1
|
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?
Collapse
|
2
|
Gu Z, Yang G, Ju W, Li M, Chen H, Gu K, Liu H, Chen M. Empirical superior vena cava isolation improves outcomes of radiofrequency re-ablation in pulmonary vein isolation non-responders: A 2-center retrospective study in China. Front Cardiovasc Med 2022; 9:1049414. [PMID: 36568556 PMCID: PMC9768188 DOI: 10.3389/fcvm.2022.1049414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
Background Pulmonary vein isolation (PVI) is the standard ablation strategy for treating atrial fibrillation (AF). However, the optimal strategy of a repeat procedure for PVI non-responders remains unclear. Objective This study aims to investigate the incidence of PVI non-responders in patients undergoing a repeat procedure, as well as the predictors for the recurrence of repeat ablation. Methods A total of 276 consecutive patients who underwent repeat ablation from August 2016 to July 2019 in two centers were screened. A total of 64 (22%) patients with durable PVI were enrolled. Techniques such as low voltage zone modification, linear ablation, non-PV trigger ablation, and empirical superior vena cava (SVC) isolation were conducted. Results After the 20.0 ± 9.9 month follow-up, 42 (65.6%) patients were free from atrial arrhythmias. A significant difference was reported between the recurrent and non-recurrent groups in non-paroxysmal AF (50 vs. 23.8%, p = 0.038), diabetes mellitus (27.3 vs. 4.8%, p = 0.02), and empirical superior vena cava (SVC) isolation (28.6 vs. 60.5%, p = 0.019). Multivariate regression analysis demonstrated that empirical SVC isolation was an independent predictor of freedom from recurrence (95% CI: 1.64-32.8, p = 0.009). Kaplan-Meier curve demonstrates significant difference in recurrence between empirical and non-empirical SVC isolation groups (HR: 0.338; 95% CI: 0.131-0.873; p = 0.025). Conclusion About 22% of patients in repeat procedures were PVI non-responders. Non-paroxysmal AF and diabetes mellitus were associated with recurrence post-re-ablation. Empirical SVC isolation could potentially improve the outcome of repeat procedures in PVI non-responders.
Collapse
Affiliation(s)
- Zhoushan Gu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hailei Liu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China,*Correspondence: Minglong Chen,
| |
Collapse
|
3
|
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.
Collapse
|
4
|
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]
|
5
|
Tanaka Y, Takahashi A, Takagi T, Nakajima J, Takagi K, Hikita H, Goya M, Hirao K. Novel Ablation Strategy for Isolating the Superior Vena Cava Using Ultra High-Resolution Mapping. Circ J 2018; 82:2007-2015. [DOI: 10.1253/circj.cj-17-1352] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Jun Nakajima
- The Cardiovascular Center, Yokosuka Kyosai Hospital
| | | | | | - Masahiko Goya
- The Heart Rhythm Center, Tokyo Medical and Dental University
| | - Kenzo Hirao
- The Heart Rhythm Center, Tokyo Medical and Dental University
| |
Collapse
|
6
|
Nakashima T, Kubota T, Takasugi N, Kawasaki M, Nishigaki K, Minatoguchi S. Simultaneous independent double tachycardias: What is the mechanism? J Cardiovasc Electrophysiol 2018; 29:800-802. [PMID: 29436062 DOI: 10.1111/jce.13463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 02/06/2018] [Accepted: 02/09/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Takashi Nakashima
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tomoki Kubota
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Nobuhiro Takasugi
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Masanori Kawasaki
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kazuhiko Nishigaki
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shinya Minatoguchi
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| |
Collapse
|
7
|
Wang H, Wang Y, Fu J, Wang L. Complicated atrial tachycardia due to atrial fibrillation originating from the superior vena cava: A case report. Medicine (Baltimore) 2017; 96:e7192. [PMID: 28640102 PMCID: PMC5484210 DOI: 10.1097/md.0000000000007192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The superior vena cava (SVC) can act as an origin of atrial fibrillation (AF). The complex structure and special conductive properties of the SVC can result in complicated atrial tachycardia (AT), atrial flutter, or AF. SYMPTOMS AND CLINICAL FINDINGS We report a case of the clinical observation of various kinds of AT and AF in 1 patient. Electrophysiological (EP) studies confirmed the muscle sleeve in the SVC to be the primary trigger and the only site or origin of tachycardia in this patient. Furthermore, we describe the mechanism of AT observed in clinic, which was misdiagnosed as multiorigin AF. INTERVENTION AND OUTCOMES Circumferential pulmonary vein isolation and circumferential SVC isolation resulted in termination of tachycardia. CONCLUSION We present an atypical case of AF originating from the SVC with unusual intra-atrial conduction characteristics and arrhythmogenic pulmonary veins. Stepwise EP studies were conducive to clarify the mechanism of this rare AT.
Collapse
Affiliation(s)
- Huan Wang
- Department of Cardiology, Zhejiang Province People's Hospital
- Department of Cardiology, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Yunfan Wang
- Department of Cardiology, Zhejiang Province People's Hospital
- Department of Cardiology, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Jianwei Fu
- Department of Cardiology, Zhejiang Province People's Hospital
- Department of Cardiology, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| | - Lihong Wang
- Department of Cardiology, Zhejiang Province People's Hospital
- Department of Cardiology, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang Province, China
| |
Collapse
|
8
|
Huang HK, Chang SL, Lin YJ, Lo LW, Hu YF, Chung FP, Huang YC, Lin CH, Chan CS, Chang HY, Lin CY, Chang YT, Huang CH, Chen SA. Atrial fibrillation originating from superior vena cava with atrial flutter-electrocardiogram pattern. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:754-761. [PMID: 28436566 DOI: 10.1111/pace.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 03/10/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUNDS Substrate property is related to the genesis and maintenance of atrial fibrillation (AF). The aim of the study was to investigate the impact of substrate property on the electrocardiogram (ECG) in patients with AF originating from the superior vena cava (SVC). METHODS AND RESULTS Seventy-six patients with AF originating from SVC who underwent catheter ablation were included from 2004 to 2013. Of these patients, 16 had a presentation of atrial flutter (AFL)-pattern ECG during AF (group 1), and 60 patients did not (group 2). There was no significant difference in clinical characteristics between the groups. The percentage of low voltage zone (LVZ) in SVC below the level of pulmonary artery in group 1 was significantly larger than that in group 2. The polarities of the flutter wave in 12-lead ECG were compared with another 26 subjects with reverse typical AFL. The ECG morphology was characterized by negative or biphasic P waves in lead V1 in most of the patients in group 1 (62.5%), which was analogous to that in reverse typical AFL. The negative polarity of flutter waves in aVL might distinguish SVC AF with an AFL-pattern from reverse typical AFL. CONCLUSION The ECG characteristics of AF originating from SVC can mimic atypical AFL. LVZ in the SVC may be associated with the presentation of AFL-pattern ECG.
Collapse
Affiliation(s)
- Hung-Kai Huang
- Division of Cardiology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan
| | - Yen-Chang Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan.,Department of Medicine, Taipei City Hospital, Taipei, Taiwan
| | - Chung-Hsing Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao-Shun Chan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Yu Chang
- Division of Cardiology, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yao-Ting Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ching-Hui Huang
- Division of Cardiology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taiwan
| |
Collapse
|
9
|
NAKAMURA TOMOFUMI, HACHIYA HITOSHI, YAGISHITA ATSUHIKO, TANAKA YASUAKI, HIGUCHI KOJI, KAWABATA MIHOKO, SASANO TETSUO, HIRAO KENZO. The Relationship between the Profiles of SVC and Sustainability of SVC Fibrillation Induced by Provocative Electrical Stimulation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:352-60. [DOI: 10.1111/pace.12814] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 12/22/2015] [Accepted: 01/11/2016] [Indexed: 12/01/2022]
Affiliation(s)
- TOMOFUMI NAKAMURA
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| | - HITOSHI HACHIYA
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| | | | - YASUAKI TANAKA
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| | - KOJI HIGUCHI
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| | - MIHOKO KAWABATA
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| | - TETSUO SASANO
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| | - KENZO HIRAO
- Heart Rhythm Center; Tokyo Medical and Dental University; Tokyo Japan
| |
Collapse
|
10
|
Masuda R, Miyazaki S, Kusa S, Komatsu Y, Hachiya H, Iesaka Y. Discrimination of thoracic vein potentials facilitated by atrial pacing during the isolation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:225-30. [PMID: 25223478 DOI: 10.1111/pace.12502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 06/16/2014] [Accepted: 08/04/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although electrical thoracic vein (TV) isolation is an established strategy during atrial fibrillation (AF) ablation, discriminating TV potentials from far-field signals is critical for the achievement. METHODS AND RESULTS One hundred consecutive drug-refractory symptomatic paroxysmal AF patients who underwent AF catheter ablation were included. All patients underwent circumferential pulmonary vein (PV) isolation during distal coronary sinus (CS) pacing with a cycle length of 600 ms. A superior vena cava (SVC) isolation was added during high right atrial (HRA) pacing with the same cycle length in 79 patients in whom SVC potentials were identified. The interval between the near-field PV potentials and far-field atrial signals significantly prolonged more during distal CS pacing than sinus rhythm (SR) in the left superior (26.0 [18.5-32.8] ms to 36.0 [24.3-55.5] ms, P < 0.01) and left inferior PVs (21.0 [14.0-30.0] ms to 40.0 [23.0-56.0] ms, P < 0.01), but not in the right superior (34.0 [20.0-40.0] ms to 23.0 [18.0-36.0] ms, P = 0.13) and right inferior PVs (22.0 [16.0-28.0] ms to 25.0 [18.0-38.0] ms, P = 0.05). The interval between the SVC potentials and far-field atrial signals significantly prolonged more during HRA pacing than SR (20.0 [0-32.0] ms to 34.0 [24.0-46.0] ms, P < 0.01). Electrical isolation was successfully achieved in all TVs without any complications except for transient right phrenic nerve palsy in two patients. CONCLUSIONS Discrimination of ipsilateral left PVs and SVC potentials is facilitated by pacing from the distal CS and HRA, respectively. Better recognition of TV potentials would help to achieve electrical isolation.
Collapse
Affiliation(s)
- Ryo Masuda
- Cardiology Division, Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | | | | | | | | | | |
Collapse
|