( n = 55 [ 81 % ] vs. n = 58 [ 68 % ] , P = 0.043 ) . At 1-year follow-up , the arrhythmia-free survival after a single procedure was significantly lower in patients with P-persAF ( 26 % vs. 43 % , P = 0.016 ) . Categorization to P-persAF was the strongest independent predictor of arrhythmia recurrence . CONCLUSIONS P-persAF seems to be a specific arrhythmia entity that is associated with a lower AF-termination rate and a worse outcome after catheter ablation as compared to S-persAF Background Long-term results after circumferential pulmonary vein isolation ( CPVI ) for the treatment of paroxysmal atrial fibrillation ( PAF ) using a robotic navigation system ( RNS ) have not yet been reported . Objective To evaluate long-term results of patients with PAF after CPVI using RNS .  Methods In this study , 200 patients ( n = 151 ( 75.5 % ) male ; median age 62.2 ( 54.7–67.7 ) years ) with PAF were evaluated . In 100 patients , RNS ( RN-group ) was used for CPVI and compared to 100 manually ablated control patients ( MN-group ) . Radiofrequency was used in conjunction with 3D electroanatomic mapping . Power was limited to 30 watts ( W ) at the posterior left atrial ( LA ) wall in the first 49 RNS patients ( RN-group-a ) . After esophageal perforation occurred in one RN-group-a patient , maximum power was reduced to 20 W for the subsequent 51 patients ( RN-group-b ) . Results After a median follow-up of 2 years , single ( 77/100 vs 77/100 , p = 0.89 ) and multiple ( 90/100 vs 93/100 , p = 0.29 ) procedure success rates were comparable between RN-group and MN-group . Single procedure success rate was significantly lower in RN-group-a as compared to RN-group-b ( 65.3 vs 88.2 % , p = 0.047 ) . In RN-group-a patients , procedural times [ 200 ( 170–230 ) vs 152 ( 132–200 ) minutes , p < 0.01 ] and fluoroscopy times [ 16.6 ( 12.9–21.6 ) minutes vs 13.7 ( 9.5–19 ) minutes , p = 0.043 ] were significantly longer compared to RN-group-b patients . Conclusion Long-term success rate after CPVI using RNS was comparable to manual ablation . Despite a lower power limit of 20 W at the posterior LA wall , single procedure success rate was higher in RN-group-b as compared to RN-group-a . Procedure time and fluoroscopy time decreased , whilst success rate increased with increasing experience in the RN-group BACKGROUND Catheter ablation is now an alternative approach to antiarrhythmic drug therapy for patients with symptomatic atrial fibrillation ( AF ) . We focused on younger patients in whom the prevalence of AF is low , and we sought clinical factors associated with unsuccessful ablation outcomes . METHODS AND RESULTS Among 1983 consecutive symptomatic patients who underwent AF ablation procedures , 95 patients ( 4.8 % ) , age ≤ 40 years , were prospect ively included . Of them , 64 had paroxysmal AF , and the remaining 31 had persistent AF . All patients underwent pulmonary vein isolation and cavotricuspid isthmus ablation . When AF recurred , redo ablations were performed if the patients desired . The mean number of ablation procedures was 1.3 ± 0.6 times per patient . During the follow-up of 40 [ 27.8 - 49.6 ] months , sinus rhythm was maintained in 86 patients ( 90.5 % ) without any antiarrhythmic drugs , but not in the remaining 9 patients ( 9.5 % ) . Low body mass index ( BMI ) and persistent AF were associated with unsuccessful ablation procedures . In multivariate logistic regression analysis , a low BMI had the most significant value , with an odds ratio of 7.33 ( p=0.022 ) . The receiver operating characteristic curve demonstrated a BMI cut point of 22.1 kg/m(2 ) , with an area under the curve of 0.773 . CONCLUSION In symptomatic younger AF patients , a low BMI was an independent clinical factor for unsuccessful AF ablation outcomes BACKGROUND Pre-procedural predictors ( PP ) of  atrial fibrillation ( AF ) recurrence ( AFR ) after repeated catheter ablation of AF ( RCAF )  are unknown . The aim of this study was identification of PP of outcome after RCAF . METHODS AND RESULTS In 213 patients ( 73 % male ) with drug-refractory AF ( 47 % paroxysmal AF ; PAF ) RCAF was performed . CHADS2 , CHA2DS2-VASc and ALARMEc ( AF type , Left Atrium size , Renal insufficiency , MEtabolic syndrome , cardiomyopathy ) scores were calculated for each patient . Complete success was defined as no AFR . After RCAF , 125 patients ( 59 % ) were free of atrial flutter or atrial tachycardia ( AFLAT ) on long-term follow-up ( FU ) . The univariate predictors of AFR were : type of AF ( non-PAF vs. PAF , P=0.001 ) , normalized left atrium area ( NLA ≥10.25 vs. NLA < 10.25 , P=0.012 ) and estimated glomerular filtration rate ( < 68ml/min vs. ≥68ml/min , P=0.048 ) . The independent predictors of AFLAT-free survival after RCAF were non-PAF ( P=0.002 ) and NLA ≥10.25 ( P=0.018 ) . Among combined predictors , only ALARMEc score , and neither CHADS2 or CHA2DS2-VASc , predicted outcome after RCAF ( P<0.0001 ) . CONCLUSIONS RCAF results in a moderate success rate on very long-term FU . Lower success was observed in patients with non-PAF and enlarged LA . ALARMEc score allows for clear description of expected outcome after RCAF
target: This review article provides an overview on the published clinical risk scores related to outcomes of rhythm control strategy or AF progression
background: Patients with atrial fibrillation ( AF ) are commonly managed with rhythm control strategy , but the natural history of this common arrhythmia leads itself to progression from paroxysmal to persistent or permanent AF , and recurrences are evident despite rhythm control treatments using cardioversion or catheter ablation .
  Numerous clinical factors have been associated with outcomes of rhythm control or arrhythmia progression in patients with AF .
  The more common factors have been used to formulate risk stratification scores , to help predict the outcomes of rhythm control treatments  or AF progression .