Provocation and ablation of non-pulmonary vein triggers in nonparoxysmal atrial fibrillation: Role of the coronary sinus

Results of ICE-Guided Isolation of the Superior Vena Cava With Pulsed Field Ablation

BACKGROUND

Earlier studies have documented the risk for sinoatrial node injury and phrenic nerve paralysis as complications following radiofrequency catheter ablation for electrical isolation of the superior vena cava (SVCI).

OBJECTIVES

The aim of this study was to assess the safety and feasibility of SVCI in patients with atrial fibrillation undergoing pulsed field ablation (PFA) METHODS: Six hundred sixteen consecutive patients undergoing PFA for pulmonary vein isolation plus SVCI were included in this multicenter analysis. Superior vena cava (SVC) ablation was performed under the continuous guidance of intracardiac echocardiography. The PFA catheter was placed at the junction between the SVC and the right atrium at the level of the lower border of the pulmonary artery. A total of 4 applications were given to achieve complete electrical isolation of the SVC. Sinus node injury and phrenic nerve stunning were checked during the procedure, before discharge, and at 2-month follow-up.

RESULTS

A total of 616 patients receiving SVCI were included in the analysis. Acute SVCI was achieved in all 616 patients (100%). In the flower configuration used in the first 10 patients, 2 transient sinus node injuries and 2 episodes of phrenic nerve stunning were observed, which resolved spontaneously during the procedure. In the remaining patients, the basket configuration was used; only 1 episode of phrenic nerve stunning was registered, which regressed before the end of the procedure. No permanent damages were registered at discharge and at 2-month follow-up.

CONCLUSIONS

Intracardiac echocardiography-guided PFA can effectively isolate the SVC with a good safety profile.

Clinical anatomy of the coronary venous system and relevance to retrograde cardioplegia and cardiac electrophysiological interventions

Anomalies of coronary venous system, the valve of the coronary sinus (Thebesian valve) and other cardiac malformations may make interventions through the coronary sinus difficult. These variants may pose a challenge in cannulating the coronary sinus for retrograde cardioplegia and for interventions performed through the coronary sinus by cardiac electrophysiologist/interventional cardiologist. Retrograde cardioplegia is an established method of myocardial protection with advantages, indications, and complications. A good knowledge of the anatomy of the coronary sinus and its variants is important in understanding the difficulties encountered while cannulating the coronary sinus for the delivery of retrograde cardioplegia, cardiac resynchronization therapy, treatment of arrhythmias, and percutaneous mitral valve annuloplasty.

Catheter ablation approach and outcome in HIV+ patients with recurrent atrial fibrillation

INTRODUCTION

Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long-term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients.

METHODS

This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non-PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high-dose isoproterenol challenge.

RESULTS

Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p < .001]. Among patients that underwent redo ablation non-PV triggers were higher in HIV group [93.5% vs. 54%, p < .001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p < .001] and left atrial appendage [41.9% vs. 25.8%, p < .001]. After focal ablation of non-PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p = .753] at 1-year follow up was found.

CONCLUSION

Our findings suggest that non-PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid- and long-term arrhythmia recurrence.