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Turagam MK, Neuzil P, Petru J, Funasako M, Koruth JS, Skoda J, Kralovec S, Reddy VY. AF ablation using a novel "single-shot" map-and-ablate spherical array pulsed field ablation catheter: 1-Year outcomes of the first-in-human PULSE-EU trial. Heart Rhythm 2024:S1547-5271(24)02536-0. [PMID: 38768840 DOI: 10.1016/j.hrthm.2024.04.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND During pulsed field ablation (PFA), electrode-tissue proximity optimizes lesion quality. A novel "single-shot" map-and-ablate spherical multielectrode PFA array catheter that is able to verify electrode-tissue contact was recently studied in a first-in-human trial of atrial fibrillation (AF). OBJECTIVE The aim of this study was to report lesion durability data, safety, and 12-month effectiveness outcomes. METHODS The spherical PFA catheter, an all-in-one mapping and ablation system, was used to render anatomy and to deliver biphasic pulses (ungated 1.7 kV pulses; ∼40 seconds/application). Ablation sites included pulmonary veins (PVs) and, in selected patients, posterior wall and mitral isthmus. Follow-up was invasive remapping at ∼3 months, electrocardiograms, Holter monitoring at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy end points were acute PV isolation (PVI), PVI durability, and atrial arrhythmia recurrence. RESULTS In the 48-patient AF cohort (paroxysmal, 48%; persistent, 52%), lesion sets included PVI (n = 48; 1.2 applications/PV), posterior wall (n = 20; 3.6 applications/posterior wall), and mitral isthmus (n = 11; 2.9 applications/mitral isthmus). Lesions were acutely successful for all 187 of 187 PVs (100%), 20 of 20 posterior walls (100%), and 10 of 11 mitral isthmuses (91%). Pulse delivery time, left atrial catheter dwell time, and procedure time were 61.5 ± 32.8 seconds, 53.9 ± 26.5 minutes, and 87.8 ± 29.8 minutes, respectively. Remapping (43/48 patients [89.5%]) revealed that 158 of 169 PVs (93.5%) were durably isolated. The only complication was a drug-responsive pericarditis. The 1-year Kaplan-Meier estimates of freedom from atrial arrhythmia were 84.2% (paroxysmal AF) and 80.0% (persistent AF). CONCLUSION The single-shot spherical array PFA catheter can safely achieve durable lesions, translating into good clinical efficacy. CLINICALTRIALS GOV IDENTIFIER NCT05164107.
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Affiliation(s)
| | | | - Jan Petru
- Homolka Hospital, Prague, Czech Republic
| | | | - Jacob S Koruth
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jan Skoda
- Homolka Hospital, Prague, Czech Republic
| | | | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York; Homolka Hospital, Prague, Czech Republic.
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Pierucci N, Mariani MV, Laviola D, Silvetti G, Cipollone P, Vernile A, Trivigno S, La Fazia VM, Piro A, Miraldi F, Vizza CD, Lavalle C. Pulsed Field Energy in Atrial Fibrillation Ablation: From Physical Principles to Clinical Applications. J Clin Med 2024; 13:2980. [PMID: 38792520 PMCID: PMC11121906 DOI: 10.3390/jcm13102980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Atrial fibrillation, representing the most prevalent sustained cardiac arrhythmia, significantly impacts stroke risk and cardiovascular mortality. Historically managed with antiarrhythmic drugs with limited efficacy, and more recently, catheter ablation, the interventional approach field is still evolving with technological advances. This review highlights pulsed field ablation (PFA), a revolutionary technique gaining prominence in interventional electrophysiology because of its efficacy and safety. PFA employs non-thermal electric fields to create irreversible electroporation, disrupting cell membranes selectively within myocardial tissue, thus preventing the non-selective damage associated with traditional thermal ablation methods like radiofrequency or cryoablation. Clinical studies have consistently shown PFA's ability to achieve pulmonary vein isolation-a cornerstone of AF treatment-rapidly and with minimal complications. Notably, PFA reduces procedure times and has shown a lower incidence of esophageal and phrenic nerve damage, two common concerns with thermal techniques. Emerging from oncological applications, the principles of electroporation provide a unique tissue-selective ablation method that minimizes collateral damage. This review synthesizes findings from foundational animal studies through to recent clinical trials, such as the MANIFEST-PF and ADVENT trials, demonstrating PFA's effectiveness and safety. Future perspectives point towards expanding indications and refinement of techniques that promise to improve AF management outcomes further. PFA represents a paradigm shift in AF ablation, offering a safer, faster, and equally effective alternative to conventional methods. This synthesis of its development and clinical application outlines its potential to become the new standard in AF treatment protocols.
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Affiliation(s)
- Nicola Pierucci
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Domenico Laviola
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Giacomo Silvetti
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Pietro Cipollone
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Antonio Vernile
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Sara Trivigno
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | | | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Fabio Miraldi
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Carmine Dario Vizza
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza”, University of Rome, 00161 Rome, Italy; (N.P.); (M.V.M.); (D.L.); (G.S.); (P.C.); (A.V.); (S.T.); (A.P.); (F.M.); (C.D.V.)
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3
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Deneke T, Kutyifa V, Hindricks G, Sommer P, Zeppenfeld K, Carbuccichio C, Pürerfellner H, Heinzel FR, Traykov VB, De Riva M, Pontone G, Lehmkuhl L, Haugaa K. Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology. Europace 2024; 26:euae108. [PMID: 38743765 PMCID: PMC11104536 DOI: 10.1093/europace/euae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.
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Affiliation(s)
- Thomas Deneke
- Clinic for Rhythmology at Klinikum Nürnberg Campus Süd, University Hospital of the Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Helmut Pürerfellner
- Department of Clinical Electrophysiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Frank R Heinzel
- Städtisches Klinikum Dresden, Department of Cardiology, Angiology and Intensive Care Medicine, Dresden, Germany
| | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Marta De Riva
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Lukas Lehmkuhl
- Department of Radiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Germany
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4
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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5
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Varrias D, Saralidze T, Borkowski P, Pargaonkar S, Spanos M, Bazoukis G, Kokkinidis D. Atrial Fibrillation and Dementia: Pathophysiological Mechanisms and Clinical Implications. Biomolecules 2024; 14:455. [PMID: 38672471 PMCID: PMC11048426 DOI: 10.3390/biom14040455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/17/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Numerous longitudinal studies suggest a strong association between cardiovascular risk factors and cognitive impairment. Individuals with atrial fibrillation are at higher risk of dementia and cognitive dysfunction, as atrial fibrillation increases the risk of cerebral hypoperfusion, inflammation, and stroke. The lack of comprehensive understanding of the observed association and the complex relationship between these two diseases makes it very hard to provide robust guidelines on therapeutic indications. With this review, we attempt to shed some light on how atrial fibrillation is related to dementia, what we know regarding preventive interventions, and how we could move forward in managing those very frequently overlapping conditions.
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Affiliation(s)
- Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.); (S.P.)
| | - Tinatin Saralidze
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.); (S.P.)
| | - Pawel Borkowski
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.); (S.P.)
| | - Sumant Pargaonkar
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.); (S.P.)
| | - Michail Spanos
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
| | - George Bazoukis
- School of Medicine, European University Cyprus, 2417 Nicosia, Cyprus
| | - Damianos Kokkinidis
- Section of Cardiovascular Medicine, Yale University, New Haven, CT 06520, USA
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital and Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil and Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, California, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France and Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, USA
| | - Ngai-Yin Chan
- Department of Medicine & Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Cardiac Electrophysiology and Stimulation Department, Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Cardiac Electrophysiology and Stimulation Department, Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, and Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas and Case Western Reserve University, Cleveland, Ohio and Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, USA
| | - Kevin L Thomas
- Duke University Medical Center, Durham, North Carolina, USA
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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7
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Reddy VY, Anter E, Peichl P, Rackauskas G, Petru J, Funasako M, Koruth JS, Marinskis G, Turagam M, Aidietis A, Kautzner J, Natale A, Neuzil P. First-in-human clinical series of a novel conformable large-lattice pulsed field ablation catheter for pulmonary vein isolation. Europace 2024; 26:euae090. [PMID: 38584468 PMCID: PMC11057205 DOI: 10.1093/europace/euae090] [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: 03/26/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS Pulsed field ablation (PFA) has significant advantages over conventional thermal ablation of atrial fibrillation (AF). This first-in-human, single-arm trial to treat paroxysmal AF (PAF) assessed the efficiency, safety, pulmonary vein isolation (PVI) durability and one-year clinical effectiveness of an 8 Fr, large-lattice, conformable single-shot PFA catheter together with a dedicated electroanatomical mapping system. METHODS AND RESULTS After rendering the PV anatomy, the PFA catheter delivered monopolar, biphasic pulse trains (5-6 s per application; ∼4 applications per PV). Three waveforms were tested: PULSE1, PULSE2, and PULSE3. Follow-up included ECGs, Holters at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy endpoints were acute PVI and post-blanking atrial arrhythmia recurrence, respectively. Invasive remapping was conducted ∼75 days post-ablation. At three centres, PVI was performed by five operators in 85 patients using PULSE1 (n = 30), PULSE2 (n = 20), and PULSE3 (n = 35). Acute PVI was achieved in 100% of PVs using 3.9 ± 1.4 PFA applications per PV. Overall procedure, transpired ablation, PFA catheter dwell and fluoroscopy times were 56.5 ± 21.6, 10.0 ± 6.0, 19.1 ± 9.3, and 5.7 ± 3.9 min, respectively. No pre-defined primary safety events occurred. Upon remapping, PVI durability was 90% and 99% on a per-vein basis for the total and PULSE3 cohort, respectively. The Kaplan-Meier estimate of one-year freedom from atrial arrhythmias was 81.8% (95% CI 70.2-89.2%) for the total, and 100% (95% CI 80.6-100%) for the PULSE3 cohort. CONCLUSION Pulmonary vein isolation (PVI) utilizing a conformable single-shot PFA catheter to treat PAF was efficient, safe, and effective, with durable lesions demonstrated upon remapping.
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Affiliation(s)
- Vivek Y Reddy
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1030, New York, NY, USA
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Elad Anter
- Division of Cardiovascular Medicine, Shamir Medical Center, Be'er Yaakov, Tel Aviv, Israel
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | | | - Jan Petru
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | | | - Jacob S Koruth
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1030, New York, NY, USA
| | | | - Mohit Turagam
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, Box 1030, New York, NY, USA
| | - Audrius Aidietis
- Department of Cardiology, Vilnius University, Vilnius, Lithuania
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine-IKEM, Prague, Czech Republic
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
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8
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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9
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Saglietto A, Bertello E, Barra M, Ferraro I, Rovera C, Orzan F, De Ferrari GM, Anselmino M. MRI pattern characterization of cerebral cardioembolic lesions following atrial fibrillation ablation. Front Cardiovasc Med 2024; 11:1327567. [PMID: 38327489 PMCID: PMC10847299 DOI: 10.3389/fcvm.2024.1327567] [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: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background Recognizing etiology is essential for treatment and secondary prevention of cerebral ischemic events. A magnetic resonance imaging (MRI) pattern suggestive of an embolic etiology has been described but, to date, there are no uniformly accepted criteria. Aim The purpose of the study is to describe MRI features of ischemic cerebral lesions occurring after transcatheter ablation of atrial fibrillation (AF). Methods A systematic review and meta-analysis of studies performing brain imaging investigations before and after AF transcatheter ablation was performed. The incidence of cerebral ischemic lesions after AF transcatheter ablation was the primary endpoint. The co-primary endpoints were the prevalence of the different neuroimaging features regarding the embolic cerebral ischemic lesions. Results A total of 25 studies, encompassing 3,304 patients, were included in the final analysis. The incidence of ischemic cerebral lesions following AF transcatheter ablation was 17.2% [95% confidence interval (CI) 12.2%-23.8%], of which a minimal fraction was symptomatic [0.60% (95% CI 0.09%-3.9%)]. Only 1.6% of the lesions (95% CI 0.9%-3.0%) had a diameter >10 mm, and in 20.5% of the cases the lesions were multiple (95% CI 17.1%-24.4%). Brain lesions were equally distributed across the two hemispheres and the different lobes; cortical location was more frequent [64.0% (95% CI 42.9%-80.8%)] while the middle cerebral artery territory was the most involved 37.0% (95% CI 27.3-48.0). Conclusions The prevailing MRI pattern comprises a predominance of small (<10 mm) cortical lesions, more prevalent in the territory of the middle cerebral artery.
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Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Eleonora Bertello
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Barra
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ilenia Ferraro
- Division of Cardiology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Chiara Rovera
- Department of Cardiology, Civic Hospital of Chivasso, Chivasso, Italy
| | - Fulvio Orzan
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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10
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Piros K, Vida A, Szegedi N, Perge P, Salló Z, Ferencz AB, Nagy VK, Herczeg S, Ábrahám P, Csobay-Novák C, Drobni Z, Tahin T, Apponyi G, Merkely B, Gellér L, Osztheimer I. One-Day Interruption of NOAC Is Associated with Low Risk of Periprocedural Adverse Events during Pulmonary Vein Isolation If Combined with Left Atrial Thrombus Exclusion with Computed Tomography. Life (Basel) 2024; 14:133. [PMID: 38255747 PMCID: PMC10817453 DOI: 10.3390/life14010133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Safety, efficacy, and patient comfort are the expectations during pulmonary vein isolation (PVI). We aimed to validate the combined advantages of pre- and periprocedural anticoagulation with non-vitamin K anticoagulants (NOACs) and rigorous left atrial appendage thrombus (LAAT) exclusion with computed tomography (CT). METHODS This study included a population of consecutive patients, between March 2018 and June 2020, who underwent cardiac CT within 24 h before PVI to guide the ablation and rule out LAAT. NOAC was omitted 24 h before the ablation. RESULTS A total of 187 patients (63% male) underwent CT before PVI. None of the patients experienced stroke during or after the procedure. The complication rate was low, with no thromboembolic events and 2.1% of patients experiencing a major bleeding event. CONCLUSIONS Omitting NOAC 24 h before the ablation might be safe if combined with left atrial thrombus exclusion with computed tomography.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, Városmajor Street 68, 1122 Budapest, Hungary; (K.P.); (A.V.); (N.S.); (P.P.); (Z.S.); (A.B.F.); (V.K.N.); (S.H.); (P.Á.); (C.C.-N.); (Z.D.); (T.T.); (G.A.); (B.M.); (L.G.)
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11
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Bao W, Hu X, Ge L, Tang S, Zhao X, Huang S, Liu C, Li F, Zhang C, Li C. Establishment and Validation of the Nomogram Model and the Probability of Silent Cerebral Infarction After Ablation Atrial Fibrillation. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07530-4. [PMID: 38103153 DOI: 10.1007/s10557-023-07530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND The objective of this study is to establish and validate a nomogram model for predicting the probability of silent cerebral infarction following ablation of atrial fibrillation. METHODS AND RESULTS A retrospective observational study was conducted on the data of 238 patients with atrial fibrillation who underwent radiofrequency ablation in our hospital from October 2019 to December 2022. LASSO regression and multivariate logistics regression analysis were used to assess the independent risk factors for silent cerebral infarction after ablation. The AUC of the predictive model was 0.733 (95% CI, 0.649-0.816) and the internal validation (bootstrap = 1000) of the bootstrap method was 0.733 (95% CI 0.646-0.813). The Hosmer-Lemeshow test yields an insignificant p-value of X-squared = 10.212 and p-value = 0.2504, thus indicating an insignificant difference between predicted and observed values and good calibration results. The clinical impact curve (CIC) and clinical decision curve also prove that this graph is useful in the clinical setting. CONCLUSION We developed an easy-to-use nomogram model to predict the probability of silent cerebral infarction following radiofrequency ablation of atrial fibrillation. This model can provide a valid assessment of the probability of postoperative silent cerebral infarction in patients undergoing radiofrequency ablation of atrial fibrillation.
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Affiliation(s)
- Wei Bao
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Xiaoqin Hu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Liqi Ge
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Shiyun Tang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Xinliang Zhao
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Shuo Huang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Chen Liu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Fei Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Chaoqun Zhang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China.
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12
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Chen WJ, Gan CX, Cai YW, Liu YY, Xiao PL, Zou LL, Xiong QS, Qin F, Tao XX, Li R, Du HA, Liu ZZ, Yin YH, Ling ZY. Impact of high-power short-duration atrial fibrillation ablation technique on the incidence of silent cerebral embolism: a prospective randomized controlled study. BMC Med 2023; 21:461. [PMID: 37996906 PMCID: PMC10666361 DOI: 10.1186/s12916-023-03180-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND High-power short-duration (HPSD) ablation strategy has emerged as a popular approach for treating atrial fibrillation (AF), with shorter ablation time. The utilized Smart Touch Surround Flow (STSF) catheter, with 56 holes around the electrode, lowers electrode-tissue temperature and thrombus risk. Thus, we conducted this prospective, randomized study to investigate if the HPSD strategy with STSF catheter in AF ablation procedures reduces the silent cerebral embolism (SCE) risk compared to the conventional approach with the Smart Touch (ST) catheter. METHODS From June 2020 to September 2021, 100 AF patients were randomized 1:1 to the HPSD group using the STSF catheter (power set at 50 W) or the conventional group using the ST catheter (power set at 30 to 35 W). Pulmonary vein isolation was performed in all patients, with additional lesions at operator's discretion. High-resolution cerebral diffusion-weighted magnetic resonance imaging (hDWI) with slice thickness of 1 mm was performed before and 24-72 h after ablation. The incidence of new periprocedural SCE was defined as the primary outcome. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) test. RESULTS All enrolled AF patients (median age 63, 60% male, 59% paroxysmal AF) underwent successful ablation. Post-procedural hDWI identified 106 lesions in 42 enrolled patients (42%), with 55 lesions in 22 patients (44%) in the HPSD group and 51 lesions in 20 patients (40%) in the conventional group (p = 0.685). No significant differences were observed between two groups regarding the average number of lesions (p = 0.751), maximum lesion diameter (p = 0.405), and total lesion volume per patient (p = 0.669). Persistent AF and CHA2DS2-VASc score were identified as SCE determinants during AF ablation procedure by multivariable regression analysis. No significant differences in MoCA scores were observed between patients with SCE and those without, both immediately post-procedure (p = 0.572) and at the 3-month follow-up (p = 0.743). CONCLUSIONS Involving a small sample size of 100 AF patients, this study reveals a similar incidence of SCE in AF ablation procedures, comparing the HPSD strategy using the STSF catheter to the conventional approach with the ST catheter. TRIAL REGISTRATION Clinicaltrials.gov: NCT04408716. AF = Atrial fibrillation, DWI = Diffusion-weighted magnetic resonance imaging, HPSD = High-power short-duration, ST = Smart Touch, STSF = Smart Touch Surround Flow.
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Affiliation(s)
- Wei-Jie Chen
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Chun-Xia Gan
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Yang-Wei Cai
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Yang-Yang Liu
- Department of Radiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Pei-Lin Xiao
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Li-Li Zou
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Qing-Song Xiong
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Fang Qin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Xie-Xin Tao
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Ran Li
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Hua-An Du
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Zeng-Zhang Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Yue-Hui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China
| | - Zhi-Yu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, No. 288, Tianwen Avenue, Chayuan, Nan'an District, Chongqing, 400060, China.
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13
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Tohoku S, Schmidt B, Schaack D, Bordignon S, Hirokami J, Chen S, Ebrahimi R, Efe TH, Urbanek L, Chun KRJ. Impact of Pulsed-Field Ablation on Intrinsic Cardiac Autonomic Nervous System After Pulmonary Vein Isolation. JACC Clin Electrophysiol 2023; 9:1864-1875. [PMID: 37480870 DOI: 10.1016/j.jacep.2023.05.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Although the autonomic reaction such as bradycardia is observed frequently during pulsed-field ablation (PFA)-guided pulmonary vein isolation (PVI), its mechanism and effect on the adjacent intrinsic cardiac autonomic nervous system (ICANS) are unclear. OBJECTIVES This study aimed to reveal the clinical impact of PFA on ICANS by investigating the serum S100 increase (ΔS100), a well-known denervation relevant biomarker. METHODS Pre- and postprocedural serum S100 analyses were systematically conducted in patients undergoing PVI using either the pentaspline PFA or cryoballoon ablation (CBA) system. ΔS100 release kinetics were compared between both technologies. Cerebral magnetic resonance imaging was conducted to eliminate the effect of central nervous system release. RESULTS A total of 97 patients (PFA: n = 54 and CBA: n = 43) were enrolled. Overall S100 increased in both groups with a lower amount in PFA (0.035 μg/L; IQR: 0.02-0.063 μg/L) compared with CBA (0.12 μg/L; IQR: 0.09-0.17 μg/L; P < 0.0001). In cerebral magnetic resonance imaging, silent emboli were detected in 10 patients (18.5%) in PFA and 7 patients (16.3%) in CBA (P = 0.773). Even after excluding patients with cerebral emboli, ΔS100 was lower in PFA. During PFA PVI, 30 patients (56%) demonstrated transient bradycardia in 70 of 210 PVs (35%). ΔS100 was similar between patients with or without transient bradycardia. CONCLUSIONS We report a significantly lower S100 release following PFA PVI vs CBA PVI even if silent cerebral emboli were excluded. Notably, vagal response during PFA was not associated with S100 release. These observations are in line with lower nervous tissue destruction of PFA compared with CBA.
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Affiliation(s)
- Shota Tohoku
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; Klinik für Rhythmologie, Universität zu Lübeck, Lübeck, Germany.
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - David Schaack
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Jun Hirokami
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Ramin Ebrahimi
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Tolga Han Efe
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Lukas Urbanek
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany; Klinik für Rhythmologie, Universität zu Lübeck, Lübeck, Germany
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Zhang J, Li S, Sang C, Ma C. Atrial fibrillation catheter ablation associated silent cerebral emboli: A narrative review. Pacing Clin Electrophysiol 2023; 46:1124-1133. [PMID: 37578003 DOI: 10.1111/pace.14779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
The incidence of silent cerebral emboli (SCE) associated with atrial fibrillation catheter ablation (AFCA) is much higher than that of stroke/transient ischemic attack (TIA). Interventional electrophysiologists have been increasingly alerted to asymptomatic cerebral infarction over the years. Plentiful studies revealed that diagnostic definitions, detection modalities, energy sources, ablation strategies, perioperative anticoagulation regimens, and patient-related factors were associated with the risk of AFCA-associated SCE. Studies related to non-interventional procedures found that SCE may prompt stroke, cognitive decline, and dementia later in life, suggesting a possible role of AFCA-associated SCE in the cognitive function of patients with AF. However, there is no consistent evidence for this view to date. Given that the majority of patients with AF being elderly and the increased risk of cognitive impairment in AF itself, efforts should be made to minimize the occurrence of AFCA-associated SCE.
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Affiliation(s)
- Jingrui Zhang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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15
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Reddy VY, Peichl P, Anter E, Rackauskas G, Petru J, Funasako M, Minami K, Koruth JS, Natale A, Jais P, Marinskis G, Aidietis A, Kautzner J, Neuzil P. A Focal Ablation Catheter Toggling Between Radiofrequency and Pulsed Field Energy to Treat Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1786-1801. [PMID: 37227340 DOI: 10.1016/j.jacep.2023.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Because of its safety, "single-shot" pulsed field ablation (PFA) catheters have been developed for pulmonary vein isolation (PVI). However, most atrial fibrillation (AF) ablation procedures are performed with focal catheters to permit flexibility of lesion sets beyond PVI. OBJECTIVES This study sought to determine the safety and efficacy of a focal ablation catheter able to toggle between radiofrequency ablation (RFA) or PFA to treat paroxysmal or persistent AF. METHODS In a first-in-human study, a focal 9-mm lattice tip catheter was used for PFA posteriorly and either irrigated RFA (RF/PF) or PFA (PF/PF) anteriorly. Protocol-driven remapping was at ∼3 months postablation. The remapping data prompted PFA waveform evolution: PULSE1 (n = 76), PULSE2 (n = 47), and the optimized PULSE3 (n = 55). RESULTS The study included 178 patients (paroxysmal/persistent AF = 70/108). Linear lesions, either PFA or RFA, included 78 mitral, 121 cavotricuspid isthmus, and 130 left atrial roof lines. All lesion sets (100%) were acutely successful. Invasive remapping of 122 patients revealed improvement of PVI durability with waveform evolution: PULSE1: 51%; PULSE2: 87%; and PULSE3: 97%. After 348 ± 652 days of follow-up, the 1-year Kaplan-Meier estimates for freedom from atrial arrhythmias were 78.3% ± 5.0% and 77.9% ± 4.1% for paroxysmal and persistent AF, respectively, and 84.8% ± 4.9% for the subset of persistent AF patients receiving the PULSE3 waveform. There was 1 primary adverse event-inflammatory pericardial effusion not requiring intervention. CONCLUSIONS AF ablation with a focal RF/PF catheter allows efficient procedures, chronic lesion durability, and good freedom from atrial arrhythmias-for both paroxysmal and persistent AF. (Safety and Performance Assessment of the Sphere-9 Catheter and the Affera Mapping and RF/PF Ablation System to Treat Atrial Fibrillation; NCT04141007 and NCT04194307).
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Affiliation(s)
- Vivek Y Reddy
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic; Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gediminas Rackauskas
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Jan Petru
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | | | - Kentaro Minami
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Pierre Jais
- University of Bordeaux, CHU Bordeaux, IHU LIRYC (L'Institut des maladies du rhythm cardiaque) ANR-10-IAHU-04, Bordeaux, France
| | - Germanas Marinskis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Audrius Aidietis
- Centre for Cardiology and Angiology, Department of Cardiovascular Diseases, Vilnius University, Vilnius, Lithuania
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
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16
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Kisling AJ, Symons JG, Daubert JP. Catheter ablation of atrial fibrillation: anticipating and avoiding complications. Expert Rev Med Devices 2023; 20:929-941. [PMID: 37691572 DOI: 10.1080/17434440.2023.2257131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Atrial fibrillation (AF) ablation is being performed more frequently and more widely at more centers. This stems from several factors including 1) demographic forces leading to an increased prevalence of the arrhythmia; 2) greater availability of ambulatory monitoring making diagnosis more frequent; 3) relative inefficacy of medications; and 4) improved safety and efficacy of the procedure. Ablation has become much more streamlined and reproducible than a decade ago, but life-threatening complications may still arise. AREAS COVERED This review will focus on awareness, avoidance, and early recognition and management of complications of AF ablation. This literature review is challenged by differing approaches to ablation of AF both within a center and between centers, the rapid improvement of technology making the outcomes associated with a therapeutic strategy begun a few years prior relatively obsolete, as well as the heterogeneity of the population being studied. EXPERT OPINION Newer technologies are on the horizon which will allow us to ablate AF with increasing efficacy, efficiency, and hopefully safety. Such new technology and changing usage mandate vigilance to avoid complications.
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Affiliation(s)
- Adam J Kisling
- Walter Reed National Military Medical Center, Department of Cardiology, Bethesda, MD, United States of America
| | - John G Symons
- Walter Reed National Military Medical Center, Department of Electrophysiology, Bethesda, MD, United States of America
| | - James P Daubert
- Electrophysiology Section/Duke Center for Atrial Fibrillation, Division of Cardiology, Duke Clinical Research Institute, Department of Medicine, Duke University, Durham, NC, United States of America
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17
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Anić A, Phlips T, Brešković T, Koopman P, Girouard S, Mediratta V, Jurišić Z, Sikirić I, Lisica L, Vijgen J. Pulsed field ablation using focal contact force-sensing catheters for treatment of atrial fibrillation: acute and 90-day invasive remapping results. Europace 2023; 25:euad147. [PMID: 37335976 PMCID: PMC10279421 DOI: 10.1093/europace/euad147] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/17/2023] [Indexed: 06/21/2023] Open
Abstract
AIMS Pulsed field ablation (PFA) has emerged as a promising alternative to thermal ablation for treatment of atrial fibrillation (AF). We report performance and safety using the CENTAURI™ System (Galvanize Therapeutics) with three commercial, focal ablation catheters. METHODS AND RESULTS ECLIPSE AF (NCT04523545) was a prospective, single-arm, multi-centre study evaluating safety and acute and chronic pulmonary vein isolation (PVI) durability using the CENTAURI System in conjunction with the TactiCath SE, StablePoint, and ThermoCool ST ablation catheters. Patients with paroxysmal or persistent AF were treated at two centres. Patients were analysed in five cohorts based upon ablation settings, catheter, and mapping system. Pulsed field ablation was performed in 82 patients (74% male, 42 paroxysmal AF). Pulmonary vein isolation was achieved in 100% of pulmonary veins (322/322) with first-pass isolation in 92.2% (297/322). There were four serious adverse events of interest (three vascular access complications and one lacunar stroke). Eighty patients (98%) underwent invasive remapping. Pulsed field ablation development Cohorts 1 and 2 showed a per-patient isolation rate of 38% and 26% and a per-PV isolation rate of 47% and 53%, respectively. Optimized PFA Cohorts 3-5 showed a per-patient isolation rate of 60%, 73%, and 81% and a per-PV isolation rate of 84%, 90%, and 92%, respectively. CONCLUSION ECLIPSE AF demonstrated that optimized PFA using the CENTAURI System with three commercial, contact force-sensing, solid-tip focal ablation catheters resulted in transmural lesion formation and high proportion of durable PVI with a favourable safety profile, thus providing a viable treatment option for AF that integrates with contemporary focal ablation workflows.
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Affiliation(s)
- Ante Anić
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | | | - Toni Brešković
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | | | - Steven Girouard
- Galvanize Therapeutics, Inc. (previously Galaxy Medical), Redwood City, CA, USA
| | | | - Zrinka Jurišić
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | - Ivan Sikirić
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
| | - Lucija Lisica
- Heart and vascular center, Klinički Bolnički Centar (KBC) Split, Spinčićeva ul. 1, Split 21000, Croatia
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18
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Verma A, Haines DE, Boersma LV, Sood N, Natale A, Marchlinski FE, Calkins H, Sanders P, Packer DL, Kuck KH, Hindricks G, Onal B, Cerkvenik J, Tada H, DeLurgio DB. Pulsed Field Ablation for the Treatment of Atrial Fibrillation: PULSED AF Pivotal Trial. Circulation 2023; 147:1422-1432. [PMID: 36877118 PMCID: PMC10158608 DOI: 10.1161/circulationaha.123.063988] [Citation(s) in RCA: 102] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Pulsed field ablation uses electrical pulses to cause nonthermal irreversible electroporation and induce cardiac cell death. Pulsed field ablation may have effectiveness comparable to traditional catheter ablation while preventing thermally mediated complications. METHODS The PULSED AF pivotal study (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF) was a prospective, global, multicenter, nonrandomized, paired single-arm study in which patients with paroxysmal (n=150) or persistent (n=150) symptomatic atrial fibrillation (AF) refractory to class I or III antiarrhythmic drugs were treated with pulsed field ablation. All patients were monitored for 1 year using weekly and symptomatic transtelephonic monitoring; 3-, 6-, and 12-month ECGs; and 6- and 12-month 24-hour Holter monitoring. The primary effectiveness end point was freedom from a composite of acute procedural failure, arrhythmia recurrence, or antiarrhythmic escalation through 12 months, excluding a 3-month blanking period to allow recovery from the procedure. The primary safety end point was freedom from a composite of serious procedure- and device-related adverse events. Kaplan-Meier methods were used to evaluate the primary end points. RESULTS Pulsed field ablation was shown to be effective at 1 year in 66.2% (95% CI, 57.9 to 73.2) of patients with paroxysmal AF and 55.1% (95% CI, 46.7 to 62.7) of patients with persistent AF. The primary safety end point occurred in 1 patient (0.7%; 95% CI, 0.1 to 4.6) in both the paroxysmal and persistent AF cohorts. CONCLUSIONS PULSED AF demonstrated a low rate of primary safety adverse events (0.7%) and provided effectiveness consistent with established ablation technologies using a novel irreversible electroporation energy to treat patients with AF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04198701.
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Affiliation(s)
- Atul Verma
- McGill University Health Centre, Montreal, Canada (A.V.)
| | | | - Lucas V. Boersma
- St. Antonius Hospital, Nieuwegein and Amsterdam UMC, the Netherlands (L.V.B.)
| | - Nitesh Sood
- Southcoast Health Center, Fall River, MA (N.S.)
| | | | | | | | | | | | | | | | - Birce Onal
- Medtronic, Inc, Minneapolis, MN (B.O., J.C.)
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19
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Erkapic D, Aleksic M, Roussopoulos K, Weipert KF, Sözener K, Kostev K, Allendörfer J, Rosenbauer J, Guenduez D, Tanislav C. Microembolizations in the Arterial Cerebral Circulation in Patients with Atrial Fibrillation Ablation Using the Cryoballoon Technique-Protocol and Methodology of a Prospective Observational Study. Diagnostics (Basel) 2023; 13:diagnostics13091660. [PMID: 37175051 PMCID: PMC10178285 DOI: 10.3390/diagnostics13091660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
There is considerable uncertainty regarding the impact of microembolic signals (MESs) on neuropsychological abilities in patients receiving pulmonary vein isolation and beyond using the cryoballoon technique. We conducted the largest prospective observational study on this topic, providing insights into the gradual unmasking of procedure-related MESs and their impacts on neuropsychological outcomes. MESs were continuously detected periprocedurally using transcranial Doppler ultrasonography. Neuropsychological status was evaluated comprehensively using the CERAD Plus test battery, which consists of 11 neuropsychological subtests. Patients with atrial fibrillation were included in the study with an equal distribution (50:50) of paroxysmal or persistent presentations. Of 167 consecutive eligible patients, 100 were included within the study enrollment period from February 2021 to August 2022. The study, including the documentation of all follow-up visits, ended in November 2022. This paper focuses on describing the study protocol and methodology and presenting the baseline data.
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Affiliation(s)
- Damir Erkapic
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
- Department of Cardiology and Angiology, University Clinic of Giessen, 35392 Giessen, Germany
| | - Marko Aleksic
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
| | - Konstantinos Roussopoulos
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
| | - Kay Felix Weipert
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
| | - Korkut Sözener
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
- Department of Rhythmology, Klinikum Hanau, 63450 Hanau, Germany
| | - Karel Kostev
- Epidemiology, IQVIA, Unterschweinstiege 2-14, 60549 Frankfurt am Main, Germany
| | | | - Josef Rosenbauer
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
| | - Dursun Guenduez
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
- Department of Cardiology and Angiology, University Clinic of Giessen, 35392 Giessen, Germany
| | - Christian Tanislav
- Department of Geriatrics and Neurology, Diakonie Klinikum Jung Stilling, 57074 Siegen, Germany
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20
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Garber L, Barbhaiya C. High Power Short Duration: Is There a Chink in the Armor? JACC Clin Electrophysiol 2023:S2405-500X(23)00110-X. [PMID: 37115118 DOI: 10.1016/j.jacep.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Leonid Garber
- Section of Cardiac Electrophysiology, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Chirag Barbhaiya
- Section of Cardiac Electrophysiology, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA.
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21
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Reddy VY, Lehmann J, Gerstenfeld EP, Mugglin AS, Schneider C, Achyutha A, Mansour M. A Randomized Controlled Trial of Pulsed Field Ablation versus Standard-of-Care Ablation for Paroxysmal Atrial Fibrillation: The ADVENT Trial Rationale and Design. Heart Rhythm O2 2023. [DOI: 10.1016/j.hroo.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
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22
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PV Isolation Using a Spherical Array PFA Catheter: Application Repetition and Lesion Durability (PULSE-EU Study). JACC Clin Electrophysiol 2023; 9:638-648. [PMID: 36828771 DOI: 10.1016/j.jacep.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Preclinical studies have revealed that pulsed field ablation (PFA) lesion dimensions increase with repetitive applications at a similar electric field. OBJECTIVES This study investigated whether pulmonary vein isolation (PVI) durability varies with single vs repetitive pulsed field (PF) applications. METHODS Atrial fibrillation patients underwent PVI using a spherical multielectrode array PFA catheter delivered with a 19-F deflectable sheath under intracardiac echocardiographic guidance. Esophagogastroduodenoscopy and brain magnetic resonance imaging were performed within 1 to 3 days, and invasive remapping at ∼2 to 3 months. RESULTS The patient cohort (n = 21; age 63 ± 11 years; 67% women) underwent PVI in either of 2 groups: group 1 (n = 11)-single PF application/PV; and group 2 (n = 10)-3 PF applications/PV. In both groups, PVI was acutely successful in all (100%) patients. Despite significantly longer pulse delivery times (75.2 ± 7.4 s/patient vs 24.5 ± 5.5 s/patient) the procedure times (73.2 ± 13.7 minutes vs 93.7 ± 18.5 minutes) were shorter with group 2 vs group 1. There was no stroke/transient ischemic attack, pericardial effusion, phrenic nerve injury, or esophageal complications. Esophagogastroduodenoscopy was normal in both groups of patients (n = 9). Screening brain magnetic resonance imaging revealed asymptomatic cerebral lesions (diffusion weighted imaging+/ fluid attenuated inversion recovery-) in 3 of 16 (18.7%) patients. PV remapping revealed durable PVI in 62.5% PVs in group 1 (n = 10), compared with all 100% PVs in group 2 (n = 9); this translates to all PVs being durably isolated in 30% vs 100% (P < 0.05) of patients in groups 1 and 2, respectively. CONCLUSIONS In his first-in-human trial, the "single-shot" spherical array PFA catheter was shown to safely isolate PVs. Repetitive PF application is key for lesion consolidation to maximize PVI durability.
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23
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Zenger B, Rizzi S, Steinberg BA, Ranjan R, Bunch TJ. This is Your Brain, and This is Your Brain on Atrial Fibrillation: The Roles of Cardiac Malperfusion Events and Vascular Dysfunction in Cognitive Impairment. Arrhythm Electrophysiol Rev 2023; 12:e01. [PMID: 36845168 PMCID: PMC9945461 DOI: 10.15420/aer.2022.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023] Open
Abstract
AF is an independent and strong predictor of long-term cognitive decline. However, the mechanism for this cognitive decline is difficult to define and likely multifactorial, leading to many different hypotheses. Examples include macro- or microvascular stroke events, biochemical changes to the blood-brain barrier related to anticoagulation, or hypo-hyperperfusion events. This review explores and discusses the hypothesis that AF contributes to cognitive decline and dementia through hypo-hyperperfusion events occurring during cardiac arrhythmias. We briefly explain several brain perfusion imaging techniques and further examine the novel findings associated with changes in brain perfusion in patients with AF. Finally, we discuss the implications and areas requiring more research to further understand and treat patients with cognitive decline related to AF.
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Affiliation(s)
- Brian Zenger
- School of Medicine, University of Utah, Salt Lake City, UT, US
| | - Scott Rizzi
- Department of Internal Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - Benjamin A Steinberg
- School of Medicine, University of Utah, Salt Lake City, UT, US
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - T Jared Bunch
- School of Medicine, University of Utah, Salt Lake City, UT, US
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
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24
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Miyamoto K, Kanaoka K, Ohta Y, Yoh M, Takahashi H, Tonegawa‐Kuji R, Miyazaki Y, Shimamoto K, Wakamiya A, Ueda N, Nakajima K, Kamakura T, Wada M, Ishibashi K, Inoue Y, Nagase S, Aiba T, Narai A, Nakase T, Koga M, Fukuda T, Kataoka N, Takagi M, Kusano K. A multicenter prospective randomized study comparing the incidence of periprocedural cerebral embolisms caused by catheter ablation of atrial fibrillation between cryoballoon and radiofrequency ablation (Embo-Abl study): Study design. Clin Cardiol 2022; 46:214-222. [PMID: 36413635 PMCID: PMC9933100 DOI: 10.1002/clc.23949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although catheter ablation (CA) has become a standard therapeutic approach to atrial fibrillation (AF), it imposes a low but relevant risk of thromboembolic complications of around 0.5%-1%, including ischemic strokes, and has an additional risk of clinically silent cerebral embolisms (SCEs) of 10%-40%. Both cryoballoon (CB) and radiofrequency (RF) ablation are routinely used clinically worldwide, yet there are few prospective data comparing the incidence of cerebral embolism after CA of AF between CB and RF ablation. METHODS The aim of the Embo-Abl study will be to compare the incidence of cerebral embolisms on 3 T diffusion-weighted image magnetic resonance imaging (MRI) after CA of AF between CB and RF ablation in patients with AF in a prospective, multicenter, open-label, controlled, randomized fashion. The primary endpoint of the Embo-Abl study will be the occurrence of MRI-detected SCE 1-3 days after CA. The patients will be registered and randomly assigned to either the CB or RF ablation group in a 1:1 ratio. The study cohort will include 230 patients with AF from a multicenter in Japan. RESULTS The results of this study are currently under investigation. CONCLUSION The Embo-Abl study will be the first to compare the incidence of periprocedural cerebral embolisms caused by CA of AF between CB and RF ablation in a prospective, multicenter, randomized, controlled fashion.
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Affiliation(s)
- Koji Miyamoto
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Koshiro Kanaoka
- Center for Cerebral and Cardiovascular Disease Information, Open Innovation CenterNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yasutoshi Ohta
- Department of RadiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masue Yoh
- Department of Medicine IIKansai Medical UniversityMoriguchiJapan
| | - Hiroki Takahashi
- Department of Medicine IIKansai Medical UniversityMoriguchiJapan
| | - Rena Tonegawa‐Kuji
- Center for Cerebral and Cardiovascular Disease Information, Open Innovation CenterNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yuichiro Miyazaki
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Keiko Shimamoto
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Akinori Wakamiya
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Nobuhiko Ueda
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kenzaburo Nakajima
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Tsukasa Kamakura
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Mitsuru Wada
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kohei Ishibashi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yuko Inoue
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Satoshi Nagase
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Takeshi Aiba
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Akihisa Narai
- New Development GroupHashimoto Electronic Industry Co., LtdMatsusakaJapan
| | - Tomohiro Nakase
- New Development GroupHashimoto Electronic Industry Co., LtdMatsusakaJapan
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Tetsuya Fukuda
- Department of RadiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Naoya Kataoka
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Masahiko Takagi
- Department of Medicine IIKansai Medical UniversityMoriguchiJapan
| | - Kengo Kusano
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
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Reinsch N, Füting A, Höwel D, Bell J, Lin Y, Neven K. Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation. Heart Rhythm 2022; 19:1813-1818. [PMID: 35718318 DOI: 10.1016/j.hrthm.2022.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a novel, nonthermal ablation modality that can ablate myocardial tissue with minimal effects on surrounding tissue. Preclinical data show an absence of cerebral emboli after extensive PFA. However, clinical data on silent cerebral lesions (SCLs) and/or silent cerebral events (SCEs) after PFA are lacking. OBJECTIVES The purpose of this study was to investigate the occurrence of neurological deficits and SCL and/or SCE after PFA in paroxysmal atrial fibrillation (AF) using National Institutes of Health Stroke Scale (NIHSS) scores and magnetic resonance imaging (MRI). METHODS In patients with symptomatic paroxysmal AF, pulmonary vein isolation (PVI) using PFA was performed. NIHSS scores were assessed before and 2 days and 30 days after PVI. One day after PVI, patients underwent cerebral 1.5-T MRI scanning using diffusion-weighted imaging and fluid-attenuated inversion recovery sequences to document the occurrence of SCL/SCE. RESULTS PFA was performed in 30 patients (age 63 ± 10 years). No patient showed neurological deficits. All NIHSS scores showed the minimum value of 0. Cerebral MRI scans were normal in 29 of 30 patients (97%). In 1 patient (3%), a single 7-mm cerebellar lesion was observed. Forty days after the procedure, follow-up cerebral MRI scan showed complete regression of the lesion. CONCLUSION In patients treated with PFA for symptomatic paroxysmal AF, the incidence of MRI-detected asymptomatic thromboembolic cerebral events or lesions was as low as 3%. No neurological deficits occurred in any of the patients.
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Affiliation(s)
- Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany.
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Dennis Höwel
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - John Bell
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Yali Lin
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
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Bodagh N, Yap R, Kotadia I, Sim I, Bhalla A, Somerville P, O'Neill M, Williams SE. Impact of catheter ablation versus medical therapy on cognitive function in atrial fibrillation: a systematic review. J Interv Card Electrophysiol 2022; 65:271-286. [PMID: 35380337 PMCID: PMC9550702 DOI: 10.1007/s10840-022-01196-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE Atrial fibrillation is associated with an increased risk of cognitive impairment. It is unclear whether the restoration of sinus rhythm with catheter ablation may modify this risk. We conducted a systematic review of studies comparing cognitive outcomes following catheter ablation with medical therapy (rate and/or rhythm control) in atrial fibrillation. METHODS Searches were performed on the following databases from their inception to 17 October 2021: PubMed, OVID Medline, Embase and Cochrane Library. The inclusion criteria comprised studies comparing catheter ablation against medical therapy (rate and/or rhythm control in conjunction with anticoagulation where appropriate) which included cognitive assessment and/or a diagnosis of dementia as an outcome. RESULTS A total of 599 records were screened. Ten studies including 15,886 patients treated with catheter ablation and 42,684 patients treated with medical therapy were included. Studies which compared the impact of catheter ablation versus medical therapy on quantitative assessments of cognitive function yielded conflicting results. In studies, examining new onset dementia during follow-up, catheter ablation was associated with a lower risk of subsequent dementia diagnosis compared to medical therapy (hazard ratio: 0.60 (95% confidence interval 0.42-0.88, p < 0.05)). CONCLUSION The accumulating evidence linking atrial fibrillation with cognitive impairment warrants the design of atrial fibrillation treatment strategies aimed at minimising cognitive decline. However, the impact of catheter ablation and atrial fibrillation medical therapy on cognitive decline is currently uncertain. Future studies investigating atrial fibrillation treatment strategies should include cognitive outcomes as important clinical endpoints.
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Affiliation(s)
- Neil Bodagh
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Reuben Yap
- Princess Royal University Hospital, Orpington, UK
| | - Irum Kotadia
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Iain Sim
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Ajay Bhalla
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | | | - Mark O'Neill
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Steven E Williams
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Gerstenecker A, Norling AM, Jacob A, Lazar RM. Silent Brain Infarction, Delirium, and Cognition in Three Invasive Cardiovascular Procedures: a Systematic Review. Neuropsychol Rev 2022; 33:474-491. [PMID: 35804216 DOI: 10.1007/s11065-022-09548-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/09/2022] [Indexed: 12/19/2022]
Abstract
Silent brain infarctions (SBIs) are brain lesions noted on neuroimaging that are not associated with clinical symptoms. SBIs are associated with a number of vascular risk factors and are common following invasive cardiovascular procedures such as atrial fibrillation (AF) ablation, coronary artery bypass graft (CABG), and transcatheter aortic valve replacement (TAVR). Although not eliciting signs of clinical stroke, SBIs are associated with increased frailty, and motor and mood features. Less is known, however, about the relationship between SBI, cognition, and delirium following invasive cardiac procedures and most investigations into these relationships have been reported in large-scale epidemiological studies. In the current paper, we conducted a systematic review to evaluate evidence of a relationship between SBI, delirium, and cognitive decline following CABG, AF ablation, and TAVR. Twenty studies met inclusion criteria. In general, our review identified conflicting results for each cardiac procedure, with some studies suggesting a relationship between SBI, cognitive impairment, and delirium, whereas others showed no relationship between SBI, cognitive impairment, and delirium. Potential reasons for this discrepancy as well as suggestions for future research are discussed.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA. .,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA. .,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Amani M Norling
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alexandra Jacob
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ronald M Lazar
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA
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Temperature-controlled high-power short-duration ablation with 90 W for 4 s: outcome, safety, biophysical characteristics and cranial MRI findings in patients undergoing pulmonary vein isolation. J Interv Card Electrophysiol 2022; 65:491-497. [PMID: 35748975 DOI: 10.1007/s10840-022-01146-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/31/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND High-power short-duration (HPSD) radiofrequency ablation (RFA) is highly efficient and safe while reducing procedure and RF time in pulmonary vein isolation (PVI). The QDot™ catheter is a novel contact force ablation catheter that allows automated flow and power adjustments depending on the local tissue temperature to maintain a target temperature during 90 W/4 s lesions. We analysed intraprocedural data and periprocedural safety using the QDot-catheter in patients undergoing PVI for paroxysmal atrial fibrillation (PAF). METHODS We included n = 48 patients undergoing PVI with the QDot-catheter with a temperature-controlled HPSD ablation mode with 90 W/4 s (TC-HPSD). If focal reconnection occurred besides repeat ablation, the ablation mode was changed to 50 W/15 s (QMode). N = 23 patients underwent cerebral MRI to detect silent cerebral lesions. RESULTS Mean RF time was 8.1 ± 2.8 min, and procedure duration was 84.5 ± 30 min. The overall maximal measured catheter tip temperature was 52.0 °C ± 4.6 °C, mean overall applied current was 871 mA ± 44 mA and overall applied energy was 316 J ± 47 J. The mean local impedance drop was 12.1 ± 2.4 Ohms. During adenosine challenge, n = 14 (29%) patients showed dormant conduction. A total of n = 24 steam pops were detected in n = 18 patients (39.1%), while no pericardial tamponade occurred. No periprocedural thromboembolic complications occurred, while n = 4 patients (17.4%) showed silent cerebral lesion. CONCLUSIONS TC-HPSD ablation with 90 W/4 s using the QDot-catheter led to a reduction of procedure and RF time, while no major complications occurred. Despite optimized temperature control and power adjustment, steam pops occurred in a rather high number of patients, while none of them leads to tamponade or to clinical or neurological deficits.
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Innovations in atrial fibrillation ablation. J Interv Card Electrophysiol 2022; 66:737-756. [PMID: 35411440 DOI: 10.1007/s10840-022-01215-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Catheter-based ablation to perform pulmonary vein isolation (PVI) has established itself as a mainstay in the rhythm control strategy of atrial fibrillation. This review article aims to provide an overview of recent advances in atrial fibrillation ablation technology. METHODS We reviewed the available literature and clinical trials of innovations in atrial fibrillation ablation technologies including ablation catheter designs, alternative energy sources, esophageal protection methods, electroanatomical mapping, and novel ablation targets. RESULTS Innovative radiofrequency (RF) catheter designs maximize energy delivery while avoiding overheating associated with conventional catheters. Single-shot balloon catheters in the form of cryoballoons, radiofrequency, and laser balloons have proven effective at producing pulmonary vein isolation and improving procedural efficiency and reproducibility. Pulsed field ablation (PFA) is a highly anticipated novel nonthermal energy source under development, which demonstrates selective ablation of the myocardium, producing durable lesions while also minimizing collateral damage. Innovative devices for esophageal protection including esophageal deviation and cooling devices have been developed to reduce esophageal complications. Improved electroanatomical mapping systems are being developed to help identify additional non-pulmonary triggers, which may benefit from ablation, especially with persistent atrial fibrillation. Lastly, the vein of Marshall alcohol ablation has been recently studied as an adjunct therapy for improving outcomes with catheter ablation for persistent atrial fibrillation. CONCLUSIONS Numerous advances have been made in the field of atrial fibrillation ablation in the past decade. While further long-term data is still needed for these novel technologies, they show potential to improve procedural efficacy and safety.
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Rivard L, Friberg L, Conen D, Healey JS, Berge T, Boriani G, Brandes A, Calkins H, Camm AJ, Yee Chen L, Lluis Clua Espuny J, Collins R, Connolly S, Dagres N, Elkind MSV, Engdahl J, Field TS, Gersh BJ, Glotzer TV, Hankey GJ, Harbison JA, Haeusler KG, Hills MT, Johnson LSB, Joung B, Khairy P, Kirchhof P, Krieger D, Lip GYH, Løchen ML, Madhavan M, Mairesse GH, Montaner J, Ntaios G, Quinn TJ, Rienstra M, Rosenqvist M, Sandhu RK, Smyth B, Schnabel RB, Stavrakis S, Themistoclakis S, Van Gelder IC, Wang JG, Freedman B. Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration. Circulation 2022; 145:392-409. [PMID: 35100023 DOI: 10.1161/circulationaha.121.055018] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.
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Affiliation(s)
- Léna Rivard
- Montreal Heart Institute, Université de Montréal, Canada (L.R., P. Khairy)
| | - Leif Friberg
- Karolinska Institute, Stockholm, Sweden (L.F., M.R.)
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (D.C., J.S.H., S.C.)
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (D.C., J.S.H., S.C.)
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy (G.B.)
| | | | | | - A John Camm
- Cardiovascular Clinical Academic Group, St Georges Hospital, London, UK (A.J.C.)
| | | | | | | | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (D.C., J.S.H., S.C.)
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Germany (N.D.)
| | | | - Johan Engdahl
- Karolinska Institutet, Department of Clinical Sciences, Danderyds Hospital, Stockholm, Sweden (J.E.)
| | - Thalia S Field
- University of British Columbia, Vancouver Stroke Program, Canada (T.S.F.)
| | | | | | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia (G.J.H.)
| | | | - Karl G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Germany (K.G.H.)
| | | | | | - Boyoung Joung
- Yonsei University College of Medicine, Seoul, South Korea (B.J.)
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Canada (L.R., P. Khairy)
| | - Paulus Kirchhof
- University Heart and Vascular Center UKE Hamburg, Germany (P. Kirchhof)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany (P. Kirchhof)
- Institute of Cardiovascular Sciences, University of Birmingham, UK, and AFNET, Münster, Germany (P. Kirchhof)
| | - Derk Krieger
- University Hospital of Zurich, Switzerland (D.K.)
| | | | - Maja-Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø (M.L.L.)
| | - Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.M.)
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain (J.M.)
- Stroke Research Program, Institute of Biomedicine of Seville, Spain (J.M.)
- IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Spain (J.M.)
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain (J.M.)
| | | | | | - Michiel Rienstra
- Karolinska Institute, Stockholm, Sweden (L.F., M.R.)
- University of Groningen, University Medical Center Groningen, the Netherlands (M.R., I.C.V.G.)
| | | | | | - Breda Smyth
- Department of Public Health, Health Service Executive West, Galway, Ireland (B.S.)
| | | | | | | | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, the Netherlands (M.R., I.C.V.G.)
| | - Ji-Guang Wang
- Jiaotong University School of Medicine, China (J.G.W.)
| | - Ben Freedman
- Charles Perkins Centre and Concord Hospital Cardiology, University of Sydney, Australia (B.F.)
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Tokuda M, Yamashita S, Kato M, Sato H, Oseto H, Yokoyama M, Tokutake K, Narui R, Yoshimura M, Yamane T. Cerebral Embolism During Catheter Ablation of Atrial Fibrillation Using Radiofrequency Catheter, Cryoballoon, Hotballoon, or Laserballoon. JACC Clin Electrophysiol 2022; 8:255-257. [PMID: 35210086 DOI: 10.1016/j.jacep.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022]
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The AF-FICIENT magnetic resonance imaging and endoscopy safety substudy: A visually guided radiofrequency balloon ablation catheter for pulmonary vein isolation. Heart Rhythm O2 2021; 3:15-22. [PMID: 35243431 PMCID: PMC8859808 DOI: 10.1016/j.hroo.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Early experience with a novel multielectrode saline-irrigated radiofrequency balloon (RFB) catheter with an integrated camera system found that it was safe and effective in performing single-shot pulmonary vein isolation (PVI) for atrial fibrillation. Objective The purpose of this study was to further assess potential treatment risks by looking for subclinical events. Methods The study was performed at 2 sites. Patients underwent PVI by RFB. A control group underwent conventional point-by-point radiofrequency ablation. Stroke scale questionnaire and brain magnetic resonance imaging (MRI) were performed before and after the ablation procedure, and esophageal endoscopy was performed after the procedure in RFB patients only. Results We enrolled 27 patients in the RFB group and 15 patients in the control group. The RFB and control groups were well matched [predominantly male: 62% vs 53%; CHA2DS2-VASc score: 1.9 ± 1.3 vs 1.5 ± 1.6; mean age 60 years in both groups]. All patients underwent successful ablation and completed study assessments. Clinically silent, new MRI diffusion weighted imaging cerebral lesions were observed in 8 patients (30%) in the RFB group and 1 patient (7%) in the control group, and 11 susceptibility weighted imaging lesions in the RFB group and 1 in the control group. Endoscopy showed a minor thermal injury in 1 patient in the RFB group. Conclusion An increased rate of clinically silent cerebral events was seen in the RFB group. A low rate of esophageal thermal injury was observed.
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Bawazeer GA, Alkofide HA, Alsharafi AA, Babakr NO, Altorkistani AM, Kashour TS, Miligkos M, AlFaleh KM, Al-Ansary LA. Interrupted versus uninterrupted anticoagulation therapy for catheter ablation in adults with arrhythmias. Cochrane Database Syst Rev 2021; 10:CD013504. [PMID: 34674223 PMCID: PMC8530018 DOI: 10.1002/14651858.cd013504.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The management of anticoagulation therapy around the time of catheter ablation (CA) procedure for adults with arrhythmia is critical and yet is variable in clinical practice. The ideal approach for safe and effective perioperative management should balance the risk of bleeding during uninterrupted anticoagulation while minimising the risk of thromboembolic events with interrupted therapy. OBJECTIVES To compare the efficacy and harms of interrupted versus uninterrupted anticoagulation therapy for catheter ablation (CA) in adults with arrhythmias. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and SCI-Expanded on the Web of Science for randomised controlled trials on 5 January 2021. We also searched three registers on 29 May 2021 to identify ongoing or unpublished trials. We performed backward and forward searches on reference lists of included trials and other systematic reviews and contacted experts in the field. We applied no restrictions on language or publication status. SELECTION CRITERIA We included randomised controlled trials comparing uninterrupted anticoagulation with any modality of interruption with or without heparin bridging for CA in adults aged 18 years or older with arrhythmia. DATA COLLECTION AND ANALYSIS Two review authors conducted independent screening, data extraction, and assessment of risk of bias. A third review author resolved disagreements. We extracted data on study population, interruption strategy, ablation procedure, thromboembolic events (stroke or systemic embolism), major and minor bleeding, asymptomatic thromboembolic events, cardiovascular and all-cause mortality, quality of life (QoL), length of hospital stay, cost, and source of funding. We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We identified 12 studies (4714 participants) that compared uninterrupted periprocedural anticoagulation with interrupted anticoagulation. Studies performed an interruption strategy by either a complete interruption (one study) or by a minimal interruption (11 studies), of which a single-dose skipped strategy was used (nine studies) or two-dose skipped strategy (two studies), with or without heparin bridging. Studies included participants with a mean age of 65 years or greater, with only two studies conducted in relatively younger individuals (mean age less than 60 years). Paroxysmal atrial fibrillation (AF) was the primary type of AF in all studies, and seven studies included other types of AF (persistent and long-standing persistent). Most participants had CHADS2 or CHADS2-VASc demonstrating a low-moderate risk of stroke, with almost all participants having normal or mildly reduced renal function. Ablation source using radiofrequency energy was the most common (seven studies). Ten studies (2835 participants) were conducted in East Asian countries (Japan, China, and South Korea), while the remaining two studies were conducted in the USA. Eight studies were conducted in a single centre. Postablation follow-up was variable among studies at less than 30 days (three studies), 30 days (six studies), and more than 30 days postablation (three studies). Overall, the meta-analysis showed high uncertainty of the effect between the interrupted strategy compared to uninterrupted strategy on the primary outcomes of thromboembolic events (risk ratio (RR) 1.76, 95% confidence interval (CI) 0.33 to 9.46; I2 = 59%; 6 studies, 3468 participants; very low-certainty evidence). However, subgroup analysis showed that uninterrupted vitamin A antagonist (VKA) is associated with a lower risk of thromboembolic events without increasing the risk of bleeding. There is also uncertainty on the outcome of major bleeding events (RR 1.10, 95% CI 0.59 to 2.05; I2 = 6%; 10 studies, 4584 participants; low-certainty evidence). The uncertainty was also evident for the secondary outcomes of minor bleeding (RR 1.01, 95% CI 0.46 to 2.22; I2 = 87%; 9 studies, 3843 participants; very low-certainty evidence), all-cause mortality (RR 0.34, 95% CI 0.01 to 8.21; 442 participants; low-certainty evidence) and asymptomatic thromboembolic events (RR 1.45, 95% CI 0.85 to 2.47; I2 = 56%; 6 studies, 1268 participants; very low-certainty evidence). There was a lower risk of the composite endpoint of thromboembolic events (stroke, systemic embolism, major bleeding, and all-cause mortality) in the interrupted compared to uninterrupted arm (RR 0.23, 95% CI 0.07 to 0.81; 1 study, 442 participants; low-certainty evidence). In general, the low event rates, different comparator anticoagulants, and use of different ablation procedures may be the cause of imprecision and heterogeneity observed. AUTHORS' CONCLUSIONS This meta-analysis showed that the evidence is uncertain to inform the decision to either interrupt or continue anticoagulation therapy around CA procedure in adults with arrhythmia on outcomes of thromboembolic events, major and minor bleeding, all-cause mortality, asymptomatic thromboembolic events, and a composite endpoint of thromboembolic events (stroke, systemic embolism, major bleeding, and all-cause mortality). Most studies in the review adopted a minimal interruption strategy which has the advantage of reducing the risk of bleeding while maintaining a lower level of anticoagulation to prevent periprocedural thromboembolism, hence low event rates on the primary outcomes of thromboembolism and bleeding. The one study that adopted a complete interruption of VKA showed that uninterrupted VKA reduces the risk of thromboembolism without increasing the risk of bleeding. Hence, future trials with larger samples, tailored to a more generalisable population and using homogeneous periprocedural anticoagulant therapy and ablation source are required to address the safety and efficacy of the optimal management of anticoagulant therapy prior to ablation.
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Affiliation(s)
- Ghada A Bawazeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hadeel A Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Aya A Alsharafi
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nada O Babakr
- College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | | | - Tarek S Kashour
- Department of Cardiology, King Saud University, Riyadh, Saudi Arabia
| | - Michael Miligkos
- Department of Biomathematics, Medical School, University of Thessaly, Larissa, Greece
| | - Khalid M AlFaleh
- Department of Pediatrics (Division of Neonatology), King Saud University, Riyadh, Saudi Arabia
| | - Lubna A Al-Ansary
- Department of Family and Community Medicine, King Saud University, Riyadh, Saudi Arabia
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Kim D, Yang PS, Joung B. Lower dementia risk with anticoagulation and ablation in patients with atrial fibrillation. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2021. [DOI: 10.1186/s42444-021-00044-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2023] Open
Abstract
AbstractAtrial fibrillation (AF), the most common cardiac arrhythmia in the elderly population, has been associated with an impairment of cognitive function and an increased risk of dementia. Even though there does not appear to be solid evidence that any specific treatment prevents or delays AF-associated cognitive decline, evidence is accumulating regarding the possible treatment strategies for preventing dementia. Oral anticoagulation, especially non-vitamin K antagonist oral anticoagulants rather than warfarin use, has been suggested to be associated with reduced risk of dementia. Successfully maintaining sinus rhythm using catheter ablation might be also helpful in preventing subsequent dementia in patients with AF. In this review, we critically appraise the proposed treatment strategies for preventing AF-associated cognitive decline.
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A Little Help From Our Neighbors to the North: Stroke Reduction After Catheter Ablation of Ventricular Tachycardia. JACC Clin Electrophysiol 2021; 7:1502-1504. [PMID: 34393086 DOI: 10.1016/j.jacep.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/20/2022]
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Groen MHA, van Es R, van Klarenbosch BR, Stehouwer M, Loh P, Doevendans PA, Wittkampf FH, Neven K. In vivo analysis of the origin and characteristics of gaseous microemboli during catheter-mediated irreversible electroporation. Europace 2021; 23:139-146. [PMID: 33111141 PMCID: PMC7842095 DOI: 10.1093/europace/euaa243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/27/2020] [Indexed: 01/21/2023] Open
Abstract
Aims Irreversible electroporation (IRE) ablation is a non-thermal ablation method based on the application of direct current between a multi-electrode catheter and skin electrode. The delivery of current through blood leads to electrolysis. Some studies suggest that gaseous (micro)emboli might be associated with myocardial damage and/or (a)symptomatic cerebral ischaemic events. The aim of this study was to compare the amount of gas generated during IRE ablation and during radiofrequency (RF) ablation. Methods and results In six 60–75 kg pigs, an extracorporeal femoral shunt was outfitted with a bubble-counter to detect the size and total volume of gas bubbles. Anodal and cathodal 200 J IRE applications were delivered in the left atrium (LA) using a 14-electrode circular catheter. The 30 and 60 s 40 W RF point-by-point ablations were performed. Using transoesophageal echocardiography (TOE), gas formation was visualized. Average gas volumes were 0.6 ± 0.6 and 56.9 ± 19.1 μL (P < 0.01) for each anodal and cathodal IRE application, respectively. Also, qualitative TOE imaging showed significantly less LA bubble contrast with anodal than with cathodal applications. Radiofrequency ablations produced 1.7 ± 2.9 and 6.7 ± 7.4 μL of gas, for 30 and 60 s ablation time, respectively. Conclusion Anodal IRE applications result in significantly less gas formation than both cathodal IRE applications and RF applications. This finding is supported by TOE observations.
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Affiliation(s)
- Marijn H A Groen
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - René van Es
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bas R van Klarenbosch
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Marco Stehouwer
- Department of Extracorporeal Circulation, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Loh
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Fred H Wittkampf
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Kars Neven
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany.,Faculty of Health, Witten/Herdecke University, Witten, Germany
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Incidence and risk factors of post-operative cognitive decline after ablation for atrial fibrillation. BMC Cardiovasc Disord 2021; 21:341. [PMID: 34261448 PMCID: PMC8278748 DOI: 10.1186/s12872-021-02139-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/24/2021] [Indexed: 12/05/2022] Open
Abstract
Background Catheter ablation is widely used in atrial fibrillation (AF) management. In this study, we are aimed to investigate the incidence of postprocedural cognitive decline in a larger population undergoing AF ablation under local anesthesia, and to evaluate the associated risk factors. Methods This study included 287 patients with normal cognitive functions, with 190 ablated AF patients (study group) and 97 AF patients who are awaiting ablation (practice group). We assessed the neuropsychological function of each patient for twice (study group: 24 h prior to ablation and 48 h post ablation; practice group: on the day of inclusion and 72 h later but before ablation). The reliable change index was used to analyze the neuropsychological testing scores and to identify postoperative cognitive dysfunction (POCD) at 48 h post procedure. Patients in the study group accepting a 6-month follow up were given an extra cognitive assessment. Results Among the ablated AF patients, 13.7% (26/190) had POCD at 48 h after the ablation procedure. Multivariable analysis revealed that, a minimum intraoperative activated clotting time (ACT) < 300 s (OR 3.82, 95% CI 1.48–9.96, P = 0.006) and not taking oral anticoagulants within one month prior to ablation(OR 10.35, 95% CI 3.54–30.27, P < 0.001) were significantly related to POCD at 48 h post-ablation. In 172 patients of the study group accepting a 6-month follow up, there were 23 patients with POCD at 48 h post-ablation and 149 patients without POCD. The global cognitive scores were decreased in 48 h post-operation tests (0 ± 1 vs − 0.15 ± 1.10, P < 0.001) and improved significantly at 6 months post-operation (0 ± 1 vs 0.43 ± 0.92, P < 0.001). In the 23 patients with POCD at 48 h after the procedure, global cognitive performance at 6 months was not significantly different compared with that at baseline (− 0.05 ± 1.25 vs − 0.19 ± 1.33, P = 0.32), while 13 of them had higher scores than baseline level. Conclusions Incident of POCD after ablation procedures is high in the short term. Inadequate periprocedural anticoagulation are possible risk factors. However, most POCD are reversible at 6 months, and a general improvement was observed in cognitive function at 6 months after ablation.
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Kim D, Yang PS, Sung JH, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Pak HN, Lee MH, Lip GYH, Joung B. Less dementia after catheter ablation for atrial fibrillation: a nationwide cohort study. Eur Heart J 2021; 41:4483-4493. [PMID: 33022705 DOI: 10.1093/eurheartj/ehaa726] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/14/2020] [Accepted: 08/21/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Accumulating evidence shows that atrial fibrillation (AF) is associated with an increased risk of dementia. Catheter ablation for AF prolongs the duration of sinus rhythm, thereby improving the quality of life. We investigated the association of catheter ablation for AF with the occurrence of dementia. METHODS AND RESULTS Using the Korean National Health Insurance Service database, among 194 928 adults with AF treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between 1 January 2005 and 31 December 2015, we studied 9119 patients undergoing ablation and 17 978 patients managed with medical therapy. The time-at-risk was counted from the first medical therapy, and ablation was analysed as a time-varying exposure. Propensity score-matching was used to correct for differences between the groups. During a median follow-up of 52 months, compared with patients with medical therapy, ablated patients showed lower incidence and risk of overall dementia (8.1 and 5.6 per 1000 person-years, respectively; hazard ratio 0.73, 95% confidence interval 0.58-0.93). The associations between ablation and dementia risk were consistently observed after additionally censoring for incident stroke (hazard ratio 0.76, 95% confidence interval 0.61-0.95) and more pronounced in cases of ablation success whereas no significant differences observed in cases of ablation failure. Ablation was associated with lower risks of dementia subtypes including Alzheimer's disease and vascular dementia. CONCLUSION In this nationwide cohort of AF patients treated with catheter ablation or medical therapy, ablation was associated with decreased dementia risk. This relationship was evident after censoring for stroke and adjusting for clinical confounders.
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Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13496, Republic of Korea
| | - Jung-Hoon Sung
- Department of Cardiology, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13496, Republic of Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jong-Youn Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
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Brockmeyer M, Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Heinen Y, Bejinariu A, Müller P, Makimoto H, Kelm M, Wolff G. Uninterrupted anticoagulation during catheter ablation for atrial fibrillation: no difference in major bleeding and stroke between direct oral anticoagulants and vitamin K antagonists in an updated meta-analysis of randomised controlled trials. Acta Cardiol 2021; 76:288-295. [PMID: 32056498 DOI: 10.1080/00015385.2020.1724689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Periprocedural uninterrupted anticoagulation for catheter ablation of atrial fibrillation (AF) became standard after positive results of vitamin K antagonist (VKA) trials. Previous studies of uninterrupted direct oral anticoagulants (DOACs) vs. VKA have given controversial results. We thus aimed to elucidate the risk/benefit ratio of uninterrupted DOAC vs. VKA during catheter ablation of AF in an updated meta-analysis of randomised controlled trials (RCTs). METHODS Online databases were searched for RCTs comparing uninterrupted DOAC to VKA in patients undergoing catheter ablation of AF. Data from retrieved studies were analysed in a comprehensive meta-analysis. Primary safety outcome was major bleeding; primary efficacy outcome was stroke or transient ischaemic attack (TIA). Secondary outcomes included a composite of major bleeding and stroke or TIA, minor bleeding, acute cerebral lesions on magnetic resonance imaging (MRI), and mortality. RESULTS Six eligible RCTs comprising 2,369 patients were included. There were no significant differences in DOAC vs. VKA concerning the rates of major bleeding (2.2% vs. 3.8%; odds ratio (OR) 0.69, 95% confidence interval (CI) 0.30-1.56; p = .37) and stroke or TIA (0.2% vs. 0.2%; OR 0.97, CI 0.20-4.72; p = .97). Pooled meta-analysis of secondary outcomes revealed no significant differences (OR 0.73, p = .49 for composite of major bleeding and stroke or TIA; OR 1.08, p = .52 for minor bleeding; OR 1.12, p = .59 for acute cerebral lesions on MRI; and OR 0.60, p = .64 for all-cause mortality). CONCLUSION Our meta-analysis suggests that uninterrupted DOAC is not superior to VKA in patients undergoing catheter ablation of AF with comparable rates of major bleeding and stroke.
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Affiliation(s)
- Maximilian Brockmeyer
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Claudio Parco
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Alexandru Bejinariu
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Patrick Müller
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hisaki Makimoto
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
- CARID – Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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Abstract
PURPOSE OF REVIEW Pulsed field ablation is a nonthermal ablative modality that uses short living, strong electrical field created around catheter to create microscopic pores in cell membranes (electroporation). When adequately dosed/configured it shows a preference for myocardial tissue necrosis. Thus, it holds a promise to become a 'perfect' energy source for cardiac ablation to treat arrhythmias. Herein, we present update on platforms in clinical development. RECENT FINDINGS First in human series using pulsed field ablation for atrial fibrillation ablation have been completed and data published for several platforms. Acute safety outcomes are similar across the platforms with exceptionally low rate of those complications that are typically reported for thermal ablation methods (esophageal injury, pulmonary vein stenosis, phrenic nerve palsy). Promising acute data on pulmonary vein isolation had been corroborated with satisfactory 1-year clinical follow-up for a single platform, whereas reports are pending for the rest. Research efforts are being expanded to a development of focal catheters, and therefore, pulsed field ablation application for ventricular arrhythmias. SUMMARY As the reports confirming its safety and efficacy build up, there seems to be no way that the promise of pulsed field ablation could end in a blind alley.
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Basu‐Ray I, Khanra D, Kupó P, Bunch J, Theus SA, Mukherjee A, Shah SK, Komócsi A, Adeboye A, Jefferies J. Outcomes of uninterrupted vs interrupted Periprocedural direct oral Anticoagulants in atrial Fibrillation ablation: A meta-analysis. J Arrhythm 2021; 37:384-393. [PMID: 33850580 PMCID: PMC8021981 DOI: 10.1002/joa3.12507] [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] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/27/2020] [Accepted: 01/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Studies indicate that uninterrupted anticoagulation (UA) is superior to interrupted anticoagulation (IA) in the periprocedural period during catheter ablation of atrial fibrillation. Still IA is followed in many centers considering the bleeding risk. This meta-analysis compares interrupted and uninterrupted direct oral anticoagulation during catheter ablation of atrial fibrillation. METHODS A systematic search into PubMed, EMBASE, and the Cochrane databases was performed and five studies were selected that directly compared IA vs UA before ablation and reported procedural outcomes, embolic, and bleeding events. The primary outcome of the study was major adverse cerebro-cardiovascular events. RESULTS The meta-analysis included 840 patients with UA and 938 patients with IA. Median follow-up was 30 days. Activated clotting time (ACT) before first heparin bolus was significantly longer with UA (P = .006), whereas mean ACT was similar between the two groups (P = .19). Total heparin dose needed was significantly higher with IA (mean, ‒1.61; 95% CI, ‒2.67 to ‒0.55; P = .003). Mean procedure time did not vary between groups (P = .81). Overall complication rates were low, with similar major adverse cerebro-cardiovascular event (P = .40) and total bleeding (P = .55) rates between groups. Silent cerebral events (SCEs) were significantly more frequent with IA (log odds ratio, ‒0.90; 95% CI, ‒1.59 to ‒0.22; P < .01; I 2, 33%). Rates of major bleeding, minor bleeding, pericardial effusion, cardiac tamponade, and puncture complications were similar between groups. CONCLUSIONS UA during atrial fibrillation ablation has similar bleeding event rates, procedural times, and mean ACTs as IA, with fewer SCEs.
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Affiliation(s)
- Indranill Basu‐Ray
- Department of CardiologyMemphis VA Medical CenterMemphisTNUSA
- The University of Tennessee Health Science CenterMemphisTNUSA
- All India Institute of Medical SciencesRishikeshIndia
| | | | | | - Jared Bunch
- Intermountain Heart InstituteIntermountain Medical CenterMurrayUTUSA
| | | | | | - Sumit K. Shah
- University of Arkansas for Medical SciencesLittle RockARUSA
| | | | - Adedayo Adeboye
- The University of Tennessee Health Science CenterMemphisTNUSA
| | - John Jefferies
- The University of Tennessee Health Science CenterMemphisTNUSA
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Absence of (sub-)acute cerebral events or lesions after electroporation ablation in the left-sided canine heart. Heart Rhythm 2021; 18:1004-1011. [PMID: 33617997 DOI: 10.1016/j.hrthm.2021.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/03/2021] [Accepted: 02/12/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Irreversible electroporation (IRE) is a nonthermal ablation modality. A 200-J application can create deep myocardial lesions, but gas bubbles are created at the ablation electrode. Cerebral effects of these bubbles are unknown. OBJECTIVE The purpose of this study was to investigate gas microemboli-induced brain lesions after IRE and radiofrequency (RF) ablation to the left side of the canine heart, using magnetic resonance imaging (MRI) and histopathology. METHODS In 11 canines, baseline cerebral MRI scans were performed. In 9 animals, after retrograde femoral artery access, 12 ± 4 200-J IRE applications were administered in the ascending aorta. In 2 animals, 30 minutes of irrigated 30-W RF ablation using 10-30g of contact force was applied in the left ventricle. At days 1 and 5 after ablation, MRI was repeated. The brain tissue then was histopathologically examined. RESULTS All ablations and follow-up were uneventful. Intracardiac echography confirmed gas bubble formation after each IRE application. Neurologic examination was normal. MRI scans were normal in all animals at day 1 and were normal in 10 of 11 animals at day 5. In 1 animal, a single <2-mm-diameter lesion in the right temporal region could not be excluded as a small infarct or early hemorrhagic site. Histopathologic analysis of the same region showed no pathologic changes. In all other animals, gross and microscopic pathology were normal. CONCLUSION MRI images alone or in combination with histologic follow-up did not reveal treatment-related embolic events. Gross and microscopic pathology did not reveal evidence of treatment-related embolic events. IRE seems to be a safe ablation modality for the brain.
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Jia Q, Han W, Shi S, Hu Y. The effects of ACEI/ARB, aldosterone receptor antagonists and statins on preventing recurrence of atrial fibrillation: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2021; 100:e24280. [PMID: 33429839 PMCID: PMC7793435 DOI: 10.1097/md.0000000000024280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/21/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is one of the most common arrhythmias, and is high relative to cardiovascular morbidity and mortality. AF-related complications and treatment costs bring about huge health burden, therefore the prevention recurrence of AF is imperative. "Upstream therapy" refers to the use of non-antiarrhythmic drugs (non-AADs) that modify the atrial substrate or target-specific mechanisms of AF to prevent the occurrence or recurrence of the arrhythmia. RAAS Blockers, aldosterone receptor antagonists and statins have an effect on preventing recurrence of atrial fibrillation. This protocol is designed for systematic review and network meta-analysis, which will assess comparative effects and safety of various non-antiarrhythmic drugs in preventing recurrence of atrial fibrillation. METHODS The Cochrane Library, MEDLINE, EMBASE, ClinicalTrials.gov will be searched from inception to Aug 31, 2020 to identify relevant studies. The Cochrane "Risk of bias" tool will be used to assess the methodological quality of eligible studies. The pair-wise meta-analysis will be performed by STATA 14.0 software. The network meta-analysis will be implemented in a Bayesian framework using Win BUGS 1.4.3 and the package "gemtc" V.0.8.1 of R-3.6.2 software. The network plots will be drawn using STATA 14.0 software. A comparison-adjusted funnel plot will be used to assess the publication bias using STATA 14.0 software. Quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS The results of this network meta-analysis will determine the preventive effect and rank ordering of these interventions for recurrence of AF. The report will follow the PRISMA checklist for network meta-analysis. CONCLUSION This network meta-analysis will provide comprehensive evidence-based information in clinical practice. INPLASY REGISTRATION NUMBER INPLASY202090004.
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Affiliation(s)
- Qiulei Jia
- Department of Cardiovascular, Guang’anmen Hospital, China Academy of Chinese Medical Sciences
| | - Wenbing Han
- Emergency Department, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shuqing Shi
- Department of Cardiovascular, Guang’anmen Hospital, China Academy of Chinese Medical Sciences
| | - Yuanhui Hu
- Department of Cardiovascular, Guang’anmen Hospital, China Academy of Chinese Medical Sciences
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Kim D, Yang PS, Joung B. Prevention of Dementia in Patients with Atrial Fibrillation. Korean Circ J 2021; 51:308-319. [PMID: 33821580 PMCID: PMC8022029 DOI: 10.4070/kcj.2021.0027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) has been associated with an increased risk of dementia. Although there does not appear to be solid evidence that any specific treatment prevents or delays AF-associated cognitive decline, evidence is accumulating regarding the possible treatment strategies for preventing dementia. In this review, we summarize the evidence linking AF to dementia and critically appraise the proposed treatment strategies. Atrial fibrillation (AF) is the most common form of arrhythmia in the elderly population and increases stroke risk by a factor of 4- to 5-fold. There is increasing evidence to suggest that incident AF may contribute to the development of dementia, independent of overt stroke. In particular, relatively younger patients with AF are more prone to dementia development than older patients with AF. Evidence is accumulating regarding the possible treatment strategies for preventing dementia in patients with AF. Oral anticoagulation may be effective for reducing the risk of dementia, even in patients with low stroke risks. Among oral anticoagulants, the use of non-vitamin K antagonists have been associated with a considerably decreased risk of dementia than warfarin. Moreover, successful catheter ablation for AF has also been associated with decreased dementia risk compared to medical therapy, suggesting that restoration of sinus rhythm, and not the ablation procedure itself, as the important mechanism in the prevention of AF-associated dementia. Among midlife patients with AF, there appeared to be a U-shaped association of blood pressure (BP) and a linear association of hypertension with dementia risk. A BP of 120 to 129/80 to 84 mmHg has been identified as the optimal range. Finally, integrated management of AF was associated with a reduced risk of dementia in AF patients.
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Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Pil Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Koh CH. Commercial Air Travel for Passengers With Cardiovascular Disease: Recommendations for Common Conditions. Curr Probl Cardiol 2020; 46:100768. [PMID: 33348221 DOI: 10.1016/j.cpcardiol.2020.100768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022]
Abstract
The exponential growth of commercial flights has resulted in an explosion of air travelers over the last few decades, including passengers with a wide range of cardiovascular conditions. Notwithstanding the ongoing COVID-19 pandemic that had set back the aviation industry for the next 1-2 years, air travel is expected to rebound fully by 2024. Guidelines and evidence-based recommendations for safe air travel in this group vary, and physicians often encounter situations where opinions and assessments on fitness for flights are sought. This article aims to provide an updated suite of recommendations for the aeromedical disposition of passenger with common cardiovascular conditions, such as ischemic heart disease, congestive heart failure, valvular heart disease, cardiomyopathies, and common arrhythmias.
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Affiliation(s)
- Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore; Changi Aviation Medical Centre, Changi General Hospital, Singapore.
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Nakamura K, Sasaki T, Take Y, Minami K, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Effect of preventing air intrusion on silent strokes during atrial fibrillation ablation using a mini-basket catheter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:71-81. [PMID: 33216388 DOI: 10.1111/pace.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Rostock T, Konrad T, Spittler R. Underrecognized consequence of three-dimensional mapping tool selection for atrial fibrillation ablation: When the operators' decision determines the amount of silent micro-embolic burden. J Cardiovasc Electrophysiol 2020; 32:27-28. [PMID: 33141459 DOI: 10.1111/jce.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Thomas Rostock
- Center for Cardiology, Cardiology II/Electrophysiology, University Hospital Mainz, Mainz, Germany
| | - Torsten Konrad
- Center for Cardiology, Cardiology II/Electrophysiology, University Hospital Mainz, Mainz, Germany
| | - Raphael Spittler
- Center for Cardiology, Cardiology II/Electrophysiology, University Hospital Mainz, Mainz, Germany
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Nakamura K, Sasaki T, Take Y, Minami K, Inoue M, Asahina C, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Motoda H, Niijima K, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation. J Cardiovasc Electrophysiol 2020; 32:16-26. [PMID: 33141496 DOI: 10.1111/jce.14800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/24/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Chisa Asahina
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
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