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Dong Y, Zhao D, Chen X, Shi L, Chen Q, Zhang H, Yu Y, Ullah I, Kojodjojo P, Zhang F. Role of electroanatomical mapping-guided superior vena cava isolation in paroxysmal atrial fibrillation patients without provoked superior vena cava triggers: a randomized controlled study. Europace 2024; 26:euae039. [PMID: 38306471 PMCID: PMC10906951 DOI: 10.1093/europace/euae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/27/2023] [Indexed: 02/04/2024] Open
Abstract
AIMS Data about whether empirical superior vena cava (SVC) isolation (SVCI) improves the success rate of paroxysmal atrial fibrillation (PAF) are conflicting. This study sought to first investigate the characteristics of SVC-triggered atrial fibrillation and secondly investigate the impact of electroanatomical mapping-guided SVCI, in addition to circumferential pulmonary vein isolation (CPVI), on the outcome of PAF ablation in the absence of provoked SVC triggers. METHODS AND RESULTS A total of 130 patients undergoing PAF ablation underwent electrophysiological studies before ablation. In patients for whom SVC triggers were identified, SVCI was performed in addition to CPVI. Patients without provoked SVC triggers were randomized in a 1:1 ratio to CPVI plus SVCI or CPVI only. The primary endpoint was freedom from any documented atrial tachyarrhythmias lasting over 30 s after a 3-month blanking period without anti-arrhythmic drugs at 12 months after ablation. Superior vena cava triggers were identified in 30 (23.1%) patients with PAF. At 12 months, 93.3% of those with provoked SVC triggers who underwent CPVI plus SVCI were free from atrial tachyarrhythmias. In patients without provoked SVC triggers, SVCI, in addition to CPVI, did not increase freedom from atrial tachyarrhythmias (87.9 vs. 79.6%, log-rank P = 0.28). CONCLUSION Electroanatomical mapping-guided SVCI, in addition to CPVI, did not increase the success rate of PAF ablation in patients who had no identifiable SVC triggers. REGISTRATION ChineseClinicalTrials.gov: ChiCTR2000034532.
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Affiliation(s)
- Yan Dong
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Dongsheng Zhao
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Xinguang Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Linshen Shi
- Department of Cardiology, The Second Affiliated Hospital of Nantong University, Nantong, China
| | - Qiushi Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Haiyan Zhang
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Yu
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Inam Ullah
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Pipin Kojodjojo
- Asian Heart and Vascular Centre, National University of Singapore, Singapore, Singapore
| | - Fengxiang Zhang
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
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Kugler S, Tőkés A, Nagy N, Fintha A, Danics K, Sághi M, Törő K, Rácz G, Nemeskéri Á. Strong desmin immunoreactivity in the myocardial sleeves around pulmonary veins, superior caval vein and coronary sinus supports the presumed arrhythmogenicity of these regions. J Anat 2024; 244:120-132. [PMID: 37626442 PMCID: PMC10734648 DOI: 10.1111/joa.13947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 08/04/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Myocardial sleeve around human pulmonary veins plays a critical role in the pathomechanism of atrial fibrillation. Besides the well-known arrhythmogenicity of these veins, there is evidence that myocardial extensions into caval veins and coronary sinus may exhibit similar features. However, studies investigating histologic properties of these structures are limited. We aimed to investigate the immunoreactivity of myocardial sleeves for intermediate filament desmin, which was reported to be more abundant in Purkinje fibers than in ventricular working cardiomyocytes. Sections of 16 human (15 adult and 1 fetal) hearts were investigated. Specimens of atrial and ventricular myocardium, sinoatrial and atrioventricular nodes, pulmonary veins, superior caval vein and coronary sinus were stained with anti-desmin monoclonal antibody. Intensity of desmin immunoreactivity in different areas was quantified by the ImageJ program. Strong desmin labeling was detected at the pacemaker and conduction system as well as in the myocardial sleeves around pulmonary veins, superior caval vein, and coronary sinus of adult hearts irrespective of sex, age, and medical history. In the fetal heart, prominent desmin labeling was observed at the sinoatrial nodal region and in the myocardial extensions around the superior caval vein. Contrarily, atrial and ventricular working myocardium exhibited low desmin immunoreactivity in both adults and fetuses. These differences were confirmed by immunohistochemical quantitative analysis. In conclusion, this study indicates that desmin is abundant in the conduction system and venous myocardial sleeves of human hearts.
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Affiliation(s)
- Szilvia Kugler
- Heart and Vascular CentreSemmelweis UniversityBudapestHungary
| | - Anna‐Mária Tőkés
- Department of Pathology, Forensic and Insurance MedicineSemmelweis UniversityBudapestHungary
| | - Nándor Nagy
- Department of Anatomy, Histology and EmbryologySemmelweis UniversityBudapestHungary
| | - Attila Fintha
- Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Krisztina Danics
- Department of Pathology, Forensic and Insurance MedicineSemmelweis UniversityBudapestHungary
| | - Márton Sághi
- Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Klára Törő
- Department of Pathology, Forensic and Insurance MedicineSemmelweis UniversityBudapestHungary
| | - Gergely Rácz
- Department of Pathology and Experimental Cancer ResearchSemmelweis UniversityBudapestHungary
| | - Ágnes Nemeskéri
- Department of Anatomy, Histology and EmbryologySemmelweis UniversityBudapestHungary
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Vrachatis DA, Papathanasiou KA, Kossyvakis C, Giotaki SG, Deftereos G, Kousta MS, Iliodromitis KE, Bogossian H, Avramides D, Giannopoulos G, Lambadiari V, Siasos G, Papaioannou TG, Deftereos S. Efficacy, Safety and Feasibility of Superior Vena Cava Isolation in Patients Undergoing Atrial Fibrillation Catheter Ablation: An Up-to-Date Review. Biomedicines 2023; 11:biomedicines11041022. [PMID: 37189639 DOI: 10.3390/biomedicines11041022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/10/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Pulmonary vein isolation (PVI) is the cornerstone in atrial fibrillation (AF) ablation; yet, the role of arrhythmogenic superior vena cava (SVC) is increasingly recognized and different ablation strategies have been employed in this context. SVC can act as a trigger or perpetuator of AF, and its significance might be more pronounced in patients undergoing repeated ablation. Several cohorts have examined efficacy, safety and feasibility of SVC isolation (SVCI) among AF patients. The majority of these studies explored as-needed SVCI during index PVI, and only a minority of them included repeated ablation subjects and non-radiofrequency energy sources. Studies of heterogeneous design and intent have explored both empiric and as-needed SVCI on top of PVI and reported inconclusive results. These studies have largely failed to demonstrate any clinical benefit in terms of arrhythmia recurrence, although safety and feasibility are undisputable. Mixed population demographics, small number of enrollees and short follow-up are the main limitations. Procedural and safety data are comparable between empiric SVCI and as-needed SVCI, and some studies suggested that empiric SVCI might be associated with reduced AF recurrences in paroxysmal AF patients. Currently, no study has compared different ablation energy sources in the setting of SVCI, and no randomized study has addressed as-needed SVCI on top of PVI. Furthermore, data regarding cryoablation are still in their infancy, and regarding SVCI in patients with cardiac devices more safety and feasibility data are needed. PVI non-responders, patients undergoing repeated ablation and patients with long SVC sleeves could be potential candidates for SVCI, especially via an empiric approach. Although many technical aspects remain unsettled, the major question to answer is which clinical phenotype of AF patients might benefit from SVCI?
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Patel RS, Khayata M, De Ponti R, Bagliani G, Leonelli FM. Relationships Between Atrial Flutter and Fibrillation: The Border Zone. Card Electrophysiol Clin 2022; 14:421-434. [PMID: 36153124 DOI: 10.1016/j.ccep.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Atrial flutter and fibrillation have been inextricably linked in the study of electrophysiology. With astute clinical observation, advanced diagnostic equipment in the Electrophysiology Laboratory, and thoughtful study of animal models, the mechanism and inter-relationship between the 2 conditions have been elucidated and will be reviewed in this article. Though diagnosis and management of these conditions have many similarities, the mechanisms by which they develop and persist are quite unique.
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Affiliation(s)
- Ritesh S Patel
- University of South Florida Morsani, College of Medicine, Division of Cardiovascular Diseases, 4202 E Fowler Avenue, Tampa, FL 33620, USA
| | - Mohamed Khayata
- University of South Florida Morsani, College of Medicine, Division of Cardiovascular Diseases, 4202 E Fowler Avenue, Tampa, FL 33620, USA
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, 21100, Varese, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, 21100, Varese, Italy
| | - Giuseppe Bagliani
- Cardiology And Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, 60126, Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
| | - Fabio M Leonelli
- University of South Florida Morsani, College of Medicine, Division of Cardiovascular Diseases, 4202 E Fowler Avenue, Tampa, FL 33620, USA; James A Haley Veterans Hospital, Tampa, FL, USA.
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Yamamoto T, Iwasaki YK, Fujimoto Y, Oka E, Hayashi H, Murata H, Yodogawa K, Hayashi M, Igawa O, Shimizu W. The characteristics and efficacy of catheter ablation of focal atrial tachycardia arising from an epicardial site. Clin Cardiol 2021; 44:563-572. [PMID: 33598933 PMCID: PMC8027578 DOI: 10.1002/clc.23577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Although epicardial structures around the atrium such as adipose tissue possess arrhythmogenicity, little is known about atrial tachycardias (ATs) originating from epicardial sites (Epi-ATs). This study aimed to elucidate the prevalence, characteristics, and outcome after radiofrequency catheter ablation (RFCA) of Epi-ATs and to reveal the association between Epi-ATs and the epicardial structures. METHODS The electrocardiographic, electrophysiologic, and anatomical properties and results of RFCA were analyzed in 42 patients with a total of 49 ectopic ATs. RESULTS Six Epi-ATs (12%) were observed in six patients (14%). Four of six were respiratory cycle-dependent ATs and one was a swallowing-induced AT. The Epi-AT origins were adjacent to a pulmonary vein (five cases) and vein of Marshall (one case). A Valsalva maneuver or atropine infusion to define the arrhythmia mechanism affected the appearance of the Epi-ATs. The congruity rate between epicardial adipose tissue and the AT origin was significantly higher (100% vs. 44%, p = .045), and the epicardial adipose tissue volume of the atrium was significantly larger (104.1 vs. 64.6 ml, p = .04) in the Epi-AT group. Endocardial RFCA targeting the AT foci resulted in acute success in five of five cases. However, electrical isolation including of the AT foci resulted in acute failures (two of three cases) or a recurrence (one of one case). CONCLUSIONS Six Epi-ATs were associated with thoracic veins and epicardial arrhythmogenic structures. The main cause provoking the Epi-ATs was associated with autonomic nerve activity.
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Affiliation(s)
- Teppei Yamamoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Yuhi Fujimoto
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Eiichiro Oka
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Hiroshige Murata
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Meiso Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Osamu Igawa
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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Nyuta E, Takemoto M, Sakai T, Mito T, Masumoto A, Todoroki W, Yagyu K, Ueno J, Antoku Y, Koga T, Ueno T, Tsuchihashi T. Importance of the length of the myocardial sleeve in the superior vena cava in patients with atrial fibrillation. J Arrhythm 2021; 37:43-51. [PMID: 33664885 PMCID: PMC7896468 DOI: 10.1002/joa3.12494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/03/2020] [Accepted: 12/17/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Pulmonary vein (PV) antrum isolation (PVAI) has proven to be a useful strategy for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) worldwide. However, non-PV foci, especially from the superior vena cava (SVC), play an important role in initiating and maintaining AF. METHODS In all, 427 consecutive patients with non-valvular AF who were admitted to our hospitals to undergo RFCA of AF using an EnSite™ system were evaluated. The length from the top of the sinus node to the top of the myocardial sleeve of SVC (L-SVC), longer and shorter diameter of SVC of 1 cm above of junction of right atrium and SVC, and local activation time (LAT) of SVC were measured. Then, the SVC firing was evaluated by an intravenous administration of isoproterenol and adenosine triphosphate. RESULTS L-SVC, longer and shorter diameter of SVC, and LAT of SVC were significantly longer in the SVC firing group than non-SVC firing group (P < .05). Moreover, in accordance with the L-SVC, the frequency of the SVC firing significantly increased (P < .001). A univariate analysis and multivariate statistical analysis revealed that L-SVC longer than 37.0 mm (odds ratio 6.39) and longer diameter of SVC (odds ratio 6.78) were independent risk factors for SVC firing in patients with AF who underwent RFCA of AF. CONCLUSIONS In view of these findings, L-SVC longer than 37.0 mm longer diameter SVC longer than 17.0 mm may be one of the important predictors of SVC firing in patients with AF.
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Affiliation(s)
- Eiji Nyuta
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Masao Takemoto
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
- CardiologyMunakata Suikokai General HospitalFukutsuJapan
| | - Togo Sakai
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Takahiro Mito
- CardiologyMunakata Suikokai General HospitalFukutsuJapan
- CardiologyHakujuji HospitalFukuokaJapan
| | | | - Wataru Todoroki
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Keishiro Yagyu
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Jiro Ueno
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Yoshibumi Antoku
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
- CardiologyMunakata Suikokai General HospitalFukutsuJapan
| | - Tokushi Koga
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
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Comparison between superior vena cava ablation in addition to pulmonary vein isolation and standard pulmonary vein isolation in patients with paroxysmal atrial fibrillation with the cryoballoon technique. J Interv Card Electrophysiol 2021; 62:579-586. [PMID: 33447964 PMCID: PMC8645537 DOI: 10.1007/s10840-020-00932-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/27/2020] [Indexed: 11/18/2022]
Abstract
Background Paroxysmal atrial fibrillation (PAF) can be triggered by non-pulmonary vein foci, like the superior vena cava (SVC). The latter is correlated with improved result in terms of freedom from atrial tachycardias (ATs), when electrical isolation of this vessel utilizing radiofrequency energy (RF) is achieved. Objectives Evaluate the clinical impact, in patients with PAF, of the SVC isolation (SVCi) in addition to ordinary pulmonary vein isolation (PVI) by means of the second-generation cryoballoon (CB) Methods A total of 100 consecutive patients that underwent CB ablation for PAF were retrospectively selected. Fifty consecutive patients received PVI followed by SVCi by CB application, and the following 50 consecutive patients received standard PVI. All patients were followed 12 months. Results The mean time to SVCi was 36.7 ± 29.0 s and temperature at SVC isolation was − 35 (− 18 to − 40) °C. Real-time recording (RTR) during SVCi was observed in 42 (84.0%) patients. At the end of 12 months of follow-up, freedom from ATs was achieved in 36 (72%) patients in the PVI only group and in 45 (90%) patients of the SVC and PV isolation group (Fisher’s exact test p = 0.039, binary logistic regression: p = 0.027, OR = 0.28, 95%CI = 0.09–0.86). In survival analysis, SVC and PV isolation group was also associated with improved freedom from ATs (log-rank test: p = 0.017, Cox regression: p = 0.026, HR = 0.31, 95%CI = 0.11–0.87). Conclusion Superior vena cava isolation with the CB in addition to PVI might improve freedom from ATs if compared to PVI alone at 1-year follow-up.
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Safety and feasibility of electrical isolation of the superior vena cava in addition to pulmonary vein ablation for paroxysmal atrial fibrillation using the cryoballoon: lessons from a prospective study. J Interv Card Electrophysiol 2020; 60:255-260. [DOI: 10.1007/s10840-020-00740-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/26/2020] [Indexed: 01/12/2023]
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Vahdatpour CA, Luebbert JJ, Palevsky HI. Atrial arrhythmias in chronic lung disease-associated pulmonary hypertension. Pulm Circ 2020; 10:2045894020910685. [PMID: 32215200 PMCID: PMC7065292 DOI: 10.1177/2045894020910685] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Atrial arrhythmias are common during episodes of acute respiratory failure in patients with chronic lung disease-associated pulmonary hypertension. Expert opinion suggests that management of atrial arrhythmias in patients with pulmonary hypertension should aim to restore sinus rhythm. This is clinically challenging in pulmonary hypertension patients with coexisting chronic lung disease, as there is controversy on the use of rhythm control agents; generally, in regard to either their pulmonary toxicity profile or the lack of evidence supporting their use. Rate control methods are largely focused on the use of beta blockers and calcium channel blockers. Concerns regarding their use involve their negative inotropic properties in cor pulmonale, the risk of bronchospasm associated with beta blockers, and the potential for ventilation/perfusion mismatching associated with calcium channel blockers. While digoxin has been associated with promising outcomes during acute right ventricular failure, there is limited evidence to suggest its routine use. Electrical cardioversion is associated with a high failure rate and it frequently requires multiple attempts. Radiofrequency catheter ablation is a more definitive approach, but concerns surrounding mechanical ventilation and sedation limit its applicability in decompensated pulmonary hypertension. Individual approaches are needed to address atrial arrhythmia management during acute episodes of respiratory failure.
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Affiliation(s)
- Cyrus A. Vahdatpour
- Department of Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Jeffrey J. Luebbert
- Department of Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Harold I. Palevsky
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Shi R, Parikh P, Chen Z, Angel N, Norman M, Hussain W, Butcher C, Haldar S, Jones DG, Riad O, Markides V, Wong T. Validation of Dipole Density Mapping During Atrial Fibrillation and Sinus Rhythm in Human Left Atrium. JACC Clin Electrophysiol 2019; 6:171-181. [PMID: 32081219 DOI: 10.1016/j.jacep.2019.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study sought to validate the accuracy of noncontact electrograms against contact electrograms in the left atrium during sinus rhythm (SR) and atrial fibrillation (AF). BACKGROUND Noncontact mapping offers the opportunity to assess global cardiac activation in the chamber of interest. A novel noncontact mapping system, which records intracardiac voltage to derive cellular charge sources (dipole density), allows real-time mapping of AF to guide ablation. METHODS Noncontact and contact unipolar electrogram pairs were recorded simultaneously from multiple locations. Morphology correlation and timing difference of reconstructed electrograms obtained from a noncontact catheter were compared with those from contact electrograms obtained from a contact catheter at the same endocardial locations. RESULTS A total of 796 electrogram pairs in SR and 969 electrogram pairs in AF were compared from 20 patients with persistent AF. The median morphology correlation and timing difference (ms) in SR was 0.85 (interquartile range [IQR]: 0.71 to 0.94) and 6.4 ms (IQR: 2.6 to 17.1 ms); in AF was 0.79 (IQR: 0.69 to 0.88) and 14.4 ms (IQR: 6.7 to 26.2 ms), respectively. The correlation was stronger and the timing difference was less when the radial distance (r) from the noncontact catheter center to the endocardium was ≤ 40 versus > 40 mm; 0.87 (IQR: 0.72 to 0.94) versus 0.73 (IQR: 0.56 to 0.88) and 5.7 ms (IQR: 2.6 to 15.4 ms) versus 15.1 ms (IQR: 4.1 to 27.7 ms); p < 0.01 when in SR; 0.81 (IQR: 0.69 to 0.89) versus 0.67 (IQR: 0.45 to 0.82) and 12.3 ms (IQR: 5.9 to 21.8 ms) versus 28.3 ms (IQR: 16.2 to 36.0 ms); p < 0.01 when in AF. CONCLUSIONS This novel noncontact dipole density mapping system provides comparable reconstructed atrial electrogram measurements in SR or AF in human left atrium when the anatomical site of interest is ≤40 mm from the mapping catheter.
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Affiliation(s)
- Rui Shi
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China; Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | | | - Zhong Chen
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | | | - Mark Norman
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Wajid Hussain
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Charlie Butcher
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Shouvik Haldar
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - David G Jones
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Omar Riad
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Vias Markides
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Tom Wong
- Heart Rhythm Centre, The Royal Brompton and Harefield National Health Service Foundation Trust, National Heart and Lung Institute, Imperial College London, United Kingdom.
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Gianni C, Sanchez JE, Mohanty S, Trivedi C, Della Rocca DG, Al-Ahmad A, Burkhardt JD, Gallinghouse GJ, Hranitzky PM, Horton RP, Di Biase L, Natale A. Isolation of the superior vena cava from the right atrial posterior wall: a novel ablation approach. Europace 2019; 20:e124-e132. [PMID: 29016788 DOI: 10.1093/europace/eux262] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/10/2017] [Indexed: 11/14/2022] Open
Abstract
Aims Superior vena cava (SVC) isolation might be difficult to achieve because of the vicinity of the phrenic nerve (PN) and sinus node. Based on its embryogenesis, we hypothesized the presence of preferential conduction from the right atrial (RA) posterior wall, making it possible to isolate the SVC antrally, sparing its anterior and lateral aspect. Methods and results This is a descriptive cohort study of 105 consecutive patients in which SVC isolation was obtained with radiofrequency ablation, starting in the septal aspect of the SVC-RA junction and continued posteriorly and inferiorly targeting sites of early activation until electrical isolation was obtained. Acute SVC isolation was achieved in 103 (98%) patients; the mean distance between the site of SVC isolation and the SVC-RA junction was 19.9 ± 5.3 (range 9.7-33.7) mm. During follow-up, 2 (2%) patients developed symptomatic diaphragmatic paralysis due to transient right PN injury; 13 patients underwent a repeat ablation: SVC reconnection was observed in 5 patients, and re-isolation was easily achieved by targeting the corresponding sites of early activation. Conclusion Superior vena cava isolation can be completed by targeting its septal segment and sites of early activation in the posterior SVC-RA junction and RA posterior wall; this is a feasible alternative ablation strategy in patients in which SVC isolation cannot be completed with the standard approach. The risk of sinus node injury or SVC stenosis are eliminated; PN injury is still possible but can easily be prevented with high-output pacing to exclude a true posterior course of the PN.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA.,Dell Medical School, University of Texas, Austin, TX, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA.,Department of Cardiology, University of Tor Vergata, Rome, Italy
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - G Joseph Gallinghouse
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - Patrick M Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N IH-35, Suite 720, Austin, TX, USA.,Dell Medical School, University of Texas, Austin, TX, USA.,Department of Biomedical Engineering, University of Texas, Austin, TX, USA.,Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA.,Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Cardiology, Stanford University, Stanford, CA, USA.,Electrophysiology and Arrhythmia Services, California Pacific Medical Center, San Francisco, CA, USA
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12
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Higa S, Lo LW, Chen SA. Catheter Ablation of Paroxysmal Atrial Fibrillation Originating from Non-pulmonary Vein Areas. Arrhythm Electrophysiol Rev 2018; 7:273-281. [PMID: 30588316 DOI: 10.15420/aer.2018.50.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/16/2018] [Indexed: 02/04/2023] Open
Abstract
Pulmonary veins (PVs) are a major source of ectopic beats that initiate AF. PV isolation from the left atrium is an effective therapy for the majority of paroxysmal AF. However, investigators have reported that ectopy originating from non-PV areas can also initiate AF. Patients with recurrent AF after persistent PV isolation highlight the need to identify non-PV ectopy. Furthermore, adding non-PV ablation after multiple AF ablation procedures leads to lower AF recurrence and a higher AF cure rate. These findings suggest that non-PV ectopy is important in both the initiation and recurrence of AF. This article summarises current knowledge about the electrophysiological characteristics of non-PV AF, suitable mapping and ablation strategies, and the safety and efficacy of catheter ablation of AF initiated by ectopic foci originating from non-PV areas.
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Affiliation(s)
- Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital Okinawa, Japan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital Taipei, Taiwan.,Institute of Clinical Medicine, Department of Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital Taipei, Taiwan.,Institute of Clinical Medicine, Department of Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
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13
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Hasebe H, Yoshida K, Iida M, Hatano N, Muramatsu T, Nogami A, Aonuma K. Differences in the structural characteristics and distribution of epicardial adipose tissue between left and right atrial fibrillation. Europace 2018; 20:435-442. [PMID: 28387822 DOI: 10.1093/europace/eux051] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/09/2017] [Indexed: 11/12/2022] Open
Abstract
Aims Right atrial (RA) fibrillation (RAF) was previously characterized by initiation from RA ectopies, presence of a right-to-left dominant frequency gradient during atrial fibrillation (AF), and augmentation of the gradient by adenosine triphosphate infusion. We investigated structural characteristics of the bi-atria and epicardial adipose tissue (EAT) volume in patients with RAF. Methods and results By using multidetector computed tomography, RA, left atrial (LA), right and LA appendage (RAA and LAA, respectively) volumes, pulmonary vein (PV) sizes, and EAT volumes were compared between the RAF group (n = 8) and LA fibrillation (LAF) group (n = 32). Compared with the LAF group, the LA volume was smaller (median 81.3 [95% CI, 74.2-88.5] vs. 64.5 [54.8-74.2] mL/m2; P = 0.04), the LAA volume was smaller (10.1 [9.0-11.3] vs. 6.5 [4.5-8.5] mL/m2; P = 0.008), and the RAA volume was larger (10.8 [9.1-12.4] vs. 14.1 [11.6-16.6] mL/m2; P = 0.044) in the RAF group. The RA volume was not significantly different between the groups (73.6 [66.8-80.3] vs. 68.1 [57.1-79.1] mL/m2; P = 0.47). The RAF group had smaller PVs (1.44 [1.33-1.55] vs. 1.12 [0.94-1.30] cm2/m2 for the left inferior PV; P = 0.01). Both the LA-EAT and RA-EAT volumes were smaller in the RAF group than the LAF group (4.2 [2.8-5.6] vs. 9.1 [7.8-10.4] mL/m2; P < 0.001 and 5.3 [4.3-6.3] vs. 9.5 [8.4-10.6] mL/m2; P < 0.001, respectively). Conclusion RAF was structurally characterized by predominant RAA enlargement, small left atrium, and less EAT surrounding the atria. Electrical properties that determine the features of AF (RAF vs. LAF) may be genetically linked to structural properties.
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Affiliation(s)
- Hideyuki Hasebe
- Division of Arrhythmology, Shizuoka Saiseikai General Hospital, 1-1-1, Oshika, Suruga-ku, Shizuoka 422-8527, Japan
| | - Kentaro Yoshida
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
| | - Masataka Iida
- Division of Clinical Engineering, Shizuoka Saiseikai General Hospital, 1-1-1, Oshika, Suruga-ku, Shizuoka 422-8527, Japan
| | - Naoki Hatano
- Division of Clinical Engineering, Shizuoka Saiseikai General Hospital, 1-1-1, Oshika, Suruga-ku, Shizuoka 422-8527, Japan
| | - Toshiro Muramatsu
- Division of Clinical Engineering, Shizuoka Saiseikai General Hospital, 1-1-1, Oshika, Suruga-ku, Shizuoka 422-8527, Japan
| | - Akihiko Nogami
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kazutaka Aonuma
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
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14
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Cheniti G, Vlachos K, Pambrun T, Hooks D, Frontera A, Takigawa M, Bourier F, Kitamura T, Lam A, Martin C, Dumas-Pommier C, Puyo S, Pillois X, Duchateau J, Klotz N, Denis A, Derval N, Jais P, Cochet H, Hocini M, Haissaguerre M, Sacher F. Atrial Fibrillation Mechanisms and Implications for Catheter Ablation. Front Physiol 2018; 9:1458. [PMID: 30459630 PMCID: PMC6232922 DOI: 10.3389/fphys.2018.01458] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/26/2018] [Indexed: 01/14/2023] Open
Abstract
AF is a heterogeneous rhythm disorder that is related to a wide spectrum of etiologies and has broad clinical presentations. Mechanisms underlying AF are complex and remain incompletely understood despite extensive research. They associate interactions between triggers, substrate and modulators including ionic and anatomic remodeling, genetic predisposition and neuro-humoral contributors. The pulmonary veins play a key role in the pathogenesis of AF and their isolation is associated to high rates of AF freedom in patients with paroxysmal AF. However, ablation of persistent AF remains less effective, mainly limited by the difficulty to identify the sources sustaining AF. Many theories were advanced to explain the perpetuation of this form of AF, ranging from a single localized focal and reentrant source to diffuse bi-atrial multiple wavelets. Translating these mechanisms to the clinical practice remains challenging and limited by the spatio-temporal resolution of the mapping techniques. AF is driven by focal or reentrant activities that are initially clustered in a relatively limited atrial surface then disseminate everywhere in both atria. Evidence for structural remodeling, mainly represented by atrial fibrosis suggests that reentrant activities using anatomical substrate are the key mechanism sustaining AF. These reentries can be endocardial, epicardial, and intramural which makes them less accessible for mapping and for ablation. Subsequently, early interventions before irreversible remodeling are of major importance. Circumferential pulmonary vein isolation remains the cornerstone of the treatment of AF, regardless of the AF form and of the AF duration. No ablation strategy consistently demonstrated superiority to pulmonary vein isolation in preventing long term recurrences of atrial arrhythmias. Further research that allows accurate identification of the mechanisms underlying AF and efficient ablation should improve the results of PsAF ablation.
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Affiliation(s)
- Ghassen Cheniti
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Cardiology Department, Hopital Sahloul, Universite de Sousse, Sousse, Tunisia
| | - Konstantinos Vlachos
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Thomas Pambrun
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Darren Hooks
- Cardiology Department, Wellington Hospital, Wellington, New Zealand
| | - Antonio Frontera
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Masateru Takigawa
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Felix Bourier
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Takeshi Kitamura
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Anna Lam
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Claire Martin
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | | | - Stephane Puyo
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Xavier Pillois
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France
| | - Josselin Duchateau
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Klotz
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Arnaud Denis
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Nicolas Derval
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Pierre Jais
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Hubert Cochet
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France.,Department of Cardiovascular Imaging, Hopital Haut Leveque, Bordeaux, France
| | - Meleze Hocini
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Michel Haissaguerre
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
| | - Frederic Sacher
- Cardiac Electrophysiology Department, Hopital Haut Leveque, Bordeaux, France.,Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University, Pessac, France
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15
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Caulier-Cisterna R, Muñoz-Romero S, Sanromán-Junquera M, García-Alberola A, Rojo-Álvarez JL. A new approach to the intracardiac inverse problem using Laplacian distance kernel. Biomed Eng Online 2018; 17:86. [PMID: 29925384 PMCID: PMC6011421 DOI: 10.1186/s12938-018-0519-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/13/2018] [Indexed: 11/30/2022] Open
Abstract
Background The inverse problem in electrophysiology consists of the accurate estimation of the intracardiac electrical sources from a reduced set of electrodes at short distances and from outside the heart. This estimation can provide an image with relevant knowledge on arrhythmia mechanisms for the clinical practice. Methods based on truncated singular value decomposition (TSVD) and regularized least squares require a matrix inversion, which limits their resolution due to the unavoidable low-pass filter effect of the Tikhonov regularization techniques. Methods We propose to use, for the first time, a Mercer’s kernel given by the Laplacian of the distance in the quasielectrostatic field equations, hence providing a Support Vector Regression (SVR) formulation by following the principles of the Dual Signal Model (DSM) principles for creating kernel algorithms. Results Simulations in one- and two-dimensional models show the performance of our Laplacian distance kernel technique versus several conventional methods. Firstly, the one-dimensional model is adjusted for yielding recorded electrograms, similar to the ones that are usually observed in electrophysiological studies, and suitable strategy is designed for the free-parameter search. Secondly, simulations both in one- and two-dimensional models show larger noise sensitivity in the estimated transfer matrix than in the observation measurements, and DSM−SVR is shown to be more robust to noisy transfer matrix than TSVD. Conclusion These results suggest that our proposed DSM−SVR with Laplacian distance kernel can be an efficient alternative to improve the resolution in current and emerging intracardiac imaging systems.
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Affiliation(s)
- Raúl Caulier-Cisterna
- Department of Signal Theory and Communications and Telematics and Computation, Rey Juan Carlos University, Camino del Molino s/n, 28943, Fuenlabrada, Madrid, Spain
| | - Sergio Muñoz-Romero
- Department of Signal Theory and Communications and Telematics and Computation, Rey Juan Carlos University, Camino del Molino s/n, 28943, Fuenlabrada, Madrid, Spain.,Center for Computational Simulation, Universidad Politécnica de Madrid, Madrid, Spain
| | - Margarita Sanromán-Junquera
- Department of Signal Theory and Communications and Telematics and Computation, Rey Juan Carlos University, Camino del Molino s/n, 28943, Fuenlabrada, Madrid, Spain
| | - Arcadi García-Alberola
- Arrhythmia Unit, Hospital General Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - José Luis Rojo-Álvarez
- Department of Signal Theory and Communications and Telematics and Computation, Rey Juan Carlos University, Camino del Molino s/n, 28943, Fuenlabrada, Madrid, Spain. .,Center for Computational Simulation, Universidad Politécnica de Madrid, Madrid, Spain.
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16
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Development of Nonpulmonary Vein Foci Increases Risk of Atrial Fibrillation Recurrence After Pulmonary Vein Isolation. JACC Clin Electrophysiol 2017; 3:547-555. [DOI: 10.1016/j.jacep.2016.12.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/09/2016] [Accepted: 12/08/2016] [Indexed: 11/19/2022]
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17
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Sinus node injury during adjunctive superior vena cava isolation in a patient with triggered atrial fibrillation. Indian Pacing Electrophysiol J 2016; 16:96-98. [PMID: 27789000 PMCID: PMC5067864 DOI: 10.1016/j.ipej.2016.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 05/14/2016] [Accepted: 08/18/2016] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Atrial fibrillation is the most common sustained heart arrhythmia. Premature beats arising from foci other than pulmonary veins have been related to its pathogenesis. METHODS AND RESULTS A 64-year-old female underwent superior vena cava (SVC) isolation after triggers were identified originating from the SVC following pulmonary vein isolation; immediately after SVC isolation, she developed junctional rhythm with symptomatic hypotension requiring emergent management. Apical motion abnormalities were noticed in the echocardiography suggesting stress-induced cardiomyopathy which resolved 48 hours later. Although received a dual chamber pacemaker, intact sinus node function returned 2 weeks later. CONCLUSION Superior vena cava isolation in those with trigger mediated atrial fibrillation following pulmonary vein isolation (PVI) is performed to enhance long-term outcomes. Sinus node injury has been related previously to this procedure. We present the first case of time course of recovery of sinus node function, injured during SVC isolation.
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18
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DE REGIBUS VALENTINA, MUGNAI GIACOMO, MORAN DARRAGH, HÜNÜK BURAK, STRÖKER ERWIN, HACIOGLU EBRU, RUGGIERO DIEGO, COUTIÑO-MORENO HUGOENRIQUE, TAKARADA KEN, BRUGADA PEDRO, DE ASMUNDIS CARLO, CHIERCHIA GIANBATTISTA. Second-Generation Cryoballoon Ablation in the Setting of Lone Paroxysmal Atrial Fibrillation: Single Procedural Outcome at 12 Months. J Cardiovasc Electrophysiol 2016; 27:677-82. [DOI: 10.1111/jce.12973] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - DARRAGH MORAN
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
| | - BURAK HÜNÜK
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
| | - ERWIN STRÖKER
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
| | - EBRU HACIOGLU
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
| | - DIEGO RUGGIERO
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
| | | | - KEN TAKARADA
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
| | - PEDRO BRUGADA
- Heart Rhythm Management Center; UZ Brussel-VUB Brussels Belgium
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19
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Zhao Y, Di Biase L, Trivedi C, Mohanty S, Bai R, Mohanty P, Gianni C, Santangeli P, Horton R, Sanchez J, Gallinghouse GJ, Zagrodzky J, Hongo R, Beheiry S, Lakkireddy D, Reddy M, Hranitzky P, Al-Ahmad A, Elayi C, Burkhardt JD, Natale A. Importance of non–pulmonary vein triggers ablation to achieve long-term freedom from paroxysmal atrial fibrillation in patients with low ejection fraction. Heart Rhythm 2016; 13:141-9. [DOI: 10.1016/j.hrthm.2015.08.029] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Indexed: 12/01/2022]
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20
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Cheng H, Dai YY, Jiang RH, Liu Q, Sun YX, Lin JW, Zhang ZW, Chen SQ, Zhu J, Sheng X, Jiang CY. Non-pulmonary vein foci induced before and after pulmonary vein isolation in patients undergoing ablation therapy for paroxysmal atrial fibrillation: incidence and clinical outcome. J Zhejiang Univ Sci B 2015; 15:915-22. [PMID: 25294381 DOI: 10.1631/jzus.b1400146] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the incidence and clinical outcome of adenosine triphosphate (ATP) plus isoproterenol (ISP)-induced non-pulmonary vein (PV) foci before and after circumferential PV isolation (CPVI) during index ablation in patients with paroxysmal atrial fibrillation (PAF). METHODS In 80 consecutive patients undergoing catheter ablation for drug-refractory, symptomatic PAF at our hospital from April 2010 to January 2011, atrial fibrillation (AF) was provoked with ATP (20 mg) and ISP (20 µg/min) administration before and after CPVI. The spontaneous initiation of AF was mapped and recorded. RESULTS Before ablation, AF mostly originating from PVs (PV vs. non-PV, 36/70 vs. 3/70; P<0.01) was induced in 39 patients with sinus rhythm. CPVI significantly suppressed AF inducibility; however, more non-PV foci were provoked (post-CPVI vs. pre-CPVI, 13/76 vs. 3/70; P=0.016). Patients with pre- and post-CPVI induced AF (n=49) were divided according to non-PV foci being induced (group N, n=17) or not (group P, n=32). After mean (19.2±8.2) months follow-up, 88.2% (15/17) and 65.6% (21/32) of patients in groups N and P, respectively, were free from AF recurrence (P=0.088). CONCLUSIONS ATP+ISP administration effectively provokes non-PV foci, especially after CPVI in PAF patients. Although in this study difference did not achieve statistical significance, supplementary ablation targeting non-PV foci might benefit clinical outcome.
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Affiliation(s)
- Hui Cheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, China; Department of Cardiology, the First People's Hospital of Xiaoshan, Hangzhou 311200, China
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21
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Sugimura S, Kurita T, Kaitani K, Yasuoka R, Miyazaki S. Ectopies from the superior vena cava after pulmonary vein isolation in patients with atrial fibrillation. Heart Vessels 2015; 31:1562-9. [PMID: 26518692 DOI: 10.1007/s00380-015-0767-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/16/2015] [Indexed: 11/26/2022]
Abstract
Episodes of atrial fibrillation (AF) are mainly initiated by triggers from pulmonary veins (PVs). The superior vena cava (SVC) has been identified as a second major substrate of non-PV foci, but the electrophysiologic features of the SVC have not been fully investigated. We hypothesized that SVC ectopies are suppressed by predominant features of PV ectopies and tend to appear after PV isolation (PVI). We evaluated the electrophysiological characteristics and clinical implications of SVC ectopies in patients with AF during catheter ablation using high-dose isoproterenol and the atrial overdrive pacing maneuver. The manifestation patterns and modes of onset (coupling interval and appearance interval) of ectopies from both the PVs and SVC were investigated. 205 patients were enrolled [153 males and 52 females; mean age 64 ± 10 years; paroxysmal in 143 patients (69.8 %), persistent in 40 (19.5 %), and long-standing persistent in 22 patients (10.7 %)]. Before PVI, PV ectopies were detected in 182/205 patients (89 %). SVC ectopies were rarely observed before PVI but were significantly more frequent after the completion of PVI (3/205 vs. 14/205 patients, p = 0.011). The coupling interval (CI) and % CI (CI/preceding the A-A interval × 100) of PV ectopies were significantly shorter than those of SVC ectopies (211 ± 78 vs. 282 ± 106 ms, p = 0.021, and 34 ± 9 vs. 51 ± 17 %, p < 0.001, respectively). The appearance intervals of the PV ectopies were shorter than those of the SVC ectopies (6.3 ± 4.0 vs. 10.7 ± 6.7 s, p = 0.030). During repeat procedures, PVs with reconnection to the left atrium were less frequently observed in patients with SVC firing than in patients without SVC firing (1.7 ± 1.5 vs. 2.9 ± 1.1 PVs, p = 0.029). We demonstrated that PVI tends to manifest SVC ectopies with less spontaneous activity and that an elimination of predominant ectopies from the PVs may affect appearance of SVC ectopy.
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Affiliation(s)
- Sousuke Sugimura
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan
- Department of Clinical Laboratory, Tenri Hospital, 200 Mishima-cho, Tenri, 632-8552, Nara, Japan
| | - Takashi Kurita
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan.
| | - Kazuaki Kaitani
- Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri, 632-8552, Nara, Japan
| | - Ryobun Yasuoka
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kinki University, 377-2 Onohigashi, Osaka-Sayama, 589-8511, Osaka, Japan
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22
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Kaneko Y, Kato ‘R, Nakahara S, Tobiume T, Morishima I, Tanaka K, Nakajima T, Irie T, Kusano KF, Kamakura S, Nagase T, Takayanagi K, Matsumoto K, Kurabayashi M. Characteristics and Catheter Ablation of Focal Atrial Tachycardia Originating From the Interatrial Septum. Heart Lung Circ 2015; 24:988-95. [DOI: 10.1016/j.hlc.2015.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 02/20/2015] [Accepted: 03/05/2015] [Indexed: 10/23/2022]
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23
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Hayashi K, An Y, Nagashima M, Hiroshima K, Ohe M, Makihara Y, Yamashita K, Yamazato S, Fukunaga M, Sonoda K, Ando K, Goya M. Importance of nonpulmonary vein foci in catheter ablation for paroxysmal atrial fibrillation. Heart Rhythm 2015; 12:1918-24. [DOI: 10.1016/j.hrthm.2015.05.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Indexed: 10/23/2022]
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Dukkipati SR, Woollett I, McELDERRY HT, Böhmer MC, Doshi SK, Gerstenfeld EP, Horton R, D'Avila A, Haines DE, Valderrabano M, Mangrum JM, Ruskin JN, Natale A, Reddy VY. Pulmonary Vein Isolation Using the Visually Guided Laser Balloon: Results of the U.S. Feasibility Study. J Cardiovasc Electrophysiol 2015; 26:944-949. [PMID: 26080067 DOI: 10.1111/jce.12727] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/25/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Visually guided laser balloon (VGLB) ablation is unique in that the operator delivers ablative energy under direct visual guidance. In this multicenter study, we sought to determine the feasibility, efficacy, and safety of performing pulmonary vein isolation (PVI) using this VGLB. METHODS Patients with symptomatic, drug-refractory paroxysmal atrial fibrillation (AF) underwent PVI using the VGLB with the majority of operators conducting their first-ever clinical VGLB cases. The primary effectiveness endpoint was defined as freedom from treatment failure that included: Occurrence of symptomatic AF episodes ≥1 minutes beyond the 90-day blanking, the inability to isolate 1 superior and 2 total PVs, occurrence of left atrial flutter or atrial tachycardia, or left atrial ablation/surgery during follow-up. RESULTS A total of 86 patients (mean age 56 ± 10 years, 67% male) were treated with the VGLB at 10 US centers. Mean fluoroscopy, ablation, and procedure times were 39.8 ± 24.3 minutes, 205.2 ± 61.7 minutes, and 253.5 ± 71.3 minutes, respectively. Acute PVI was achieved in 314/323 (97.2%) of targeted PVs. Of 84 patients completing follow-up, the primary effectiveness endpoint was achieved in 50 (60%) patients. Freedom from symptomatic or asymptomatic AF was 61%. The primary adverse event rate was 16.3% (8.1% pericarditis, phrenic nerve injury 5.8%, and cardiac tamponade 3.5%). There were no cerebrovascular events, atrioesophageal fistulas, or significant PV stenosis. CONCLUSIONS This multicenter study of operators in the early stage of the learning curve demonstrates that PVI can be achieved with the VGLB with a reasonable safety profile and an efficacy similar to radiofrequency ablation.
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Affiliation(s)
- Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ian Woollett
- Sentara Cardiovascular Research Institute, Norfolk, Virginia
| | | | - Marie-Christine Böhmer
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Edward P Gerstenfeld
- University of California San Francisco School of Medicine, San Francisco, California
| | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Andre D'Avila
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York
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Higuchi K, Yamauchi Y, Hirao K. Superior Vena Cava Isolation In Ablation Of Atrial Fibrillation. J Atr Fibrillation 2014; 7:1032. [PMID: 27957077 DOI: 10.4022/jafib.1032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/19/2014] [Accepted: 06/13/2014] [Indexed: 11/10/2022]
Abstract
Superior vena cava (SVC) is one of the most important non-pulmonary vein (PV) origins of atrial fibrillation (AF). SVC isolation (SVCI) is effective especially in patients with paroxysmal AF from SVC origin. However, SVCI should be carefully performed because of potential complications such as phrenic nerve paralysis, SVC stenosis, and sinus node injury There are two major different approaches to treat SVC focus in the ablation of AF. The conventional approach is to perform SVCI only if AF from the SVC origin is actually recognized using pacing maneuvers and/or isoproterenol infusions. Another approach is the empiric empiricprophylactic SVCI in addition to PV isolation in all cases. The rate of AF freedom one year after initial AF ablation by empiric SVCI was almost same as the conventional method (85-90% AF freedom). Additionally, the conventional method has also a good result even 5 years after ablation (,73.3% AF freedom). Because of the excellent result in the conventional approach and possible complications after the SVCI, the empiric SVCI + PVI in all AF cases is still controversial. Patients with a long SVC myocardial sleeve are possible candidates for empiric SVCI in addition to PVI.
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Affiliation(s)
| | | | - Kenzo Hirao
- Tokyo Medical and Dental University, Tokyo, Japan
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Catheter ablation of extra-pulmonary vein foci improves the clinical outcome in patients with paroxysmal atrial fibrillation. Int J Cardiol 2014; 172:458-9. [DOI: 10.1016/j.ijcard.2013.12.292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/30/2013] [Indexed: 11/21/2022]
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JIANG RUHONG, JIANG CHENYANG, SHENG XIA, ZHANG ZUWEN, SUN YAXUN, LIU QIANG, FU GUOSHENG, PO SUNNYS. Marked Suppression of Pulmonary Vein Firing After Circumferential Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation: Is Pulmonary Vein Firing an Epiphenomenon? J Cardiovasc Electrophysiol 2013; 25:111-8. [DOI: 10.1111/jce.12288] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/17/2013] [Accepted: 09/03/2013] [Indexed: 11/28/2022]
Affiliation(s)
- RU-HONG JIANG
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - CHEN-YANG JIANG
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - XIA SHENG
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - ZU-WEN ZHANG
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - YA-XUN SUN
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - QIANG LIU
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - GUO-SHENG FU
- Sir Run Run Shaw Institute of Clinical Medicine of Zhejiang University; Hangzhou China
| | - SUNNY S. PO
- Department of Medicine and Heart Rhythm Institute; University of Oklahoma Health Sciences Center; Oklahoma City Oklahoma USA
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Yamaguchi T, Tsuchiya T, Nagamoto Y, Miyamoto K, Murotani K, Okishige K, Takahashi N. Long-term results of pulmonary vein antrum isolation in patients with atrial fibrillation: an analysis in regards to substrates and pulmonary vein reconnections. Europace 2013; 16:511-20. [PMID: 24078342 DOI: 10.1093/europace/eut265] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To examine the impact of left atrial (LA) low-voltage zones (LVZs) on atrial fibrillation (AF) recurrence after pulmonary vein antrum isolation (PVAI) without LA substrate modification. METHODS AND RESULTS Seventy-six patients with AF (paroxysmal/persistent 65/11) were prospectively enroled. Left atrial voltage maps were constructed during sinus rhythm using NavX to identify LVZs (<0.5 mV), and PVAI without any LA substrate modification was performed using an open-irrigation catheter. After PVAI, 20 mg of adenosine triphosphate (ATP) was injected. Adenosine triphosphate-induced PV reconnections were eliminated by touch-up ablation when unmasked. Voltage maps revealed LVZs in 24 patients (32%) and no LVZs in 52 (68%). During 24 ± 7 months of follow-up, 15 patients (63%) with LVZs and 10 (19%) without had AF recurrences off antiarrhythmic drugs (log-rank P < 0.001). A multivariate logistic regression analysis revealed that LVZ areas [odds ratio (OR): 1.12 per 1 cm(2), 95% confidence interval (CI): 1.04-1.23, P = 0.001] and ATP-induced reconnection (OR: 2.08, 95% CI: 1.01-4.91, P = 0.046) were significant predictors of recurrence. In those with LVZs, the LVZ area was strongly correlated with the LA body volume (r = 0.81, P < 0.001) and a unique predictor of recurrence (OR: 1.17 per 1 cm(2), 95% CI: 1.01-1.55, P = 0.031), while in those without an LVZ, ATP-induced PV reconnection was a unique predictor (OR: 3.24, 95% CI: 1.15-15.39, P = 0.025). CONCLUSION The LVZ area was an independent predictor of recurrence after PVAI without any LA substrate modification. Adenosine triphosphate-induced PV reconnection was also an independent predictor, especially in those without LVZs.
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Dukkipati SR, Kuck KH, Neuzil P, Woollett I, Kautzner J, McElderry HT, Schmidt B, Gerstenfeld EP, Doshi SK, Horton R, Metzner A, d’Avila A, Ruskin JN, Natale A, Reddy VY. Pulmonary Vein Isolation Using a Visually Guided Laser Balloon Catheter. Circ Arrhythm Electrophysiol 2013; 6:467-72. [DOI: 10.1161/circep.113.000431] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Srinivas R. Dukkipati
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Karl-Heinz Kuck
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Petr Neuzil
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Ian Woollett
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Josef Kautzner
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - H. Thomas McElderry
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Boris Schmidt
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Edward P. Gerstenfeld
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Shephal K. Doshi
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Rodney Horton
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Andreas Metzner
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Andre d’Avila
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Jeremy N. Ruskin
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Andrea Natale
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
| | - Vivek Y. Reddy
- From the Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY (S.R.D., A.d., V.Y.R.); Asklepios Klinik St. Georg, Hamburg, Germany (K.-H.K., A.M.); Homolka Hospital, Prague, Czech Republic (P.N.); Sentara Cardiovascular Research Institute, Norfolk, VA (I.W.); IKEM, Prague, Czech Republic (J.K.); University of Alabama at Birmingham, Birmingham, AL (H.T.M.); Cardioangiologisches Centrum Bethanien-CCB, Frankfurt, Germany (B.S.); University of California San Francisco School
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Imamura K, Yoshida A, Takei A, Fukuzawa K, Kiuchi K, Takami K, Takami M, Itoh M, Fujiwara R, Suzuki A, Nakanishi T, Yamashita S, Matsumoto A, Hirata KI. Dabigatran in the peri-procedural period for radiofrequency ablation of atrial fibrillation: efficacy, safety, and impact on duration of hospital stay. J Interv Card Electrophysiol 2013; 37:223-31. [PMID: 23585240 PMCID: PMC3738875 DOI: 10.1007/s10840-013-9801-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 03/05/2013] [Indexed: 11/25/2022]
Abstract
Purpose Dabigatran is effective for both the prevention of stroke and bleeding in patients with atrial fibrillation (AF). However, the safety and efficacy of the use of dabigatran in the peri-procedural period for radiofrequency catheter ablation (RFCA) of AF is unknown. Therefore, the purpose of this study was to evaluate the safety and efficacy of dabigatran in the peri-procedural period for RFCA of AF and the duration of hospital stay. Methods Consecutive patients (n = 227) who underwent RFCA for AF were prospectively analyzed. Peri-procedural anticoagulant therapy with dabigatran (n = 101, D group) was compared with warfarin and heparin bridging (n = 126, W group). Dabigatran was discontinued 12–24 h before and restarted 3 h after the procedure. Warfarin was stopped 3 days before the procedure and unfractionated heparin was administered. Results Ischemic stroke occurred in one patient of the D group (0.8 %). There was no significant difference between the two groups in the incidence of major bleeding (three cases of cardiac tamponade in each group and one case of intracranial bleeding in the W group, p = 0.93) or minor bleeding (five cases in the D group vs. five in the W group, p = 0.54). The duration of hospital stay was significantly shorter in the D group than in the W group (7.2 vs. 10.3 days, p = 0.0001). Conclusions Peri-procedural anticoagulation therapy with dabigatran for RFCA of AF was equally safe and effective compared with warfarin and heparin bridging. The use of dabigatran for RFCA of AF shortened the duration of hospital stay.
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Affiliation(s)
- Kimitake Imamura
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
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Abstract
PURPOSE OF REVIEW Superior vena cava (SVC) is one of the most important nonpulmonary vein origins of atrial fibrillation, and SVC should be carefully treated in order to decrease the recurrence of atrial fibrillation after ablation. Despite the fact that pulmonary vein isolation (PVI) should be performed prophylactically for all pulmonary veins, prophylactic SVC isolation (SVCI) is still controversial. This review describes recent data on treatments for SVC focus during atrial fibrillation ablation. RECENT FINDINGS There are two different major approaches to treat SVC focus during atrial fibrillation ablation. One is the conventional approach, in which SVCI is performed only if atrial fibrillation from SVC origin is recognized using pacing maneuvers and/or isoproterenol infusions. Another approach is performing SVCI in all cases prophylactically in addition to PVI. The rate of atrial fibrillation freedom 1 year after initial atrial fibrillation ablation by prophylactic PVI along with SVCI was almost the same as with the conventional method (85-90% atrial fibrillation freedom). In addition, the conventional method also had a good result even 5 years after ablation (73.3%). SUMMARY Because of the good result after using the conventional approach and possible complications during SVCI, SVCI should be performed only if SVC focus is recognized, not prophylactically.
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Kiuchi K, Kircher S, Watanabe N, Gaspar T, Rolf S, Arya A, Piorkowski C, Hindricks G, Sommer P. Quantitative Analysis of Isolation Area and Rhythm Outcome in Patients With Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Antrum Isolation Using the Pace-and-Ablate Technique. Circ Arrhythm Electrophysiol 2012; 5:667-75. [DOI: 10.1161/circep.111.969923] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We sought to determine the relationship between the size of the left atrial isolated surface area (ISA) after pulmonary vein antrum isolation for paroxysmal atrial fibrillation (AF) and rhythm outcome during a 12-month follow-up.
Methods and Results—
One hundred one consecutive patients with paroxysmal AF (mean age, 59±11 years; median [range] AF history, 36 [24–96] months; mean left atrial size, 42±6 mm) were enrolled. The ISA was defined as the ratio of the total isolated antral surface area excluding the pulmonary veins to the sum of the total isolated antral surface area and the left atrial posterior wall surface area, while considering the individual characteristics of antral anatomy. All surface areas were assessed using the NavX system. Patients were divided into 4 groups according to ISA (group I: <50%; group II: 50 to <60%; group III: 60 to <70%; group IV: ≥70%). The average ISA for all patients was 59.2±11.6%. Subgroup analysis showed that ISA was 42.8±4.2% in group I (n=23), 54.2±3.0% in group II (n=23), 64.3±3.0% in group III (n=33), and 73.9±3.6% in group IV (n=22). After a 12-month follow-up period, 70% of patients in group I, 78% in group II, 97% in group III, and 100% in group IV were free from AF and atrial macroreentrant tachycardia. There was a significant difference between groups I and III, I and IV, II and III, and II and IV but not groups I and II and groups III and IV (log-rank test
P
=0.024, 0.016, 0.037, 0.044, 0.584, and 0.500, respectively). Receiver operating characteristic curve analysis yielded an optimal cutoff value of 55% for ISA.
Conclusions—
After 12 months, a larger ISA was associated with a significantly lower AF and macroreentrant tachycardia recurrence rate. ISA≥55% may thus serve as a predictor for long-term success after pulmonary vein antrum isolation.
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Affiliation(s)
- Kunihiko Kiuchi
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Simon Kircher
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Norikazu Watanabe
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Thomas Gaspar
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Sascha Rolf
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Arash Arya
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Christopher Piorkowski
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Gerhard Hindricks
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
| | - Philipp Sommer
- From the Department of Electrophysiology, University of Leipzig Heart Center, Leipzig, Germany
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Yamaguchi T, Tsuchiya T, Nagamoto Y, Miyamoto K, Takahashi N. Characterization of atrial fibrillation and the effect of pulmonary vein antrum isolation in endurance athletes. J Arrhythm 2012. [DOI: 10.1016/j.joa.2011.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
The evolution of 3-dimensional (D) mapping systems has contributed to improved procedures for ablation of complex tachyarrhythmia in terms of providing detailed anatomical information along with the ability to integrate with pre-acquired computed tomography/magnetic resonance imaging/intracardiac echocardiography images, reducing the radiation exposure, and producing activation and substrate maps. 3-D mapping systems are categorized as magnetic based vs. impedance based according to the catheter location technology, and are also classified as contact based vs. non-contact based according to the data collection technology. Contact-based mapping systems are used widely, in which a series of electrograms is taken sequentially in contact with the heart, thus requiring a relatively stable and sustained arrhythmia to create an activation map. Non-contact mapping systems, however, allow a beat-to-beat analysis of the activation even in non-sustained, polymorphic, or hemodynamically intolerant tachycardia. In this article, the clinical utility of 3-D mapping systems is discussed based on the literature and on experience, with particular emphasis on the non-contact mapping system.
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Dukkipati SR, Neuzil P, Kautzner J, Petru J, Wichterle D, Skoda J, Cihak R, Peichl P, Dello Russo A, Pelargonio G, Tondo C, Natale A, Reddy VY. The durability of pulmonary vein isolation using the visually guided laser balloon catheter: multicenter results of pulmonary vein remapping studies. Heart Rhythm 2012; 9:919-25. [PMID: 22293143 DOI: 10.1016/j.hrthm.2012.01.019] [Citation(s) in RCA: 110] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND The visually guided laser ablation (VGLA) catheter is a compliant, variable-diameter balloon that delivers laser energy around the pulmonary vein (PV) ostium under real-time endoscopic visualization. While acute PV isolation has been shown to be feasible, limited data exist regarding the durability of isolation. OBJECTIVE We sought to determine the durability of PV isolation following ablation using the balloon-based VGLA catheter. METHODS The VGLA catheter was evaluated in patients with paroxysmal atrial fibrillation (3 sites, 10 operators). Following transseptal puncture, the VGLA catheter was advanced through a 12-F deflectable sheath and inflated at the target PV ostium. Under endoscopic guidance, the 30° aiming arc was maneuvered around the PV and laser energy was delivered to ablate tissue in a contiguous/overlapping manner. At ∼3 months, all patients returned for a PV remapping procedure. RESULTS In 56 patients, 202 of 206 PVs (98%) were acutely isolated. At 105 ± 44 (mean ± SD) days, 52 patients returned for PV remapping at which time 162 of 189 PVs (86%) remained isolated and 32 of 52 patients (62%) had all PVs still isolated. On comparing the operators performing <10 vs ≥ 10 procedures, the durable PV isolation rate and the percentage of patients with all PVs isolated were found to be 73% vs 89% (P = .011) and 57% vs 66% (P = .746), respectively. After 2 procedures and 12.0 ± 1.9 months of follow-up, the drug-free rate of freedom from atrial fibrillation was 71.2%. CONCLUSIONS In this multicenter, multioperator experience, VGLA resulted in a very high rate of durable PV isolation with a clinical efficacy similar to that of radiofrequency ablation.
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Affiliation(s)
- Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, NY 10029, USA
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Miyamoto K, Tsuchiya T, Yamaguchi T, Nagamoto Y, Ando SI, Sadamatsu K, Tanioka Y, Takahashi N. A new method of a pulmonary vein map to identify a conduction gap on the pulmonary vein antrum ablation line. Circ J 2011; 75:2363-71. [PMID: 21799274 DOI: 10.1253/circj.cj-11-0198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Electrical isolation of the pulmonary veins (PV) is crucial for atrial fibrillation (AF) ablation. Conduction gaps on the circumferential PV antrum ablation (CPVA) line sometimes remain, which are sometimes difficult to identify. METHODS AND RESULTS CPVA of the ipsilateral superior and inferior PVs was performed during sinus rhythm or coronary sinus pacing using the NavX system in 22 AF patients, in whom 1 round of CPVA failed to disconnect 26 individual PVs (30%) in 18 patients. In these patients, a local activation map within the CPVA line (PV map) was created by a 20-pole circular mapping catheter with the use of the NavX, with 71 ± 37 sampling points per PV antrum. The conduction gap was defined as a site on the CPVA line, from which the activation proceeded toward the entire PV. The mapped PV antra were comprised of the left superior PV in 11, right superior PV in 10, left inferior PV in 3, right inferior PV in 1 and a left common PV in 1 PV(s). The conduction gaps were identified at 1.4 ± 0.7 sites per PV antrum, with an electrogram amplitude of 0.8 ± 0.7 mV. A point ablation at the gap completely isolated 24 out of 26 PV antra (92%) with 1.9 ± 1.3 applications. CONCLUSIONS The PV map was useful for quickly and accurately identifying the conduction gap(s) after 1 round of CPVA.
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Affiliation(s)
- Koji Miyamoto
- EP Expert Doctors-Team Tsuchiya, Division of Cardiology, Saiseikai Futsukaichi Hospital, Fukuoka, Japan
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Adenosine-induced atrial tachycardia and multiple foci initiating atrial fibrillation eliminated by catheter ablation using a non-contact mapping system. Heart Vessels 2011; 27:221-6. [PMID: 21655902 DOI: 10.1007/s00380-011-0159-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 05/13/2011] [Indexed: 10/18/2022]
Abstract
A 47-year-old male with both atrial tachycardia and atrial fibrillation underwent catheter ablation. During the procedure, rapid administration of adenosine triphosphate induced atrial tachycardia. A non-contact mapping system revealed a focal atrial tachycardia originating from the lateral right atrium, which was successfully ablated. Following the ablation of tachycardia, atrial fibrillation was induced by the injection of adenosine along with multiple extra pulmonary vein foci, which were eliminated by the application of radiofrequency under the guidance of a non-contact mapping system.
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Yamamoto T, Hayashi M, Miyauchi Y, Murata H, Horie T, Igawa O, Kato T, Mizuno K. Respiratory cycle-dependent atrial tachycardia: prevalence, electrocardiographic and electrophysiologic characteristics, and outcome after catheter ablation. Heart Rhythm 2011; 8:1615-21. [PMID: 21699840 DOI: 10.1016/j.hrthm.2011.04.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 04/27/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the tachyarrhythmias relating to respiration. Case reports presented patients with respiratory cycle-dependent atrial tachycardias (RCATs), which cyclically emerge after starting inspiration and cease during expiration. OBJECTIVE The aim of the present study was to elucidate the prevalence, characteristics, and long-term outcome after radiofrequency catheter ablation (RFCA) of RCATs. METHODS The electrocardiographic and electrophysiologic properties and results of RFCA were analyzed in 60 patients with a total of 71 focal atrial tachycardias (ATs). RESULTS Nine RCATs (13%) were observed in 7 patients (12%). RCATs were irregular, with a mean cycle length ranging from 220 to 650 ms, and developed incessantly accounting for 32% ± 14% of the 24-hour heartbeats. The P-wave morphology was positive or biphasic (positive to negative) in V1, and positive in I and II. The electroanatomical mapping demonstrated a centrifugal activation pattern, with the earliest site located at the antrum of the right superior pulmonary vein (RSPV), inside the RSPV, and inside the superior vena cava (SVC) in 4, 2, and 3 RCATs, respectively. Radiofrequency energy delivery at the earliest site or the electrical isolation of the RSPV and SVC suppressed all RCATs. During a follow-up of 25 ± 15 months, 1 RCAT recurred and was eliminated in a second procedure. CONCLUSION RCATs were observed in 13% of the focal ATs. As presumed from the P-wave morphologies, their foci converged around the RSPV or inside the SVC. RFCA was effective to eliminate RCATs.
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Affiliation(s)
- Teppei Yamamoto
- Department of Cardiology, Nippon Medical School, Tokyo, Japan
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