1
|
Khaing E, Aroudaky A, Dircks D, Almerstani M, Alziadin N, Frankel S, Hollenberg B, Limsiri P, Schleifer W, Easley A, Tsai S, Anderson D, Windle J, Khan F, Haynatzki G, Peeraphatdit T, Goyal N, Dunbar Matos CL, Naksuk N. Representation of Women in Atrial Fibrillation Ablation Randomized Controlled Trials: Systematic Review. J Am Heart Assoc 2025; 14:e035181. [PMID: 39791402 PMCID: PMC12054437 DOI: 10.1161/jaha.124.035181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 09/16/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND Sex inequality in randomized controlled trials (RCTs) related to cardiovascular disease has been observed. This study examined the proportion of women enrolled in atrial fibrillation (AF) ablation RCTs and the potential risks of underrepresentation of women. METHODS AND RESULTS We systematically searched PubMed and Embase for AF ablation RCTs published from 2015 to 2022. Participant characteristics were compared among trials with higher and lower proportions of women. Of 147 AF ablation RCTs (30,055 participants), only 10 trials had enrolled women ≥50% of the total participants. Additionally, 42 trials (28.57%) excluded pregnant/breastfeeding women; 6 (4.1%) excluded reproductive-age women without reliable birth control. The proportion of women in AF RCTs ranged from 9% to 71% (median 31.5%), whereas the median proportion of men was 67.7%. The rate of women included in the trials was stable from 2015 to 2022 (P=0.49). Study characteristics, including funding source, showed no correlation with the rate of inclusion of women. RCTs with a higher proportion of female participants enrolled older patients with AF, had a higher prevalence of hypertension but less persistent AF, and smaller left atrium size (P<0.05 for all). Biological sex was evaluated as a risk factor or in a subgroup analysis in 28 RCTs; 10.7% of these trials observed the implication of sex on their results. CONCLUSION Women were underrepresented in contemporary AF ablation RCTs. Additionally, women enrolled in AF RCTs were likely to have more comorbidities but less advanced AF, limiting the applicability of the results to women with AF.
Collapse
Affiliation(s)
- Eh Khaing
- University of Nebraska OmahaOmahaNEUSA
| | - Ahmad Aroudaky
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Danielle Dircks
- College of Medicine, University of Nebraska Medical CenterOmahaNEUSA
| | - Muaaz Almerstani
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Nmair Alziadin
- Hospital Corporation of America Healthcare/Tufts University School of Medicine: Portsmouth Regional Hospital Internal Medicine Residency ProgramPortsmouthNHUSA
| | - Samuel Frankel
- College of Medicine, University of Nebraska Medical CenterOmahaNEUSA
| | | | - Pattarawan Limsiri
- Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital, Mahidol UniversityBangkokThailand
| | - William Schleifer
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Arthur Easley
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Shane Tsai
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Daniel Anderson
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - John Windle
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Faris Khan
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | - Gleb Haynatzki
- Department of BiostatisticsUniversity of Nebraska Medical CenterOmahaNEUSA
| | | | - Neha Goyal
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| | | | - Niyada Naksuk
- Division of Cardiovascular MedicineUniversity of Nebraska Medical CenterOmahaNEUSA
| |
Collapse
|
2
|
Leung LW, Evranos B, Gonna H, Harding I, Domenichini G, Gallagher MM. Multi-catheter cryotherapy for the treatment of resistant accessory pathways. Indian Pacing Electrophysiol J 2024; 24:1-5. [PMID: 37977548 PMCID: PMC10927982 DOI: 10.1016/j.ipej.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To investigate the utility of simultaneous multi-catheter cryotherapy for the treatment of APs that were previously resistant to standard radiofrequency (RF) catheter ablation. BACKGROUND Catheter ablation is established in the treatment of accessory pathways (AP), with high rates of permanent procedural success with a single attempt. However, there are still instances of acute procedural failure and AP recurrences with standard RF and cryotherapy methods. METHODS Seven consecutive cases of pre-excitation syndromes with prior failed RF catheter ablation had the novel treatment. Cryotherapy was delivered using two 8 mm tip focal cryoablation catheters (Freezor® Max, Medtronic, Minneapolis, Minnesota, USA). RESULTS Accessory pathway localisation was septal in 5 cases, left posterolateral in 1, right lateral in 1. In all cases, ablation of the AP was acutely successful with no procedural complications. Median procedure and fluoroscopy durations were 199 and 35 min, sequentially. Median Procedure duration fell significantly in the second half of series (174 min) compared to the first half (233 min, P = 0.05). One patient had evidence of a recurring AP conduction with pre-excitation at 5-week follow up. After a median follow up of 66.8+-6.5 months, 6 out of 7 patients remained asymptomatic and free of pre-excitation. CONCLUSION Simultaneous multi-catheter cryotherapy is feasible, safe and can provide definitive cure of accessory pathways that were previously resistant to standard radiofrequency ablation. Further study is required in the assessment of this novel form of advanced cryotherapy to treat complex and resistant arrhythmias.
Collapse
Affiliation(s)
- Lisa Wm Leung
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Banu Evranos
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Hanney Gonna
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Idris Harding
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Giulia Domenichini
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK
| | - Mark M Gallagher
- Department of Cardiology, St. George's University Hospitals NHS Foundation Trust, UK.
| |
Collapse
|
3
|
Leung LWM, Akhtar Z, Hayat J, Gallagher MM. Protecting Against Collateral Damage to Non-cardiac Structures During Endocardial Ablation for Persistent Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e15. [PMID: 35990104 PMCID: PMC9376833 DOI: 10.15420/aer.2021.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/13/2022] [Indexed: 11/04/2022] Open
Abstract
Injury to structures adjacent to the heart, particularly oesophageal injury, accounts for a large proportion of fatal and life-altering complications of ablation for persistent AF. Avoiding these complications dictates many aspects of the way ablation is performed. Because avoidance involves limiting energy delivery in areas of interest, fear of extracardiac injury can impede the ability of the operator to perform an effective procedure. New techniques are becoming available that may permit the operator to circumvent this dilemma and deliver effective ablation with less risk to adjacent structures. The authors review all methods available to avoid injury to extracardiac structures to put these developments in context.
Collapse
Affiliation(s)
- Lisa WM Leung
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Zaki Akhtar
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Jamal Hayat
- Department of Gastroenterology, St George’s Hospital NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
4
|
Gallagher MM, Yi G, Gonna H, Leung LWM, Harding I, Evranos B, Bastiaenen R, Sharma R, Wright S, Norman M, Zuberi Z, Camm AJ. Multi-catheter cryotherapy compared with radiofrequency ablation in long-standing persistent atrial fibrillation: a randomized clinical trial. Europace 2021; 23:370-379. [PMID: 33188692 DOI: 10.1093/europace/euaa289] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/04/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Restoring sinus rhythm (SR) by ablation alone is an endpoint used in radiofrequency (RF) ablation for long-standing persistent atrial fibrillation (AF) but not with cryotherapy. The simultaneous use of two cryotherapy catheters can improve ablation efficiency; we compared this with RF ablation in chronic persistent AF aiming for termination to SR by ablation alone. METHODS AND RESULTS Consecutive patients undergoing their first ablation for persistent AF of >6 months duration were screened. A total of 100 participants were randomized 1:1 to multi-catheter cryotherapy or RF. For cryotherapy, a 28-mm Arctic Front Advance was used in tandem with focal cryoablation catheters. Open-irrigated, non-force sensing catheters were used in the RF group with a 3D mapping system. Pulmonary vein (PV) isolation and non-PV triggers were targeted. Participants were followed up at 6 and 12 months, then yearly. Acute PVI was achieved in all cases. More patients in the multi-catheter cryotherapy group were restored to SR by ablation alone, with a shorter procedure duration. Sinus rhythm continued to the last available follow-up in 16/49 patients (33%) in the multi-catheter at 3.0 ± 1.6 years post-ablation and in 12/50 patients (24%) in the RF group at 4.0 ± 1.2 years post-ablation. The yearly rate of arrhythmia recurrence was similar. CONCLUSION Multi-catheter cryotherapy can restore SR by ablation alone in more cases and more quickly than RF ablation. Long-term success is difficult to achieve by either methods and is similar with both.
Collapse
Affiliation(s)
- Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Gang Yi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Hanney Gonna
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Idris Harding
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Banu Evranos
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Rachel Bastiaenen
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Rajan Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Sue Wright
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Mark Norman
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - Zia Zuberi
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| | - A John Camm
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, Blackshaw Road, London SW17 0QT, UK
| |
Collapse
|
5
|
Characterization of pulmonary vein reconnection post Cryoballoon ablation. Indian Pacing Electrophysiol J 2019; 19:129-133. [PMID: 30796960 PMCID: PMC6697463 DOI: 10.1016/j.ipej.2019.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 02/18/2019] [Indexed: 11/24/2022] Open
Abstract
Background The Arctic Front Cryoballoon System is a technology in which substrate alterations in patients with atrial fibrillation (AF) recurrence have not been well characterized. In this study, we evaluated sites of pulmonary vein (PV) reconnections and the accuracy of the Achieve™ circular mapping catheter in detecting these reconnections after cryoablation. Methods This study included 15 patients undergoing redo AF ablation after a prior single cryoablation procedure. PV reconnection sites were determined by measuring PV signals and high output pacing from 4 vectors of the Achieve catheter. The results were compared with a roving mapping catheter guided by rotational intracardiac echocardiography (ICE) in the left atrium. Results All patients had PV reconnections (2.1 ± 0.8 veins/patient). The left superior PV was most commonly reconnected (n = 11), whereas the right inferior PV was least likely (n = 3). Both carinas (left: n = 11; right: n = 7) and left atrial appendage ridge (n = 11) were also frequently reconnected. Mapping with the Achieve catheter showed a positive predictive value (PPV) 100% and negative predictive value (NPV) 96% when compared with ICE guided mapping. In 2 patients, right superior PV reconnection was not identified by the Achieve. Conclusion During redo AF ablation after index cryoablation, multiple PVs are usually reconnected, with both carinas and left atrial appendage ridge being common sites of reconnection. The Achieve mapping catheter was able to identify reconnection with high positive and negative predictive values.
Collapse
|
6
|
Sciarra L, Iacopino S, Palamà Z, De Ruvo E, Filannino P, Borrelli A, Artale P, Caragliano A, Scarà A, Golia P, De Luca L, Grieco D, Rebecchi M, Favale S, Calò L. Impact of the third generation cryoballoon on atrial fibrillation ablation: An useful tool? Indian Pacing Electrophysiol J 2018; 18:127-132. [PMID: 29476904 PMCID: PMC6090001 DOI: 10.1016/j.ipej.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/18/2017] [Accepted: 04/23/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Third-generation cryoballoon (CB3) is characterized by a 40% shorter distal tip designed to increase the rate of pulmonary veins real-time signal recording in order to measure time necessary to isolate veins, the "Time to effect" (TTE). Few data are currently available on clinical follow up of CB3 treated patients. METHODS Sixtyeight consecutive patients (mean age 57.8 ± 9.6 years, 48 male) with paroxysmal or persistent atrial fibrillation (AF) were enrolled. Thirthyfour (25 paroxysmal AF) underwent to a 28 mmCB3 pulmonary veins isolation and were compared to 34 treated (21 paroxysmal AF) with 28 mmCB2. RESULTS CB3 use was correlated to significant increase of the possibility to measure TTE in every treated veins (left superior 82,35% vs 23,53%, left inferior 70,59% vs 38,24%, right superior 58,82% vs 14,71%, right inferior 52,94% vs 17,65%). When it is measured, TTE wasn't different between two groups. Higher nadir temperature was observed in CB3 patients (-39.4 ± 5.2 °C vs -43.0 ± 7.2 °C, p = 0.03). CB3 procedures were shorter (91.4 ± 21.7 vs 110.9 ± 31.8 min, p = 0.018), with a significant reduction in cryoenergy delivery time (24.2 ± 8.5 vs 20.3 ± 6.7 min, p < 0.05), and a significant reduction in left atrium dwell time (59.3 ± 9.8 vs 69.3 ± 10.8 min, p = 0.02, p < 0.05). At one year follow up period the Kaplan-Meier curve didn't show any significant difference in AF-free survival (Log p = 0,49). CONCLUSIONS Novel CB3 is a useful tool in order to simplify AF cryoballoon ablation when compared to second generation cryoballoon, as observed in our experience. Follow up data seem confirm a clinical CB3 efficacy at least comparable CB2.
Collapse
Affiliation(s)
- Luigi Sciarra
- Cardiology Department, Policlinico Casilino, Rome, Italy
| | - Saverio Iacopino
- Cardiac Electrophysiology Unit, Villa Maria Cecilia Hospital, GVM, Cotignola, Italy
| | | | | | - Pasquale Filannino
- Cardiac Electrophysiology Unit, Villa Maria Cecilia Hospital, GVM, Cotignola, Italy
| | | | - Paolo Artale
- Cardiac Electrophysiology Unit, Villa Maria Cecilia Hospital, GVM, Cotignola, Italy
| | - Alberto Caragliano
- Cardiac Electrophysiology Unit, Villa Maria Cecilia Hospital, GVM, Cotignola, Italy
| | - Antonio Scarà
- Cardiology Department, Policlinico Casilino, Rome, Italy
| | - Paolo Golia
- Cardiology Department, Policlinico Casilino, Rome, Italy
| | - Lucia De Luca
- Cardiology Department, Policlinico Casilino, Rome, Italy
| | | | - Marco Rebecchi
- Cardiology Department, Policlinico Casilino, Rome, Italy
| | - Stefano Favale
- Cardiac Unit, University of Bari, Policlinico di Bari, Bari, Italy
| | - Leonardo Calò
- Cardiology Department, Policlinico Casilino, Rome, Italy
| |
Collapse
|
7
|
Gonna H, Domenichini G, Zuberi Z, Norman M, Kaba R, Grimster A, Gallagher MM. Initial clinical results with the ThermoCool® SmartTouch® Surround Flow catheter. Europace 2016; 19:1317-1321. [DOI: 10.1093/europace/euw177] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 05/22/2016] [Indexed: 11/13/2022] Open
|
8
|
Gonna H, Domenichini G, Zuberi Z, Adhya S, Sharma R, Anderson LJ, Beeton I, Dhillon PS, Gallagher MM. Femoral implantation and pull through as an adjunct to traditional methods in cardiac resynchronization therapy. Heart Rhythm 2016; 13:1260-5. [PMID: 26820509 DOI: 10.1016/j.hrthm.2016.01.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND We have described the use of femoral access followed by pull through of the lead to a pectoral position to circumvent difficulty in implanting a left ventricular (LV) lead by standard methods. OBJECTIVE The purpose of this study was to establish the effect of femoral implantation and pull through on the overall rate of success in percutaneous implantation of LV leads. METHODS We collected data prospectively in all attempts at LV lead implantation from the time that we envisioned the femoral pull-through approach. RESULTS In the 6 years to September 30, 2014, our group attempted to implant a new LV lead in 736 patients, including 16 who previously had failed attempts by other groups. A standard superior approach was successful in 726 of 731 patients (99.3%) in whom it was attempted. In 5 patients (0.7%), we failed to deliver a lead from a superior approach; in 5 of 16 patients, with previous failed attemtps (31%), we judged that those attempts had been exhaustive. In all 10 cases, LV lead placement was achieved from a femoral approach, with the procedure time being 186 ± 65 minutes. In the first case attempted, the pull through failed; the lead was tunneled to the pectoral generator. In 1 case, the coronary sinus was found to be occluded at the ostium: a transseptal approach was used with the subsequent pull through. No complication occurred. At 22.3 ± 18.5 months after the implantation, all systems implanted by a femoral approach continued to function. CONCLUSION Used as an adjunct to standard methods, the femoral access and pull through method allows percutaneous LV lead placement in virtually all cases.
Collapse
Affiliation(s)
- Hanney Gonna
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Giulia Domenichini
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Zia Zuberi
- Department of Cardiology, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Shaumik Adhya
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Rajan Sharma
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Lisa J Anderson
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom
| | - Ian Beeton
- Department of Cardiology, St Peter's Hospital, Chertsey, United Kingdom
| | - Paramdeep S Dhillon
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom; Department of Cardiology, St Peter's Hospital, Chertsey, United Kingdom
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, United Kingdom; Department of Cardiology, St Peter's Hospital, Chertsey, United Kingdom.
| |
Collapse
|