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van Waaij K, Keçe F, de Riva M, Alizadeh Dehnavi R, Wijnmaalen AP, Piers SRD, Mertens BJ, Zeppenfeld K, Trines SA. Validation of a prediction model for early reconnection after cryoballoon ablation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01811-0. [PMID: 38743141 DOI: 10.1007/s10840-024-01811-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND We previously developed an early reconnection/dormant conduction (ERC) prediction model for cryoballoon ablation to avoid a 30-min waiting period with adenosine infusion. We now aimed to validate this model based on time to isolation, number of unsuccessful cryo-applications, and nadir balloon temperature. METHODS Consecutive atrial fibrillation patients who underwent their first cryoballoon ablation in 2018-2019 at the Leiden University Medical Center were included. Model performance at the previous and at a new optimal cutoff value was determined. RESULTS A total of 201 patients were included (85.57% paroxysmal AF, 139 male, median age 61 years (IQR 53-69)). ERC was found in 35 of 201 included patients (17.41%) and in 41 of 774 veins (5.30%). In the present study population, the previous cutoff value of - 6.7 provided a sensitivity of 37.84% (previously 70%) and a specificity of 89.07% (previously 86%). Shifting the cutoff value to - 7.2 in both study populations resulted in a sensitivity of 72.50% and 72.97% and a specificity of 78.22% and 78.63% in data from the previous and present study respectively. Negative predictive values were 96.55% and 98.11%. Applying the model on the 101 patients of the present study with all necessary data for all veins resulted in 43 out of 101 patients (43%) not requiring a 30-min waiting period with adenosine testing. Two patients (2%) with ERC would have been missed when applying the model. CONCLUSIONS The previously established ERC prediction model performs well, recommending its use for centers routinely using adenosine testing following PVI.
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Affiliation(s)
- Kevin van Waaij
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fehmi Keçe
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Marta de Riva
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Reza Alizadeh Dehnavi
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sebastiaan R D Piers
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Bart J Mertens
- Bioinformatics Center of Expertise, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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2
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Dzhinsov KR. Methods and techniques for increasing the safety and efficacy of pulmonary vein isolation in patients with atrial fibrillation. Folia Med (Plovdiv) 2023; 65:713-719. [PMID: 38351752 DOI: 10.3897/folmed.65.e103031] [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: 03/05/2023] [Accepted: 07/16/2023] [Indexed: 02/16/2024] Open
Abstract
The most common type of sustained arrhythmia is atrial fibrillation (AF). Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation, which has emerged as the primary therapeutic strategy for atrial fibrillation patients. Unfortunately, about one-third of patients experience recurrent atrial arrhythmias after the procedure.
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3
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Nair GM, Birnie DH, Nery PB, Redpath CJ, Sarrazin JF, Roux JF, Parkash R, Bernier M, Sterns LD, Sapp J, Novak P, Veenhuyzen G, Morillo CA, Singh SM, Sadek MM, Golian M, Klein A, Sturmer M, Chauhan VS, Angaran P, Green MS, Bernick J, Wells GA, Essebag V. Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation Recurrence: The AWARE Randomized Clinical Trial. JAMA Cardiol 2023; 8:475-483. [PMID: 36947030 PMCID: PMC10034661 DOI: 10.1001/jamacardio.2023.0212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/24/2023] [Indexed: 03/23/2023]
Abstract
Importance Recurrent atrial fibrillation (AF) commonly occurs after catheter ablation and is associated with patient morbidity and health care costs. Objective To evaluate the superiority of an augmented double wide-area circumferential ablation (WACA) compared with a standard single WACA in preventing recurrent atrial arrhythmias (AA) (atrial tachycardia, atrial flutter, or atrial fibrillation [AF]) in patients with paroxysmal AF. Design, Setting, and Participants This was a pragmatic, multicenter, prospective, randomized, open, blinded end point superiority clinical trial conducted at 10 university-affiliated centers in Canada. The trial enrolled patients 18 years and older with symptomatic paroxysmal AF from March 2015 to May 2017. Analysis took place between January and April 2022. Analyses were intention to treat. Interventions Patients were randomized (1:1) to receive radiofrequency catheter ablation for pulmonary vein isolation with either a standard single WACA or an augmented double WACA. Main Outcomes and Measures The primary outcome was AA recurrence between 91 and 365 days postablation. Patients underwent 42 days of ambulatory electrocardiography monitoring after ablation. Secondary outcomes included need for repeated catheter ablation and procedural and safety variables. Results Of 398 patients, 195 were randomized to the single WACA (control) arm (mean [SD] age, 60.6 [9.3] years; 65 [33.3%] female) and 203 to the double WACA (experimental) arm (mean [SD] age, 61.5 [9.3] years; 66 [32.5%] female). Overall, 52 patients (26.7%) in the single WACA arm and 50 patients (24.6%) in the double WACA arm had recurrent AA at 1 year (relative risk, 0.92; 95% CI, 0.66-1.29; P = .64). Twenty patients (10.3%) in the single WACA arm and 15 patients (7.4%) in the double WACA arm underwent repeated catheter ablation (relative risk, 0.72; 95% CI, 0.38-1.36). Adjudicated serious adverse events occurred in 13 patients (6.7%) in the single WACA arm and 14 patients (6.9%) in the double WACA arm. Conclusions and Relevance In this randomized clinical trial of patients with paroxysmal AF, additional ablation by performing a double ablation lesion set did not result in improved freedom from recurrent AA compared with a standard single ablation set. Trial Registration ClinicalTrials.gov Identifier: NCT02150902.
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Affiliation(s)
- Girish M. Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H. Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pablo B. Nery
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | - Ratika Parkash
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Martin Bernier
- McGill University Health Center, Montreal, Québec, Canada
| | | | - John Sapp
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Paul Novak
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - George Veenhuyzen
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlos A. Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Mehrdad Golian
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marcio Sturmer
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vijay S. Chauhan
- University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Martin S. Green
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jordan Bernick
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A. Wells
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Québec, Canada
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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4
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Nair GM, Birnie DH, Wells GA, Nery PB, Redpath CJ, Sarrazin JF, Roux JF, Parkash R, Bernier M, Sterns LD, Novak P, Veenhuyzen G, Morillo CA, Singh SM, Sturmer M, Chauhan VS, Angaran P, Essebag V. Augmented wide area circumferential catheter ablation for reduction of atrial fibrillation recurrence (AWARE) trial: Design and rationale. Am Heart J 2022; 248:1-12. [PMID: 35219715 DOI: 10.1016/j.ahj.2022.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/03/2022] [Accepted: 02/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Recurrence of atrial fibrillation (AF) after a pulmonary vein isolation procedure is often due to electrical reconnection of the pulmonary veins. Repeat ablation procedures may improve freedom from AF but are associated with increased risks and health care costs. A novel ablation strategy in which patients receive "augmented" ablation lesions has the potential to reduce the risk of AF recurrence. OBJECTIVE The Augmented Wide Area Circumferential Catheter Ablation for Reduction of Atrial Fibrillation Recurrence (AWARE) Trial was designed to evaluate whether an augmented wide-area circumferential antral (WACA) ablation strategy will result in fewer atrial arrhythmia recurrences in patients with symptomatic paroxysmal AF, compared with a conventional WACA strategy. METHODS/DESIGN The AWARE trial was a multicenter, prospective, randomized, open, blinded endpoint trial that has completed recruitment (ClinicalTrials.gov NCT02150902). Patients were randomly assigned (1:1) to either the control arm (single WACAlesion set) or the interventional arm (augmented- double WACA lesion set performed after the initial WACA). The primary outcome was atrial tachyarrhythmia (AA; atrial tachycardia [AT], atrial flutter [AFl] or AF) recurrence between days 91 and 365 post catheter ablation. Patient follow-up included 14-day continuous ambulatory ECG monitoring at 3, 6, and 12 months after catheter ablation. Three questionnaires were administered during the trial- the EuroQuol-5D (EQ-5D) quality of life scale, the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale, and a patient satisfaction scale. DISCUSSION The AWARE trial was designed to evaluate whether a novel approach to catheter ablation reduced the risk of AA recurrence in patients with symptomatic paroxysmal AF.
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Affiliation(s)
- Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Canada
| | | | | | - Pablo B Nery
- University of Ottawa Heart Institute, Ottawa, Canada
| | | | | | | | - Ratika Parkash
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Martin Bernier
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Laurence D Sterns
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - Paul Novak
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - George Veenhuyzen
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlos A Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Marcio Sturmer
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vijay S Chauhan
- University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Centre, Montreal, Quebec, Canada; Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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5
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Wei W, Fang X, Shehata M, Wang X, Zhan X, Deng H, Liao H, Liao Z, Liu Y, Xue Y, Wu S. Administration of Adenosine Triphosphate Provides Additional Value Over Programmed Electrophysiologic Study in Confirmation of Successful Ablation of Atrioventricular Accessory Pathways. Front Cardiovasc Med 2021; 8:716400. [PMID: 34869625 PMCID: PMC8635057 DOI: 10.3389/fcvm.2021.716400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/30/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives: To study the benefit of adenosine triphosphate (ATP) in evaluating ablation endpoints of accessory pathways (AP) and subsequent long-term prognosis. Methods: We reviewed consecutive patients with supraventricular tachycardias due to APs that underwent radiofrequency catheter ablation (RFCA) from January 2016 to September 2018 in our center. The patients were divided into two groups: the ATP group (who had passed both the ATP test and PES after ablation as the endpoint) and the non-ATP group (who had passed PES only after ablation as the endpoint). We reviewed the patients' intra-cardiac electrograms and analyzed their long-term outcomes. Results: In total, 1,343 patients underwent successful RFCA. There were 215 patients in the ATP group with one lost to follow-up. There were 1,128 patients in the non-ATP group with 39 lost to follow-up. Twenty-three patients in the ATP group demonstrated additional electrophysiological entities due to ATP administration, including reappearance of the ablated APs in 16 patients, discovery of PES-undetected APs in 5, induction of atrial fibrillation in 5, premature atrial contractions in 1, and premature ventricular contractions in another. During the 7 to 39 months (average 24.4 ± 9.5 months) follow-up, the recurrence rate was 8.41% (18/214) in the ATP group and 6.80% (74/1,084) in the non-ATP group. In subjects with recurrence, 14 patients (14/18 = 77.8%) in the ATP group and 50 patients (50/74 = 67.6%) in the non-ATP group accepted redo ablations. Among the ATP-group, all the 14 redo APs were the old ones as before. Among the non-ATP-group, redo ablations confirmed that 39 APs were the old ones, while 20 APs were newly detected ones which had been missed previously. The difference in recurrent AP locations confirmed by redo procedures between the two groups was significant (p = 0.008). In the non-ATP group, 20 (40%) of redo cases were proven to have multiple APs, while 33 (3.3%) cases who did not suffer from recurrence had multiple APs. Existences of multiple APs in recurred cases were significantly higher than that in non-recurred ones in the non-ATP group (p < 0.001), while there was no such difference in the ATP group (p = 0.114). Conclusions: The existence of multiple APs was more common in recurrent cases if ATP was not used for confirmation of ablation endpoints. ATP probably has additional value over PES alone by detecting weak AP conductions. ATP can evoke atrial and ventricular arrhythmias.
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Affiliation(s)
- Wei Wei
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xianhong Fang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Michael Shehata
- Cedars Sinai Medical Center, Heart Institute, Los Angeles, CA, United States
| | - Xunzhang Wang
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Cedars Sinai Medical Center, Heart Institute, Los Angeles, CA, United States
| | - Xianzhang Zhan
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hai Deng
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hongtao Liao
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zili Liao
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yang Liu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yumei Xue
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shulin Wu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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6
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Ninomiya Y, Inoue K, Tanaka N, Okada M, Tanaka K, Onishi T, Hirao Y, Oka T, Inoue H, Takayasu K, Nakamaru R, Kitagaki R, Koyama Y, Okamura A, Iwakura K, Ohishi M, Fujii K. Absence of first-pass isolation is associated with poor pulmonary vein isolation durability and atrial fibrillation ablation outcomes. J Arrhythm 2021; 37:1468-1476. [PMID: 34887951 PMCID: PMC8637089 DOI: 10.1002/joa3.12629] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pulmonary vein (PV) reconnection is the main cause of atrial fibrillation (AF) recurrence. This study aimed to examine the effect of first-pass PV isolation (PVI) on PV reconnection frequency during the procedure and on AF ablation outcomes. METHODS This retrospective study included 446 patients with drug-refractory AF (370 men, aged 64 ± 10 years) who underwent initial PVI using an open-irrigated contact force catheter between January 2015 and October 2016. We investigated the effect of first-pass PVI on PV reconnection during spontaneous PV reconnection and dormant conduction after an adenosine triphosphate challenge. RESULTS First-pass PVI was achieved in 69% (617/892) of ipsilateral PVs, of which we observed PV reconnection during the procedure in 134 (22%) PVs. This value was significantly lower than that observed in those without first-pass PVI (50%, 138/275) (P < .0001). We divided the subjects into two groups based on the presence or absence of first-pass PVI in at least one of two ipsilateral PVs: first-pass (n = 383, 86%) and non-first-pass groups (n = 63, 14%). The 2-year AF recurrence-free rate was significantly higher in the first-pass group than in the other group (75% vs 59%, log-rank P = .032). In 78 patients with repeat AF ablation, the PV reconnection rate in the second procedure was significantly lower in PVs that had first-pass isolation in the first procedure (34% vs 73%, P < .0001). CONCLUSIONS Absence of first-pass PVI was associated with a higher frequency of spontaneous PV reconnection and dormant conduction and poor ablation outcomes. First-pass isolation may be a useful marker for better PVI durability.
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Affiliation(s)
- Yuichi Ninomiya
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
- Department of Cardiovascular Medicine and HypertensionKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Koichi Inoue
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Nobuaki Tanaka
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Masato Okada
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Koji Tanaka
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | | | - Yuko Hirao
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Takafumi Oka
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Hiroyuki Inoue
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | | | - Ryo Nakamaru
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Ryo Kitagaki
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | - Yasushi Koyama
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
| | | | | | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and HypertensionKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Kenshi Fujii
- Cardiovascular CenterSakurabashi Watanabe HospitalOsakaJapan
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7
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Inoue K, Tanaka N, Ikada Y, Mizutani A, Yamamoto K, Matsuhira H, Harada S, Okada M, Iwakura K, Fujii K. Characterizing clinical outcomes and factors associated with conduction gaps in VISITAG SURPOINT-guided catheter ablation for atrial fibrillation. J Arrhythm 2021; 37:574-583. [PMID: 34141010 PMCID: PMC8207404 DOI: 10.1002/joa3.12544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/31/2021] [Accepted: 04/08/2021] [Indexed: 01/17/2023] Open
Abstract
PURPOSE Although usefulness of VISITAG SURPOINT (VS) on pulmonary vein isolation (PVI) in catheter ablation of atrial fibrillation has been reported, optimal VS thresholds can depend on the inter-tag distance (ITD) and vice versa. We validated the efficacy of PVI with lower target ITDs and VS values than in previous studies. METHODS Retrospective review of consecutive patients (N = 100) with paroxysmal (n = 32) or persistent AF (n = 68) undergoing VS-guided ablation between 09/2018 and 08/2019 was conducted. All procedures were performed by two operators. Target VS values were 425 (anterior), 375 (posterior), and 325 (near the esophagus). Target ITD was 4 mm. RESULTS Acute PVI was achieved in all cases, however, 13 residual gaps in 12 patients were observed after initial encirclement (first pass isolation: 88%). Ten gaps due to spontaneous PV reconnections (PVR) were found in nine patients (9%). These 23 gaps had similar median VS (gap-related vs non-gap: 429 vs 410, P = .4545) and power (36 vs 36W, P = .4843), higher contact force (13.8 vs 11.0g, P = .0061), and larger ITD (5.3 vs 3.7mm, P < .001) when compared to the remaining tags. Only ITDs were independently associated with gap formation in multivariate analysis. One-year Kaplan-Meier freedom from any atrial arrhythmia was 87.2%. Eight patients received repeat ablation (8.1%) and of these, 6 (75%) were free from PVR. CONCLUSION Favorable rates of first pass isolation, acute PVR, and long-term procedure success were achieved using lower VS values than in previous reports. With a target VS value of 375-425, ITDs of 4 mm was sufficient for durable PVI.
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Affiliation(s)
- Koichi Inoue
- Sakurabashi Watanabe HospitalOsakaJapan
- Cardiovascular DivisionNational Hospital Organization Osaka National HospitalOsakaJapan
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8
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Gupta A, Lokhandwala Y, Rai N, Malviya A. Adenosine-A drug with myriad utility in the diagnosis and treatment of arrhythmias. J Arrhythm 2021; 37:103-112. [PMID: 33664892 PMCID: PMC7896475 DOI: 10.1002/joa3.12453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/30/2020] [Accepted: 10/16/2020] [Indexed: 12/31/2022] Open
Abstract
Adenosine has been used in the emergency treatment of arrhythmia for more than nine decades. However, cardiologists are often unfamiliar about its basic mechanism and various diagnostic and therapeutic uses, considering it mainly as a therapeutic drug for supraventricular tachycardia. This article discusses the role of adenosine relevant to emergency physicians, cardiologists, and electrophysiologists. Understanding of the mechanisms of adenosine and its electrophysiological effects is discussed first, followed by dosing, side effects, diagnostic, and therapeutic uses. Finally, the role of adenosine in the electrophysiology laboratory is discussed.
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Affiliation(s)
- Anunay Gupta
- Department of CardiologyVardhman Mahavir Medical College and Safdarjung HospitalDelhiIndia
| | - Yash Lokhandwala
- Department of CardiologyLokmanya Tilak Municipal General HospitalMumbaiIndia
| | - Nitish Rai
- Department of CardiologyVardhman Mahavir Medical College and Safdarjung HospitalDelhiIndia
| | - Amit Malviya
- Department of CardiologyNorth Eastern Indira Gandhi Regional Institute of Health and Medical SciencesShillongIndia
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9
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Sakamoto Y, Osanai H, Hiramatsu S, Matsumoto H, Tagahara K, Hosono H, Miyamoto S, Uno H, Kurokawa H, Kondo S, Tokuda K, Kanbara T, Nakashima Y, Asano H, Ajioka M. Efficacy of isoproterenol in the evaluation of dormant conduction and arrhythmogenic foci identification in atrial fibrillation ablation. BMC Cardiovasc Disord 2020; 20:397. [PMID: 32867695 PMCID: PMC7461289 DOI: 10.1186/s12872-020-01685-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/25/2020] [Indexed: 11/10/2022] Open
Abstract
Background Catheter ablation for atrial fibrillation (AF) is an established therapy. However, postoperative recurrence is a serious issue caused by the reconduction of the isolated pulmonary veins (PV) and the onset of non-PV foci. The objectives of this study were to elucidate dormant conduction, confirm PV arrhythmia substrate, induce non-PV foci after PV isolation, and assess the acute efficacy of high dose isoproterenol (ISP) when administered in addition to adenosine. Methods The study consisted of 100 patients with drug-refractory AF (paroxysmal and persistent) who underwent ablation therapy (either radio-frequency or cryoballoon ablation) as the first-line of therapy at our hospital. All patients first underwent PV isolation (PVI) and were administered adenosine followed by ISP (6 μg × 5 min). The effects were observed, and the therapeutic strategy was evaluated. Results Persistent dormant conduction due to ISP administration was observed in 13 patients. In over half of the patients, arrhythmia substrates were identified in the PV. Ten patients presented with persistent PV firing. The ablation of non-PV foci was additionally performed in 23 patients. Conclusions We found that dormant conduction, as a result of ISP administration, is persistent and ISP is useful when performing an ablation. In addition, ISP administration is useful for the identification of PV arrhythmia substrates and induction of non-PV foci. However, the effectiveness of ISP may be partially due to the complementary effect of adenosine, and, therefore, a combination of the two drugs seems preferable.
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Affiliation(s)
- Yusuke Sakamoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan.
| | - Hiroyuki Osanai
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shotaro Hiramatsu
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hikari Matsumoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Kensuke Tagahara
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hirotaka Hosono
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shun Miyamoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hiroto Uno
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hideki Kurokawa
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shun Kondo
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Kotaro Tokuda
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Takahiro Kanbara
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Yoshihito Nakashima
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hiroshi Asano
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Masayoshi Ajioka
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
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10
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van Rosmalen F, Delhaas T, Dagres N, Arbelo E, Blomström-Lundqvist C, Crijns HJGM, Da Costa A, Pytkowski M, Sharikov N, Laroche C, Tavazzi L, Brugada J, Pison L. Adenosine usage during AF ablation in Europe and selected long-term findings from the ESC-EHRA EORP Atrial Fibrillation Ablation Long-Term registry. J Interv Card Electrophysiol 2020; 60:395-406. [PMID: 32356163 PMCID: PMC8134287 DOI: 10.1007/s10840-020-00744-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/02/2020] [Indexed: 12/20/2022]
Abstract
Background Adenosine can be used to reveal dormant pulmonary vein (PV) conduction after PV isolation (PVI). This study presents a subanalysis of real-world 1-year follow-up data from the ESC-EHRA EORP Atrial Fibrillation (AF) Ablation Long-Term registry to analyze the usage of adenosine during PVI treatment in terms of rhythm outcome and safety. Methods The registry consists of 104 participating centers in 27 countries within the European Society of Cardiology. The registry data was split into an adenosine group (AG) and no-adenosine group (NAG). Procedure characteristics and patient outcome were compared. Results Adenosine was administered in 10.8% of the 3591 PVI patients included in the registry. Spain, the Netherlands, and Italy included the majority of adenosine cases (48.8%). Adenosine was applied more often in combination with open irrigation radiofrequency (RF) energy (74.7%) and less often in combination with nonirrigated RF energy (1.6%). After 1 year, a higher percentage of the AG was free from AF compared with the NAG (68.9% vs 59.1%, p < 0.001). Adenosine was associated with better rhythm outcome in RF ablation procedures, but not in cryo-ablation procedures (freedom from AF: RF: AG: 70.9%, NAG: 58.1%, p < 0.001, cryo: AG: 63.9%, NAG: 63.8%, p = 0.991). Conclusions The use of adenosine was associated with a better rhythm outcome after 1 year follow-up and seems more useful in patients treated with RF energy compared with patients treated with cryo energy. Given the improved rhythm outcome at 1-year follow-up, it seems reasonable to encourage the use of adenosine during RF AF ablation.
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Affiliation(s)
- Frank van Rosmalen
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig, Leipzig, Germany
| | - Elena Arbelo
- Department of Cardiology, Cardiovascular Institute, Hospital Clinic de Barcelona, Universitat de Barcelona, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Antoine Da Costa
- C.H.U. de Saint Etienne, Hôpital Nord, Saint-Priest-en-Jarez, France
| | - Mariusz Pytkowski
- Heart Rhythm Division of the 2nd Department of Coronary Artery Disease, Institute of Cardiology, Warszawa, Poland
| | - Nikita Sharikov
- Department of Surgical Treatment of Complex Rhythm Disturbances and Electro-cardio-stimulation, District Clinical Hospital, Khanty-Mansiysk, Autonomous Okrug-Yugra, Russia
| | - Cécile Laroche
- EURObservational Research Programme (EORP), Scientific Division, European Society of Cardiology, Sophia Antipolis, France
| | - Luigi Tavazzi
- GVM Care and Research, E.S., Maria Cecilia Hospital, Cotignola, Italy
| | - Joseph Brugada
- Cardiovascular Institute, Hospital Clínic Pediatric Arrhythmia Unit, Hospital Sant Joan de Déu University of Barcelona, Barcelona, Spain
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium.
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11
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Porterfield C, J Gora P, Wystrach A, Rossi P, Rillo M, A Sebag F, Giuggia M, Mantica M, Dorszewski A, Eldadah Z, Volpicelli M, Bottoni N, Jøns C, T Hollis Z, Dekker L, Mathew S, Schmitt J, Nilsson K. Confirmation of Pulmonary Vein Isolation with High-Density Mapping: Comparison to Traditional Workflows. J Atr Fibrillation 2020; 12:2361. [PMID: 33024494 DOI: 10.4022/jafib.2361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/11/2019] [Accepted: 10/12/2019] [Indexed: 02/03/2023]
Abstract
Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Yet tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. It has been suggested the use of a high-density mapping catheter, which enables simultaneous recording of adjacent bipolar EGMs in two directions, may provide improved sensitivity for gap identification. Anonymized, acute procedural data was prospectively collected in AF ablation cases utilizing various workflows for confirmation of PVI. Post-hoc analysis was performed to evaluate the incidence of gaps detected by different diagnostic catheter technologies, including a high-density mapping catheter and circular mapping catheters (CMCs), and common techniques such as pacing the ablation lines. A total of 139 cases were included across three subgroup analyses: 99 cases were included in an indirect comparison of three mapping catheter technologies, revealing gaps in 36.7%, 38.9%, and 81.8% of cases utilizing a 10-pole CMC, 20-pole CMC, and a high-density mapping catheter, respectively; a direct comparison of diagnostic catheter technologies in 18 cryoballoon ablation cases revealed residual gaps in 22.2% of patients identified by high-density mapping which were missed previously with the use of a 3.3F CMC; in 22 cases utilizing a technique of pacing the ablation lines, high-density mapping identified residual gaps in 68.2% of patients. This proof of concept analysis demonstrated that the use of a high-density catheter which records orthogonal bipoles simultaneously, appears to improve acute detection of gaps in PVI lines relative to other commonly utilized techniques and technologies. The long-term impact of ablating these concealed gaps remains unclear. Further study, including direct comparison of diagnostic catheter technologies in a randomized setting with long-term followup, is warranted.
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Affiliation(s)
| | | | | | - Pietro Rossi
- S. Giovanni Calibita FateBeneFratelli - Isola Tiberina, Rome, Italy
| | | | - Frederic A Sebag
- Institut Mutualiste Montsouris, Departement de Cardiologie, Paris, France
| | | | | | | | - Zayd Eldadah
- Medstar Washington Hospital Center, Washington D.C., USA
| | | | | | | | | | - Lukas Dekker
- Catharina Ziekenhuis Eindhoven, Eindhoven, Netherlands
| | | | | | - Kent Nilsson
- Piedmont Athens Regional Medical Center, Athens, GA, USA
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12
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Ücer E, Jungbauer C, Hauck C, Kaufmann M, Poschenrieder F, Maier L, Fredersdorf S. The low acute effectiveness of a high-power short duration radiofrequency current application technique in pulmonary vein isolation for atrial fibrillation. Cardiol J 2020; 28:663-670. [PMID: 32207843 DOI: 10.5603/cj.a2020.0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/11/2020] [Accepted: 02/21/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Application of high power radiofrequency (RF) energy for a short duration (HPSD) to isolate pulmonary vein (PV) is an emerging technique. But power and duration settings are very different across different centers. Moreover, despite encouraging preclinical and clinical data, studies measuring acute effectiveness of various HPSD settings are limited. METHODS Twenty-five consecutive patients with symptomatic atrial fibrillation (AF) were treated with pulmonary vein isolation (PVI) using HPSD. PVI was performed with a contact force catheter (Thermocool SF Smart-Touch) and Carto 3 System. The following parameters were used: energy output 50 W, target temperature 43°C, irrigation 15 mL/min, targeted contact force of > 10 g. RF energy was applied for 6-10 s. Required minimal interlesion distance was 4 mm. Twenty minutes after each successful PVI adenosine provocation test (APT) was performed by administrating 18 mg adenosine to unmask dormant PV conduction. RESULTS All PVs (100 PVs) were successfully isolated. RF lesions needed per patient were 131 ± 41, the average duration for each RF application was 8.1 ± 1.7 s. Procedure time was 138 ± 21 min and average of total RF energy duration was 16.3 ± 5.2 min and average amount of RF energy was 48209 ± 12808 W. APT application time after PVI was 31.1 ± 8.3 min for the left sided PVs and 22.2 ± 4.6 min (p = 0.005) for the right sided PVs. APT was transiently positive in 18 PVs (18%) in 8 (32%) patients. CONCLUSIONS Pulmonary vein isolation with high power for 6-10 s is feasible and shortens the procedure and ablation duration. However, acute effectiveness of the HPSD seems to be lower than expected. Further studies combining other ablation parameters are needed to improve this promising technique.
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Affiliation(s)
- Ekrem Ücer
- Internal Medicine II, Cardiology, University Hospital Regensburg, Germany.
| | - Carsten Jungbauer
- Internal Medicine II, Cardiology, University Hospital Regensburg, Germany
| | - Christian Hauck
- Internal Medicine II, Cardiology, University Hospital Regensburg, Germany
| | - Manuel Kaufmann
- Internal Medicine II, Cardiology, University Hospital Regensburg, Germany
| | | | - Lars Maier
- Internal Medicine II, Cardiology, University Hospital Regensburg, Germany
| | - Sabine Fredersdorf
- Internal Medicine II, Cardiology, University Hospital Regensburg, Germany
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13
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Matthews GDK, Grace AA. Unmasking Adenosine: The Purinergic Signalling Molecule Critical to Arrhythmia Pathophysiology and Management. Arrhythm Electrophysiol Rev 2020; 8:240-248. [PMID: 32685154 PMCID: PMC7358948 DOI: 10.15420/aer.2019.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Adenosine was identified in 1929 and immediately recognised as having a potential role in therapy for arrhythmia because of its negative chronotropic and dromotropic effects. Adenosine entered mainstream use in the 1980s as a highly effective agent for the termination of supraventricular tachycardia (SVT) involving the atrioventricular node, as well as for its ability to unmask the underlying rhythm in other SVTs. Adenosine has subsequently been found to have applications in interventional electrophysiology. While considered a safe agent because of its short half-life, adenosine may provoke arrhythmias in the form of AF, bradyarrhythmia and ventricular tachyarrhythmia. Adenosine is also associated with bronchospasm, although this may reflect irritant-induced dyspnoea rather than true obstruction. Adenosine is linked to numerous pathologies relevant to arrhythmia predisposition, including heart failure, obesity, ischaemia and the ageing process itself. This article examines 90 years of experience with adenosine in the light of new European Society of Cardiology guidelines for the management of SVT.
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Affiliation(s)
- Gareth DK Matthews
- Cambridge University NHS Foundation Trust, Cambridge, UK; Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew A Grace
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; Department of Biochemistry, University of Cambridge, Cambridge, UK
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14
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[Catheter ablation of atrial fibrillation : Status quo]. Herzschrittmacherther Elektrophysiol 2019; 30:343-348. [PMID: 31713025 DOI: 10.1007/s00399-019-00655-w] [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: 09/29/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Catheter ablation of atrial fibrillation (AF) is a standard part of treatment with respect to rhythm control. In this article, the authors provide a review of the state-of-the-art knowledge of AF catheter ablation including current indications, possible energy forms, procedural methods and endpoints as well as follow-up and further anticoagulation.
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15
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Skala T, Precek J, Hutyra M, Moravec O, Tudos Z, Skalova J, Klementova O, Antonicka A, Zapletalova J, Taborsky M. Long-term outcome of paroxysmal atrial fibrillation catheter ablation with and without pulmonary vein dormant conduction after adenosine challenge. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 164:147-153. [PMID: 30829343 DOI: 10.5507/bp.2019.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/26/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The prognostic significance of adenosine-mediated pulmonary vein (PV) dormant conduction is unclear. We prospectively followed patients with adenosine-mediated PV reconduction with a subsequent repeated ablation until there was no reconduction inducible with patients without reconduction after PV isolation. METHOD AND RESULTS Consecutive patients (n=179) with paroxysmal atrial fibrillation (AF) without prior catheter ablation (CA) were enlisted in the study. We used a point-by-point CA and general anesthesia in all patients. Twenty minutes after PV isolation we administered adenosine in a dose sufficient to produce an atrioventricular block. If a dormant conduction was present (n=54) we performed additional ablation until there was no adenosine mediated reconduction inducible. During 36 months of follow-up, all patients were examined for eight 7-day ECG recordings. There was no difference in arrhythmia recurrence rate between patients with and without dormant conduction (29.6 vs. 24.8% at 12 months, P=0.500; 31.5 vs. 30.4% at 36 months, P=1.000), for any echocardiographic parameter or any parameter of the ablation procedure. CONCLUSION The patients with dormant conduction after adenosine during catheter ablation of paroxysmal atrial fibrillation with complete elimination of the dormant conduction by additional extensive ablation have the same outcome in the long term as patients without a dormant conduction.
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Affiliation(s)
- Tomas Skala
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Jan Precek
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Ondrej Moravec
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Zbynek Tudos
- Department of Radiology, University Hospital Olomouc, Czech Republic
| | - Jitka Skalova
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Czech Republic
| | - Olga Klementova
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Olomouc, Czech Republic
| | - Andrea Antonicka
- Cardiovascular Center, Tomas Bata County Hospital, Zlin, Czech Republic
| | - Jana Zapletalova
- Department of Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
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16
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Chen C, Li D, Ho J, Liu T, Li X, Wang Z, Lin Y, Zou F, Tse G, Xia Y. Clinical Implications of Unmasking Dormant Conduction After Circumferential Pulmonary Vein Isolation in Atrial Fibrillation Using Adenosine: A Systematic Review and Meta-Analysis. Front Physiol 2019; 9:1861. [PMID: 30705634 PMCID: PMC6345194 DOI: 10.3389/fphys.2018.01861] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/11/2018] [Indexed: 12/04/2022] Open
Abstract
Purpose: Circumferential pulmonary vein isolation (CPVI) is a routine ablation strategy of atrial fibrillation (AF). The adenosine test can be used to unmask dormant conduction (DC) of pulmonary veins after CPVI, thereby demonstrating possible pulmonary vein re-connection and the need for further ablation. However, whether adenosine test could help improve the long term successful rate of CPVI is still controversial. This systemic review and meta-analysis was to determine the clinical utility of the adenosine test. Methods: PubMed, EMBASE, Web of Science and Cochrane Library database were searched through July 2016 to identify relevant studies using the keywords “dormant pulmonary vein conduction,” “adenosine test,” “circumferential pulmonary vein isolation,” and “atrial fibrillation.” A random-effects model was used to compare pooled outcomes and tested for heterogeneity. Results: A total of 17 studies including 5,169 participants were included in the final meta-analysis. Two groups of comparisons were classified: (1) Long-term successful rate in those AF patients underwent CPVI with and without adenosine test [Group A (+) and Group A (−)]; (2) Long-term successful rate in those patients who had adenosine test with and without dormant conduction [Group DC (+) and Group DC (−)]. The overall meta-analysis showed that no significant difference can be observed between Group A (+) and Group A (−) (RR 1.08; 95% CI 0.97–1.19; P = 0.16; I2 = 66%) and between Group DC (+) and Group DC (−) (RR 1.01; 95% CI 0.91–1.12; P = 0.88; I2 = 60%). Conclusion: Pooled meta-analysis suggested adenosine test may not improve long-term successful rate in AF patients underwent CPVI. Furthermore, AF recurrence may not be decreased by eliminating DC provoked by adenosine, even though adenosine test was applied after CPVI.
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Affiliation(s)
- Cheng Chen
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Daobo Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jeffery Ho
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xintao Li
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhao Wang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yajuan Lin
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Fuquan Zou
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gary Tse
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China.,Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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17
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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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18
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Kottmaier M, Bourier F, Wünscher S, Kornmayer M, Semmler V, Lengauer S, Telishevska M, Koch-Büttner K, Risse E, Brooks S, Hessling G, Deisenhofer I, Reents T. Repeat ablation for paroxysmal atrial fibrillation - Does adenosine play a role in predicting pulmonary vein reconnection patterns? Indian Pacing Electrophysiol J 2018; 18:203-207. [PMID: 30290206 PMCID: PMC6302775 DOI: 10.1016/j.ipej.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/05/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pulmonary vein (PV) reconduction after PV isolation (PVI) unmasked by adenosine is associated with a higher risk for paroxysmal atrial fibrillation (PAF) recurrence. It is unknown if the reconnected PVs after adenosine testing and immediate re-ablation can predict reconnection and reconnection patterns of PVs at repeat procedures. We assessed reconnection of PVs with and without dormant-conduction (DC) during the first and the repeat procedure. METHODS We included 67 patients undergoing PVI for PAF and a second procedure for PAF recurrence. DC during adenosine administration at first procedure was seen in 31 patients (46%). 264 PVs were tested with adenosine; DC was found in 48 PVs (18%) and re-ablated during first procedure. During the second procedure, all PVs where checked for reconnection. RESULTS Fifty-eight patients (87%) showed PV reconnection during the second procedure. Reconnection was found in 152/264 PVs (58%). Of 216 PVs without reconnection during adenosine testing at the first ablation, 116 PVs (53.7%) showed reconnection at the repeat procedure. Overall, 14.9% of patients showed the same PV reconnection pattern in the first and second procedure, expected statistical probability of encountering the same reconnection pattern was only 6.6%(p = 0.012). CONCLUSIONS In repeat procedures PVs showed significantly more often the same reconnection pattern as during first procedure than statistically expected. More than 50% of initial isolated PVs without reconnection during adenosine testing showed a reconnection during repeat ablation. Techniques to detect susceptibility for PV re-connection like prolonged waiting-period should be applied. Elimination of DC should be expanded from segmental to circumferential re-isolation or vaster RF application.
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Affiliation(s)
- M Kottmaier
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany.
| | - F Bourier
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - S Wünscher
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - M Kornmayer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - V Semmler
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - S Lengauer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - M Telishevska
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - K Koch-Büttner
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - E Risse
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - S Brooks
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - G Hessling
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - I Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
| | - T Reents
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Germany
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19
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Linz D, Kadhim K, Lau D, Sanders P. Recovery of adenosine-sensitive dormant conduction is but one mechanism of pulmonary vein reconnection. Indian Pacing Electrophysiol J 2018; 18:201-202. [PMID: 30472987 PMCID: PMC6303175 DOI: 10.1016/j.ipej.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/23/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Dominik Linz
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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20
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Watanabe R, Okumura Y, Nagashima K, Iso K, Takahashi K, Arai M, Wakamatsu Y, Kurokawa S, Ohkubo K, Nakai T, Yoda S, Watanabe I, Hirayama A, Sonoda K, Tosaka T. Influence of balloon temperature and time to pulmonary vein isolation on acute pulmonary vein reconnection and clinical outcomes after cryoballoon ablation of atrial fibrillation. J Arrhythm 2018; 34:511-519. [PMID: 30327696 PMCID: PMC6174370 DOI: 10.1002/joa3.12108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/30/2018] [Accepted: 07/20/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Limited data exist on indicators of durable pulmonary vein isolation (PVI) undergoing cryoballoon ablation (CBA) for atrial fibrillation (AF). We investigated whether balloon temperature and time to PVI can be used to predict early PV reconduction (EPVR), including residual PV conduction and adenosine triphosphate-induced dormant conduction and the relation between touch-up ablation of EPVR sites and mid-term recurrence of AF. METHODS We obtained procedural and outcome data from the records of 130 consecutive patients who underwent CBA and followed up for 13.4 months. RESULTS EPVR was identified in 86 (17%) PVs of 61 (47%) patients. Balloon temperatures during 30 seconds (-27 ± 5.7°C vs -31 ± 5.5°C), 60 seconds (-36 ± 5.6°C vs -41 ± 5.4°C), and at the nadir point (-41 ± 7.4°C vs -49 ± 7.0°C) were significantly higher, and the time to PVI was longer (90 ± 50 seconds vs 52 ± 29 seconds) in PVs with EPVR than in those without (P < 0.0001 for all). Among PVs without EPVR, the time to PVI was longer and balloon temperature was lower for the left superior pulmonary vein/ right inferior pulmonary vein (LSPV/RIPV) than for the right superior pulmonary vein/left inferior pulmonary vein (RSPV/LIPV) (time: 60 ± 25/73 ± 37 seconds vs 41 ± 31/45 ± 20 seconds, P < 0.0001) (temp: -39.2 ± 11.3/-39.4 ± 8.3°C vs -33.8 ± 10.6/-33.6 ± 6.8°C, P = 0.0023). AF recurrence rates were equivalent between patients with and without EPVR (13% [8/69] vs 15% [9/61], P = 0.845). CONCLUSIONS Cryoballoon temperature and time to PVI appear to be useful in predicting durable PVI, that is, prevention of EPVR, but the balloon temperature and time required for PVI differ between PVs. Although EPVR does not predict AF recurrence, high success rates can be expected when touch-up ablation of EPVR sites is performed.
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Affiliation(s)
- Ryuta Watanabe
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Yasuo Okumura
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Koichi Nagashima
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Kazuki Iso
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Keiko Takahashi
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Masaru Arai
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Yuji Wakamatsu
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Sayaka Kurokawa
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Kimie Ohkubo
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Toshiko Nakai
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Shunichi Yoda
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Ichiro Watanabe
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Atsushi Hirayama
- Division of CardiologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Kazumasa Sonoda
- Division of CardiologyDepartment of MedicineTokyo Rinkai HospitalTokyoJapan
| | - Toshimasa Tosaka
- Division of CardiologyDepartment of MedicineTokyo Rinkai HospitalTokyoJapan
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Inaba O, Nagata Y, Sekigawa M, Miwa N, Yamaguchi J, Miyamoto T, Goya M, Hirao K. Impact of impedance decrease during radiofrequency current application for atrial fibrillation ablation on myocardial lesion and gap formation. J Arrhythm 2018; 34:247-253. [PMID: 29951139 PMCID: PMC6009992 DOI: 10.1002/joa3.12056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 03/18/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The clinical impact of a decrease in impedance during radiofrequency catheter ablation (RFCA) has not been fully clarified. The aim of the study was to analyze the impact of impedance decrease and to determine its optimal cutoff value during RFCA. METHODS We evaluated 34 consecutive patients (total 3264 lesions, mean age 66 ± 8.7 years, 10 females) who underwent their first ablation for atrial fibrillation (AF). The impedance decrease, average contact force (CF), application time, force-time integral (FTI), product of impedance decrease and application time (PIT), and the product of impedance decrease and FTI (PIFT) were measured for all lesions. Levels of cardiac troponin I (TrpI) were measured for assessment of myocardial injury. The incidence of intraprocedural pulmonary vein-left atrium reconnection or dormant conduction (reconnection) was determined. The relationships between the ablation parameters and the increase in TrpI (ΔTrpI) were evaluated. The predictive value of the parameters for reconnection was assessed using receiver operating characteristic (ROC) curve analysis. RESULTS Reconnection was detected in 18 patients. Average FTI and PIT were significantly correlated with ΔTrpI (FTI: r2 = .19, P = .0090, PIT: r2 = .21, P = .0058). PIFT was correlated with ΔTrpI and was the best of the three indexes (PIFT: r2 = .29, P = .0010). In ROC curve analysis, the area under the curve for predicting reconnection was 0.71 and the optimal cutoff value was 5200 for PIFT (sensitivity 78%, specificity 63%). CONCLUSION The combination of CF and a decrease in impedance could be important in the evaluation of myocardial lesions and reconnection during RFCA.
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Affiliation(s)
- Osamu Inaba
- Department of CardiologyMusashino Red Cross HospitalMusashinoJapan
- Heart Rhythm CenterTokyo Medical and Dental UniversityBunkyo‐kuTokyoJapan
| | - Yasutoshi Nagata
- Department of CardiologyMusashino Red Cross HospitalMusashinoJapan
| | | | - Naoyuki Miwa
- Department of CardiologyMusashino Red Cross HospitalMusashinoJapan
| | - Junji Yamaguchi
- Department of CardiologyMusashino Red Cross HospitalMusashinoJapan
| | | | - Masahiko Goya
- Heart Rhythm CenterTokyo Medical and Dental UniversityBunkyo‐kuTokyoJapan
| | - Kenzo Hirao
- Heart Rhythm CenterTokyo Medical and Dental UniversityBunkyo‐kuTokyoJapan
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22
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Kaplan RM, Dandamudi S, Bohn M, Verma N, Tomson TT, Arora R, Chicos AB, Goldberger JJ, Kim SS, Knight BP, Lin AC, Passman RS. Reconnection Rate and Long-Term Outcome with Adenosine Provocation During Cryoballoon Ablation for Pulmonary Vein Isolation. J Atr Fibrillation 2017; 9:1510. [PMID: 29250268 DOI: 10.4022/jafib.1510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 11/30/2016] [Accepted: 01/23/2017] [Indexed: 11/10/2022]
Abstract
Background Adenosine can unmask dormant conduction during pulmonary vein isolation (PVI) for atrial fibrillation (AF). Studies of adenosine use in radiofrequency PVI show high reconnection rates and conflicting results for long-term success, however there is limited data with cryoballoon ablation (CBA). Methods A prospectively maintained database of patients undergoing first CBA at a single institution was analyzed. Adenosine use was at the discretion of the primary operator. Additional freezes were delivered for reconnected veins until dormant conduction was eliminated. The primary endpoint, time to AF recurrence defined as any episode < 30 seconds after a 3-month blanking period, was assessed by Kaplan-Meier analysis. Results From 2011 to 2015, 406 patients underwent CBA, 361 of whom had > 3 months follow-up. The mean age was 61.7 years, 69% were male, and the prevalence of paroxysmal AF was 79% with no significant difference between those that did and did not receive adenosine (77% vs 86%, respectively, p = 0.23). Adenosine testing was performed in 78 patients (21.6%) with a mean dose of 10.6 mg/vein. Of the 306 veins evaluated, 17 (6%) demonstrated dormant conduction. Over a median 14.4 months follow-up, there was no significant difference in freedom from AF with adenosine use (p= 0.86). Conclusions Dormant conduction with adenosine is uncommon following CBA and its use does not improve long-term success rates.
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Affiliation(s)
- Rachel M Kaplan
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Sanjay Dandamudi
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Martha Bohn
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Nishant Verma
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Todd T Tomson
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Rishi Arora
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Alexandru B Chicos
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | | | - Susan S Kim
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Bradley P Knight
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Albert C Lin
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
| | - Rod S Passman
- Division of Cardiology, Northwestern University, Feinberg School of Medicine
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Iqbal M, Jena A, Park HS, Baek YS, Lee KN, Roh SY, Shim JM, Choi JI, Kim YH. Value of adenosine test to reveal dormant conduction or adenosine-induced atrial fibrillation after pulmonary vein isolation. J Arrhythm 2017; 33:602-607. [PMID: 29255508 PMCID: PMC5728995 DOI: 10.1016/j.joa.2017.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/03/2017] [Accepted: 07/18/2017] [Indexed: 11/17/2022] Open
Abstract
Background Recent studies investigating the implications of additional ablation guided by dormant pulmonary vein (PV) conduction testing using adenosine showed conflicting results, and the data about atrial fibrillation (AF) recurrence after trigger site elimination in adenosine-induced AF are still lacking. Methods Of 846 patients with paroxysmal AF (PAF) who underwent PV isolation (PVI), adenosine test after PVI was performed in 148 patients. Results PVI was successfully achieved in 846 patients. We excluded 58 patients due to loss to the follow-up. A higher rate of AF recurrence was found in the group without adenosine test (136/644, 21%) compared to the group with adenosine test (20/144, 13%, log-rank P=0.047). In multivariate analysis model for AF freedom during the follow-up period, the only significant clinical predictor of AF freedom was adenosine test (hazard ratio [HR] 1.97; 95% confidence interval [CI]: 1.2-3.23; P=0.007).Among 148 patients with adenosine test, 114 (77%) patients showed neither dormant conductions nor AF-induced, 22 (15%) showed positive dormant conductions only, and 12 (8%) revealed adenosine-induced AF (6 of them also showed dormant conduction). After additional ablation in positive dormant conduction group and adenosine-induced AF group, AF recurrence was noted in 4/21 (19%) patients in positive dormant conduction group and 2/11 (18%) patients in adenosine-induced AF group, which was not different from that of patients in negative dormant conduction/ no AF-induced group (14/112, 12%, log-rank P=0.67). Conclusions Adenosine test after PVI to confirm the absence of dormant conduction and triggers initiating AF is beneficial to improve the outcomes after catheter ablation of PAF.
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Affiliation(s)
- Mohammad Iqbal
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea.,Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Jalan Eyckman 38, Bandung 40161, Indonesia
| | - Anupam Jena
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Hee-Soon Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Yong-Soo Baek
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Kwang-No Lee
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Jae-Min Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, 73 Inchon-Ro, Seongbuk-Gu, Seoul 02841, Republic of Korea
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Zakeri R, Van Wagoner DR, Calkins H, Wong T, Ross HM, Heist EK, Meyer TE, Kowey PR, Mentz RJ, Cleland JG, Pitt B, Zannad F, Linde C. The burden of proof: The current state of atrial fibrillation prevention and treatment trials. Heart Rhythm 2017; 14:763-782. [PMID: 28161513 PMCID: PMC5403606 DOI: 10.1016/j.hrthm.2017.01.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is an age-related arrhythmia of enormous socioeconomic significance. In recent years, our understanding of the basic mechanisms that initiate and perpetuate AF has evolved rapidly, catheter ablation of AF has progressed from concept to reality, and recent studies suggest lifestyle modification may help prevent AF recurrence. Emerging developments in genetics, imaging, and informatics also present new opportunities for personalized care. However, considerable challenges remain. These include a paucity of studies examining AF prevention, modest efficacy of existing antiarrhythmic therapies, diverse ablation technologies and practice, and limited evidence to guide management of high-risk patients with multiple comorbidities. Studies examining the long-term effects of AF catheter ablation on morbidity and mortality outcomes are not yet completed. In many ways, further progress in the field is heavily contingent on the feasibility, capacity, and efficiency of clinical trials to incorporate the rapidly evolving knowledge base and to provide substantive evidence for novel AF therapeutic strategies. This review outlines the current state of AF prevention and treatment trials, including the foreseeable challenges, as discussed by a unique forum of clinical trialists, scientists, and regulatory representatives in a session endorsed by the Heart Rhythm Society at the 12th Global CardioVascular Clinical Trialists Forum in Washington, DC, December 3-5, 2015.
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Affiliation(s)
- Rosita Zakeri
- Royal Brompton & Harefield NHS Trust, London, United Kingdom.
| | | | | | - Tom Wong
- Royal Brompton & Harefield NHS Trust, London, United Kingdom
| | | | - E Kevin Heist
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Wynnewood, Pennsylvania
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - John G Cleland
- Royal Brompton & Harefield NHS Trust, London, United Kingdom
| | | | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, France
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What Is the Appropriate Lesion Set for Ablation in Patients with Persistent Atrial Fibrillation? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:35. [PMID: 28401455 DOI: 10.1007/s11936-017-0534-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OPINION STATEMENT Special attention must be paid to detect, diagnose, and optimize management of reversible or treatable causes of long-standing persistent atrial fibrillation (LSPAF) such as obesity, obstructive sleep apnea (OSA), hypertension, hypo or hyperthyroidism, inflammatory and infectious diseases, and stress. Though, we strongly believe that the role of the pulmonary veins (PVs) is more pronounced in paroxysmal atrial fibrillation (AF) than in persistent AF, performing an adequate pulmonary vein isolation is still key in LSPAF. Patients with LSPAF will frequently require a more aggressive mapping and ablative approach. We do not encourage the use of empiric lines or complex fractionated atrial electrograms. Ablation of sites associated with non-PV triggers such as the entire posterior wall, the roof, the anterior part of the left atrium septum, left atrial appendage (LAA), the CS and SVC has been shown to improve the freedom from AF at follow-up when combined with PVs isolation. During the isoproterenol challenge, non-PV triggers are detected in most patients with AF. Mapping non-PV triggers is guided by multiple catheters positioned along both the right and left atriums: a 10-pole circular mapping catheter in the left superior PV recording the far-field LAA activity, the ablation catheter in the right superior PV that records the far-field interatrial septum and a 20-pole catheter with electrodes spanning from the SVC to the CS. With this simple catheter setup, when focal ectopic atrial activity is observed (a single ectopic beat is enough) their activation sequence is compared to that of sinus rhythm, allowing to quickly identify their area of origin. For significant non-PV triggers (repetitive isolated beats, focal atrial tachycardias or beats triggering AF/atrial flutter, a more detailed activation mapping is performed in the area of origin. They are subsequently targeted with focal ablation, exception being the triggers originating from the SVC, LAA or CS, in which cases complete isolation of these structures is the ablation strategy of choice. We truly believe the LAA deserves special consideration when managing patients with persistent AF and LSPAF.
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26
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Chen YH, Lin H, Xie CL, Hou JW, Li YG. Role of adenosine-guided pulmonary vein isolation in patients undergoing catheter ablation for atrial fibrillation: a meta-analysis. Europace 2017; 19:552-559. [PMID: 28431050 DOI: 10.1093/europace/euw201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/08/2016] [Indexed: 10/13/2023] Open
Abstract
AIMS Adenosine had been reported to unmask dormant conduction and thus identify pulmonary vein at risk of reconnection. However, the role of adjunctive adenosine infusion after pulmonary vein isolation (PVI) on long-term arrhythmia-free survival was still contentious. The purpose of the present meta-analysis was to assess the association of adenosine testing with long-term ablation success in patients with atrial fibrillation (AF) (i.e. freedom from AF recurrence). METHODS AND RESULTS We systematically searched the electronic databases and finally included 10 studies, with 1771 patients undergoing adenosine-guided PVI and 1787 patients undergoing conventional PVI. In comparison to conventional PVI alone, adenosine-guided PVI improved the arrhythmia-free survival by 17% during a median follow-up of 12 months [relative risk (RR): 1.17; 95% confidence interval (CI): 1.07 to 1.27; P = 0.014]. Patients undergoing adenosine-guided PVI had similar fluoroscopy time to those who undergoing conventional PVI [weighted mean difference (WMD): 1.76; 95% CI: -5.66 to 9.17; P = 0.64], despite longer procedure time (WMD: 20.6; 95% CI: 0.70 to 40.50; P = 0.042). CONCLUSION From the available data of clinical studies, adenosine-guided PVI was associated with an increased arrhythmia-free survival when compared with conventional PVI in patients undergoing catheter ablation for AF.
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Affiliation(s)
- Yi-He Chen
- Department of Cardiology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai 200092, China
| | - Hui Lin
- Department of Respiratory, The Second Af?liated Hospital of Wenzhou Medical University, Wenzhou 325027, China
| | - Cheng-Long Xie
- Department of Neurology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, Shanghai 200092, China
| | - Jian-Wen Hou
- Department of Cardiology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai 200092, China
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital Affiliated to the Medical School of Shanghai Jiaotong University, 1665 Kongjiang Road, Shanghai 200092, China
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Letsas KP, Georgopoulos S, Efremidis M, Liu T, Bazoukis G, Vlachos K, Karamichalakis N, Lioni L, Sideris A, Ehrlich JR. Adenosine-guided radiofrequency catheter ablation of atrial fibrillation: A meta-analysis of randomized control trials. J Arrhythm 2017; 33:247-255. [PMID: 28765753 PMCID: PMC5529608 DOI: 10.1016/j.joa.2017.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 01/16/2017] [Accepted: 02/19/2017] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The prognostic significance of adenosine-mediated dormant pulmonary vein conduction, and whether such dormant conduction should be eliminated, remains controversial. We sought to perform a meta-analysis of data from eligible studies to delineate the prognostic impact of adenosine-guided radiofrequency catheter ablation of atrial fibrillation. METHODS A systematic literature search was performed using online databases in order to identify relevant studies from January 2004 to September 2016. Ten studies [six observational and four randomized control trials (RCTs)] were included in the analysis. RESULTS Five studies (two observational and three RCTs) compared the efficacy of adenosine-mediated elimination of dormant conduction versus no adenosine test. Overall, the adenosine-guided ablation strategy displayed better long-term outcomes as compared with no adenosine testing (RR 1.08, 95% CI 1.01-1.14, p=0.02; Heterogeneity: I2=42%, p: 0.14). The meta-analysis of only RCTs failed to show any differences between the two strategies (RR 1.03, 95% CI 0.96-1.11, p=0.37; Heterogeneity: I2 0%, p: 0.41). Eight studies (five observational and three RCTs) addressed the efficacy of adenosine-induced dormant conduction and additional ablation versus no dormant conduction during adenosine challenge. Overall, a trend towards a better outcome in those without dormant conduction during drug challenge was noted (RR 0.89, 95% CI 0.77-1.03, p=0.11; Heterogeneity: I2 65% p: 0.006). The pooled analysis of RCTs failed to show any differences between the two arms (RR 0.90, 95% CI 0.62-1.30, p= 0.57; Heterogeneity: I2 88%, p: 0.0002). CONCLUSIONS Adenosine-guided radiofrequency catheter ablation of atrial fibrillation does not provide additional benefit in terms of freedom of arrhythmia recurrence.
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Affiliation(s)
- Konstantinos P Letsas
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Stamatis Georgopoulos
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Michael Efremidis
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, People׳s Republic of China
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Konstantinos Vlachos
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | | | - Louiza Lioni
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Antonios Sideris
- Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
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Pedrote A, Acosta J, Jáuregui-Garrido B, Frutos-López M, Arana-Rueda E. Paroxysmal atrial fibrillation ablation: Achieving permanent pulmonary vein isolation by point-by-point radiofrequency lesions. World J Cardiol 2017; 9:230-240. [PMID: 28400919 PMCID: PMC5368672 DOI: 10.4330/wjc.v9.i3.230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/14/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
Pulmonary vein isolation by point-by-point radiofrequency catheter ablation constitutes the cornerstone of catheter ablation strategies for the treatment of atrial fibrillation. However, despite advances in pulmonary vein isolation ablation strategies, long-term success rates after ablation remain suboptimal, which highlights the need to develop techniques to achieve more durable lesions. Strategies proposed to improve the durability of pulmonary vein isolation can be divided into two groups: Those addressed to improving the quality of the lesion and those that optimize the detection of acute PV reconnection during the ablation procedure. This manuscript reviews the role and potential benefits of these techniques according to current clinical evidence.
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Adenosine administration during hybrid atrial fibrillation ablation to test dormant pulmonary vein conduction. J Interv Card Electrophysiol 2017; 49:59-65. [PMID: 28285383 PMCID: PMC5403878 DOI: 10.1007/s10840-017-0239-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/01/2017] [Indexed: 11/22/2022]
Abstract
Background Adenosine administration after initial pulmonary vein isolation (PVI) reveals dormant conduction and predicts atrial fibrillation (AF) recurrence. Elimination of dormant conduction when present may increase a long-term success rate of AF ablation procedures. There are no studies till date using adenosine to reveal acute reconduction of pulmonary veins (PVs) after epicardial PVI during a hybrid AF ablation procedure. Methods We included 24 patients (21 male, 55 ± 9 years) undergoing hybrid ablation for symptomatic paroxysmal (n = 12) and persistent (n = 12) AF, using an epicardial bipolar radiofrequency clamp to perform PVI. All antiarrhythmic medications were discontinued 5 days prior to the procedure, except for patients on amiodarone. Thirty minutes after PVI and once sinus rhythm was obtained, a bolus of adenosine (12 to 36 mg) was administered intravenously. The subsequent response was assessed for each PV (n = 96) using an in situ circular mapping catheter. Results Dormant conduction (i.e., the reappearance of PV potentials during at least one beat) was seen in 1 out of 96 PVs (1%). If reconduction was seen, further endocardial ablation using a 3.5-mm irrigated tip catheter was performed until no more reconduction occurred after repeating the adenosine bolus. Conclusions Adenosine administration after PVI with the use of an epicardial bipolar radiofrequency clamp in the setting of hybrid AF ablation reveals acute reconduction in 1% of the PVs.
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30
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Kocyigit D, Canpolat U, Aytemir K. Who Needs Catheter Ablation And Which Approach? J Atr Fibrillation 2016; 8:1335. [PMID: 27957233 DOI: 10.4022/jafib.1335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 12/29/2022]
Abstract
Catheter ablation therapy for atrial fibrillation (AF) has gained a significant role during maintenance of sinus rhythm compared to anti-arrhythmic medication. Catheter ablation techniques are also improved and progressed over years in parallel to better understanding of disease mechanisms and technological advancements. However, due to invasive nature of the therapy with its pertinent procedural risks, both appropriate patient selection and use of relevant approach should be considered by all electrophysiologists before decide to perform catheter ablation.
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Affiliation(s)
- Duygu Kocyigit
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Canpolat
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4683] [Impact Index Per Article: 585.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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Iso K, Okumura Y, Watanabe I, Nagashima K, Sonoda K, Kogawa R, Sasaki N, Takahashi K, Kurokawa S, Nakai T, Ohkubo K, Hirayama A. Wall thickness of the pulmonary vein-left atrial junction rather than electrical information as the major determinant of dormant conduction after contact force-guided pulmonary vein isolation. J Interv Card Electrophysiol 2016; 46:325-33. [PMID: 27221713 DOI: 10.1007/s10840-016-0147-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 05/16/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE The usefulness of electrogram (EGM)-based information has been reported for assessing lesion transmurality during atrial fibrillation (AF) ablation, but the wall thickness of the pulmonary vein-left atrial (PV-LA) junction has not been considered. We conducted a study to evaluate the relation between PV-LA junction wall thickness and the presence of adenosine triphosphate (ATP)-provoked dormant PV conduction. METHODS Eighteen AF patients underwent extensive encircling pulmonary vein isolation (EEPVI) with a target CF of >10 g. RF energy was delivered point-by-point at a power setting of 25-30 W for 30 s, and EGM-based information (change in filtered unipolar EGM morphology and bipolar EGM amplitude), decrease in impedance, CF, and CT-based measurement of the PV-LA junction wall thickness were characterized at sites of ATP-provoked dormant conduction. RESULTS After EEPVI, ATP-induced dormant conduction was observed at 12 of the 288 PV sites (8 segments per ipsilateral PVs × 2 × 18 patients). Of the 974 ablation points, 72 were located at dormant conduction sites and were strongly associated with thickened PV-LA junction walls (1.02± 0.23 vs. 0.86 ± 0.26 mm, p < 0.0001) and decreased impedance (13.3 ± 6.4 vs. 14.9 ± 7.1 Ω, p = 0.0498) but not with EGM-based information or CF. Multivariate analysis identified the thickened PV-LA junction wall as the strongest predictor of dormant conduction. CONCLUSIONS A thickened PV-LA junction wall is a robust predictor of ATP-provoked dormant conduction; EGM-based information appears to be insufficient for ensuring adequate lesions during CF-guided EEPVI.
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Affiliation(s)
- Kazuki Iso
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kazumasa Sonoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Naoko Sasaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Keiko Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review. Cardiol Res Pract 2016; 2016:8632509. [PMID: 26981309 PMCID: PMC4770126 DOI: 10.1155/2016/8632509] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/04/2016] [Indexed: 01/19/2023] Open
Abstract
The cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI), which can be achieved in more than 95% of patients at the end of the procedure. However, AF recurrence rates remain high and are related to recovery of PV conduction. Adenosine testing is used to unmask dormant pulmonary vein conduction (DC). The aim of this study is to review the available literature addressing the role of adenosine testing and determine the impact of ablation at sites of PV reconnection on freedom from AF. Adenosine infusion, by restoring the excitability threshold, unmasks reversible injury that could lead to recovery of PV conduction. The studies included in this review suggest that adenosine is useful to unmask nontransmural lesions at risk of reconnection and that further ablation at sites of DC is associated with improvement in freedom from AF. Nevertheless it has been demonstrated that adenosine is not able to predict all veins at risk of later reconnection, which means that veins without DC are not necessarily at low risk. The role of the waiting period in the setting of adenosine testing has also been analyzed, suggesting that in the acute phase adenosine use should be accompanied by enough waiting time.
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Steffel J, Jais P, Hindricks G. The year in cardiology 2015: arrhythmias and device therapy. Eur Heart J 2016; 37:587-93. [PMID: 26726044 PMCID: PMC5137382 DOI: 10.1093/eurheartj/ehv725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 12/10/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jan Steffel
- Cardiac Arrhythmia Unit, Department of Cardiology, University Hospital Zurich, Zürich, Switzerland
| | - Pierre Jais
- Hôpital Haut-l'évêque, Departments of Cardiology and Radiology, Centre Hospitalier Universitaire (CHU) de Bordeaux & LIRYC Institute, Institut Hospitalo-Universitaire (IHU), Bordeaux, France
| | - Gerhard Hindricks
- Department of Electrophysiology, University of Leipzig-Heart Center, Leipzig 04289, Germany
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Macle L, Nattel S. Arrhythmias in 2015: Advances in drug, ablation, and device therapy for cardiac arrhythmias. Nat Rev Cardiol 2016; 13:67-8. [PMID: 26727299 DOI: 10.1038/nrcardio.2015.196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Laurent Macle
- Department of Medicine, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec H1T 1C8, Canada
| | - Stanley Nattel
- Department of Medicine, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec H1T 1C8, Canada
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Gourraud JB, Andrade JG, Macle L, Mondésert B. Pharmacological Tests in Atrial Fibrillation Ablation. Arrhythm Electrophysiol Rev 2016; 5:170-176. [PMID: 28116081 DOI: 10.15420/aer.2016:27:2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The invasive management of atrial fibrillation (AF) has been considerably changed by the identification of major sites of AF initiation and/or maintenance within the pulmonary vein antra. Percutaneous catheter ablation of these targets has become the standard of care for sustained maintenance of sinus rhythm. Long-term failure of ablation is related to an inability to create a durable transmural lesion or to identify all of the non-pulmonary vein arrhythmia triggers. Pharmacological challenges during catheter ablation have been suggested to improve outcomes in both paroxysmal and persistent AF. Herein we review the mechanism and evidence for the use of pharmacological adjuncts during the catheter ablation of AF.
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Affiliation(s)
- Jean-Baptiste Gourraud
- Electrophysiology Service, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Jason G Andrade
- Electrophysiology Service, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Laurent Macle
- Electrophysiology Service, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Blandine Mondésert
- Electrophysiology Service, Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
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Lüscher TF. Supraventricular and ventricular arrhythmias. Eur Heart J 2015; 36:3215-7. [DOI: 10.1093/eurheartj/ehv632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Jared Bunch T. One drug, two outcomes after atrial fibrillation ablation: the situational irony of adenosine. Eur Heart J 2015; 36:3288-90. [DOI: 10.1093/eurheartj/ehv473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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