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Kinjo T, Kimura M, Itoh T, Kaname N, Toyama Y, Tomita H. Cryothermal catheter ablation for focal atrial tachycardia originating from the left atrial appendage: The utility and safety of a soft and flexible multispline mapping catheter for the detailed anatomical evaluation. HeartRhythm Case Rep 2024; 10:545-548. [PMID: 39155896 PMCID: PMC11328541 DOI: 10.1016/j.hrcr.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024] Open
Affiliation(s)
- Takahiko Kinjo
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masaomi Kimura
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Taihei Itoh
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Noriyoshi Kaname
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuichi Toyama
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of Cardiac Remote Management System, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
- Department of the Advanced Therapeutics for Cardiovascular Diseases, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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2
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Zhang M, Cao X, Zhang Y. Combination of electrophysiological mapping, radiofrequency catheter ablation, and atrial appendectomy in a 5-year-old girl with tachycardia-induced cardiomyopathy: a case report. J Cardiothorac Surg 2024; 19:169. [PMID: 38566062 PMCID: PMC10986129 DOI: 10.1186/s13019-024-02693-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/24/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Atrial tachycardia (AT) originating from the left atrial appendage (LAA) is uncommon and the most difficult arrhythmia to eliminate. Therefore, we present the case of a 5-year-old girl with tachycardia-induced cardiomyopathy (TIC) caused by AT originating from the LAA and successfully treated with RFCA associated to left atrial appendectomy. With resolution of AT, we observed a progressive improvement of LV function. The effectiveness and safety of this combination therapy were evaluated over a one-month follow-up period. CASE PRESENTATION A 5 -year-old female was evaluated for three days of incessant cough and a syncopal episode. Surface echocardiography and 24-hour monitoring showed that the infant had persistent atrial tachycardia. Echocardiography revealed an enlarged tele diastolic diameter (46.1 mm) and malfunctioning (EF 28.53%) left ventricle. The location of the lesion at the apex of the LAA was further confirmed by electrophysiological study and RFCA. After RFCA, the infant's ECG monitor showed that sinus rhythm was maintained for up to 22 h. Subsequently, atrial tachycardia recurred and sinus rhythm disappeared. Finally, atrial appendectomy was performed and sinus rhythm returned to normal. CONCLUSIONS The heart function of the infant improved and sinus rhythm was maintained, further demonstrating the safety and effectiveness of combined treatment with RFCA and atrial appendectomy after electrophysiological localization of AT from LAA to TIC.
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Affiliation(s)
- Min Zhang
- Wuhan Women and Children Medical care center, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science & Technology, 100 Hongkong Road, Jiangan District, Wuhan, Hubei, China.
| | - Xiaoxiao Cao
- Wuhan Women and Children Medical care center, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science & Technology, 100 Hongkong Road, Jiangan District, Wuhan, Hubei, China
| | - Yong Zhang
- Wuhan Women and Children Medical care center, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science & Technology, 100 Hongkong Road, Jiangan District, Wuhan, Hubei, China
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3
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Brahier MS, Friedman DJ, Bahnson TD, Piccini JP. Repeat catheter ablation for atrial fibrillation. Heart Rhythm 2024; 21:471-483. [PMID: 38101500 DOI: 10.1016/j.hrthm.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
Catheter ablation of atrial fibrillation (AF) is an established therapy that reduces AF burden, improves quality of life, and reduces the risks of cardiovascular outcomes. Although there are clear guidelines for the application of de novo catheter ablation, there is less evidence to guide recommendations for repeat catheter ablation in patients who experience recurrent AF. In this review, we examine the rationale for repeat ablation, mechanisms of recurrence, patient selection, optimal timing, and procedural strategies. We discuss additional important considerations, including treatment of comorbidities and risk factors, risk of complications, and effectiveness. Mechanisms of recurrent AF are often due to non-pulmonary vein (non-PV) triggers; however, there is insufficient evidence supporting the routine use of empiric lesion sets during repeat ablation. The emergence of pulsed field ablation may alter the safety and effectiveness of de novo and repeat ablation. Extrapolation of data from randomized trials of de novo ablation does not optimally inform efficacy in cases of redo ablation. Additional large, randomized controlled trials are needed to address important clinical questions regarding procedural strategies and timing of repeat ablation.
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Affiliation(s)
- Mark S Brahier
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel J Friedman
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Tristram D Bahnson
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Jonathan P Piccini
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina.
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4
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Raval M, Jain A, Desai R, Siddiq S. Left atrial appendage doppler velocity as a predictor of recurrence of atrial fibrillation after transesophageal echocardiogram guided electrical cardioversion. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2023; 48:101268. [PMID: 37719869 PMCID: PMC10504478 DOI: 10.1016/j.ijcha.2023.101268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/19/2023]
Abstract
Background There is a paucity of data on average left atrial appendage emptying velocity (LAAV) measured by doppler during transesophageal echocardiogram (TEE) being able to predict the risk of AF recurrence after electrical cardioversion (ECV). Methods Using electronic medical records from a community hospital, retrospective study was conducted after identifying all patients that received TEE-guided ECV. Data pertaining to LAAV, AF recurrence, and variables were obtained and analyzed. Results Out of 625 patients receiving TEE-guided ECV, 94 were excluded, and 51 did not convert to sinus rhythm. 480 patients had a successful ECV; out of these, 201 (41.87%) and 243 (50.62%) had a recurrence of atrial fibrillation at the end of 1 month and 3 months, respectively. Low LAAV (<=30 cm/s) was independently associated with an increased risk of AF recurrence at the end of 1 month (aOR 2.37, 95CI 1.5-3.73; p < 0.001) and 3 months (aOR 2.51, 95CI 1.59-3.96; p < 0.001) after TEE-guided ECV. Conclusions Low LAAV is associated with a high risk of AF recurrence. Identifying a specific subgroup of individuals at high risk of AF recurrence with the help of pre-ECV LAAV will facilitate the early institution of alternate treatment strategies and the plan for additional therapies.
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Affiliation(s)
- Maharshi Raval
- Internal Medicine, Landmark Medical Center, Woonsocket, RI, USA
| | - Akhil Jain
- Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Sajid Siddiq
- Cardiology, Landmark Medical Center, Woonsocket, RI, USA
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5
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Importance of searching for epicardial foci and losing recalcitrant "FAT". Heart Rhythm 2023; 20:383-384. [PMID: 36549631 DOI: 10.1016/j.hrthm.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
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6
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Zhang J, Ju W, Yang G, Tang C, Luo J, Xu J, Chen M. Epicardial ablation of refractory focal atrial tachycardia after a failed endocardial approach. Heart Rhythm 2023; 20:374-382. [PMID: 36410677 DOI: 10.1016/j.hrthm.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/30/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Endocardial ablation is effective for most focal atrial tachycardias (FATs). In rare circumstances, the FAT can originate from the epicardial side of the atrium. OBJECTIVE In the present study, we retrospectively assessed the percutaneous approach for epicardial ablation of FAT when standard endocardial ablation had failed. METHODS Among a consecutive 186 patients undergoing ablation for 198 FATs, epicardial mapping and ablation via a percutaneous subxiphoid approach were attempted in 10 patients because of failed endocardial ablation. RESULTS In 3 cases, the origin of FAT was at the epicardial side of the junction of the right atrial appendage and superior vena cava. In 3 cases, the origin of FAT was located in the epicardial region of the left atrial insertion of Bachmann bundle. In 2 cases, the FAT originated from the epicardial side of the right atrial free wall. In 1 case, the FAT was successfully ablated from the epicardial side of the right atrial appendage, and in the remaining case, the origin of FAT was located in the epicardial region of the vein of Marshall. All FATs were successfully eliminated by ablation at the epicardial earliest activation site. CONCLUSION Epicardial mapping and ablation can be considered as an effective and safe option for FAT resistant to endocardial ablation.
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Affiliation(s)
- Jinlin Zhang
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China.
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Cheng Tang
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China
| | - Jianfeng Luo
- The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Jian Xu
- The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Ye C, Han X, Chen Y, Liu F, Ma H, Yang Y, Liu Y, Hu Q, Yao Q, Xie W, Xu D. Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial. BMJ Open 2022; 12:e063931. [PMID: 36307161 PMCID: PMC9621168 DOI: 10.1136/bmjopen-2022-063931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA2DS2-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population. METHODS AND ANALYSIS This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences. TRIAL REGISTRATION NUMBER ChiCTR2200058109.
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Affiliation(s)
- Cong Ye
- Department of Cardiac Surgery, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Xuesong Han
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yiming Chen
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Fei Liu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Ma
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yu Yang
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yang Liu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Qingfeng Hu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Qing Yao
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Wenting Xie
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Dong Xu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
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8
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Chen P, Shi Y, Ju J, Pan D, Miao L, Guo X, Chen Z, Du J. Left atrial appendage flow velocity predicts recurrence of atrial fibrillation after catheter ablation: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:971848. [PMID: 36148065 PMCID: PMC9485569 DOI: 10.3389/fcvm.2022.971848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose There is increasing evidence that left atrial appendage flow velocity (LAAFV) is linked to the recurrence of atrial fibrillation (AF) after catheter ablation (CA), suggesting the potential predictable significance of LAAFV in this setting. We performed a systematic review and meta-analysis to assess whether LAAFV is association with AF recurrence after CA. Methods Up to May 1, 2022, six databases (PubMed, EMBASE, Web of Science, Cochrane Library, Scopus, and CINAHL) were searched for literature reporting the association between LAAFV and AF recurrence after CA. All statistical analyses were carried out using STATA version 16 software. Heterogeneity was determined by the Cochrane’s Q test and I2 statistics. The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of each included study, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was adopted to evaluate the quality of evidence. Result Sixteen studies with 5,006 AF patients after CA (1,479 patients with AF recurrence, 3,527 without AF recurrence) were included in the meta-analysis. The meta-analysis of 15 studies (16 data sets) showed that patients with recurrence exhibited lower LAAFV values than those without recurrence [standardized mean difference (SMD): −0.65, 95% CI: −0.88 to −0.42, P < 0.01]. Moreover, we evaluated the association of LAAFV and the risk of AF recurrence after CA. Nine studies (11 data sets) defined LAAFV as continuous variables, and the pooled analysis suggested that for every 1 cm/s rise in LAAFV values, the risk of AF recurrence after CA decreased by 3% [Odds Ratio (OR): 0.97, 95% CI: 0.95 to 0.99, P < 0.01]. Seven studies defined LAAFV as categorical variables, and the pooled analysis showed that lower LAAFV were associated with an increased risk of AF recurrence after CA [OR: 2.28, 95% CI: 1.46 to 3.57, P < 0.01]. The subgroup analyses showed that the association between LAAFV and AF recurrence after CA was not significantly affected by the AF type and ablation procedure. The NOS indicated that included studies were moderate to high quality, while the GRADE assessment suggested a low certainty of the evidence. Conclusion Lower LAAFV may be associated with an increased risk of AF recurrence after CA. Further studies with well designed and randomized studies for LAAFV should be conducted. Systematic review registration [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022333627].
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Affiliation(s)
- Pengfei Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yujiao Shi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianqing Ju
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Lina Miao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Xiaolin Guo
- Shanxi University of Traditional Chinese Medicine, Taiyuan, China
| | - Zhuhong Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Zhuhong Chen,
| | - Jianpeng Du
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Jianpeng Du,
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Polselli M, Cauti FM, Rossi P, Maddalena R, Bianchi S. Epicardial Termination of Left Atrial Appendage Atrial Tachycardia. J Innov Card Rhythm Manag 2021; 12:4710-4714. [PMID: 34712505 PMCID: PMC8545436 DOI: 10.19102/icrm.2021.121004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022] Open
Abstract
This case report describes a third successful attempt to ablate a focal atrial tachycardia originating from the left atrial appendage in a highly symptomatic 49-year-old woman using a combined endocardial–epicardial approach, which could be taken into consideration as a safe and effective alternative method for treating similar arrhythmias originating from complex sites.
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Affiliation(s)
- Marco Polselli
- Arrhythmology and Electrophysiology Unit, Ospedale San Giovanni Calibita, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Filippo M Cauti
- Arrhythmology and Electrophysiology Unit, Ospedale San Giovanni Calibita, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Pietro Rossi
- Arrhythmology and Electrophysiology Unit, Ospedale San Giovanni Calibita, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Riccardo Maddalena
- Arrhythmology and Electrophysiology Unit, Ospedale San Giovanni Calibita, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology and Electrophysiology Unit, Ospedale San Giovanni Calibita, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
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10
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Losantos C, Barrón D, Márquez MF, Gómez J, Levinstein M, Nava S. Epicardial ablation of incessant left atrial appendage tachycardia in a case with tachycardiomyopathy. J Interv Card Electrophysiol 2021; 62:495-497. [PMID: 34236565 DOI: 10.1007/s10840-021-01015-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 05/30/2021] [Indexed: 11/30/2022]
Abstract
Atrial tachycardias originated at the left atrial appendage (LAA) are uncommon; often they are incessant and might induce tachycardiomyopathy, as discussed by Hillock et al. (Heart Rhythm;3(4):467-469, 2006). A case of a 21-year-old woman with incessant atrial tachycardia is presented, refractory to medical therapy, echocardiography showed global dilation with LV ejection fraction of 20%. After two failed endocardial ablations, an epicardial access was attempted. The earliest activation site was located at the tip of the epicardial aspect of the LAA. RFCA was successful at this site. The patient remains asymptomatic during a follow-up of 10 months; the ventricular function was completely recovered after 6 months (LVEF of 50%).
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Affiliation(s)
- Carla Losantos
- Electrocardiology Department, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - David Barrón
- Electrocardiology Department, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Manlio F Márquez
- Electrocardiology Department, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Jorge Gómez
- Electrocardiology Department, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Moises Levinstein
- Electrocardiology Department, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Santiago Nava
- Electrocardiology Department, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico.
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11
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Khakpour H, Hayase JH, Bradfield JS, Buch E, Shivkumar K. Atrial tachycardia arising from the distal left atrial appendage requiring high-power endocardial and epicardial ablation. HeartRhythm Case Rep 2021; 7:157-161. [PMID: 33786311 PMCID: PMC7987893 DOI: 10.1016/j.hrcr.2020.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Houman Khakpour
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Justin H Hayase
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric Buch
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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12
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Yamamoto T, Iwasaki YK, Fujimoto Y, Oka E, Hayashi H, Murata H, Yodogawa K, Hayashi M, Igawa O, Shimizu W. The characteristics and efficacy of catheter ablation of focal atrial tachycardia arising from an epicardial site. Clin Cardiol 2021; 44:563-572. [PMID: 33598933 PMCID: PMC8027578 DOI: 10.1002/clc.23577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Although epicardial structures around the atrium such as adipose tissue possess arrhythmogenicity, little is known about atrial tachycardias (ATs) originating from epicardial sites (Epi-ATs). This study aimed to elucidate the prevalence, characteristics, and outcome after radiofrequency catheter ablation (RFCA) of Epi-ATs and to reveal the association between Epi-ATs and the epicardial structures. METHODS The electrocardiographic, electrophysiologic, and anatomical properties and results of RFCA were analyzed in 42 patients with a total of 49 ectopic ATs. RESULTS Six Epi-ATs (12%) were observed in six patients (14%). Four of six were respiratory cycle-dependent ATs and one was a swallowing-induced AT. The Epi-AT origins were adjacent to a pulmonary vein (five cases) and vein of Marshall (one case). A Valsalva maneuver or atropine infusion to define the arrhythmia mechanism affected the appearance of the Epi-ATs. The congruity rate between epicardial adipose tissue and the AT origin was significantly higher (100% vs. 44%, p = .045), and the epicardial adipose tissue volume of the atrium was significantly larger (104.1 vs. 64.6 ml, p = .04) in the Epi-AT group. Endocardial RFCA targeting the AT foci resulted in acute success in five of five cases. However, electrical isolation including of the AT foci resulted in acute failures (two of three cases) or a recurrence (one of one case). CONCLUSIONS Six Epi-ATs were associated with thoracic veins and epicardial arrhythmogenic structures. The main cause provoking the Epi-ATs was associated with autonomic nerve activity.
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Affiliation(s)
- Teppei Yamamoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuhi Fujimoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Eiichiro Oka
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshige Murata
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Meiso Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Osamu Igawa
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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Sanchez JM, Lee A, Bartus K, Lee RJ. Percutaneous epicardial approach for LAA ligation. J Interv Card Electrophysiol 2020; 62:293-297. [PMID: 33085054 DOI: 10.1007/s10840-020-00894-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The left atrial appendage (LAA) is believed to be a source for thrombus formation and an ancillary structure involved in the initiation and maintenance of atrial fibrillation (AF). LAA ligation has been proposed as adjunctive therapy for the treatment of AF. This study will determine the feasibility of a percutaneous epicardial approach for LAA ligation. METHODS The pericardium of 5 dogs was accessed via percutaneous subxyphoid approach. A 20F epicardial cannula was inserted into the pericardial space and contrast-injected to visualize the LAA. Under fluoroscopic guidance, a suction cup catheter was inserted and attached to the LAA. A 12F snare device was inserted over the vacuum cup to ligate the LAA. The closure of the LAA was verified with LA angiography, in the first 2 dogs, and ICE in all 5 animals. All animals were sacrificed for post hoc assessment of LAA closure. RESULTS All 5 dogs underwent successful epicardial suture ligation of the LAA. In the first 2 dogs, LA angiography demonstrated complete closure of the LAA. All dogs underwent gross examination of the LAA. Post hoc assessment was notable for a small well-circumscribed hematoma on the LAA, consistent with point of suction cup attachment, as well as complete closure of the entire LAA. No laceration or perforation was noted on the LAA. CONCLUSIONS Exclusion of the LAA via a novel percutaneous epicardial-only approach was successful without complications. This demonstrates the feasibility of this technique in an animal model, and may provide an effective approach for epicardial-only LAA exclusion in humans.
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Affiliation(s)
- José M Sanchez
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantation, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Randall J Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA.
- , San Francisco, USA.
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Abstract
Supraventricular arrhythmias are the most common cardiac arrhythmias encountered; however, it is uncommon that supraventricular tachycardias require percutaneous epicardial access for successful mapping and ablation. There are particular scenarios where epicardial access and ablation should be considered. Certain accessory pathways particularly in the posteroseptal region may require epicardial access for successful ablation. These pathways may also be approached from within the coronary sinus system. In addition, tachycardias near the phrenic nerve in the right atrium or left atrium may require epicardial access for successful ablation or to allow displacement of the phrenic nerve facilitating safe catheter ablation.
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Affiliation(s)
- Martin Aguilar
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Usha B Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School; Clinical Cardiac Electrophysiology Fellowship; Ventricular Arrhythmia Program.
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15
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Sato T, Miyamoto K, Nishii T, Kusano K. Pace-and-Ablate Technique for Atrial Tachycardia Originating From the Left Atrial Appendage. Circ J 2020; 84:1046. [PMID: 32307355 DOI: 10.1253/circj.cj-19-1172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Taiki Sato
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tatsuya Nishii
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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16
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Parikh V, Rasekh A, Mohanty S, Yarlagadda B, Atkins D, Bommana S, Turagam M, Jeffery C, Carroll H, Nydegger C, Jaeger M, Dar T, Cheng J, Gopinnathanair R, Dibiase L, Lee R, Horton R, Natale A, Lakkireddy D. Exclusion of electrical and mechanical function of the left atrial appendage in patients with persistent atrial fibrillation: differences in efficacy and safety between endocardial ablation vs epicardial LARIAT ligation (the EXCLUDE LAA study). J Interv Card Electrophysiol 2019; 57:409-416. [DOI: 10.1007/s10840-019-00657-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
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17
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Karim N, Ho SY, Nicol E, Li W, Zemrak F, Markides V, Reddy V, Wong T. The left atrial appendage in humans: structure, physiology, and pathogenesis. Europace 2019; 22:5-18. [DOI: 10.1093/europace/euz212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
For many years, the left atrial appendage (LAA) was considered a dormant embryological remnant; however, it is a structurally complex and functional organ that contributes to cardiac haemodynamic changes and volume homeostasis through both its contractile properties and neurohormonal peptide secretion. When dysfunctional, the LAA contributes to thrombogenesis and subsequent increased predisposition to cardioembolic events. Consequently, the LAA has gained much attention as a therapeutic target to lower this risk. In addition, attention has focused on the LAA in its role as an electrical trigger for atrial tachycardia and atrial fibrillation with ablation of the LAA to achieve electrical isolation showing promising results in the maintenance of sinus rhythm. This in-depth review explores the structure, physiology and pathophysiology of the LAA, as well as LAA intervention and their sequelae.
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Affiliation(s)
- Nabeela Karim
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Siew Yen Ho
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Edward Nicol
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Filip Zemrak
- Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - Vias Markides
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Vivek Reddy
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York City, NY, USA
| | - Tom Wong
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
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18
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Wei HQ, Sun Q, Guo XG, Yang JD, Ma J. Successful ablation of focal atrial tachycardia originating from the left atrial appendage using 23-mm second-generation cryoballoon. HeartRhythm Case Rep 2019; 5:325-328. [PMID: 31285991 PMCID: PMC6587051 DOI: 10.1016/j.hrcr.2019.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hui-Qiang Wei
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Sun
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Gang Guo
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Du Yang
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Ma
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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19
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Verma N, Knight BP. Left atrial appendage isolation at the time of atrial fibrillation ablation. Heart Rhythm 2018; 15:1754-1755. [DOI: 10.1016/j.hrthm.2018.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Indexed: 11/27/2022]
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20
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AlTurki A, Huynh T, Dawas A, AlTurki H, Joza J, Healey JS, Essebag V. Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta-analysis. J Arrhythm 2018; 34:478-484. [PMID: 30327692 PMCID: PMC6174377 DOI: 10.1002/joa3.12095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 11/10/2022] Open
Abstract
A significant proportion of patients' experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random-effects meta-analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow-up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10-0.37; P < 0.00001). Left atrial appendage isolation was also associated with a reduction in AF recurrence after repeat ablation (OR = 0.40; CI = 0.25-0.65; P = 0.0003). The addition of LAA isolation to PVI was associated with a decrease in AF recurrence in patients with persistent AF. Further studies are needed to assess the effect on long-term risk of stroke.
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Affiliation(s)
- Ahmed AlTurki
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Thao Huynh
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Ahmed Dawas
- Faculty of MedicineMcGill UniversityMontrealQuebecCanada
| | | | - Jacqueline Joza
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Jeff S. Healey
- Population Health Research InstituteHamiltonOntarioCanada
| | - Vidal Essebag
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
- Hôpital Sacré‐Coeur de MontréalMontrealQuebecCanada
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21
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Turagam MK, Velagapudi P, Kar S, Holmes D, Reddy VY, Refaat MM, Di Biase L, Al-Ahmed A, Chung MK, Lewalter T, Edgerton J, Cox J, Fisher J, Natale A, Lakkireddy DR. Cardiovascular Therapies Targeting Left Atrial Appendage. J Am Coll Cardiol 2018; 72:448-463. [PMID: 29954658 PMCID: PMC8420938 DOI: 10.1016/j.jacc.2018.05.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 12/28/2022]
Abstract
Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.
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Affiliation(s)
- Mohit K Turagam
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Poonam Velagapudi
- Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Saibal Kar
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California
| | - David Holmes
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiology/Cardiac Electrophysiology and Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
| | - Luigi Di Biase
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Amin Al-Ahmed
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - James Edgerton
- Department of Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - James Cox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John Fisher
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya R Lakkireddy
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park Regional Medical Center, Kansas City, Kansas.
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22
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Killu AM, Naksuk N, Syed FF, DeSimone CV, Gaba P, Witt C, Ladewig DJ, Suddendorf SH, Powers JM, Satam G, Stárek Z, Kara T, Wolf J, Leinveber P, Crha M, Novák M, Bruce CJ, Friedman PA, Asirvatham SJ. Feasibility of directional percutaneous epicardial ablation with a partially insulated catheter. J Interv Card Electrophysiol 2018; 53:105-113. [PMID: 30008046 DOI: 10.1007/s10840-018-0404-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To demonstrate the feasibility of directional percutaneous epicardial ablation using a partially insulated catheter. METHODS Partially insulated catheter prototypes were tested in 12 (6 canine, 6 porcine) animal studies in two centers. Prototypes had interspersed windows to enable visualization of epicardial structures with ultrasound. Epicardial unipolar ablation and ablation between two electrodes was performed according to protocol (5-60 W power, 0-60 mls/min irrigation, 78 s mean duration). RESULTS Of 96 epicardial ablation attempts, unipolar ablation was delivered in 53.1%. Electrogram evidence of ablation, when analyzable, occurred in 75 of 79 (94.9%) therapies. Paired pre/post-ablation pacing threshold (N = 74) showed significant increase in pacing threshold post-ablation (0.9 to 2.6 mA, P < .0001). Arrhythmias occurred in 18 (18.8%) therapies (11 ventricular fibrillation, 7 ventricular tachycardia), mainly in pigs (72.2%). Coronary artery visualization was variably successful. No phrenic nerve injury was noted during or after ablation. Furthermore, there were minimal pericardial changes with ablation. CONCLUSIONS Epicardial ablation using a partially insulated catheter to confer epicardial directionality and protect the phrenic nerve seems feasible. Iterations with ultrasound windows may enable real-time epicardial surface visualization thus identifying coronary arteries at ablation sites. Further improvements, however, are necessary.
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Affiliation(s)
- Ammar M Killu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Niyada Naksuk
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Faisal F Syed
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | - Chance Witt
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Gaurav Satam
- Mayo Clinic Ventures, Mayo Clinic, Rochester, MN, USA
| | - Zdeněk Stárek
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Tomas Kara
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Jiří Wolf
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Pavel Leinveber
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Michal Crha
- Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Brno, Czech Republic
| | - Miroslav Novák
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Charles J Bruce
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA. .,Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.
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23
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Hoskins MH, Patel AM, DeLurgio DB. Left Atrial Appendage Occlusion, Shared Decision-Making, and Comprehensive Atrial Fibrillation Management. Interv Cardiol Clin 2018. [PMID: 29526294 DOI: 10.1016/j.iccl.2017.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The epidemic of atrial fibrillation (AF) requires a comprehensive management strategy that uses the full force of available data and technology, including anticoagulation, ablative therapy, and left atrial appendage occlusion. Patient-centered care with an emphasis on shared decision-making is particularly relevant to the authors' understanding of the complexity of AF and has helped them tailor therapy in this ever-growing patient population.
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Affiliation(s)
- Michael H Hoskins
- Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road Northeast, Suite F424, Atlanta, GA 30322, USA
| | - Anshul M Patel
- Emory University School of Medicine, Emory St. Joseph's Hospital, 5671 Peachtree Dunwoody Road, Suite 300, Atlanta, GA 30342, USA
| | - David B DeLurgio
- Emory University School of Medicine, Emory St. Joseph's Hospital, 5671 Peachtree Dunwoody Road, Suite 300, Atlanta, GA 30342, USA.
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24
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Lin AC, Knight BP. What Is the Role of Left Atrial Appendage Closure in the Rhythm Control of Atrial Fibrillation? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:24. [DOI: 10.1007/s11936-018-0620-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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25
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E Gul E, Boles U, Haseeb S, Flood J, Bansal A, Glover B, Redfearn D, Simpson C, Abdollah H, Baranchuk A, Michael KA. Left Atrial Appendage characteristics in patients with Persistent Atrial Fibrillation undergoing catheter ablation (LAAPAF Study). J Atr Fibrillation 2017; 9:1526. [PMID: 29250273 DOI: 10.4022/jafib.1526] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 01/09/2017] [Accepted: 01/15/2017] [Indexed: 12/13/2022]
Abstract
Background Despite technological and scientific efforts, the recurrence rate of persistent atrial fibrillation (AF) remains high. Several studies have shown that in addition to pulmonary vein (PV) isolation other non-PV triggers, particularly left atrial appendage may be the source of initiation and maintenance of AF. There are few studies showing the role of left atrial appendage (LAA) isolation in order to obtain higher success rate in persistent AF patients. Objective We analyzed the LAA volume, volume index and shape relative to the LA in patients with persistent AF undergoing AF ablation. Methods Fifty-nine consecutive patients with persistent AF who underwent catheter ablation were enrolled. Computerized tomography (CT) was performed in order to assess left atrial and PV anatomy including the LAA. Digital subtraction software (GE Advantage Workstation 4.3) was used to separate the LAA from the LA and calculate: LA volume (LAV), LA volume index (LAV/body surface area), LAA volume (LAAV), LAA volume index (LAA volume/LA volume), and LAA morphology [chicken wing (CW) or non-chicken wing (NCW)]. Results The mean age was 64.6 ± 9.8 years, 44 % male, and LA diameter 47.6 ± 7.8 mm. Median follow-up (FU) was 13 months. All patients had antral isolation of PVs and ablation of complex fractionation ± linear ablation (roof line/superior coronary sinus/mitral line). Among 59 patients with persistent AF, 26 (44 %) patients were diagnosed with AF recurrences. Mean LAV was 145.0 ± 45.9 ml, LAVI 68.9 ± 20.0 ml/m2, LAAV 10.3 ± 4.0 ml, and LAAVI 7.3 ± 2.7 ml/m2. LAA shape was non-chicken wing (NCW) in the majority of patients (51 %). LAA parameters were not significantly different between patients with and without AF recurrence (LAAV 11.0 ± 4.3 ml vs. 9.7 ± 3.8 ml, p=0.26; LAAVI 7.5 ± 3.0 ml/m2 vs. 7.2 ± 2.5 ml/m2, p=0.71; LAA shape of NCW 50 % vs 52 %, p=0.75, respectively). LAV was significantly correlated with the LAAV (r: o.47, p=0.009). The incidence of NCW LAA was significantly higher in patients with previous stroke/TIA (80 % vs. 20 %, p=0.04). Conclusion The LAA anatomical characteristics (volume/volume index and the shape) were comparable in patients with/out AF recurrence post PVI. It remains to be determined if additional LAA isolation will impact outcomes in patients with persistent AF.
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Affiliation(s)
- Enes E Gul
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Usama Boles
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Sohaib Haseeb
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Justin Flood
- Department of Diagnostic Radiology, Queens University, Kingston, ON, Canada
| | - Ayuish Bansal
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Benedict Glover
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Damian Redfearn
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Chris Simpson
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Hoshiar Abdollah
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
| | - Kevin A Michael
- Heart Rhythm Service, Kingston General Hospitaş, Queens University, Kingston, ON, Canada
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26
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Turagam M, Atkins D, Earnest M, Lee R, Nath J, Ferrell R, Bartus K, Badhwar N, Rasekh A, Cheng J, Di Biase L, Natale A, Wilber D, Lakkireddy D. Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry. J Cardiovasc Electrophysiol 2017; 28:1433-1442. [DOI: 10.1111/jce.13343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mohit Turagam
- Division of Cardiovascular Medicine; University of Missouri Hospital and Clinics; Columbia MO USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Randall Lee
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Jayant Nath
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Ryan Ferrell
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | | | - Nitish Badhwar
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Abdi Rasekh
- Baylor St. Luke's Medical Center; Houston TX USA
| | - Jie Cheng
- Texas Heart Institute; Houston TX USA
| | - Luigi Di Biase
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - Andrea Natale
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
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27
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Upadhyay S, Walsh EP, Cecchin F, Triedman JK, Villafane J, Saul JP. Epicardial ablation of tachyarrhythmia in children: Experience at two academic centers. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1017-1026. [PMID: 28744873 DOI: 10.1111/pace.13152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Experience with percutaneous epicardial ablation of tachyarrhythmia in pediatrics is limited. This case series addresses the feasibility, safety, and complications of the procedure in children. METHODS A total of nine patients underwent 10 epicardial ablation procedures from 2002 to 2013 at two academic centers. Activation mapping was performed in all cases, and electroanatomic map was utilized in nine of the 10 procedures. Patients had undergone one to three failed endocardial catheter ablations in addition to medical management, and all had symptoms, a high-risk accessory pathway (AP), aborted cardiac arrest with Wolff-Parkinson-White syndrome (WPW), or ventricular dysfunction. A standard epicardial approach was used for access in all cases, using a 7- or 8- Fr sheath. Epicardial ablation modality was radiofrequency (RF) in seven, cryoablation (CRYO) in one, and CRYO plus RF in one. RESULTS Median age was 14 (range 8-19) years. INDICATIONS drug refractory ectopic atrial tachycardia (one), ventricular tachycardia (VT) (five), high-risk AP (two), and aborted cardiac arrest from WPW - (one). Epicardial ablation was not performed in one case despite access due to an inability to maneuver the catheter around a former pericardial scar. VT foci included the right ventricular outflow tract septum, high posterior left ventricle (LV), LV outflow tract, postero-basal LV, and scar from previous rhabdomyoma surgery. WPW foci were in the area of the posterior septum and coronary sinus in all three cases. Overall procedural success was 70% (7/10), with epicardial ablation success in five and endocardial ablation success after epicardial mapping in two. The VT focus was close to the left anterior descending coronary artery in one of the unsuccessful cases in which both RF and CRYO were used. There was one recurrence after a successful epicardial VT ablation, which was managed with a second successful epicardial procedure. There were no other recurrences at more than 1 year of follow-up. Complications were minimal, with one case of inadvertent pleural access requiring no specific therapy. No pericarditis or effusion was seen in any of the patients who underwent epicardial ablation. CONCLUSION Epicardial ablation in pediatric patients can be performed with low complications and acceptable success. It can be considered for a spectrum of tachycardia mechanisms after failed endocardial ablation attempts and suspected epicardial foci. Success and recurrence may be related to foci in proximity to the epicardial coronaries, pericardial scar, or a distant location from the closest epicardial location. Repeat procedures may be necessary.
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Affiliation(s)
- Shailendra Upadhyay
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, CT, USA
| | - Edward P Walsh
- Department of Pediatrics, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Frank Cecchin
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - John K Triedman
- Department of Pediatrics, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Juan Villafane
- Department of Pediatrics, University of Kentucky, Louisville, KY, USA
| | - J Philip Saul
- Department of Pediatrics, University of West Virginia School of Medicine, Morgantown, WV, USA
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Spectrum of atrial arrhythmias using the ligament of Marshall in patients with atrial fibrillation. Heart Rhythm 2017; 15:17-24. [PMID: 28765086 DOI: 10.1016/j.hrthm.2017.07.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The role of the ligament of Marshall (LOM) in patients with atrial fibrillation (AF) has not been well defined. OBJECTIVE The purpose of this study was to describe the role of the LOM in patients with AF and related arrhythmias. METHODS Fifty-six patients (mean age 63 ± 11 years; persistent AF in 48 [86%]; ejection fraction 0.49 ± 0.13; left atrial diameter 4.7 ± 0.6 cm) with LOM-mediated arrhythmias were included. RESULTS A LOM-pulmonary vein (PV) connection was present in 18 patients (32%) and was eliminated with radiofrequency (RF) ablation at the left lateral ridge or crux (n = 12), at the mitral annulus (n = 3), or with alcohol/ethanol (EtOH) ablation of the vein of Marshall (VOM; n = 3). A LOM-mediated atrial tachycardia (AT) was present in 13 patients (23%). Thirty-one patients with refractory mitral isthmus conduction were referred for potential EtOH ablation. In the 6 patients in whom VOM was injected during perimitral reentry, EtOH resulted in slowing in 3 patients and termination in 1 patient. In others, EtOH infusion resulted in complete isolation of the left-sided PVs and left atrial appendage. Repeat RF and adjunctive EtOH ablation of the VOM tended to be more effective in creating conduction block across the mitral isthmus than RF ablation alone (P = .057). CONCLUSION The LOM is responsible for a variety of arrhythmia mechanisms in patients with AF and atrial tachycardia. It may be ablated at any point along its course, at the mitral annulus, at the lateral ridge/PV antrum, and epicardially in the coronary sinus and the VOM itself. EtOH ablation of the VOM may be an adjunctive strategy in patients with refractory perimitral reentry.
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TURAGAM MOHITK, LAVU MADHAV, AFZAL MUHAMMADR, VUDDANDA VENKAT, JAZAYERI MOHAMMADALI, PARIKH VALAY, ATKINS DONITA, BOMMANA SUDHARANI, DI BIASE LUIGI, HORTON RODNEY, BAI RONG, SWARUP VIJAY, CHENG JIE, NATALE ANDREA, LAKKIREDDY DHANUNJAYA. Catheter Ablation for Atrial Fibrillation in Patients With Watchman Left Atrial Appendage Occlusion Device: Results from a Multicenter Registry. J Cardiovasc Electrophysiol 2017; 28:139-146. [DOI: 10.1111/jce.13148] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/25/2016] [Accepted: 11/01/2016] [Indexed: 01/01/2023]
Affiliation(s)
- MOHIT K. TURAGAM
- Division of Cardiovascular Disease; University of Missouri Hospital and Clinics; Columbia Missouri USA
| | - MADHAV LAVU
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
| | - MUHAMMAD R. AFZAL
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
| | - VENKAT VUDDANDA
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
| | - MOHAMMAD-ALI JAZAYERI
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
| | - VALAY PARIKH
- Division of Cardiovascular Disease; University of Missouri Hospital and Clinics; Columbia Missouri USA
| | - DONITA ATKINS
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
| | - SUDHARANI BOMMANA
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
| | | | | | - RONG BAI
- Beijing Anzhen Hospital; Capital Medical University; Beijing China
| | - VIJAY SWARUP
- Arizona Heart Rhythm Institute; Phoenix Arizona USA
| | - JIE CHENG
- Texas Heart Institute; Houston Texas USA
| | | | - DHANUNJAYA LAKKIREDDY
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital and Medical Center; Kansas City Kansas USA
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Ban JE, Park TY, Park SW. Percutaneous epicardial ablation of incessant atrial tachycardia originating from the left atrial appendage. J Thorac Dis 2017; 8:E1551-E1554. [PMID: 28066659 DOI: 10.21037/jtd.2016.11.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 38-year-old woman presented with antiarrhythmic drug-refractory atrial tachycardia (AT). Holter recording demonstrated incessant episodes of AT followed by a long sinus pause. Electrophysiologic study revealed that the earliest endocardial activation was observed at the neck of the left atrial appendage (LAA). After unsuccessful endocardial ablation, epicardial access via a percutaneous subxiphoid approach demonstrated that the earliest epicardial atrial activation was observed on the opposite site to the endocardial LAA neck suggestive of ligament of Marshall (LOM) muscle sleeve as regarding the epicardial sharp potentials under guidance of a circular mapping catheter. Application of radiofrequency (RF) energy at this site terminated the tachycardia. After tachycardia ablation, the sinus pause also resolved.
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Affiliation(s)
- Ji-Eun Ban
- Division of Cardiology, Department of Pediatrics, Hallym University Medical Center, Seoul, Republic of Korea
| | - Tae Young Park
- Division of Cardiology, Department of Pediatrics, Hallym University Medical Center, Seoul, Republic of Korea
| | - Sang-Weon Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
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Di Biase L, Burkhardt JD, Mohanty P, Mohanty S, Sanchez JE, Trivedi C, Güneş M, Gökoğlan Y, Gianni C, Horton RP, Themistoclakis S, Gallinghouse GJ, Bailey S, Zagrodzky JD, Hongo RH, Beheiry S, Santangeli P, Casella M, Dello Russo A, Al-Ahmad A, Hranitzky P, Lakkireddy D, Tondo C, Natale A. Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation. J Am Coll Cardiol 2016; 68:1929-1940. [DOI: 10.1016/j.jacc.2016.07.770] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 07/14/2016] [Accepted: 07/27/2016] [Indexed: 10/20/2022]
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Wilber DJ. What Should We Believe About Electrical Isolation of the Left Atrial Appendage? ∗. J Am Coll Cardiol 2016; 68:1941-1943. [DOI: 10.1016/j.jacc.2016.06.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 06/01/2016] [Indexed: 11/28/2022]
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Di Biase L, Natale A. To "isolate" or "not to isolate," the left atrial appendage, "that is the question". J Interv Card Electrophysiol 2016; 47:261-263. [PMID: 27541304 DOI: 10.1007/s10840-016-0174-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/05/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Luigi Di Biase
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Silver Zone, Bronx, NY, 10467-2400, USA.
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA.
- Department of Biomedical Engineering, University of Texas, Austin, TX, USA.
- Department of Cardiology, University of Foggia, Foggia, Italy.
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Scripps Clinic, San Diego, CA, USA
- Dell Medical School, Austin, TX, USA
- California Pacific Medical Center, San Francisco, CA, USA
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Affiliation(s)
- Luigi Di Biase
- From the Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (L.D.B.); Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin (L.D.B., A.N.); Department of Biomedical Engineering, University of Texas, Austin (L.D.B.); Department of Cardiology, University of Foggia, Italy (L.D.B.); Division of Cardiology, Stanford University, Palo Alto, CA (A.N.); Section of Electrophysiology, Case Western Reserve University, Cleveland, OH (A.N.); Section of Electrophysiology,
| | - Andrea Natale
- From the Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (L.D.B.); Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin (L.D.B., A.N.); Department of Biomedical Engineering, University of Texas, Austin (L.D.B.); Department of Cardiology, University of Foggia, Italy (L.D.B.); Division of Cardiology, Stanford University, Palo Alto, CA (A.N.); Section of Electrophysiology, Case Western Reserve University, Cleveland, OH (A.N.); Section of Electrophysiology,
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36
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Atoui M, Gunda S, Lakkireddy D. Left atrial appendage closure is preferred to chronic warfarin therapy: the pro perspective. Card Electrophysiol Clin 2015; 7:403-13. [PMID: 26304519 DOI: 10.1016/j.ccep.2015.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Atrial fibrillation (AF) is associated with increased rates of death, stroke, heart failure, hospitalization, degraded quality of life, reduced exercise capacity, and left ventricular dysfunction. An oral anticoagulant reduces the risk of stroke; however, it places the patient at risk for bleeding complications. Weighing the stroke and bleeding risks remains the key for optimal treatment. Cardiac interventions that can obviate long-term oral anticoagulation hold great promise for the future care of patients with AF and high stroke risk. The percutaneously deployable Watchman device is a paradigm shift in how clinicians can abate the need for continued oral anticoagulation.
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Affiliation(s)
- Moustapha Atoui
- Division of Electrophysiology, Kansas University Medical Center, University of Kansas Hospital, 3901 Rainbow Boulevard, Rm 1001B Eaton, MS 3006, Kansas City, KS 66160, USA
| | - Sampath Gunda
- Division of Electrophysiology, University of Kansas Hospital, 3901, Rainbow Boulevard, G-600, Kansas City, KS 66160, USA
| | - Dhanunjaya Lakkireddy
- Division of Electrophysiology, University of Kansas Hospital, 3901, Rainbow Boulevard, G-600, Kansas City, KS 66160, USA; Division of Cardiovascular Diseases, Center for Excellence in Atrial Fibrillation & EP Research, University of Kansas Medical Center and Hospital, 3901, Rainbow Boulevard, G-600, Kansas City, KS 66160, USA.
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Taylor CM, Samardhi H, Haqqani HM. Atrial tachycardias arising from the atrial appendages and aortic sinus of valsalva. Curr Cardiol Rev 2015; 11:118-26. [PMID: 25308812 PMCID: PMC4356718 DOI: 10.2174/1573403x10666141013121631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 09/25/2013] [Accepted: 04/05/2014] [Indexed: 11/22/2022] Open
Abstract
Focal atrial tachycardias arising from the atrial appendages and the aortic sinuses of Valsalva are less frequently encountered in clinical practice. This review article describes the clinical presentation, surface P wave morphology, electrophysiologic characteristics and treatment of these arrhythmias. Catheter ablation of these focal tachycardias has a high success rate. It is however important to be aware of specific anatomic considerations in these locations for optimal treatment outcomes with low complication rates.
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Affiliation(s)
| | | | - Haris M Haqqani
- Department of Cardiology, Prince Charles Hospital, 627 Rode Road, Chermside, Brisbane, QLD Australia 4032.
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38
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Lakkireddy D, Sridhar Mahankali A, Kanmanthareddy A, Lee R, Badhwar N, Bartus K, Atkins D, Bommana S, Cheng J, Rasekh A, Di Biase L, Natale A, Nath J, Ferrell R, Earnest M, Reddy YM. Left Atrial Appendage Ligation and Ablation for Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2015; 1:153-160. [DOI: 10.1016/j.jacep.2015.04.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/13/2015] [Accepted: 04/16/2015] [Indexed: 10/23/2022]
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Afzal MR, Kanmanthareddy A, Earnest M, Reddy M, Atkins D, Bommana S, Bartus K, Rasekh A, Han F, Badhwar N, Cheng J, Dibiase L, Ellis CR, Dawn B, Natale A, Lee RJ, Lakkireddy D. Impact of left atrial appendage exclusion using an epicardial ligation system (LARIAT) on atrial fibrillation burden in patients with cardiac implantable electronic devices. Heart Rhythm 2015; 12:52-9. [DOI: 10.1016/j.hrthm.2014.09.053] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Indexed: 11/25/2022]
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40
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Hanumandla A, Kaur D, Shah M, Calambur N. Epicardial ablation of focal atrial tachycardia arising from left atrial appendage in children. Indian Pacing Electrophysiol J 2014; 14:199-202. [PMID: 25057221 PMCID: PMC4100085 DOI: 10.1016/s0972-6292(16)30776-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Focal left atrial tachycardia (FLAT) although a common cause of supraventricular tachycardia(SVT) among children, the one's arising from left atrial appendage (LAA) present a unique challenge for successful ablation because of anatomical location. We present two children with FLAT arising from the epicardial LAA, successfully mapped and ablated through percutaneuous epicardial approach.
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Affiliation(s)
| | - Daljeet Kaur
- Care Hospital, the Institute of Medical Sciences, Hyderabad, India
| | - Mandar Shah
- Care Hospital, the Institute of Medical Sciences, Hyderabad, India
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Torok RD, Wei B, Kanter RJ, Jaquiss RDB, Lodge AJ. Thoracoscopic resection of the left atrial appendage after failed focal atrial tachycardia ablation. Ann Thorac Surg 2014; 97:1322-7. [PMID: 24462413 DOI: 10.1016/j.athoracsur.2013.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/30/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND This case series describes 3 patients with the unusual location of focal atrial tachycardia in the left atrial appendage who failed catheter ablation but were successfully treated by left atrial appendage resection by a totally thoracoscopic surgical technique. METHODS In all 3 cases, left atrial appendage resection was carried out by video-assisted thoracoscopic surgery using only 3 5- to 10-mm incisions, eliminating the need for median sternotomy or thoracotomy. An endoscopic stapler was used to resect the left atrial appendage at its base, successfully eliminating the source of the patients' focal atrial tachycardia. RESULTS The mean operative time was 84 minutes. All 3 patients tolerated the procedure without any complications and were discharged on postoperative day 3. At an average follow-up of 4.5 years, all patients remained asymptomatic and with normal ambulatory rhythm monitoring off all antiarrhythmic medications. CONCLUSIONS Surgical resection of the left atrial appendage using a totally thoracoscopic approach is a safe and successful treatment option for patients who have failed endocardial catheter ablation. This novel approach utilizes smaller incisions and shorter operative times than the more invasive surgical techniques previously described in the literature.
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Affiliation(s)
- Rachel D Torok
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Wei
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ronald J Kanter
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Robert D B Jaquiss
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew J Lodge
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Di Biase L, Santangeli P, Bai R, Tung R, David Burkhardt J, Shivkumar K, Natale A. The Emerging Role of Epicardial Ablation. Card Electrophysiol Clin 2012; 4:425-437. [PMID: 26939962 DOI: 10.1016/j.ccep.2012.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Sosa and colleagues first described a percutaneous approach (via the subxiphoid area) to access the pericardial space in 1996. Epicardial mapping and ablation is increasingly used for the treatment of supraventricular and ventricular arrhythmias and represents an adjunctive approach for challenging arrhythmias to improve procedural success rates. Epicardial ablation should be considered not only after the failure of an endocardial ablation but often as a first-line approach. Complications may occur during percutaneous access and epicardial ablation, and these might be reduced or avoided by improved operator skills and experience. New tools to access the epicardial space are being evaluated.
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Affiliation(s)
- Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, 3000 North I-35, Suite 720, Austin, TX 78705, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Pasquale Santangeli
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Rong Bai
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | - Roderick Tung
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, 3000 North I-35, Suite 720, Austin, TX 78705, USA; EP Services, California Pacific Medical Center, San Francisco, CA, USA; Division of Cardiology, Stanford University, Palo Alto, CA, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
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Yang Q, Ma J, Zhang S, Hu JQ, Liao ZL. Focal atrial tachycardia originating from the distal portion of the left atrial appendage: characteristics and long-term outcomes of radiofrequency ablation. Europace 2011; 14:254-60. [PMID: 21933799 DOI: 10.1093/europace/eur302] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The characteristics and response to ablation therapy of focal atrial tachycardia (AT) originating from the distal portion of left atrial appendage (LAAd) are still not quite clear up to now. The goal of this study is to characterize electrocardiographic and electrophysiological features and radiofrequency ablation (RFA) outcomes in patients with focal AT originating from the LAAd. METHODS AND RESULTS Fourteen patients (2.1%) (mean age, 25 ± 10 years; nine women; mean symptom duration, 5 ± 5 years) undergoing RFA of focal AT originating from the LAAd were included out of 668 RFA patients. Activation mapping was performed. P waves were classified as negative, positive, isoelectric, or biphasic. Tachycardia that was incessant in all, demonstrated a characteristic P-wave morphology and endocardial activation pattern: P wave was negative in leads I and aVL, highly positive in the inferior leads, and broad and positive in lead V₁. Radiofrequency ablation was acutely successful in 13 of 14 patients. The endocardial activation time of the successful RFA sites was 47.1 ± 4.3 ms before the onset of P wave. There were no complications in any of the 14 patients and long-term success was achieved in 13 of 13 successful RFA patients during follow-up (5 ± 2 years). CONCLUSION The LAAd is an uncommon site of origin for focal AT (2.1% incidence). In this case series, focal ATs originating from the LAAd had typical electrophysiological and electrocardiographic characteristics. Focal ablation yielded high acute success rate with low rate of recurrence during follow-up.
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Affiliation(s)
- Qian Yang
- Department of Cardiology, Cardiovascular Institute and Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 167 Beilishi Road, Beijing 100037, China
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Hocini M, Shah AJ, Nault I, Sanders P, Wright M, Narayan SM, Takahashi Y, Jaïs P, Matsuo S, Knecht S, Sacher F, Lim KT, Clémenty J, Haïssaguerre M. Localized reentry within the left atrial appendage: arrhythmogenic role in patients undergoing ablation of persistent atrial fibrillation. Heart Rhythm 2011; 8:1853-61. [PMID: 21762673 DOI: 10.1016/j.hrthm.2011.07.013] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 07/06/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) is implicated in maintenance of atrial fibrillation (AF) and atrial tachycardia (AT) associated with persistent AF (PsAF) ablation, although little is known about the incidence and mechanism of LAA AT. OBJECTIVE The purpose of this study was to characterize LAA ATs associated with PsAF ablation. METHODS In 74 consecutive patients undergoing stepwise PsAF ablation, 142 ATs were encountered during index and repeat procedures. Out of 78 focal-source ATs diagnosed by activation and entrainment mapping, 15 (19%) arose from the base of LAA. Using a 20-pole catheter, high-density maps were constructed (n = 10; age 57 ± 6 years) to characterize the mechanism of LAA-AT. The LAA orifice was divided into the posterior ridge and anterior-superior and inferior segments to characterize the location of AT. RESULTS Fifteen patients with LAA AT had symptomatic PsAF for 17 ± 15 months before ablation. LAA AT (cycle length [CL] 283 ± 30 ms) occurred during the index procedure in four and after 9 ± 7 months in 11 patients. We could map 89% ± 8% AT CLs locally with favorable entrainment from within the LAA, which is suggestive of localized reentry with centrifugal atrial activation. ATs were localized to inferior segment (n = 4), anterior-superior segment (n = 5), and posterior ridge (n = 6) with 1:1 conduction to the atria. Ablation targeting long fractionated or mid-diastolic electrogram within the LAA resulted in tachycardia termination. Postablation, selective contrast radiography demonstrated atrial synchronous LAA contraction in all but one patient. At 18 ± 7 months, 13/15 (87%) patients remained in sinus rhythm without antiarrhythmic drugs. CONCLUSION LAA is an important source of localized reentrant AT in patients with PsAF at index and repeat ablation procedures. Ablation targeting the site with long fractionated or mid-diastolic LAA electrogram is highly effective in acute and medium-term elimination of the arrhythmia.
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Affiliation(s)
- Mélèze Hocini
- Hôpital Cardiologique du Haut-Lévêque, Bordeaux, France.
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Left atrial appendectomy after failed catheter ablation of a focal atrial tachycardia originating in the left atrial appendage. Pediatr Cardiol 2010; 31:908-11. [PMID: 20503041 DOI: 10.1007/s00246-010-9737-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 05/10/2010] [Indexed: 10/19/2022]
Abstract
This report describes a case of left atrial appendectomy after a failed endocardial catheter ablation of a continuous drug-refractory left atrial appendage (LAA) tachycardia in a 9-year-old boy. Electrophysiologic study showed atrial tachycardia (AT) originating in the LAA. Numerous radiofrequency applications with an irrigated-tip catheter were ineffective. During surgery, direct pressure on the apex of the LAA by forceps immediately terminated the AT and restored sinus rhythm. After a left atrial appendectomy, the patient remained free of any arrhythmias during a follow-up period of 18 months.
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Yamada T, Kay GN. Recognition and Prevention of Complications During Epicardial Ablation. Card Electrophysiol Clin 2010; 2:127-134. [PMID: 28770731 DOI: 10.1016/j.ccep.2009.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Although the transthoracic epicardial mapping and ablation technique is a relatively safe procedure, complications can and do occur. The possible complications associated with this technique should be well understood before the procedure. If these complications are recognized early and managed appropriately, the outcome is usually excellent. This review describes the details of how to recognize, prevent, and manage the complications that occur during pericardial access, mapping and ablation, and post procedure.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, VH B147, 1670 University Boulevard, 1530 3rd Avenue South, Birmingham, AL 35294-0019, USA
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Schweikert RA. Epicardial Ablation of Supraventricular Tachycardia. Card Electrophysiol Clin 2010; 2:105-111. [PMID: 28770728 DOI: 10.1016/j.ccep.2009.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Epicardial catheter-based mapping and ablation of a variety of supraventricular tachycardias is feasible, safe, and effective. Supraventricular tachycardia substrates are not uncommonly epicardial, and approaches with percutaneous epicardial instrumentation or via the epicardial venous structures, such as the coronary sinus, are becoming more widely accepted. These techniques are an important treatment option as an alternative to a more invasive surgical approach or to allowing patients to suffer from an ongoing arrhythmia. New technologies and innovative techniques are being developed that hold great potential to improve the efficacy and safety of the epicardial catheter-based approach to these challenging arrhythmias.
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Affiliation(s)
- Robert A Schweikert
- Department of Cardiology, Akron General Medical Center, 400 Wabash Avenue, Akron, OH 44307, USA; Department of Internal Medicine, Northeast Ohio Universities College of Medicine, 4209 State Route 44, PO Box 95, Rootstown, OH 44272, USA
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Di Biase L, Saliba WI, Natale A. Successful ablation of epicardial arrhythmias with cryoenergy after failed attempts with radiofrequency energy. Heart Rhythm 2008; 6:109-12. [PMID: 19121810 DOI: 10.1016/j.hrthm.2008.09.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 09/23/2008] [Indexed: 11/26/2022]
Affiliation(s)
- Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, Texas, USA
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