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Background Little evidence exists regarding the endpoint and optimum approach to catheter ablation for long‐standing persistent atrial fibrillation ( LSPAF ). We examined the efficacy of pulmonary vein isolation ( PVI ) plus left atrium posterior wall isolation ( PWI ) and additional non‐ PV trigger ablation using high‐dose isoproterenol for LSPAF . Methods One‐hundred and fifty‐five patients (median AF duration, 36 months) underwent catheter ablation for LSPAF ; After PVI plus PWI , they underwent provocation of non‐ PV triggers by high‐dose isoproterenol and were divided into 3 groups based on the results: group A, PVI plus PWI alone, without induced non‐ PV triggers (single procedure: 105 patients, multiple procedures: 90 patients); group B, mappable non‐ PV triggers demonstrated and ablated (single procedure: 41 patients, multiple procedures: 45 patients); group C, if non‐ PV triggers were unmappable or could not be induced in repeated procedures, adjunctive complex fractionated atrial electrogram ablation was performed (single procedure: 9 patients, multiple procedures: 20 patients). Results The Kaplan‐Meier estimate of the 1‐year freedom from atrial tachyarrhythmias without antiarrhythmic drugs was 65% in all patients, (73%, 56%, and 11% in groups A, B, and C, respectively) after a single procedure, which improved to 86% in all patients (93%, 86%, and 53% in groups A, B, and C, respectively) after multiple procedures. Conclusion Even for LSPAF , in approximately 60% of patients, non‐ PV triggers were not elicited, and PVI plus PWI alone achieved good outcomes. Although the inducibility of non‐ PV triggers was associated with recurrence of atrial tachyarrhythmias, additional non‐ PV trigger ablation may improve the outcome after multiple procedures.

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Introduction: Pulmonary vein isolation (PVI) using cryoballoon is effective for patients with paroxysmal atrial fibrillation (PAF); however, few reports have evaluated the non-pulmonary vein (PV) foci after cryoballoon ablation. We aimed to evaluate the characteristics of non-PV foci and predictors of atrial fibrillation (AF) recurrence after cryoballoon ablation. Methods and Results:This was a single-center retrospective study of 647 patients with PAF who underwent initial PVI using a second-generation cryoballoon. After PVI, all patients underwent high-dose isoproterenol infusion to assess the existence of non-PV foci. Non-PV foci were observed in 211 patients (32.6%), which were most frequently observed in the superior vena cava. Higher age (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.00-1.04; P = .025), female sex (OR = 1.65; 95% CI = 1.13-2.41; P = .009), and lower body mass index (OR = 0.95; 95% CI = 0.89-1.00; P = .049) were significantly associated with non-PV foci. The existence of non-PV foci was an independent predictor of AF recurrence (Hazard's ratio = 1.70; 95% CI = 1.12-2.60; P = .014). When non-PV foci were mappable and successfully ablated, patients with non-PV foci showed similar outcomes with those without non-PV foci (1-year AF-free survival rates of 88.5% vs 91.5%; P = .338). Conversely, when we failed to detect and eliminate non-PV foci because they had multiple origins and were not consistently inducible (multichanging non-PV foci), the 1-year AF-free survival rate was 56.4% even after substrate modification.Conclusion: Non-PV foci were observed in one-third of patients with PAF after cryoballoon ablation and were associated with AF recurrence. Catheter ablation for non-PV foci was effective when they were mappable; however, multichanging non-PV foci were associated with worse prognosis. K E Y W O R D Scatheter ablation, nonpulmonary vein foci, paroxysmal atrial fibrillation, pulmonary vein isolation, second-generation cryoballoon

The prognosis of patients with out-of-hospital cardiac arrest (OHCA) remains poor. Even among patients who are initially resuscitated, only about 25% patients survive to hospital discharge [1][2][3][4]. Patients after cardiac arrest often exhibit unstable systemic conditions such as hypovolemia, cardiogenic shock, or vasodilatory shock after the return of spontaneous circulation (ROSC). The reperfusion to systemic organ after prolonged ischemia during cardiac arrest induces an increase of inflammatory cytokines [5]. As a result of the systemic inflammatory response, post-cardiac arrest patients present sepsis-like status and often exhibit multiorgan failure in the intensive care unit (ICU), which has been