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Lianru Z, Yu Z, Jia K, Yinmin X, ChengLi S. A Computational and Experimental Study to Compare the Effectiveness of Bipolar Mode With Phase-Shift Angle Mode in Radiofrequency Fat Dissolution on Subcutaneous Tissue. Lasers Surg Med 2021; 53:1395-1412. [PMID: 34036607 DOI: 10.1002/lsm.23420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/02/2021] [Accepted: 05/09/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Radiofrequency (RF) energy exposure refers to a popular non-invasive method employed to generate heat in cutaneous and subcutaneous tissues. RF thermal stimulation of adipose tissue has been considered to cause adipocyte metabolism and enzymatic degradation of triglycerides into free fatty acids and glycerol. Bipolar mode (BM) has achieved extensive applications in clinical studies on RF fat dissolution, whereas BM has a less penetration depth than monopolar, result in a higher RF voltage that may be required to increase power to the deeper fat layer of the subcutaneous tissue, and improper power control may easily cause the skin layer to be thermally damaged. To tackle down the mentioned defect, a novel phase-shift angle mode (PM) was proposed in this study based on double-channel bipolar RF. By employing the finite element method (FEM) and performing the ex vivo experiment, the effectiveness of BM was compared with that of PM in RF fat dissolution on subcutaneous tissue. In addition, this study attempted to develop reasonable phase-shift angles capable of achieving fat dissolution effects, while the RF energy of which would not cause the skin layer to be thermally damaged. STUDY DESIGN/MATERIALS AND METHODS Two electrode spacings (1 and 2 cm) were applied in BM (BM-1 cm and BM-2 cm, respectively), and six phase-shift angles (i.e., 30°, 60°, 90°, 120°, 150°, and 180°) were set in PM (i.e., PM-30°, PM-60°, PM-90°, PM-120°, PM-150°, and PM-180°). In addition, COMSOL was adopted to conduct a finite element analysis for achieving thermoelectric coupling. Ex vivo experiments were performed with a self-developed double-channel bipolar RF device, through which up to two adjustable phase-shift angle sinusoidal voltages could be generated. Such a device was isolated with a transformer and then connected to four electrodes with a 5 mm diameter contacting the ex vivo porcine abdominal tissue. RESULTS Under the RF voltage amplitude of 30 V, and after 1800 seconds of RF heating, no thermally damaged area was formed in the tissue in BM-1 cm and BM-2 cm; in PM-30°, PM-60°, and PM-90°, thermally damaged areas were formed in the fat layer, while the skin layer was not located in the thermally damaged area. Moreover, the temperature in the thermally damaged area attributed to the mentioned three conditions may satisfy the requirement of fat dissolution temperature. CONCLUSIONS Under the identical RF voltage and heating time, PM is easier to cause the fat layer of the subcutaneous tissue to be thermally damaged as compared with BM. Accordingly, PM may be enabled to achieve the fat dissolution effect under a relatively low RF voltage as opposed to BM, thus avoiding the possibility of thermal damage of the skin layer attributed to the use of higher RF voltage. In PM, different phase-shift angle significantly affects the electrical and thermal properties of RF energy applied on subcutaneous tissue; the phase-shift angle of RF voltage is likely to be regulated for fat dissolution effect, while the RF energy of which will not cause the skin layer to be thermally damaged.© 2021 Wiley Periodicals LLC.
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Affiliation(s)
- Zang Lianru
- Shanghai Institute for Minimally Invasive Therapy, University of Shanghai for Science and Technology, 516 Jungong Road, 200082, Shanghai, China
| | - Zhou Yu
- Shanghai Institute for Minimally Invasive Therapy, University of Shanghai for Science and Technology, 516 Jungong Road, 200082, Shanghai, China
| | - Kang Jia
- Shanghai Institute for Minimally Invasive Therapy, University of Shanghai for Science and Technology, 516 Jungong Road, 200082, Shanghai, China
| | - Xue Yinmin
- Shanghai Institute for Minimally Invasive Therapy, University of Shanghai for Science and Technology, 516 Jungong Road, 200082, Shanghai, China
| | - Song ChengLi
- Shanghai Institute for Minimally Invasive Therapy, University of Shanghai for Science and Technology, 516 Jungong Road, 200082, Shanghai, China
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Yu HT, Jeong DS, Pak HN, Park HS, Kim JY, Kim J, Lee JM, Kim KH, Yoon NS, Roh SY, Oh YS, Cho YJ, Shim J. 2018 Korean Guidelines for Catheter Ablation of Atrial Fibrillation: Part II. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, (Natasja) de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20:e1-e160. [PMID: 29016840 PMCID: PMC5834122 DOI: 10.1093/europace/eux274] [Citation(s) in RCA: 681] [Impact Index Per Article: 113.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hugh Calkins
- From the Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N(N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275-e444. [PMID: 28506916 PMCID: PMC6019327 DOI: 10.1016/j.hrthm.2017.05.012] [Citation(s) in RCA: 1293] [Impact Index Per Article: 184.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B. Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | | | - D. Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D. Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M. Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E. Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
INTRODUCTION Over the last decade, tremendous progress has been made in defining the genetic architecture of atrial fibrillation (AF). This has in part been driven by poor understanding of the pathophysiology of AF, limitations of current therapies and failure to target therapies to the underlying mechanisms. AREAS COVERED Genetic approaches to AF have identified mutations encoding cardiac ion channels, and signaling proteins linked with AF and genome-wide association studies have uncovered common genetic variants modulating AF risk. These studies have provided important insights into the underlying mechanisms of AF and defined responses to therapies. Common AF-risk alleles at the chromosome 4q25 locus modulate response to antiarrhythmic drugs, electrical cardioversion and catheter ablation. While the translation of these discoveries to the bedside care of individual patients has been limited, emerging evidence supports the hypothesis that genotype-directed approaches that target the underlying mechanisms of AF may not only improve therapeutic efficacy but also minimize adverse effects. Expert commentary: There is an urgent need for randomized controlled trials that are genotype-based for the treatment of AF. Nonetheless, emerging data suggest that selecting therapies for AF that are genotype-directed may soon be upon us.
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Affiliation(s)
- Henry Huang
- a Division of Cardiology, Department of Medicine , University of Illinois at Chicago , Chicago , IL , USA
| | - Dawood Darbar
- a Division of Cardiology, Department of Medicine , University of Illinois at Chicago , Chicago , IL , USA
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Nishida K, Datino T, Macle L, Nattel S. Atrial Fibrillation Ablation. J Am Coll Cardiol 2014; 64:823-31. [DOI: 10.1016/j.jacc.2014.06.1172] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 10/24/2022]
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2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33:171-257. [PMID: 22382715 DOI: 10.1007/s10840-012-9672-7] [Citation(s) in RCA: 256] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14:528-606. [PMID: 22389422 DOI: 10.1093/europace/eus027] [Citation(s) in RCA: 1130] [Impact Index Per Article: 94.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJG, Damiano RJ, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm 2012; 9:632-696.e21. [PMID: 22386883 DOI: 10.1016/j.hrthm.2011.12.016] [Citation(s) in RCA: 1284] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Indexed: 12/20/2022]
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Efficacy of hybrid therapy in the form of right atrial ablation and adjunctive therapy in refractory atrial fibrillation in symptomatic patients. Am J Ther 2010; 19:e18-20. [PMID: 20720486 DOI: 10.1097/mjt.0b013e3181e7a501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Symptomatic atrial fibrillation is often treated with antiarrhythmic drugs. Responsiveness is poor and adverse effects common. Nonpharmacologic treatments consisting of the Maze procedure and catheter-based pulmonary vein isolation are highly successful but invasive with complications. Right atrial ablation is relatively simple in comparison. Success ranges between 20% and 80%. Some studies have shown improved response when combined with antiarrhythmic drugs (AADs). We performed a review of available literature to determine the efficacy of hybrid therapy in the form of right atrial ablation, AAD with cardioversion, and pacing in reducing atrial fibrillation burden. All human studies studying efficacy of right atrial ablation and postablation AAD therapy in refractory atrial fibrillation were considered. The primary outcome was reduction of atrial fibrillation burden. The secondary outcome was significant adverse events. We searched Medline, EMBASE, CINAHL, and Cochrane databases. Data collection, analysis, and selection of studies were done independently by two review authors. We included six studies with variable numbers of participants and outcomes. We defined success of hybrid therapy as reduced burden of atrial fibrillation. Total subjects studied was 189, 26% female and 74% male. Average age was 58 years. Left atrial diameter was less than 5 cm and mean ejection fraction was 64%. Mean atrial fibrillation duration was 3.35 years. Most patients had failed at least two AADs. Hybrid therapy was successful in 82% patients. All forms of hybrid therapy consisting of right atrial ablation and AAD therapy seem to be reasonably effective in relief of symptoms from refractory atrial fibrillation with minimal side effects; however, much larger randomized trials need to be performed before a significant superiority of any one may be established.
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Perrin DP, Vasilyev NV, Novotny P, Stoll J, Howe RD, Dupont PE, Salgo IS, del Nido PJ. Image guided surgical interventions. Curr Probl Surg 2009; 46:730-66. [PMID: 19651287 DOI: 10.1067/j.cpsurg.2009.04.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Douglas P Perrin
- Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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Nonpharmacologic therapy of atrial fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2008. [DOI: 10.1007/s12170-008-0065-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Affiliation(s)
- Davina Banner
- University of the West of England, Bristol
- University Northern British Columbia, Prince George, Canada
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Abstract
Atrial fibrillation (AF) undoubtedly has become one of the most well studied arrhythmias today in terms of pathophysiology and diagnostic and therapeutic (interventional) electrophysiology. Although it lends itself to an apparently easy diagnosis on a surface ECG, myriad electromechanical mechanisms underlie its origin. An era of technology has been reached that makes AF not only "treatable" but also potentially "curable." This article aims at walking through the historical corridors and maze that have led to the present-day understanding of this most common yet complex arrhythmia.
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Affiliation(s)
- Atul Khasnis
- Michigan State University, Thoracic and Cardiovascular Institute, Sparrow Health System, 405 West Greenlawn, Suite 400, Lansing, MI 48910, USA
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Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJG, Damiano RJ, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007; 4:816-61. [PMID: 17556213 DOI: 10.1016/j.hrthm.2007.04.005] [Citation(s) in RCA: 886] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Erdogan A, Walleck E, Rueckleben S, Neumann T, Tillmanns HH, Waldecker B, Hoelschermann H, Heidt M. Comparison between pulsed and continuous radiofrequency delivery. J Interv Card Electrophysiol 2006; 20:21-4. [PMID: 17165135 DOI: 10.1007/s10840-006-9008-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 04/30/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Potentials arising in the pulmonary veins (PV) have been proposed to be a trigger of atrial fibrillation. Percutaneously, the best results for curative treatment of atrial fibrillation have been achieved by segmental or circumferential isolation of the PV. The purpose of our study was to determine the feasibility of ostial pulmonary vein isolation and to compare continuous radiofrequency (RF) with pulsed RF concerning homogeneity and transmurality of produced lesions. MATERIALS AND METHODS In vivo tests were performed in seven anesthetized and ventilated pigs. Under fluoroscopy and guided by intracardiac electrograms each of the 28 pulmonary veins was targeted for circumferential isolation near its ostium. After the continuous energy application in one PV-ostium the catheter was placed into the next PV-ostium and the same procedure was repeated using pulsed energy. The ablations were performed with an octapolar circumferential ablation catheter, with either continuous RF energy delivery to each electrode for 120 s or pulsed energy delivery to four electrodes simultaneously with a 5 ms duty cycle. Lesion diameter was measured with a microcaliper and homogeneity classified from 1 (highest) to 4 (least). RESULTS More homogeneous lesions were produced in significantly less time with pulsed rather than with continuous energy delivery. There were no significant differences in impedance or temperature of the electrodes. We did not observe tissue carbonization or "popping," pulmonary vein stenosis, pericardial effusion/perforation at any time. CONCLUSION Ostial ablation of the PV with pulsed energy delivery proved feasible. It was the faster and more reliable method of creating linear circumferential lesions with a maximum amount of homogeneity and transmurality. We observed no elevated risk of PV stenosis during our experiments.
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Affiliation(s)
- Ali Erdogan
- Justus-Liebig-University of Giessen, Department of Cardiology/Angiology, 35392, Giessen, Germany.
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Abstract
Following the advent of the surgical maze procedure, several catheter techniques have been developed to provide permanent prophylaxis against atrial fibrillation. These noninvasive techniques work by compartmentalizing the atria, by ablating the arrhythmogenic foci, or by isolating the atria from these foci. Although still at an early stage of development, preliminary results using focal ablation and circumferential ablation show extreme promise.
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Affiliation(s)
- Fu Siong Ng
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, U.K
| | - Ajohn Camm
- Department of Cardiological Sciences, St. George's Hospital Medical School, London, U.K
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Abstract
Since cases were first reported in 1994, catheter ablation of atrial fibrillation has undergone rapid development and expansion. The procedure began as an attempt to recreate the Maze III operation with a catheter technique. Understanding the contribution of the pulmonary veins to the initiation and maintenance of atrial fibrillation led to dramatic changes in procedural technique. The segmental ostial and the circumferential approaches have emerged as the 2 dominant methods. Efforts continue in academic centers to better understand the pathophysiology of the arrhythmia and to further refine the ablation procedure to improve patient outcomes.
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Affiliation(s)
- Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Park HW, Cho SH, Kim KH, Cho JG. Disseminated Intravascular Coagulation as a Complication of Radiofrequency Catheter Ablation of Atrial Fibrillation. J Cardiovasc Electrophysiol 2005; 16:1011-3. [PMID: 16174024 DOI: 10.1111/j.1540-8167.2005.40800.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Since Haissaguerre and his colleagues demonstrated the importance of the pulmonary veins in the generation of atrial fibrillation (AF) in 1998, a variety of different ablative interventions have been performed to eliminate AF. Various complications related to catheterization, ablation itself including pulmonary vein stenosis, pericardial effusion, stroke, and atrioesophageal fistula have been reported. Disseminated intravascular coagulation (DIC) is a systemic syndrome characterized by enhanced activation of coagulation with some intravascular fibrin formation and deposition. This is the first report, to our knowledge, of a patient whose condition was complicated by DIC after segmental ostial isolation of pulmonary veins for persistent AF. The patient has completely recovered from the DIC by hemodialysis, administration of blood constituents for 15 days.
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Affiliation(s)
- Hyung-Wook Park
- Division of Cardiology, The Heart Center, Chonnam National University Hospital, The Research Institute of Medical Sciences, Chonnam National University, Gwangju, Korea
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Su WW, Johnson SB, Jain MK, Hall J, Packer DL. Creating Continuous Linear Lesions in the Atria: A Comparison of the Multipolar Ablation Technique Versus the Conventional Drag-and-Burn. J Cardiovasc Electrophysiol 2005; 16:905-11. [PMID: 16101635 DOI: 10.1111/j.1540-8167.2005.40821.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Catheter-based treatment of atrial fibrillation (AF) requires the isolation of the triggering foci as well as modification of the atria with substrate that sustains AF. The creation of linear lesions in the left atrium with standard radiofrequency ablative methods requires long procedural times with unpredictable results. METHODS The simultaneous delivery of phase-shifted radiofrequency energy from a multipolar catheter was compared to the conventional drag-and-burn technique for creating linear lesions in 10 dogs. Four atrial sites were targeted under intracardiac ultrasound and fluoroscopic guidance in each of 10 dogs. The conventional drag-and-burn technique or the multipolar phase-shifted ablation catheter was randomly applied for 60 seconds and compared. RESULTS Creating linear lesions using the simultaneous multipolar phase-shifted ablation catheter was on average 11.0 minutes faster (33.6 minutes vs 44.6 minutes, P < 0.01) than the drag-and-burn method. The fraction of the lesion length achieved using phase-shifted ablation compared to that intended was 23% greater (76% vs 53%, P < 0.01), and has less discontinuities (0.1 compared to 0.8 discontinuities/line, P < 0.003). There was no significant difference in either the lesion transmurality, or fluoroscopy times. CONCLUSION The simultaneous delivery of phase-shifted, radiofrequency energy using a multipolar catheter is more effective and efficient in producing linear lesions than the traditional drag-and-burn technique. Using the multipolar ablative method to create linear lesions may be a useful technique in the treatment of patients with substrate-mediated atrial fibrillation.
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Affiliation(s)
- Wilber W Su
- Division of Cardiology, Department of Internal Medicine, Mayo Foundation, Rochester, Minnesota, USA
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Fahey BJ, Nightingale KR, McAleavey SA, Palmeri ML, Wolf PD, Trahey GE. Acoustic radiation force impulse imaging of myocardial radiofrequency ablation: initial in vivo results. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2005; 52:631-41. [PMID: 16060512 DOI: 10.1109/tuffc.2005.1428046] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Acoustic radiation force impulse (ARFI) imaging techniques were used to monitor radiofrequency (RF) ablation of ovine cardiac tissue in vivo. Additionally, ARFI M-mode imaging methods were used to interrogate both healthy and ablated regions of myocardial tissue. Although induced cardiac lesions were not visualized well in conventional B-mode images, ARFI images of ablation procedures allowed determination of lesion location, shape, and relative size through time. The ARFI M-mode images were capable of distinguishing differences in behavior through the cardiac cycle between healthy and damaged tissue regions. As conventional sonography is often used to guide ablation catheters, ARFI imaging, which requires no additional equipment, may be a convenient modality for monitoring lesion formation in vivo.
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Affiliation(s)
- Brian J Fahey
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.
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Kocheril AG, Calkins H, Sharma AD, Cher D, Stubbs HA, Block JE. Hybrid Therapy with Right Atrial Catheter Ablation and Previously Ineffective Antiarrhythmic Drugs for the Management of Atrial Fibrillation. J Interv Card Electrophysiol 2005; 12:189-97. [PMID: 15875109 DOI: 10.1007/s10840-005-0620-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2004] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many patients with paroxysmal atrial fibrillation (AF) become refractory to antiarrhythmic drugs (AADs). Early studies suggested that linear catheter ablation in the right atrium may provide sufficient substrate modification to reestablish therapeutic efficacy of previously ineffective AADs. METHODS This prospective before-after multicenter trial evaluated the safety and effectiveness of hybrid therapy that included right atrial catheter ablation coupled with a regimen of previously ineffective AADs on AF episode frequency and symptoms in drug refractory patients with paroxysmal AF. A standard linear lesion set (lateral, septal, isthmus) was used in all subjects. AF episode frequency, clinical arrhythmia symptoms, condition-specific (AFSS) and global health-related quality of life (SF-36) were assessed prior to ablation and at 6 months. RESULTS Ninety-three subjects, refractory to an average 2.9 AADs at baseline, qualified for inclusion and underwent right atrial catheter ablation. Eighty-four subjects (90%) provided 6 month AF episode frequency data which demonstrated a significant decrease compared to baseline (3.4 vs. 9.5, p < 0.0001). Forty-nine subjects (58%) were considered a clinical success by virtue of achieving a pre-specified target level episode frequency reduction of 50% or greater. Substantial and statistically significant improvements were realized almost uniformly for all measured arrhythmia symptoms as well as for both quality of life measures. The incidence of major complications was 5.4%. CONCLUSIONS The addition of right atrial catheter ablation to a regimen of previously ineffective AADs is associated with a significant reduction in the frequency, duration and severity of AF episodes and symptoms.
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Affiliation(s)
- Abraham G Kocheril
- Section of Cardiac Electrophysiology, Carle Heart Center and University of Illinois, Urbana, 61801, USA.
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Bunch TJ, Bruce GK, Johnson SB, Sarabanda A, Milton MA, Packer DL. Analysis of Catheter-Tip (8-mm) and Actual Tissue Temperatures Achieved During Radiofrequency Ablation at the Orifice of the Pulmonary Vein. Circulation 2004; 110:2988-95. [PMID: 15505085 DOI: 10.1161/01.cir.0000146905.19945.99] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Many ablative approaches in or near the orifice of the pulmonary vein (PV) have demonstrated success in eliminating atrial fibrillation. Despite current practice, there are no data regarding the in vivo efficacy and safety of an 8-mm catheter tip for ablation at the PV orifice.
Methods and Results—
Ten mongrel dogs were studied. Thermocouples were implanted in the atrial muscle of the PV orifice. Intracardiac echocardiography monitored catheter position, tip/tissue orientation, and microbubble formation. Ninety-four ablations were performed for 120 seconds. A temperature discrepancy >10°C between the catheter tip and tissue occurred during 47 (50%) of the ablations. Despite termination of energy delivery, the average tissue temperature remained within 1°C of the achieved steady state for 9 seconds. A temperature discrepancy >10°C was more common in the right superior PV, with oblique catheter positioning, when tissue temperatures were >60°C or 80°C, and with type 1 or type 2 microbubble formation. However, microbubbles were not present in 7 (13%, type 1) and 10 (40%, type 2) ablations with tissue temperatures >80°C. The maximum tissue temperature achieved with non–full-thickness lesions was 47.3±7.4°C vs 75.9±11.7°C (
P
<0.0001) for full-thickness lesions.
Conclusions—
Marked discrepancies between catheter-tip and tissue temperatures occurred with higher temperatures, prolonged ablation times, and unfavorable catheter thermistor–tissue contact. Also, these data suggest a conservative approach to atrial ablation, because full-thickness lesions were obtained when tissue temperatures reached 50°C to 60°C and the tissue retained high heat levels despite termination of radiofrequency energy. Finally, microbubbles are inconsistent markers of tissue overheating.
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Affiliation(s)
- T Jared Bunch
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic, Rochester, Minn 55902, USA
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Magnano AR, Woollett I, Garan H. Percutaneous Catheter Ablation Procedures for the Treatment of Atrial Fibrillation. J Card Surg 2004; 19:188-95. [PMID: 15151643 DOI: 10.1111/j.0886-0440.2004.04035.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In light of the significant morbidity and mortality from atrial fibrillation (AF), there has been significant interest in the development of percutaneous catheter ablation procedures for the suppression of AF. Given the success of the surgical Maze procedure, initial catheter-based approaches involved creation of linear atrial lesions. Success rates were low and utility was limited by a high complication rate and long procedural times. The recent discovery that AF is often initiated by atrial ectopic beats has resulted in therapies designed to target the ectopic sources, particularly those within the pulmonary veins. Experience and technological advances have improved the efficacy and safety of such procedures. This article will review catheter ablation procedures for the maintenance of sinus rhythm in patients with AF.
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Affiliation(s)
- Anthony R Magnano
- Department of Medicine, Clinical Cardiac Electrophysiology Laboratory, New York Presbyterian Hospital-Columbia University, New York, New York 10032, USA
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Weinstock J, Wang PJ, Homoud MK, Link MS, Estes NAM. Clinical results with catheter ablation: AV junction, atrial fibrillation and ventricular tachycardia. J Interv Card Electrophysiol 2003; 9:275-88. [PMID: 14574041 DOI: 10.1023/a:1026205028816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
With the limitations of pharmacologic and device therapies for atrial fibrillation and ventricular tachycardia, catheter ablation is assuming a larger role in the management of patients with these common arrhythmias. Multiple case series and clinical trials have helped to define the evolving role of these techniques for ablation of the atrioventricular node, atrial fibrillation, and ischemic ventricular tachycardia. Based on very low complication rates, excellent efficacy and proven outcomes with radiofrequency ablation of the atrioventricular node, this approach with permanent pacing should play a larger role in the treatment of symptomatic patients with permanent atrial fibrillation. While linear ablation of atrial fibrillation has limited clinical utility for the treatment of this common arrhythmia, the results of multiple case series of focal atrial fibrillation ablation indicate the potential for an expanding role of this curative technique. Catheter ablation techniques for ventricular tachycardia in the setting of coronary artery disease have a role as supplemental therapy to the implantable cardioverter defibrillator in patients with recurrent pharmacologically refractory ventricular arrhythmias requiring frequent device interventions.
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Affiliation(s)
- Jonathan Weinstock
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Tufts University School of Medicine, Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111, USA
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Sanchez JE, Plumb VJ, Epstein AE, Kay GN. Evidence for longitudinal and transverse fiber conduction in human pulmonary veins: relevance for catheter ablation. Circulation 2003; 108:590-7. [PMID: 12874187 DOI: 10.1161/01.cir.0000081771.39010.60] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Segmental ostial ablation of the pulmonary veins (PVs) allows for successful control of paroxysmal atrial fibrillation in many patients. We hypothesized that mapping of the left atrial-PV junction with a 64-electrode basket catheter would allow characterization of conduction patterns that would identify sites where ablation is required to electrically isolate the PV. METHODS AND RESULTS A 64-electrode basket catheter was used to map the PVs of 50 patients undergoing PV isolation procedures for the treatment of atrial fibrillation. Activation along each spline was classified as reflecting either longitudinal, transverse, or no activation. A longitudinal activation pattern recorded along a spline during sinus rhythm in right-sided PV and during CS pacing in left-sided PV before the delivery of any RF energy application had a sensitivity and specificity for a required ostial ablation site of 83% and 82%, respectively. When longitudinal activation along the spline was present during preablation recordings in both sinus rhythm and CS pacing, the sensitivity and specificity were 92% and 90%, respectively. A longitudinal activation pattern after the first RF application that produced a change in PV activation sequence had a sensitivity and specificity for sites where further ablation was required of 91% and 94%, respectively. CONCLUSIONS Mapping of PV activation with a 64-electrode basket catheter allows characterization of conduction patterns that predict requirement for ablation. The presence of a longitudinal activation pattern is a strong predictor of ostial sites where ablative energy is required to electrically isolate the PV.
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Affiliation(s)
- Javier E Sanchez
- University of Alabama at Birmingham, 321G Tinsley Harrison Tower, Birmingham, Ala, USA.
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Wood MA, Ellenbogen KA, Hall J, Kay GN. Post-pericardiotomy syndrome following linear left atrial radiofrequency ablation. J Interv Card Electrophysiol 2003; 9:55-7. [PMID: 12975573 DOI: 10.1023/a:1025376605807] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Post-pericardiotomy syndrome may occur after traumatic insults to the pericardium but has not been reported after radiofrequency catheter (RF) ablation. A 54 year old man underwent extensive linear left atrial RF ablation for chronic atrial fibrillation. Five days after the procedure the patient developed signs and symptoms of the post-pericardiotomy syndrome and showed new, intense pericardial inflammation on magnetic resonance imaging. After intensive medical management, the patient recovered fully. It is believed that the patient experienced a unique complication of linear left atrial ablation, i.e., post-pericardiotomy syndrome due to extensive left atrial necrosis or direct thermal pericardial injury.
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Affiliation(s)
- Mark A Wood
- Medical College of Virginia, Box 980053, Richmond, VA 23298-0053, USA
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Affiliation(s)
- Andrew E Epstein
- Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Tinsley Harrison Tower 321L, 1530 3rd Avenue South, Birmingham, AL 35294-0006, USA.
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Fuller IA, Wood MA. Intramural coronary vasculature prevents transmural radiofrequency lesion formation: implications for linear ablation. Circulation 2003; 107:1797-803. [PMID: 12665492 DOI: 10.1161/01.cir.0000058705.97823.f4] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Blood flow near a radiofrequency (RF) lesion can reduce lesion size by convective cooling. It is unknown whether blood flow through small vasculature within an RF lesion can prevent transmural lesion formation. METHODS AND RESULTS In 40 rabbit right ventricle preparations, 2 epicardial RF lesions were created straddling a selectively perfused (0 to 12 mL/min) marginal artery (diameter, 0.34+/-0.1 mm). RF lesions were created at either 60 degrees C or 80 degrees C and delivered either sequentially or simultaneously. Conduction through the lesion area was measured. The lesions were analyzed histologically. At a perfusion rate of 0 mL/min, all RF lesions were transmural and without conduction. As little as 1 mL of flow through the artery during RF delivery could prevent transmural lesion formation by preserving a cuff of tissue along the length of the vessel. High-energy delivery (45 W) and very high tissue temperatures (93 degrees C) were needed to overcome the protective effect of vascular perfusion at 12 mL/min. The volume of preserved myocardium was related to arterial perfusion rate, artery diameter, and lesion temperature but not to the sequence of RF delivery (sequential versus simultaneous). Conduction persisted through the RF lesion in 20 experiments. Conduction through the lesion was related to the arterial perfusion rate and volume or cross-sectional area of preserved myocardium. CONCLUSIONS Flow through even small intramyocardial vessels can prevent transmural lesion formation and preserve conduction through an RF lesion. These findings may represent an unrecognized obstacle to the creation of linear RF lesions in the clinical setting.
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Affiliation(s)
- Ithiel A Fuller
- Virginia Commonwealth University's Medical College of Virginia, Richmond, USA
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Sanchez JE, Kay GN, Benser ME, Hall JA, Walcott GP, Smith WM, Ideker RE. Identification of transmural necrosis along a linear catheter ablation lesion during atrial fibrillation and sinus rhythm. J Interv Card Electrophysiol 2003; 8:9-17. [PMID: 12652172 DOI: 10.1023/a:1022315308803] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Determining whether a linear catheter radio frequency (RF) ablation lesion is transmural may be difficult, especially during atrial fibrillation. We hypothesized that changes in pacing thresholds and electrogram amplitude during atrial fibrillation and sinus rhythm could be used to assess whether a radiofrequency ablation resulted in transmural necrosis. METHODS A hexapolar, linear, RF ablation catheter was positioned between the caval veins in the right atrium of seven sheep. Pacing thresholds and electrogram amplitudes during atrial fibrillation and sinus rhythm were measured before and after the application of RF energy. Sites along the linear lesion were assessed histologically. RESULTS The electrogram amplitude in atrial fibrillation decreased significantly more at transmural sites (unipolar recording: 33 +/- 11% transmural vs. 22 +/- 13% non-transmural, p < or = 0.01; bipolar recording: 62 +/- 9% transmural vs. 43 +/- 15% non-transmural, p < or = 0.01). The electrogram amplitude in sinus rhythm decreased significantly more at transmural sites (unipolar recording: 49 +/- 18% transmural vs. 15 +/- 20% non-transmural, p < 0.001; bipolar recording: 63 +/- 17% transmural vs. 42 +/- 19% non-transmural, p = 0.002). The pacing threshold increased significantly more at sites with transmural necrosis (unipolar: increased by 378 +/- 103% transmural vs. 207 +/- 93% non-transmural, p < 0.001; bipolar: 370 +/- 80% transmural vs. 259 +/- 60% non-transmural, p < 0.001). CONCLUSIONS The amplitude of the atrial electrogram from an ablation catheter can be used to discriminate areas with transmural necrosis from those without transmural necrosis during either atrial fibrillation or sinus rhythm. Termination of atrial fibrillation may not be necessary to estimate the histologic characteristics of an ablation lesion.
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Affiliation(s)
- Javier E Sanchez
- Department of Internal Medicine, Division of Cardiovascular Diseases, Cardiac Rhythm Management Laboratory, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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Abstract
Atrial fibrillation (AF) is one of the most challenging arrhythmias to treat. Many patients have to accept this disorder and the medications required. Nonpharmacologic therapies have emerged as alternative methods of treatment. However, technical difficulty, low success rate, high recurrence, and complications still are obstacles. Pulmonary veins as the most common trigger foci of paroxysmal AF are now the most interesting source of curative ablation. With more knowledge, technologies, techniques, and equipment, AF ablation is likely to be more successful. This article introduces some exciting aspects of pulmonary vein ablation, including our hope to cure AF in some selected patients.
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Yamane T, Shah DC, Jaïs P, Hocini M, Peng JT, Deisenhofer I, Clémenty J, Haïssaguerre M. Dilatation as a marker of pulmonary veins initiating atrial fibrillation. J Interv Card Electrophysiol 2002; 6:245-9. [PMID: 12154327 DOI: 10.1023/a:1019561820830] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The pulmonary veins (PVs) have been shown to trigger paroxysmal atrial fibrillation. The relationship of anatomical dimensions versus arrhythmogenicity has not been assessed. METHODS The diameters of four PVs were measured by selective PV angiography before ablation in 39 consecutive patients (23 male, mean age 46 years) with only one (25 patients) or two (14 patients) arrhythmogenic PVs (ArPVs). After ablation of ArPVs, no patient had recurrence of atrial fibrillation from the remaining PVs. Comparisons were performed variously between ArPV and non-ArPV, and within and across both groups. RESULTS ArPVs were distributed as follows; left superior PV: 40%, left inferior PV: 28%, right superior PV: 26%, and right inferior PV: 6%. Statistical comparisons showed that (1) Triggers of atrial fibrillation were located in the largest PV in 72% of patients, (2) For each PV, the mean diameter of ArPV was significantly larger than that of non-ArPV (p < 0.05), (3) No significant difference was observed in the diameter of the four different ArPVs (range 16.2 +/- 1.3 to 17.2 +/- 4.4). CONCLUSIONS In patients with atrial fibrillation initiated from one or two ArPVs, the diameters of ArPVs were significantly larger than those of non-ArPVs irrespective of the specific PV concerned, which might imply a possible role of PV dilatation in the arrhythmogenesis.
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Affiliation(s)
- Teiichi Yamane
- Hôpital Cardiologique du Haut-Lévêque, Avenue de Magellan, 33604 Bordeaux-Pessac, France.
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Yamane T, Shah DC, Jaïs P, Hocini M M, Deisenhofer I, Choi KJ, Macle L, Clémenty J, Haïssaguerre M. Electrogram polarity reversal as an additional indicator of breakthroughs from the left atrium to the pulmonary veins. J Am Coll Cardiol 2002; 39:1337-44. [PMID: 11955852 DOI: 10.1016/s0735-1097(02)01782-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We assessed the anatomical distribution and electrogram characteristics of breakthrough from the left atrium (LA) to the pulmonary veins (PVs). BACKGROUND Localization of LA-PV breakthrough is an important technique for PV ablation in patients with atrial fibrillation (AF). METHODS A total of 157 patients with paroxysmal AF underwent PV disconnection guided by mapping with a circumferential 10-electrode catheter. Radiofrequency (RF) current was delivered ostially at the site(s) of earliest activation (113 patients) or electrogram polarity reversal defined by opposite polarity across adjacent bipoles (44 patients). Breakthrough sites were proved by changes in pulmonary vein potential activation sequence occurring as a result of localized RF delivery and were classified into four segments around the ostium (top, bottom, anterior, posterior). Results of mapping and ablation were compared between the two groups. RESULTS A total of 99% of 411 targeted PVs were successfully disconnected in both groups. Breakthroughs were most frequent at the bottom of superior PVs (85% prevalence) and the top of inferior PVs (75% prevalence). A wide activation front (>5 synchronous bipoles) indicating broad breakthrough was observed in 18% of PVs. Polarity reversal occurred with 88% sensitivity and 91% specificity at breakthrough sites. Polarity reversal was restricted to fewer bipoles (2.0 +/- 0.4 bipoles vs. 3.4 +/- 2.0 bipoles, p < 0.01) compared with earliest activation. Shorter RF application time was required to disconnect PVs with wide synchronous activation using polarity reversal compared with using conventional earliest activity (10.3 +/- 3.0 min vs. 12.3 +/- 3.4 min, p < 0.05). CONCLUSIONS Bipolar electrogram polarity reversal allows more precise localization of breakthrough compared with the earliest activation, particularly in cases of wide synchronous PV activation.
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Affiliation(s)
- Teiichi Yamane
- Hôpital Cardiologique du Haut-Lévêque, Bordeaux-Pessac, France.
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Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso-Garcia A, Blomström-Lundqvist C, de Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A. ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation)Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation 2001. [DOI: 10.1161/circ.104.17.2118] [Citation(s) in RCA: 557] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso-Garcia A, Blomström-Lundqvist C, De Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation): developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001; 38:1231-66. [PMID: 11583910 DOI: 10.1016/s0735-1097(01)01587-x] [Citation(s) in RCA: 486] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay G, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann L, Wyse D, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, Klein WW, Alonso-Garcia A, Blomström-Lundqvist C, De Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation31This document was approved by the American College of Cardiology Board of Trustees in August 2001, the American Heart Association Science Advisory and Coordinating Committee in August 2001, and the European Society of Cardiology Board and Committee for Practice Guidelines and Policy Conferences in August 2001.32When citing this document, the American College of Cardiology, the American Heart Association, and the European Society of Cardiology would appreciate the following citation format: Fuster V, Rydén LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Lévy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2001;38:XX-XX.33This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), the European Society of Cardiology (www.escardio.org), and the North American Society of Pacing and Electrophysiology (www.naspe.org). Single reprints of this document (the complete Guidelines) to be published in the mid-October issue of the European Heart Journal are available by calling +44.207.424.4200 or +44.207.424.4389, faxing +44.207.424.4433, or writing Harcourt Publishers Ltd, European Heart Journal, ESC Guidelines – Reprints, 32 Jamestown Road, London, NW1 7BY, United Kingdom. Single reprints of the shorter version (Executive Summary and Summary of Recommendations) published in the October issue of the Journal of the American College of Cardiology and the October issue of Circulation, are available for $5.00 each by calling 800-253-4636 (US only) or by writing the Resource Center, American College of Cardiology, 9111 Old Georgetown Road, Bethesda, Maryland 20814. To purchase bulk reprints specify version and reprint number (Executive Summary 71-0208; full text 71-0209) up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 214-706-1466, fax 214-691-6342; or E-mail: pubauth@heart.org. J Am Coll Cardiol 2001. [DOI: 10.1016/s0735-1097(01)01586-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
The safety and efficacy of catheter ablation for treatment of most types of cardiac arrhythmias are well established. These arrhythmias and arrhythmia substrates include AVNRT, accessory pathways, focal atrial tachycardia, atrial flutter, idiopathic ventricular tachycardia, and bundle-branch re-entry. Catheter ablation is considered as an alternative to pharmacologic therapy in the treatment of these cardiac arrhythmias.
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Affiliation(s)
- H Calkins
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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Erdogan A, Grumbrecht S, Carlsson J, Roederich H, Schulte B, Sperzel J, Berkowitsch A, Neuzner J, Pitschner HF. Homogeneity and diameter of linear lesions induced with multipolar ablation catheters: in vitro and in vivo comparison of pulsed versus continuous radiofrequency energy delivery. J Interv Card Electrophysiol 2000; 4:655-61. [PMID: 11141213 DOI: 10.1023/a:1026538204579] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND For invasive treatment of atrial fibrillation, linear lesions induced with multipolar ablation catheters (MAC) are needed to prevent recurrence. The aim of the study was to compare the efficacy of pulsed versus continuous radiofrequency (RF)-energy delivery using MAC. METHODS In vitro tests were performed using endomyocardial preparations of fresh pig hearts in a 10-liter-bath of physiologic saline solution (37 degrees C) at constant flow conditions (1.5 l/min). The MAC were placed with a constant pressure of 20 ponds onto the endocardium. The energy (generator: Osypka HAT 200 S) was delivered either pulsed (4 electrodes simultaneously, 5ms duty-cycle) or continuously (each electrode separately). In vivo experiments were performed in 6 anesthetized pigs using fluoroscopic positioning of MAC at 40 different intracardial positions and with similar conditions as in vitro experiments. Lesion volume (LV) was calculated after measuring lesion diameter with a microcaliper. The homogeneity of the lesions (LH) was classified from 1-4; with 1 as highest homogeneity. RESULTS Pulsed energy delivery produced more homogeneous linear lesions in significantly less time. There was no difference in electrode temperature values (50.2 +/- 0.8 and 51.3 +/- 1.4 degrees C) in vitro and in vivo. In the in vivo experiments, lesion depth and calculated lesion volume were less in both modes of energy delivery but pulsed energy delivery was superior regarding lesion depth and homogeneity. CONCLUSION With pulsed energy delivery it is possible to create linear lesions of significantly greater homogeneity. Moreover, larger lesions are induced in less time by pulsed energy delivery in vitro and in vivo.
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Affiliation(s)
- A Erdogan
- Kerckhoff-Clinic, Department of Cardiology/Electrophysiology, Max-Planck-Institute for Physiological Research, D-61231, Bad Nauheim, Germany.
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Haïssaguerre M, Shah DC, Jaïs P, Hocini M, Yamane T, Deisenhofer I, Garrigue S, Clémenty J. Mapping-guided ablation of pulmonary veins to cure atrial fibrillation. Am J Cardiol 2000; 86:9K-19K. [PMID: 11084094 DOI: 10.1016/s0002-9149(00)01186-3] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Catheter ablation of triggers inducing paroxysms of atrial fibrillation (AF) is an emerging therapy for this common arrhythmia. In a series of 225 consecutive patients with AF resistant to multiple drugs, 96% presented with triggering foci originating from 1 or multiple pulmonary veins (PV), independently of whether or not the patient had ectopy or structural heart disease. The present article describes the mapping and ablation techniques applicable to individual patients: (1) criteria to define an arrhythmogenic PV; (2) use of provocative maneuvers; and (3) the role of circumferential mapping catheters to provide extent, distribution, and activation of PV muscle as well as monitoring distal PV potentials (PVP) during ablation. Radiofrequency ablation can be performed by targeting the PVP during sinus rhythm (right PV) or left atrial pacing (left PV) with the procedural endpoint of PVP elimination, which is more effective in predicting a successful outcome than suppression of acute ectopy. Complete elimination of AF is presently obtained in 70% of patients, allowing interruption of arrhythmias and in use anticoagulants. It is anticipated that continued technologic improvements will improve and facilitate this technique of curative treatment of AF.
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Abstract
Although atrial fibrillation is the most common sustained arrhythmia that requires medical attention, it remains a challenge to treat. Nevertheless, considerable progress has been made toward developing curative, catheter-based treatments for selected patients with atrial fibrillation. The most significant clinical observation during electrophysiologic testing in patients with atrial fibrillation has been a recognition of the importance of the pulmonary veins for the initiation of this arrhythmia. In addition to being the most common site of arrhythmogenic foci that trigger the onset of atrial fibrillation, the unique electrophysiologic characteristics of the pulmonary veins may serve to perpetuate established atrial fibrillation. Because of the very short-duration refractory periods that are measured within the pulmonary veins, these structures may serve as a site of high frequency activation due to reentrant activation with small wavelengths. Catheter ablation strategies that are designed to ablate the site of triggering foci with the pulmonary veins have been very successful in selected patients with paroxysmal atrial fibrillation, although the risk of recurrent arrhythmias remains relatively high. In addition, ablation strategies that are designed to electrically isolate the pulmonary veins from the bulk of the left atrium are likely to lead to improvements in the long-term outcome of ablation. For patients with permanent atrial fibrillation, considerable progress has been made in the restoration of sinus rhythm by linear ablation strategies in the left atrium. It is likely that a comprehensive nonpharmacologic treatment for atrial fibrillation will incorporate the lessons learned from each of these approaches and lead to a genuine cure of this vexing arrhythmia.
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Affiliation(s)
- G N Kay
- Division of Cardiology, School of Medicine, The University of Alabama, Birmingham, Alabama 25294, USA.
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Erdogan A, Carlsson J, Roederich H, Schulte B, Sperzel J, Berkowitsch A, Neuzner J, Pitschner HF. Comparison of pulsed versus continuous radiofrequency energy delivery: diameter of lesions induced with multipolar ablation catheter. Pacing Clin Electrophysiol 2000; 23:1852-5. [PMID: 11139941 DOI: 10.1111/j.1540-8159.2000.tb07036.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to compare the efficacy of pulsed versus continuous RF energy delivery via multipolar ablation catheters. In vitro tests were performed in endomyocardial preparations of fresh bovine hearts in a both of physiological saline solution (37 degrees C) at constant flow conditions (1.5 L/min). The catheters were applied to the endocardium at a constant pressure. Energy was delivered pulsed (to 4 electrodes simultaneously, 5-ms duty cycle) or continuously (to each electrode separately). In vivo experiments were performed under fluoroscopy in eight anesthetized pigs, guided by endocardial electrograms to place the catheters in 22 different intraatrial positions. Lesion volume was calculated from measurements of the lesion diameter with a microcaliper. The homogeneity of the lesions was classified from 1 (highest) to 4 (least). More homogeneous linear lesions were produced in significantly less time with pulsed than with continuous energy delivery. There were no differences in electrode temperature or impedance values in vitro and in vivo. The results in the in vitro experiments were reproducible in the intact animal experiments. Significantly larger and more homogeneous linear lesions were created more rapidly with pulsed than with continuous energy delivery.
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Affiliation(s)
- A Erdogan
- Kerckhoff-Clinic, Department of Cardiology and Electrophysiology, Max-Planck-Institute for Physiological Research, Bad Nauheim, Germany.
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Ndrepepa G, Schneider MA, Vallaint A, Zrenner B, Karch MR, Schreieck J, Henke J, Schömig A, Schmitt C. Acute electrophysiologic effects and antifibrillatory actions of the long linear lesions in the right atrium in a sheep model. J Interv Card Electrophysiol 2000; 4:529-36. [PMID: 11046192 DOI: 10.1023/a:1009820900611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
UNLABELLED Linear lesions (LL) represent an option for curing of atrial fibrillation (AF) with ablation techniques. METHODS AND RESULTS In 11 sheep (w. 72+/-16 kg), LL were created with radiofrequency ablation in the lateral, posterior and septal walls of the right atrium (RA). AF was induced before and after LL with burst pacing. Mapping of the AF was performed with a 64-electrode basket catheter deployed in the RA. Quantitative analysis was performed with a custom-made software program. LL were confirmed histologically 7 to 10 days after the procedure. LL were transmural in 78% of their length. Stimulation thresholds and right atrial activation times were increased after LL compared to preablation values. Effective refractory periods of the RA were prolonged significantly in 7 out of 12 regions after generation of LL. Conduction velocities in the RA segments between LL were reduced in lateral, posterior and septal walls. During paced rhythms double potentials were recorded in all animals. AF could be induced in all animals of this model despite the presence of LL in the RA. AF episodes were significantly more regular after LL throughout the RA due to a significant reduction of the number of the wave fronts in the RA. During AF episodes, in the presence of LL, the RA was driven by wave fronts of left atrial origin entering the right side of the septum through interatrial connections. CONCLUSIONS 1) LL profoundly affect electrophysiologic parameters of RA. 2) In the presence of LL, AF manifest a higher degree of regularity as compared to preablation episodes. 3) Dissociation between wave fronts of left atrial origin entering the RA through the interatrial connections is an important mechanism of the antifibrillatory action of the septal LL.
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Affiliation(s)
- G Ndrepepa
- Deutsches Herzzentrum München and 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Abstract
Various nonpharmacologic interventions are available for patients with atrial fibrillation (AF) who are refractory to standard drug therapy. Atrioventricular junctional ablation and permanent pacing is a very effective therapy for patients with AF and a poorly controlled ventricular response. The surgical MAZE procedure has been performed on small numbers of patients but is remarkably successful in restoring and maintaining sinus rhythm. The role of permanent pacing as treatment for paroxysmal AF is undergoing evaluation and dual-site atrial pacing appears particularly promising in reducing the number of episodes of paroxysmal AF. Certainly the most exciting frontier in the treatment of AF is radiofrequency catheter ablation procedures. Our understanding of the mechanisms of paroxysmal AF and chronic AF has expanded enormously in the past 5 years. Radiofrequency lesions in pulmonary veins using standard technology will cure many cases of paroxysmal AF. However, catheter systems under development offer a great promise of treating most paroxysmal and chronic AF within the next few years. These developments will revolutionize our approach to this ever more prevalent clinical problem.
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Affiliation(s)
- D S Cannom
- Division of Cardiology, Good Samaritan Hospital, Los Angeles, California, USA
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46
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Abstract
There is currently an intense interest in applying the principles of the Maze procedure in a less invasive manner so that a wider group of patients with atrial fibrillation can be treated safely and effectively. These efforts have centered around surgical attempts to curtail the number of lesions placed in the atria at the time of valve surgery and catheter-based attempts to re-create a part or all of the Maze procedure with radiofrequency ablation. Thus far, these techniques remain highly experimental and largely without merit. Many of the problems that we encountered several years ago in developing the surgical Maze procedure are now being repeated in patients undergoing these highly experimental and inadequately evaluated procedures. Nevertheless, there are occasional flashes of promise with some of these approaches. Moreover, it is clear that only a miniscule percentage of the patients with atrial fibrillation will ever become candidates for the open-heart Maze procedure as it is now performed. Therefore, the continuing struggle to relieve the invasive downside of the Maze procedure is warranted but with the caveat, especially to our cardiologist colleagues, to proceed with caution.
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Affiliation(s)
- J L Cox
- Department of Thoracic and Cardiovascular Surgery, Georgetown University Medical Center, Washington, DC 20007, USA
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