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Calvert P, Ding WY, Mills MT, Snowdon R, Borbas Z, Modi S, Hall M, Morgan M, Clarkson N, Chackochen S, Barton J, Kemp I, Luther V, Gupta D. Durability of thermal pulmonary vein isolation in persistent atrial fibrillation assessed by mandated repeat invasive study. Heart Rhythm 2024; 21:1545-1554. [PMID: 38636929 DOI: 10.1016/j.hrthm.2024.04.061] [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: 02/13/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND No study has assessed the durability of pulmonary vein isolation (PVI) with radiofrequency (RF) and cryoballoon (CB) in patients with persistent atrial fibrillation. These data are especially lacking for those with significantly diseased left atria (LA). OBJECTIVES The goals of this study were to assess PVI durability in patients with significant LA disease and to compare reconnection rates between RF and CB. METHODS Forty-four patients (mean age 63 years; 34 (77%) male; median time since atrial fibrillation diagnosis 22.5 months; median indexed LA volume 36 mL/m2) were randomized 1:1 to RF or CB PVI. A redo procedure using ultra-high-density electroanatomic mapping was mandated at 2 months, where PV reconnections were identified and reisolated. RESULTS Thirty-eight patients underwent both procedures (CB n = 17; RF n = 21). Index RF procedures were longer (median 158 minutes vs 97 minutes; P < .001) but required less fluoroscopy (9.5 minutes vs 23 minutes; P < .001). At the index RF procedure, a median of 47% of LA myocardium had voltage < 0.5 mV, suggesting that half of the mapped LA comprised scar. PV reconnection was observed in 73 of 152 PVs (48.0%) and was more frequent with CB (58.8%) than with RF (39.3%) (P = .022). Reconnection of at least 1 PV was detected in >75% of patients. Significantly more ablation was required during the redo procedure to reisolate PVs in the CB arm (median 10.8 minutes vs 1.2 minutes; P < .001). CONCLUSION PVI durability may be poor in those with significant LA scarring and dilatation, even with modern thermal ablation technologies. RF resulted in significantly better PVI durability than did CB in this complex population.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Wern Yew Ding
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark T Mills
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Richard Snowdon
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Zoltan Borbas
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Simon Modi
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Hall
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Maureen Morgan
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | | | - Janet Barton
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ian Kemp
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Vishal Luther
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom.
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Calvert P, Ding WY, Griffin M, Bisson A, Koniari I, Fitzpatrick N, Snowdon R, Modi S, Luther V, Mahida S, Waktare J, Borbas Z, Ashrafi R, Todd D, Gupta D. Silent pulmonary veins at redo ablation for atrial fibrillation: Implications and approaches. J Interv Card Electrophysiol 2024; 67:1181-1189. [PMID: 38261098 PMCID: PMC11289157 DOI: 10.1007/s10840-024-01750-w] [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: 12/21/2023] [Accepted: 01/14/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. METHODS Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. RESULTS A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p<0.001), had more persistent AF (62.5% vs 41.1%; p=0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p=0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p=0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35-3.96]; p=0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56-6.62]; p=0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20-2.08]; p=0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30-2.72]; p<0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. CONCLUSIONS Patients with silent PVs at redo AF ablation have worse clinical outcomes.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Michael Griffin
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Arnaud Bisson
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Ioanna Koniari
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Noel Fitzpatrick
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Simon Modi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Johan Waktare
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Reza Ashrafi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
- Department of Cardiology, Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE, UK.
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Anter E, Mansour M, Nair DG, Sharma D, Taigen TL, Neuzil P, Kiehl EL, Kautzner J, Osorio J, Mountantonakis S, Natale A, Hummel JD, Amin AK, Siddiqui UR, Harlev D, Hultz P, Liu S, Onal B, Tarakji KG, Reddy VY. Dual-energy lattice-tip ablation system for persistent atrial fibrillation: a randomized trial. Nat Med 2024; 30:2303-2310. [PMID: 38760584 PMCID: PMC11333282 DOI: 10.1038/s41591-024-03022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024]
Abstract
Clinical outcomes of catheter ablation for atrial fibrillation (AF) are suboptimal due, in part, to challenges in achieving durable lesions. Although focal point-by-point ablation allows for the creation of any required lesion set, this strategy necessitates the generation of contiguous lesions without gaps. A large-tip catheter, capable of creating wide-footprint ablation lesions, may increase ablation effectiveness and efficiency. In a randomized, single-blind, non-inferiority trial, 420 patients with persistent AF underwent ablation using a large-tip catheter with dual pulsed field and radiofrequency energies versus ablation using a conventional radiofrequency ablation system. The primary composite effectiveness endpoint was evaluated through 1 year and included freedom from acute procedural failure and repeat ablation at any time, plus arrhythmia recurrence, drug initiation or escalation or cardioversion after a 3-month blanking period. The primary safety endpoint was freedom from a composite of serious procedure-related or device-related adverse events. The primary effectiveness endpoint was observed for 73.8% and 65.8% of patients in the investigational and control arms, respectively (P < 0.0001 for non-inferiority). Major procedural or device-related complications occurred in three patients in the investigational arm and in two patients in the control arm (P < 0.0001 for non-inferiority). In a secondary analysis, procedural times were shorter in the investigational arm as compared to the control arm (P < 0.0001). These results demonstrate non-inferior safety and effectiveness of the dual-energy catheter for the treatment of persistent AF. Future large-scale studies are needed to gather real-world evidence on the impact of the focal dual-energy lattice catheter on the broader population of patients with AF. ClinicalTrials.gov identifier: NCT05120193 .
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Affiliation(s)
- Elad Anter
- Shamir Medical Center, Be'er Ya'Akov, Israel.
| | | | - Devi G Nair
- St. Bernards Medical Center & Arrhythmia Research Group, Jonesboro, AR, USA
| | | | | | | | | | | | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, TX, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - John D Hummel
- Division of Cardiology, Ohio State University, Columbus, OH, USA
| | - Anish K Amin
- Riverside Methodist Hospital, Upper Arlington, OH, USA
| | | | | | | | | | | | | | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, NY, USA
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Calvert P, Ding WY, Griffin M, Bisson A, Koniari I, Fitzpatrick N, Snowdon R, Modi S, Luther V, Mahida S, Waktare J, Borbas Z, Ashrafi R, Todd D, Rao A, Gupta D. Predictors of the need for atrioventricular nodal ablation following redo ablation for atrial fibrillation. J Arrhythm 2024; 40:501-507. [PMID: 38939768 PMCID: PMC11199796 DOI: 10.1002/joa3.13023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/28/2024] [Accepted: 03/03/2024] [Indexed: 06/29/2024] Open
Abstract
Background Patients who have recurrent atrial fibrillation (AF) following redo catheter ablation may eventually be managed with a pace-and-ablate approach, involving pacemaker implant followed by atrioventricular nodal ablation (AVNA). We sought to determine which factors would predict subsequent AVNA in patients undergoing redo AF ablation. Methods We analyzed patients undergoing redo AF ablations between 2013 and 2019 at our institution. Follow-up was censored on December 31, 2021. Patients with no available follow-up data were excluded. Time-to-event analysis with Cox proportional hazard regression was used to compare those who underwent AVNA to those who did not. Results A total of 467 patients were included, of whom 39 (8.4%) underwent AVNA. After multivariable adjustment, female sex (aHR 4.68 [95% CI 2.30-9.50]; p < 0.001), ischemic heart disease (aHR 2.99 [95% CI 1.25-7.16]; p = 0.014), presence of a preexisting pacemaker (aHR 3.25 [95% CI 1.10-9.60]; p = 0.033), and persistent AF (aHR 2.22 [95% CI 1.07-4.59]; p = 0.032) were associated with increased risk of subsequent AVNA requirement. Conclusion Female sex, ischemic heart disease, and persistent AF may be useful clinical predictors of the requirement for subsequent AVNA and may be considered as part of shared clinical decision making.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Michael Griffin
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Arnaud Bisson
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
- Centre Hospitalier Régional Universitaire et Faculté de Médecine de ToursToursFrance
| | - Ioanna Koniari
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Noel Fitzpatrick
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Simon Modi
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Johan Waktare
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Reza Ashrafi
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Derick Todd
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Archana Rao
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest HospitalLiverpoolUK
- Liverpool Heart & Chest Hospital NHS Foundation TrustLiverpoolUK
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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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6
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Park CS, Kim H, Lee SR, Lee JH, Cho Y, Choi EK, Oh IY, Oh S. Prognostic implication of early recurrence after cryoballoon ablation in patients with atrial fibrillation. J Interv Card Electrophysiol 2024; 67:285-292. [PMID: 37126104 DOI: 10.1007/s10840-023-01555-3] [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: 02/20/2023] [Accepted: 04/20/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND It remains uncertain whether the implication of early recurrence and blanking period can be applied to patients with atrial fibrillation (AF) treated with cryoballoon ablation (CBA). We aimed to explore the prognostic value of early recurrence in patients with AF treated with CBA. METHODS We studied consecutive AF patients who were treated with CBA between April 2019 and September 2020 in two tertiary medical institutes and followed for up to 12 months. The endpoint was the late recurrence of atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia, following a 90-day blanking period. Atrial arrhythmia during the blanking period was defined as early recurrence and was not considered as an endpoint. RESULTS This study included 406 patients with AF who underwent CBA. During the follow-up, 147 (36.2%) cases of late recurrence were observed. Of the 104 patients with early recurrence, 85 experienced late recurrence during follow-up. Early recurrence was associated with an increased risk of late recurrence in the univariate and multivariate analyses (P < 0.001). When we classified the patients into paroxysmal AF and persistent AF groups, early recurrence was still significantly associated with a higher risk of late recurrence (P = 0.005 and P < 0.001, respectively). CONCLUSION Early recurrence after CBA was an independent risk factor for late recurrence in all patients as well as in those with paroxysmal AF and persistent AF. Therefore, further prospective studies could be considered to verify the risks and benefits of early rhythm control in patients with early recurrence.
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Affiliation(s)
- Chan Soon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hosu Kim
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Lee
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Republic of Korea
| | - Youngjin Cho
- Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Il-Young Oh
- Seoul National University College of Medicine, Seoul, Republic of Korea.
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-Si, Republic of Korea.
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
- Seoul National University College of Medicine, Seoul, Republic of Korea.
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Dhanjal TS, Schmidt MM, Getman MK, Brigham RC, Al-Sheikhli J, Patchett I, Robinson MR. Characterizing lesion morphology of a novel diamond-tip temperature-controlled irrigated radiofrequency ablation catheter. J Interv Card Electrophysiol 2024; 67:293-301. [PMID: 37344624 PMCID: PMC10902089 DOI: 10.1007/s10840-023-01595-9] [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: 04/28/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND The DiamondTemp ablation (DTA) system is a novel temperature-controlled irrigated radiofrequency (RF) ablation system that accurately measures tip-tissue temperatures for real-time power modulation. Lesion morphologies from longer RF durations with the DTA system have not been previously described. We sought to evaluate lesion characteristics of the DTA system when varying the application durations. METHODS A bench model using porcine myocardium was used to deliver discrete lesions in a simulated clinical environment. The DTA system was power-limited at 50 W with temperature set-points of 50 °C and 60 °C (denoted Group_50 and Group_60). Application durations were randomized with a range of 5-120 s. RESULTS In total, 280 applications were performed. Steam pops were observed in five applications: two applications at 90 s and three applications at 120 s. Lesion size (depth and maximum width) increased significantly with longer applications, until 60 s for both Group_50 and Group_60 (depth: 4.5 ± 1.2 mm and 5.6 ± 1.3 mm; maximum width: 9.3 ± 2.7mm and 11.2 ± 1.7mm, respectively). As lesions transition from resistive to conductive heating (longer than 10 s), the maximum width progressed in a sub-surface propagation. Using a "Time after Temperature 60 °C" (TaT60) analysis, depths of 2-3 mm occur in 0-5 s and depths plateau at 4.6 ± 0.8 mm between 20 and 30 s. CONCLUSIONS The DTA system rapidly creates wide lesions with lesion depth increasing over time with application durations up to 60 s. Using a TaT60 approach is a promising ablation guidance that would benefit from further investigation.
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Affiliation(s)
- Tarvinder S Dhanjal
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK.
- University of Warwick, Coventry, UK.
| | | | | | | | - Jaffar Al-Sheikhli
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
- University of Warwick, Coventry, UK
| | - Ian Patchett
- University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
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Ruwald MH, Haugdal M, Worck R, Johannessen A, Hansen ML, Sørensen SK, Hansen J. Characterization of durability and reconnection patterns at time of repeat ablation after single-shot pulsed field pulmonary vein isolation. J Interv Card Electrophysiol 2024; 67:379-387. [PMID: 37776356 PMCID: PMC10902076 DOI: 10.1007/s10840-023-01655-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/17/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a novel method of cardiac ablation where there is insufficient knowledge on the durability and reconnection patterns after pulmonary vein isolation (PVI). The aim of this study was to characterize the electrophysiological findings at time of repeat procedure in real-world atrial fibrillation (AF) patients. METHODS Patients who underwent a repeat procedure (n=26) for symptomatic recurrent arrhythmias after index first-time treatment with single-shot PFA PVI (n=266) from July 2021 to June 2023 were investigated with 3D high-density mapping and ad-hoc re-ablation by radiofrequency or focal PFA. RESULTS Index indication for PVI was persistent AF in 17 (65%) patients. The mean time to repeat procedure was 292 ± 119 days. Of the 26 patients (104 veins), complete durable PVI was observed in 11/26 (42%) with a durable vein isolation rate of 72/104 (69%). Two patients (8%) had all four veins reconnected. The posterior wall was durably isolated in 4/5 (80%) of the cases. The predominant arrhythmia mechanism was AF in 17/26 (65%) patients and regular atrial tachycardia (AT) in 9/26 (35%). Reconnection was observed 9/26 (35%) in right superior, 11/26 (42%) in right inferior, 7/26 (27%) in left superior, 5/26 (19%) in left inferior, p=0.31 between veins. The gaps were significantly clustered in the right-sided anterior carina compared to other regions (P=0.009). CONCLUSIONS Durable PVI was observed in less than half of the patients at time of repeat procedure. No significant difference in PV reconnection pattern was observed, but the gap location was preferentially located at the anterior aspects of the right-sided PVs. Predominant recurrence was AF. More data is needed to establish lesion formation and durability and AT circuits after PFA.
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Affiliation(s)
- Martin H Ruwald
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark.
| | - Martin Haugdal
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark
| | - Rene Worck
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark
| | - Arne Johannessen
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark
| | - Morten Lock Hansen
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark
| | - Samuel K Sørensen
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark
| | - Jim Hansen
- Division of Electrophysiology, Department of Cardiology, Herlev-Gentofte Hospital, Gentofte Hospitalsvej 1, DK-2900, Hellerup, Denmark
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Szegedi N, Salló Z, Nagy VK, Osztheimer I, Hizoh I, Lakatos B, Boussoussou M, Orbán G, Boga M, Ferencz AB, Komlósi F, Tóth P, Perge P, Kovács A, Merkely B, Gellér L. Long-Term Durability of High- and Very High-Power Short-Duration PVI by Invasive Remapping: The HPSD Remap Study. Circ Arrhythm Electrophysiol 2024; 17:e012402. [PMID: 38284286 PMCID: PMC10876176 DOI: 10.1161/circep.123.012402] [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: 06/07/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND High-power short-duration ablation has shown impressive efficacy and safety for pulmonary vein isolation (PVI); however, initial efficacy results with very high power short-duration ablation were discouraging. This study compared the long-term durability of PVI performed with a 90- versus 50-W power setting. METHODS Patients were randomized 1:1 to undergo PVI with the QDOT catheter using a power setting of 90 or 50 W. Three months after the index procedure, patients underwent a repeat electrophysiology study to identify pulmonary vein reconnections. Patients were followed for 12 months to detect AF recurrences. RESULTS We included 46 patients (mean age, 64 years; women, 48%). Procedure (76 versus 84 minutes; P =0.02), left atrial dwell (63 versus 71 minutes; P =0.01), and radiofrequency (303 versus 1040 seconds; P <0.0001) times were shorter with 90- versus 50-W procedures, while the number of radiofrequency applications was higher with 90 versus 50 W (77 versus 67; P =0.01). There was no difference in first-pass isolation (83% versus 82%; P =1.0) or acute reconnection (4% versus 14%; P =0.3) rates between 90 and 50 W. Forty patients underwent a repeat electrophysiology study. Durable PVI on a per PV basis was present in 72/78 (92%) versus 68/77 (88%) PVs in the 90- and 50-W energy setting groups, respectively; effect size: 72/78-68/77=0.040, lower 95% CI=-0.051 (noninferiority limit=-0.1, ie, noninferiority is met). No complications occurred. There was no difference in 12-month atrial fibrillation-free survival between the 90- and 50-W groups (P =0.2). CONCLUSIONS Similarly high rates of durable PVI and arrhythmia-free survival were achieved with 90 and 50 W. Procedure, left atrial dwell, and radiofrequency times were shorter with 90 W compared with 50 W. The sample size is too small to conclude the safety and long-term efficacy of the high and very high-power short-duration PVI; further studies are needed to address this topic. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05459831.
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Affiliation(s)
- Nándor Szegedi
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Salló
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Vivien Klaudia Nagy
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - István Osztheimer
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - István Hizoh
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Lakatos
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Melinda Boussoussou
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Gábor Orbán
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Boga
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Arnold Béla Ferencz
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ferenc Komlósi
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Patrik Tóth
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Péter Perge
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - László Gellér
- Cardiology Department, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Serban T, Mannhart D, Abid QUA, Höchli A, Lazar S, Krisai P, Bettelini AS, Knecht S, Kühne M, Sticherling C, du Fay de Lavallaz J, Badertscher P. Durability of pulmonary vein isolation for atrial fibrillation: a meta-analysis and systematic review. Europace 2023; 25:euad335. [PMID: 37944133 PMCID: PMC10664405 DOI: 10.1093/europace/euad335] [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: 08/24/2023] [Revised: 10/05/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
AIMS Pulmonary vein isolation (PVI) plays a central role in the interventional treatment of atrial fibrillation (AF). Uncertainties remain about the durability of ablation lesions from different energy sources. We aimed to systematically review the durability of ablation lesions associated with various PVI-techniques using different energy sources for the treatment of AF. METHODS AND RESULTS Structured systematic database search for articles published between January 2010 and January 2023 reporting PVI-lesion durability as evaluated in the overall cohort through repeat invasive remapping during follow-up. Studies evaluating only a proportion of the initial cohort in redo procedures were excluded. A total of 19 studies investigating 1050 patients (mean age 60 years, 31% women, time to remap 2-7 months) were included. In a pooled analysis, 99.7% of the PVs and 99.4% of patients were successfully ablated at baseline and 75.5% of the PVs remained isolated and 51% of the patients had all PVs persistently isolated at follow-up across all energy sources. In a pooled analysis of the percentages of PVs durably isolated during follow-up, the estimates of RFA were the lowest of all energy sources at 71% (95% CI 69-73, 11 studies), but comparable with cryoballoon (79%, 95%CI 74-83, 3 studies). Higher durability percentages were reported in PVs ablated with laser-balloon (84%, 95%CI 78-89, one study) and PFA (87%, 95%CI 84-90, 2 studies). CONCLUSION We observed no significant difference in the durability of the ablation lesions of the four evaluated energies after adjusting for procedural and baseline populational characteristics.
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Affiliation(s)
- Teodor Serban
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Diego Mannhart
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | | | - Andres Höchli
- Department of Cardiology, Triemli Stadtspital, Zürich, Switzerland
| | - Sorin Lazar
- Department of Cardiology, Cook County Health, Chicago, IL, USA
| | - Philipp Krisai
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Arianna Sofia Bettelini
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Sven Knecht
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Michael Kühne
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Christian Sticherling
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Patrick Badertscher
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland
- Cardiovascular Research Institute Basel, Spitalstrasse 2, 4056 Basel, Switzerland
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11
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Betts TR, Good WW, Melki L, Metzner A, Grace A, Verma A, Murray S, James S, Wong T, Boersma LVA, Steven D, Sultan A, Busch S, Neužil P, de Asmundis C, Lee J, Szili-Török T. Treatment of pathophysiologic propagation outside of the pulmonary veins in retreatment of atrial fibrillation patients: RECOVER AF study. Europace 2023; 25:euad097. [PMID: 37072340 PMCID: PMC10228624 DOI: 10.1093/europace/euad097] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/23/2023] [Indexed: 04/20/2023] Open
Abstract
AIMS RECOVER AF evaluated the performance of whole-chamber non-contact charge-density mapping to guide the ablation of non-pulmonary vein (PV) targets in persistent atrial fibrillation (AF) patients following either a first or second failed procedure. METHODS AND RESULTS RECOVER AF was a prospective, non-randomized trial that enrolled patients scheduled for a first or second ablation retreatment for recurrent AF. The PVs were assessed and re-isolated if necessary. The AF maps were used to guide the ablation of non-PV targets through elimination of pathologic conduction patterns (PCPs). Primary endpoint was freedom from AF on or off antiarrhythmic drugs (AADs) at 12 months. Patients undergoing retreatment with the AcQMap System (n = 103) were 76% AF-free at 12 months [67% after single procedure (SP)] on or off AADs (80% free from AF on AADs). Patients who had only received a pulmonary vein isolation (PVI) prior to study treatment of non-PV targets with the AcQMap System were 91% AF-free at 12 months (83% SP). No major adverse events were reported. CONCLUSION Non-contact mapping can be used to target and guide the ablation of PCPs beyond the PVs in persistent AF patients returning for a first or second retreatment with 76% freedom from AF at 12 months. The AF freedom was particularly high, 91% (43/47), for patients enrolled having only a prior de novo PVI, and freedom from all atrial arrhythmias for this cohort was 74% (35/47). These early results are encouraging and suggest that guiding individualized targeted ablation of PCPs may therefore be advantageous to target at the earliest opportunity in patients with persistent AF.
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Affiliation(s)
- Timothy R Betts
- Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK
| | | | - Lea Melki
- R&D Algorithms, Acutus Medical, Carlsbad, CA, USA
| | - Andreas Metzner
- Cardiac Electrophysiology Department, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Andrew Grace
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Atul Verma
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Stephen Murray
- Cardiology Department, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Simon James
- Cardiology Department, The James Cook University Hospital, Middlesbrough, UK
| | - Tom Wong
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Lucas V A Boersma
- Cardiology Department, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Daniel Steven
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Arian Sultan
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Sonia Busch
- Department Cardiology and Angiology, Klinikum Coburg, Coburg, Germany
| | - Petr Neužil
- Department of Cardiology, Homolka Hospital (Na Homolce Hospital), Prague, Czech Republic
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Cardiovascular Division, UZ Brussel—Vrije Universiteit Brussel, Brussels, Belgium
| | - Justin Lee
- Cardiology and Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Tamás Szili-Török
- Department of Cardiology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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12
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Sørensen SK, Johannessen A, Worck R, Hansen ML, Ruwald MH, Hansen J. Differential gap location after radiofrequency versus cryoballoon pulmonary vein isolation: Insights from a randomized trial with protocol-mandated repeat procedure. J Cardiovasc Electrophysiol 2023; 34:519-526. [PMID: 36640430 DOI: 10.1111/jce.15821] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Reconnections to pulmonary vein (PV) triggers of atrial fibrillation (AF) are the primary cause of AF recurrence after PV isolation (PVI) with radiofrequency (RF) or cryoballoon catheter ablation (CRYO), but method-specific contributions to PV reconduction pattern and conductive gap location are incompletely understood. METHODS The objective of this radiofrequency versus cryoballoon catheter ablation for paroxysmal atrial fibrillation substudy was to determine procedure-specific patterns of PV reconduction in a randomized population with protocol-mandated repeat procedures, irrespective of AF recurrence. Each PV was assessed in turn and PV reconnection sites were identified by high-density electroanatomical mapping and locating the earliest activation site. Gap locations were verified by PV re-isolation. RESULTS In 98 patients, 81% versus 76% previously isolated PVs remained isolated after CRYO versus RF (risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.96-1.18; p = .28). There were no significant differences for any PV: left superior PV: 90% versus 80%; left inferior PV: 80% versus 78%; right superior PV: 81% versus 80%, and right inferior PV: 76% versus 73%. For each reconnected PV, 34% of ipsilateral PVs were also reconnected after CRYO compared with 64% after RF (RR: 0.54; 95% CI: 0.32-0.90; p = .01). After RF, gaps were clustered by the carina and adjacent segments, whereas they were more heterogeneously distributed after CRYO. CONCLUSION Although RF and CRYO produce similar proportions of durably isolated PVs, gap locations appear to develop in procedure-specific patterns. After RF, ipsilateral PV reconduction is more frequent and gap sites cluster by the carina, suggesting that this region should be selectively ablated for more durable PVI.
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Affiliation(s)
- Samuel K Sørensen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Arne Johannessen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - René Worck
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Morten L Hansen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Martin H Ruwald
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Jim Hansen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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13
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Radiofrequency ablation using the second-generation temperature-controlled diamond tip system in paroxysmal and persistent atrial fibrillation: results from FASTR-AF. J Interv Card Electrophysiol 2023; 66:343-351. [PMID: 35581464 DOI: 10.1007/s10840-022-01234-9] [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: 03/25/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Catheter ablation (CA) technology development reflects the need to improve the effectiveness of atrial fibrillation (AF) treatment. Recently, the DiamondTemp Ablation (DTA) RF generator software was updated with a more responsive power ramp. METHODS DIAMOND FASTR-AF was a prospective, single-arm, multicenter trial. This study sought to characterize the performance of the updated DTA system for the treatment of patients with drug-refractory paroxysmal and persistent AF (PAF and PsAF). The primary effectiveness endpoint was freedom from atrial arrhythmia recurrence following a 90-day blanking period through 12 months, and the primary safety endpoint was a composite of serious adverse events. RESULTS In total, 60 subjects (34 PAF and 26 PsAF) underwent CA at three centers. Patients were 71.7% male, (age 63.9 ± 10.2 years, with an AF diagnosis duration 3.1 ± 3.9 years and left atrial size 4.4 ± 0.8 cm). Pulmonary vein isolation-only ablation strategy was performed in 34 (56.7%) subjects. The procedural characteristics show a procedure time 90.8 ± 31.6 min, total RF time 14.7 ± 7.7 min, ablation duration 10.7 ± 3.6 s, and fluid infusion 284.7 ± 111.5 ml. The serious adverse event rate was 8.3% (5/60), 3 pulmonary edema and 2 extended hospitalizations. Freedom from atrial arrhythmia recurrence was achieved in 67.6% of subjects by 12 months. CONCLUSIONS The updated DTA system demonstrated long-term safety and effectiveness through 12 months of post-ablation follow-up for patients with atrial fibrillation. Additionally, procedures were demonstrated to be highly efficient with short procedure times and low levels of fluid infusion. TRIAL REGISTRATION Sponsored by Medtronic, Inc.; FASTR-AF ClinicalTrials.gov; NCT03626649.
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14
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Guan F, Stähli BE, Jakob P, Wolber T. Perforation of Multipolar Electroanatomic Mapping Catheter in the Left Atrial Appendage during Left Atrial Mapping. HeartRhythm Case Rep 2022; 8:615-617. [PMID: 36147715 PMCID: PMC9485658 DOI: 10.1016/j.hrcr.2022.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | | | - Thomas Wolber
- Address reprint requests and correspondence: Dr Thomas Wolber, Arrhythmia and Electrophysiology Division, Department of Cardiology, University Heart Center Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
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15
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Worck R, Sørensen SK, Johannessen A, Ruwald M, Haugdal M, Hansen J. Posterior Wall Isolation in Persistent Atrial Fibrillation Feasibility, Safety, Durability and Efficacy. J Cardiovasc Electrophysiol 2022; 33:1667-1674. [PMID: 35598313 PMCID: PMC9543717 DOI: 10.1111/jce.15556] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/21/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- René Worck
- Copenhagen University Hospital Gentofte, Department of Cardiology, Gentofte Hospitalsvej 1DK2900HellerupDenmark
| | - Samuel K. Sørensen
- Copenhagen University Hospital Gentofte, Department of Cardiology, Gentofte Hospitalsvej 1DK2900HellerupDenmark
| | - Arne Johannessen
- Copenhagen University Hospital Gentofte, Department of Cardiology, Gentofte Hospitalsvej 1DK2900HellerupDenmark
| | - Martin Ruwald
- Copenhagen University Hospital Gentofte, Department of Cardiology, Gentofte Hospitalsvej 1DK2900HellerupDenmark
| | - Martin Haugdal
- Copenhagen University Hospital Gentofte, Department of Cardiology, Gentofte Hospitalsvej 1DK2900HellerupDenmark
| | - Jim Hansen
- Copenhagen University Hospital Gentofte, Department of Cardiology, Gentofte Hospitalsvej 1DK2900HellerupDenmark
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16
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Chen X, Xia Y, Lin Y, Li X, Wang C, Chen Y, Fang P, Liu J. Cryoballoon Ablation for Treatment of Atrial Fibrillation in a Chinese Population: Five-Year Outcomes and Predictors of Recurrence After a Single Procedure. Front Cardiovasc Med 2022; 9:836392. [PMID: 35571157 PMCID: PMC9091437 DOI: 10.3389/fcvm.2022.836392] [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: 12/15/2021] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe 5-year outcomes and predictors of atrial fibrillation (AF) recurrence following cryoballoon (CB) ablation in Chinese population remain scarce. Our aim was to report 5-year outcomes and predictors of AF recurrence following a single CB ablation procedure in a Chinese population.MethodsFrom December 2013 to August 2016, we included 256 consecutive patients (mean age: 58 ± 10.9 years old; female: 41.0%) with paroxysmal or persistent AF successfully underwent first-generation CB ablation at Fuwai hospital in this prospective study. All patients were followed at least 5 years or when there was recurrent AF. Independent predictors of AF recurrence were determined by Cox proportional hazards regression analysis.ResultsThe 5-year success rate after pulmonary vein isolation (PVI) by a single procedure was 59.4%. The recurrence rate was the highest (14.5%) within the first year after the index procedure, and then stabilized. Patients with paroxysmal AF had a higher incidence of freedom from AF recurrence than patients with persistent AF (63.2% vs. 36.4%, log-rank P < 0.01). The overall incidence of complications related to CB ablation was 7.8%. Phrenic nerve injury (PNI) was the most common complication, with an incidence of 3.5%, and patients with PNI were recovered within the 1-year follow-up. Only persistent AF (HR 1.72, 95%CI 1.028–2.854, P < 0.05) was significantly and independently associated with an increased risk of AF recurrence after adjusting for other factors.ConclusionPulmonary vein isolation using CB ablation was safe and effective with an acceptable complication and 5-year success rate in a Chinese population with AF, and persistent AF was the independent predictor for 5-year AF recurrence after a single CB ablation procedure.
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Affiliation(s)
- Xiongbiao Chen
- Department of Cardiology, Peking University Shenzhen Hospital, Shenzhen, China
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Xia
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Yu Xia,
| | - Yuan Lin
- Department of General Practice, School of General Practice and Continuing Education, Capital Medical University, Beijing, China
| | - Xiaofeng Li
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chun Wang
- Department of Cardiology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yanjun Chen
- Department of Cardiology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Pihua Fang
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Liu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Jun Liu,
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Kupusovic J, Kessler L, Nekolla SG, Riesinger L, Weber MM, Ferdinandus J, Kochhäuser S, Rassaf T, Wakili R, Rischpler C, Siebermair J. Visualization of thermal damage using 68 Ga-FAPI-PET/CT after pulmonary vein isolation. Eur J Nucl Med Mol Imaging 2022; 49:1553-1559. [PMID: 34778928 PMCID: PMC8940837 DOI: 10.1007/s00259-021-05612-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/31/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE 68 Ga-fibroblast-activation protein inhibitor (FAPI) positron emission tomography (PET) is a novel technique targeting FAP-alpha. This protein is expressed by activated fibroblasts which are the main contributors to tissue remodeling. The aim of this proof-of-concept study was to assess 68 Ga-FAPI uptake in the pulmonary vein (PV) region of the left atrium after pulmonary vein isolation (PVI) with cryoballoon ablation (CBA) and radiofrequency (RFA) as a surrogate for thermal damage. METHODS Twelve PVI patients (5 RFA, 7 CBA) underwent 68 Ga-FAPI-PET 20.5 ± 12.8 days after PVI. Five patients without atrial fibrillation or previous ablation served as controls. Standardized uptake values of localized tracer uptake were calculated. RESULTS Focal FAPI uptake around the PVs was observed in 10/12 (83.3%) PVI patients, no uptake was observed in 2 PVI patients and all controls. Patients after PVI had higher FAPI uptake in PVs compared to controls (SUVmax: 4.3 ± 2.2 vs. 1.6 ± 0.2, p < 0.01; SUVpeak: 2.9 ± 1.4 vs. 1.3 ± 0.2, p < 0.01). All CBA patients had an intense uptake, while in the RFA, group 2 (40%), 1 (20%), and 2 (40%) patients had an intense, moderate, and no uptake, respectively. We observed higher uptake values (SUVpeak) in CBA compared to RFA patients (4.4 ± 1.5 vs. 2.5 ± 0.8, p = 0.02). CONCLUSION We demonstrate in-vivo visualization of 68 Ga-FAPI uptake as a surrogate for fibroblast activation after PVI. CBA seems to cause more pronounced fibroblast activation following tissue injury than RFA. Future studies are warranted to assess if this modality can contribute to a better understanding of the mechanisms of AF recurrence after PVI by lesion creation and gap assessment.
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Affiliation(s)
- Jana Kupusovic
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Lukas Kessler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Stephan G Nekolla
- Department of Nuclear Medicine, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Lisa Riesinger
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Manuel M Weber
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Justin Ferdinandus
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Simon Kochhäuser
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Reza Wakili
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Christoph Rischpler
- Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Johannes Siebermair
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
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Vrachatis DA, Papathanasiou KA, Kossyvakis C, Kazantzis D, Giotaki SG, Deftereos G, Sanz-Sánchez J, Raisakis K, Kaoukis A, Avramides D, Lambadiari V, Siasos G, Giannopoulos G, Deftereos S. Early arrhythmia recurrence after cryoballoon ablation in atrial fibrillation: a systematic review and meta-analysis. J Cardiovasc Electrophysiol 2021; 33:527-539. [PMID: 34951496 DOI: 10.1111/jce.15337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early arrhythmia recurrence within the three-month blanking period is a common event that historically has been attributed to reversible phenomena. While its' mechanistic links remain obscure, accumulating evidence support the argument of shortening the blanking period. We aimed to elucidate the association between early and late arrhythmia recurrence after atrial fibrillation cryoablation. METHODS The MEDLINE database, ClinicalTrials.gov, medRxiv and Cochrane Library were searched for studies evaluating early and late arrhythmia recurrence rates in patients undergoing cryoablation for AF. Data were pooled by meta-analysis using a random-effects model. The primary endpoint was late arrhythmia recurrence. RESULTS Early arrhythmia recurrence was found predictive of decreased arrhythmia-free survival after evaluating 3975 patients with paroxysmal or persistent atrial fibrillation who underwent cryoablation (OR: 5.31; 95% CI: 3.75-7.51). This pattern remained unchanged after sub-analyzing atrial fibrillation type (paroxysmal; OR: 7.16; 95% CI: 4.40-11.65 and persistent; OR: 7.63; 95% CI: 3.62-16.07) as well as cryoablation catheter generation (first generation; OR: 5.15, 95% CI: 2.39-11.11 and advanced generation; OR: 5.83, 95% CI: 3.68-9.23). Studies permitting anti-arrhythmic drug utilization during blanking period or examining early recurrence as a secondary outcome were found to be a significant source of statistical heterogeneity. CONCLUSION Our findings suggest that early arrhythmia recurrence is predictive of late outcomes after cryoablation for atrial fibrillation. Identifying which patients deserve earlier re-intervention is an open research avenue. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | - Dimitrios Kazantzis
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotiria G Giotaki
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Deftereos
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Greece
| | - Jorge Sanz-Sánchez
- Division of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Centro de Investigacion Biomédica en Red (CIBERCV), Madrid, Spain
| | | | - Andreas Kaoukis
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Greece
| | - Dimitrios Avramides
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Greece
| | - Vaia Lambadiari
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Spyridon Deftereos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
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19
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Clarke JRD, Piccini JP, Friedman DJ. The role of posterior wall isolation in catheter ablation of persistent atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2567-2576. [PMID: 34258794 DOI: 10.1111/jce.15164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/21/2021] [Accepted: 07/09/2021] [Indexed: 11/27/2022]
Abstract
The left atrial posterior wall has many embryologic, anatomic, and electrophysiologic characteristics, that are important for the initiation and maintenance of persistent atrial fibrillation. The left atrial posterior wall is a potential target for ablation in patients with persistent atrial fibrillation, a population in whom pulmonary vein isolation alone has resulted in unsatisfactory recurrence rates. Published clinical studies report conflicting results on the safety and efficacy of posterior wall isolation. Emerging technologies including optimized use of radiofrequency ablation, pulse field ablation, and combined endocardial/epicardial ablation may optimize approaches to posterior wall isolation and reduce the risk of injury to nearby structures such as the esophagus. Critical evaluation of future and ongoing clinical studies of posterior wall isolation requires careful scrutiny of many characteristics, including intraprocedural definition of posterior wall isolation, concomitant extrapulmonary vein ablation, and study endpoints.
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Affiliation(s)
- John-Ross D Clarke
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel J Friedman
- Division of Cardiology, Duke University Medical Center & Duke Clinical Research Institute, Durham, North Carolina, USA
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20
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Shi LB, Wang YC, Chu SY, De Bortoli A, Schuster P, Solheim E, Chen J. The impacts of contact force, power and application time on ablation effect indicated by serial measurements of impedance drop in both conventional and high-power short-duration ablation settings of atrial fibrillation. J Interv Card Electrophysiol 2021; 64:333-339. [PMID: 33891228 PMCID: PMC9399015 DOI: 10.1007/s10840-021-00990-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/05/2021] [Indexed: 11/08/2022]
Abstract
Background This study aimed to clarify the interrelationship and additive effects of contact force (CF), power and application time in both conventional and high-power short-duration (HPSD) settings. Methods Among 38 patients with paroxysmal atrial fibrillation who underwent first-time pulmonary vein isolation, 787 ablation points were collected at the beginning of the procedure at separate sites. Energy was applied for 60 s under power outputs of 25, 30 or 35 W (conventional group), or 10 s when using 50 W (HPSD group). An impedance drop (ID) of 10 Ω was regarded as a marker of adequate lesion formation. Results ID ≥ 10 Ω could not be achieved with CF < 5 g under any power setting. With CF ≥ 5 g, ID could be enhanced by increasing power output or prolonging ablation time. ID for 30 and 35 W was greater than for 25 W (p < 0.05). Ablation with 35 W resulted in greater ID than with 30 W only when CF of 10–20 g was applied for 20–40 s (p < 0.05). Under the same power output, ID increased with CF level at different time points. The higher the CF, the shorter the time needed to reach ID of 10 Ω and maximal ID. ID correlated well with ablation index under each power, except for lower ID values at 25 W. ID with 50 W for 10 s was equivalent to that with 25 W for 40 s, but lower than that with 30 W for 40 s or 35 W for 30 s. Conclusions CF of at least 5 g is required for adequate ablation effect. With CF ≥ 5g, CF, power output, and ablation time can compensate for each other. Time to reach maximal ablation effect can be shortened by increasing CF or power. The effect of HPSD ablation with 50 W for 10 s is equivalent to conventional ablation with 25 W for 40 s and 30–35 W for 20–30 s in terms of ID.
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Affiliation(s)
- Li-Bin Shi
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway
| | - Yu-Chuan Wang
- Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway.,Peking University First Hospital, Beijing, China
| | - Song-Yun Chu
- Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway.,Peking University First Hospital, Beijing, China
| | | | - Peter Schuster
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway
| | - Eivind Solheim
- Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway
| | - Jian Chen
- Department of Clinical Science, University of Bergen, Bergen, Norway. .,Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway.
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21
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Sørensen SK, Johannessen A, Worck R, Hansen ML, Hansen J. Radiofrequency Versus Cryoballoon Catheter Ablation for Paroxysmal Atrial Fibrillation: Durability of Pulmonary Vein Isolation and Effect on Atrial Fibrillation Burden: The RACE-AF Randomized Controlled Trial. Circ Arrhythm Electrophysiol 2021; 14:e009573. [PMID: 33835823 PMCID: PMC8136462 DOI: 10.1161/circep.120.009573] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Recurrent paroxysmal atrial fibrillation (AF) after catheter ablation is presumably caused by failure to achieve durable pulmonary vein isolation (PVI). The primary methods of PVI are radiofrequency catheter ablation (RF) and cryoballoon catheter ablation (CRYO), but these methods have not been directly compared with respect to PVI durability and the effect thereof on AF burden (% of time in AF). Methods: Accordingly, we performed a randomized trial including 98 patients (68% male, 61 [55–67] years) with paroxysmal AF assigned 1:1 to PVI by contact-force sensing, irrigated radiofrequency catheter, or second-generation cryoballoon catheter. Implantable cardiac monitors were inserted ≥1 month before PVI for assessment of AF burden and recurrence, and all patients, irrespective of AF recurrence, underwent a second procedure 4 to 6 months after PVI to determine PVI durability. Results: In the second procedure, 152 out of 199 (76%) pulmonary veins (PVs) were found durably isolated after RF and 161 out of 200 (81%) after CRYO (P=0.32), corresponding to durable isolation of all veins in 47% of patients in both groups (P=1.0). Median AF burden before PVI was 5.4% (interquartile range, 0.5%–13.0%) versus 4.0% (0.6%–18.1%), RF versus CRYO (P=0.71), and reduced to 0.0% (0.0%–0.1%) and 0.0% (0.0%–0.5%), respectively (P=0.58)—a reduction of 99.9% (92.9%–100.0%) and 99.3% (85.9%–100.0%; P=0.36). AF burden after PVI significantly correlated to the number of durably isolated PVs (P<0.01), but 9 out of 45 (20%) patients with durable isolation of all veins had recurrence of AF within 4 to 6 months after PVI (excluding a 3-month blanking period). Conclusions: PVI by RF and CRYO produce similar moderate to high PVI durability. Both treatments lead to marked reductions in AF burden, which is related to the number of durably isolated PVs. However, for one-fifth of paroxysmal AF patients, complete and durable PVI was not sufficient to prevent even short-term AF recurrence. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03805555.
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Affiliation(s)
- Samuel K Sørensen
- Copenhagen University Hospital Gentofte, Gentofte Hospitalsvej 1, Hellerup, Denmark
| | - Arne Johannessen
- Copenhagen University Hospital Gentofte, Gentofte Hospitalsvej 1, Hellerup, Denmark
| | - René Worck
- Copenhagen University Hospital Gentofte, Gentofte Hospitalsvej 1, Hellerup, Denmark
| | - Morten L Hansen
- Copenhagen University Hospital Gentofte, Gentofte Hospitalsvej 1, Hellerup, Denmark
| | - Jim Hansen
- Copenhagen University Hospital Gentofte, Gentofte Hospitalsvej 1, Hellerup, Denmark
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22
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Ortigosa N, Ayala G, Cano Ó. Variation of P-wave indices in paroxysmal atrial fibrillation patients before and after catheter ablation. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Jackson N, Mahmoodi E, Leitch J, Barlow M, Davies A, Collins N, Leigh L, Oldmeadow C, Boyle A. Effect of Outcome Measures on the Apparent Efficacy of Ablation for Atrial Fibrillation: Why "Success" is an Inappropriate Term. Heart Lung Circ 2021; 30:1166-1173. [PMID: 33726997 DOI: 10.1016/j.hlc.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/06/2021] [Accepted: 01/30/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Different endpoint criteria, different durations of follow-up and the completeness of follow-up can dramatically affect the perceived benefits of atrial fibrillation (AF) ablation. METHODS We defined three endpoints for recurrence of AF post ablation in a cohort of 200 patients with symptomatic AF, refractory to antiarrhythmic drugs (AADs). A 'Strict Endpoint' where patients were considered to have a recurrence with any symptomatic or documented recurrence for ≥30 seconds with no blanking period, and off their AADs, a 'Liberal Endpoint' where only documented recurrences after the blanking period, either on or off AADs were counted, and a 'Patient-defined Outcome endpoint' which was the same as the Liberal endpoint but allowed for up to two recurrences and one repeat ablation or DCCV during follow-up. We also surveyed 50 patients on the waiting list for an AF ablation and asked them key questions regarding what they would consider to be a successful result for them. RESULTS Freedom from recurrence of atrial tachyarrhythmias (AT) at 5 years was 62% for the Strict Endpoint, 73% for the Liberal Endpoint, and 80% for the Patient-defined Outcome endpoint (p<0.001). Of the 50 patients surveyed awaiting AF ablation, 70% said they would still consider the procedure a success if it required one repeat ablation or one DCCV (p=0.004), and 76% would be accepting of one or two recurrences during follow-up (p<0.001). CONCLUSION In this study, the majority of patients still considered AF ablation a successful treatment if they had up to two recurrences of AF, one repeat procedure or one DCCV. Furthermore, a 'Patient-defined' definition of success lead to significantly different results in this AF ablation cohort when compared to conventionally used/guideline directed measures of success.
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Affiliation(s)
- Nicholas Jackson
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; The University of Newcastle, Newcastle, NSW, Australia.
| | - Ehsan Mahmoodi
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; The University of Newcastle, Newcastle, NSW, Australia
| | - Jim Leitch
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; The University of Newcastle, Newcastle, NSW, Australia
| | - Malcolm Barlow
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; The University of Newcastle, Newcastle, NSW, Australia
| | - Allan Davies
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia
| | - Nicholas Collins
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; The University of Newcastle, Newcastle, NSW, Australia
| | - Lucy Leigh
- The University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Christopher Oldmeadow
- The University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Andrew Boyle
- Cardiovascular Department, John Hunter Hospital, Newcastle, NSW, Australia; The University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
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24
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Gupta D. Noninvasive assessment of durability of ablation lesions with magnetic resonance imaging: Are we there yet? J Cardiovasc Electrophysiol 2020; 31:2582-2583. [PMID: 32648314 DOI: 10.1111/jce.14661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Dhiraj Gupta
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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25
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Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with considerable morbidity and mortality. Electrically isolating the pulmonary veins from the left atrium by catheter ablation is superior to antiarrhythmic drug therapy for maintaining sinus rhythm, but its success varies depending on multiple factors, including arrhythmic burden. Although procedural outcomes have improved over the years, further gains are limited by a seemingly zero-sum relationship between effectiveness and safety, which is largely a product of the available technologies. Current energies used to create contiguous, transmural, and durable atrial lesions can result in serious complications if they reach the esophagus or phrenic nerve, for instance—structures that can be adjacent to the atrial myocardium, often within millimeters of the energy source. Consequently, high rates of pulmonary vein-left atrium reconnections are consistently seen in clinical studies and in clinical practice as operators appropriately forgo ablation effectiveness to protect patients from harm. However, as ablative technologies evolve to circumvent this stalemate, safer, and more effective pulmonary vein isolation seems increasingly realistic. Furthermore, the innovative nature of these technologies raises the prospect of markedly improved procedural efficiency, which could increase patient comfort, reduce operator occupational injuries, and enhance the use of health resources—all of which are increasingly important considerations particularly as the demand for catheter ablation for atrial fibrillation continues to rise. We herein review 3 promising candidate ablation technologies with the potential to revolutionize the management of patients with atrial fibrillation: electroporation (pulsed-field ablation), expandable lattice-tip radiofrequency ablation/electroporation, and ultra-low temperature cryoablation.
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Affiliation(s)
- F. Daniel Ramirez
- From the University of Bordeaux, CHU Bordeaux, Bordeaux-Pessac, France (F.D.R., M.H., P.J.)
- IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030 (F.D.R., M.H., P.J.)
| | - Vivek Y. Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY (V.Y.R.)
- Homolka Hospital, Prague, Czech Republic (V.Y.R.)
| | | | - Mélèze Hocini
- From the University of Bordeaux, CHU Bordeaux, Bordeaux-Pessac, France (F.D.R., M.H., P.J.)
- IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030 (F.D.R., M.H., P.J.)
| | - Pierre Jaïs
- From the University of Bordeaux, CHU Bordeaux, Bordeaux-Pessac, France (F.D.R., M.H., P.J.)
- IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030 (F.D.R., M.H., P.J.)
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26
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Aryana A. Novel and Emerging Tools and Technologies in Cardiac Electrophysiology: What's on the Horizon in 2020? J Innov Card Rhythm Manag 2020; 10:3944-3948. [PMID: 32494410 PMCID: PMC7252821 DOI: 10.19102/icrm.2019.101206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
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27
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Yamashita K, Kwan E, Kamali R, Ghafoori E, Steinberg BA, MacLeod RS, Dosdall DJ, Ranjan R. Blanking period after radiofrequency ablation for atrial fibrillation guided by ablation lesion maturation based on serial MR imaging. J Cardiovasc Electrophysiol 2020; 31:450-456. [PMID: 31916637 DOI: 10.1111/jce.14340] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/20/2019] [Accepted: 12/26/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recent guidelines recommend a 3-month blanking period after atrial fibrillation (AF) ablations, which are based on clinical observation. Our goal was to quantify the timeline of the radiofrequency ablation lesion maturation using serial late gadolinium enhancement-magnetic resonance imaging (LGE-MRI) and to develop a blanking period estimate based on visible lesion maturation. METHODS Inclusion criteria targeted patients who underwent AF ablation and at least four MRI scans: at baseline before ablation, within 24 hours after (acute), between 24 hours and 90 days after (subacute), and more than 90 days after ablation (chronic). Central nonenhanced (NE) and surrounding hyperenhanced (HE) area volumes were measured and normalized to chronic lesion volume. RESULTS This study assessed 75 patients with 309 MRIs. The acute lesion was heterogeneous with a HE region surrounding a central NE region in LGE-MRI; the acute volume of the total (HE + NE) lesion was 2.62 ± 0.46 times larger than that of the chronic lesion. Acute T2-weighted imaging also showed a relatively large area of edema. Both NE and HE areas gradually receded over time and NE was not observed after 30 days. Larger initial NE volume was associated with a significantly greater chronic scar volume and this total lesion volume receded to equal the chronic lesion size at approximately 72.5 days (95% prediction interval: 57.4-92.2). CONCLUSION On the basis of serial MRI, atrial ablation lesions are often fully mature before the typical 90-day blanking period, which could support more timely clinical decision making for arrhythmia recurrence.
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Affiliation(s)
- Kennosuke Yamashita
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
| | - Eugene Kwan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Roya Kamali
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Elyar Ghafoori
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | | | - Rob S MacLeod
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
| | - Derek J Dosdall
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
- Nora Eccles Harrison, Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah
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28
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Kistler PM, Chieng D. Persistent atrial fibrillation in the setting of pulmonary vein isolation-Where to next? J Cardiovasc Electrophysiol 2019; 31:1857-1860. [PMID: 31778259 DOI: 10.1111/jce.14298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 11/07/2019] [Indexed: 01/07/2023]
Abstract
Catheter ablation for atrial fibrillation (AF) is indicated in symptomatic patients who are intolerant or refractory to antiarrhythmic therapy. However, outcomes from catheter ablation remain suboptimal in patients with persistent AF. Pulmonary vein antral isolation (PVAI) is established as the cornerstone of AF ablation strategies. The landmark STAR AF II study demonstrated a lack of incremental benefit with adjunctive linear and complex fractionated electrogram ablation beyond PVAI. Randomized studies thus far have failed to consistently show favorable outcomes from other trigger/substrate-based ablation approaches over PVAI alone. In this issue of the journal, we pose an interesting clinical scenario-of a middle-aged female who presents with recurrent persistent AF but was found to have enduring PVAI on repeat electrophysiologic study. Which approach should be undertaken next? In this review article, we aim to provide an overview of ablation strategies beyond PVAI. Finally in light of scant randomized data to guide decision making we have approached leading experts in the field to provide their approach to this scenario.
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Affiliation(s)
- Peter M Kistler
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - David Chieng
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
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Bartoletti S, Mann M, Gupta A, Khan AM, Sahni A, El‐Kadri M, Modi S, Waktare J, Mahida S, Hall M, Snowdon R, Todd D, Gupta D. Same‐day discharge in selected patients undergoing atrial fibrillation ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1448-1455. [DOI: 10.1111/pace.13807] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 09/02/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022]
Affiliation(s)
| | - Mandeep Mann
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | - Akanksha Gupta
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | | | - Ankita Sahni
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | - Moutaz El‐Kadri
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
- Sheikh Khalifa Medical City Abu Dhabi United Arab Emirates
| | - Simon Modi
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | - Johan Waktare
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | - Saagar Mahida
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | - Mark Hall
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | | | - Derick Todd
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart And Chest Hospital Liverpool United Kingdom
- Faculty of Health SciencesUniversity of Liverpool United Kingdom
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30
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Pulmonary vein reconnection following cryo-ablation: Mind the "Gap" in the carinae and the left atrial appendage ridge. Indian Pacing Electrophysiol J 2019; 19:125-128. [PMID: 31351896 PMCID: PMC6697485 DOI: 10.1016/j.ipej.2019.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/17/2019] [Indexed: 11/20/2022] Open
Abstract
Pulmonary vein (PV) isolation (PVI) remains cornerstone to ablation of atrial fibrillation (AF). For effective and durable PVI and thus fewer AF recurrences, lesion gaps in transmurality and contiguity responsible for PV reconnection (PVR) could only be addressed when one is cognizant of the potential location and sites where these lesion characteristics may be more prevalent and responsible for PVR. In the case of RF ablation, newer technologies incorporating contact force, time and power with automated monitoring of lesion formation, paying attention to difficult areas (carinae, left superior PV-LAA ridge, right inferior PV) and measuring inter-lesion distance may provide the tools to reduce PVR. On the other hand, the improved thermodynamic characteristics of the latest generation of cryoballloons and operator dexterity to achieve better PV occlusion, may be crucial determinants towards the direction of reduced PVR. Whether newer visualization tools, more vigilant testing during the index ablation procedure in these particular regions, prolonging or adding cryothermic applications, waiting longer to test for entrance and exit block, and/or use of provocative drug testing (isoproterenol/adenosine challenge) might help prevent future PVRs awaits further studies.
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31
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Siebermair J, Neumann B, Risch F, Riesinger L, Vonderlin N, Koehler M, Lackermaier K, Fichtner S, Rizas K, Sattler SM, Sinner MF, Kääb S, Estner HL, Wakili R. High-density Mapping Guided Pulmonary Vein Isolation for Treatment of Atrial Fibrillation - Two-year clinical outcome of a single center experience. Sci Rep 2019; 9:8830. [PMID: 31222008 PMCID: PMC6586935 DOI: 10.1038/s41598-019-45115-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 05/29/2019] [Indexed: 11/11/2022] Open
Abstract
Pulmonary vein isolation (PVI) as interventional treatment for atrial fibrillation (AF) aims to eliminate arrhythmogenic triggers from the PVs. Improved signal detection facilitating a more robust electrical isolation might be associated with a better outcome. This retrospective cohort study compared PVI procedures using a novel high-density mapping system (HDM) with improved signal detection vs. age- and sex-matched PVIs using a conventional 3D mapping system (COM). Endpoints comprised freedom from AF and procedural parameters. In total, 108 patients (mean age 63.9 ± 11.2 years, 56.5% male, 50.9% paroxysmal AF) were included (n = 54 patients/group). Our analysis revealed that HDM was not superior regarding freedom from AF (mean follow-up of 494.7 ± 26.2 days), with one- and two-year AF recurrence rates of 38.9%/46.5% (HDM) and 38.9%/42.2% (COM), respectively. HDM was associated with reduction in fluoroscopy times (18.8 ± 10.6 vs. 29.8 ± 13.4 min; p < 0.01) and total radiation dose (866.0 ± 1003.3 vs. 1731.2 ± 1978.4 cGy; p < 0.01) compared to the COM group. HDM was equivalent but not superior to COM with respect to clinical outcome after PVI and resulted in reduced fluoroscopy time and radiation exposure. These results suggest that HDM-guided PVI is effective and safe for AF ablation. Potential benefits in comparison to conventional mapping systems, e.g. arrhythmia recurrence rates, have to be addressed in randomized trials.
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Affiliation(s)
- J Siebermair
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.,Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - B Neumann
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - F Risch
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany
| | - L Riesinger
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.,Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - N Vonderlin
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - M Koehler
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - K Lackermaier
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany
| | - S Fichtner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany
| | - K Rizas
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - S M Sattler
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,Department of Cardiology, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - M F Sinner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - S Kääb
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany.,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - H L Estner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany
| | - R Wakili
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany. .,Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Munich, Germany. .,German Cardiovascular Research Center (DZHK), partner site: Munich Heart Alliance, Munich, Germany.
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32
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Jilek C, Ullah W. Pulmonary vein reconnections or substrate in the left atrium: what is the reason for atrial fibrillation recurrences? A dialogue on a pressing clinical situation. Europace 2019; 21:i12-i20. [DOI: 10.1093/europace/euy289] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 01/05/2019] [Indexed: 01/08/2023] Open
Affiliation(s)
- Clemens Jilek
- Internistisches Klinikum München Süd, Peter-Osypka-Heart Centre, Munich, Germany
| | - Waqas Ullah
- Cardiology Department, University Hospital Southampton, National Health Service Foundation Trust, Southampton, UK
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33
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Hussein A, Das M, Riva S, Morgan M, Ronayne C, Sahni A, Shaw M, Todd D, Hall M, Modi S, Natale A, Dello Russo A, Snowdon R, Gupta D. Use of Ablation Index-Guided Ablation Results in High Rates of Durable Pulmonary Vein Isolation and Freedom From Arrhythmia in Persistent Atrial Fibrillation Patients. Circ Arrhythm Electrophysiol 2018; 11:e006576. [DOI: 10.1161/circep.118.006576] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ahmed Hussein
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Moloy Das
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom (M.D.)
| | - Stefania Riva
- Centro Cardiologico Monzino, Milan, Italy (S.R., A.D.R.)
| | - Maureen Morgan
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Christina Ronayne
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Ankita Sahni
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Matthew Shaw
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Derick Todd
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Mark Hall
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Simon Modi
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | | | | | - Richard Snowdon
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
| | - Dhiraj Gupta
- Department of Cardiology, Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, England, United Kingdom (A.H., M.M., C.R., A.S., M.S., D.T., M.H., S.M., R.S., D.G.)
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34
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Chubb H, Aziz S, Karim R, Sohns C, Razeghi O, Williams SE, Whitaker J, Harrison J, Chiribiri A, Schaeffter T, Wright M, O’Neill M, Razavi R. Optimization of late gadolinium enhancement cardiovascular magnetic resonance imaging of post-ablation atrial scar: a cross-over study. J Cardiovasc Magn Reson 2018; 20:30. [PMID: 29720202 PMCID: PMC5932811 DOI: 10.1186/s12968-018-0449-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 04/04/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) imaging may be used to visualize post-ablation atrial scar (PAAS), and three-dimensional late gadolinium enhancement (3D LGE) is the most widely employed technique for imaging of chronic scar. Detection of PAAS provides a unique non-invasive insight into the effects of the ablation and may help guide further ablation procedures. However, there is evidence that PAAS is often not detected by CMR, implying a significant sensitivity problem, and imaging parameters vary between leading centres. Therefore, there is a need to establish the optimal imaging parameters to detect PAAS. METHODS Forty subjects undergoing their first pulmonary vein isolation procedure for AF had detailed CMR assessment of atrial scar: one scan pre-ablation, and two scans post-ablation at 3 months (separated by 48 h). Each scan session included ECG- and respiratory-navigated 3D LGE acquisition at 10, 20 and 30 min post injection of a gadolinium-based contrast agent (GBCA). The first post-procedural scan was performed on a 1.5 T scanner with standard acquisition parameters, including double dose (0.2 mmol/kg) Gadovist and 4 mm slice thickness. Ten patients subsequently underwent identical scan as controls, and the other 30 underwent imaging with a reduced, single, dose GBCA (n = 10), half slice thickness (n = 10) or on a 3 T scanner (n = 10). Apparent signal-to-noise (aSNR), contrast-to-noise (aCNR) and imaging quality (Likert Scale, 3 independent observers) were assessed. PAAS location and area (%PAAS scar) were assessed following manual segmentation. Atrial shells with standardised %PAAS at each timepoint were then compared to ablation lesion locations to assess quality of scar delineation. RESULTS A total of 271 3D acquisitions (out of maximum 280, 96.7%) were acquired. Likert scale of imaging quality had high interobserver and intraobserver intraclass correlation coefficients (0.89 and 0.96 respectively), and showed lower overall imaging quality on 3 T and at half-slice thickness. aCNR, and quality of scar delineation increased significantly with time. aCNR was higher with reduced, single, dose of GBCA (p = 0.005). CONCLUSION 3D LGE CMR atrial scar imaging, as assessed qualitatively and quantitatively, improves with time from GBCA administration, with some indices continuing to improve from 20 to 30 min. Imaging should be performed at least 20 min post-GBCA injection, and a single dose of contrast should be considered. TRIAL REGISTRATION Trial registry- United Kingdom National Research Ethics Service 08/H0802/68 - 30th September 2008.
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Affiliation(s)
- Henry Chubb
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Shadman Aziz
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Rashed Karim
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Christian Sohns
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Orod Razeghi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - James Harrison
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Tobias Schaeffter
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Matthew Wright
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
- Department of Cardiology, St Thomas’ Hospital, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas’ Hospital, Westminster Bridge Road, London, SE1 7EH UK
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