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Baykaner T, Fazal M, Patel S, Zaman J. Is there rule to the chaos: Defining stable patterns in atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2404-2407. [PMID: 34260124 DOI: 10.1111/jce.15169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tina Baykaner
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Muhammad Fazal
- Department of Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Sagar Patel
- Department of Cardiovascular Medicine, University of Southern California, Los Angeles, California, USA
| | - Junaid Zaman
- Department of Cardiovascular Medicine, University of Southern California, Los Angeles, California, USA
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2
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Ali RL, Hakim JB, Boyle PM, Zahid S, Sivasambu B, Marine JE, Calkins H, Trayanova NA, Spragg DD. Arrhythmogenic propensity of the fibrotic substrate after atrial fibrillation ablation: a longitudinal study using magnetic resonance imaging-based atrial models. Cardiovasc Res 2020; 115:1757-1765. [PMID: 30977811 DOI: 10.1093/cvr/cvz083] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/31/2019] [Accepted: 04/08/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS Inadequate modification of the atrial fibrotic substrate necessary to sustain re-entrant drivers (RDs) may explain atrial fibrillation (AF) recurrence following failed pulmonary vein isolation (PVI). Personalized computational models of the fibrotic atrial substrate derived from late gadolinium enhanced (LGE)-magnetic resonance imaging (MRI) can be used to non-invasively determine the presence of RDs. The objective of this study is to assess the changes of the arrhythmogenic propensity of the fibrotic substrate after PVI. METHODS AND RESULTS Pre- and post-ablation individualized left atrial models were constructed from 12 AF patients who underwent pre- and post-PVI LGE-MRI, in six of whom PVI failed. Pre-ablation AF sustained by RDs was induced in 10 models. RDs in the post-ablation models were classified as either preserved or emergent. Pre-ablation models derived from patients for whom the procedure failed exhibited a higher number of RDs and larger areas defined as promoting RD formation when compared with atrial models from patients who had successful ablation, 2.6 ± 0.9 vs. 1.8 ± 0.2 and 18.9 ± 1.6% vs. 13.8 ± 1.5%, respectively. In cases of successful ablation, PVI eliminated completely the RDs sustaining AF. Preserved RDs unaffected by ablation were documented only in post-ablation models of patients who experienced recurrent AF (2/5 models); all of these models had also one or more emergent RDs at locations distinct from those of pre-ablation RDs. Emergent RDs occurred in regions that had the same characteristics of the fibrosis spatial distribution (entropy and density) as regions that harboured RDs in pre-ablation models. CONCLUSION Recurrent AF after PVI in the fibrotic atria may be attributable to both preserved RDs that sustain AF pre- and post-ablation, and the emergence of new RDs following ablation. The same levels of fibrosis entropy and density underlie the pro-RD propensity in both pre- and post-ablation substrates.
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Affiliation(s)
- Rheeda L Ali
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Joe B Hakim
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Patrick M Boyle
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Sohail Zahid
- Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA
| | - Bhradeev Sivasambu
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph E Marine
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Natalia A Trayanova
- Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Biomedical Engineering, Johns Hopkins University, 3400 N Charles Street, 208 Hackerman, Baltimore, MD, USA.,Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - David D Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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Computationally guided personalized targeted ablation of persistent atrial fibrillation. Nat Biomed Eng 2019; 3:870-879. [PMID: 31427780 PMCID: PMC6842421 DOI: 10.1038/s41551-019-0437-9] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 07/03/2019] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) — the most common arrhythmia — significantly increases the risk of stroke and heart failure. Although catheter ablation can restore normal heart rhythms, patients with persistent AF who develop atrial fibrosis often undergo multiple failed ablations and thus increased procedural risks. Here, we present personalized computational modelling for the reliable predetermination of ablation targets, which are then used to guide the ablation procedure in patients with persistent AF and atrial fibrosis. We first show that a computational model of the atria of patients identifies fibrotic tissue that if ablated will not sustain AF. We then integrated the target-ablation sites in a clinical-mapping system, and tested its feasibility in 10 patients with persistent AF. The computational prediction of ablation targets avoids lengthy electrical mapping and could improve the accuracy and efficacy of targeted AF ablation in patients whilst eliminating the need for repeat procedures.
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4
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Quintanilla JG, Alfonso-Almazán JM, Pérez-Castellano N, Pandit SV, Jalife J, Pérez-Villacastín J, Filgueiras-Rama D. Instantaneous Amplitude and Frequency Modulations Detect the Footprint of Rotational Activity and Reveal Stable Driver Regions as Targets for Persistent Atrial Fibrillation Ablation. Circ Res 2019; 125:609-627. [PMID: 31366278 PMCID: PMC6735936 DOI: 10.1161/circresaha.119.314930] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
RATIONALE Costly proprietary panoramic multielectrode (64-256) acquisition systems are being increasingly used together with conventional electroanatomical mapping systems for persistent atrial fibrillation (PersAF) ablation. However, such approaches target alleged drivers (rotational/focal) regardless of their activation frequency dynamics. OBJECTIVES To test the hypothesis that stable regions of higher than surrounding instantaneous frequency modulation (iFM) drive PersAF and determine whether rotational activity is specific for such regions. METHODS AND RESULTS First, novel single-signal algorithms based on instantaneous amplitude modulation (iAM) and iFM to detect rotational-footprints without panoramic multielectrode acquisition systems were tested in 125 optical movies from 5 ex vivo Langendorff-perfused PersAF sheep hearts (sensitivity/specificity, 92.6/97.5%; accuracy, 2.5-mm) and in computer simulations. Then, 16 pigs underwent high-rate atrial pacing to develop PersAF. After a median (interquartile range [IQR]) of 4.4 (IQR, 2.5-9.9) months of high-rate atrial pacing followed by 4.1 (IQR, 2.7-5.4) months of self-sustained PersAF, pigs underwent in vivo high-density electroanatomical atrial mapping (4920 [IQR, 4435-5855] 8-second unipolar signals per map). The first 4 out of 16 pigs were used to adapt ex vivo optical proccessing of iFM/iAM to in vivo electrical signals. In the remaining 12 out of 16 pigs, regions of higher than surrounding average iFM were considered leading-drivers. Two leading-driver + rotational-footprint maps were generated 2.6 (IQR, 2.4-2.9) hours apart to test leading-driver spatiotemporal stability and guide ablation. Leading-driver regions (2.5 [IQR, 2.0-4.0] regions/map) exactly colocalized (95.7%) in the 2 maps, and their ablation terminated PersAF in 92.3% of procedures (radiofrequency until termination, 16.9 [IQR, 9.2-35.8] minutes; until nonsustainability, 20.4 [IQR, 12.8-44.0] minutes). Rotational-footprints were found at every leading-driver region, albeit most (76.8% [IQR, 70.5%-83.6%]) were located outside. Finally, the translational ability of this approach was tested in 3 PersAF redo patients. CONCLUSIONS Both rotational-footprints and spatiotemporally stable leading-driver regions can be located using iFM/iAM algorithms without panoramic multielectrode acquisition systems. In pigs, ablation of leading-driver regions usually terminates PersAF and prevents its sustainability. Rotational activations are sensitive but not specific to such regions. Single-signal iFM/iAM algorithms could be integrated into conventional electroanatomical mapping systems to improve driver detection accuracy and reduce the cost of patient-tailored/mechanistic approaches.
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Affiliation(s)
- Jorge G Quintanilla
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| | - José Manuel Alfonso-Almazán
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.)
| | - Nicasio Pérez-Castellano
- Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| | - Sandeep V Pandit
- Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor (S.V.P., J.J.)
| | - José Jalife
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.).,Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor (S.V.P., J.J.)
| | - Julián Pérez-Villacastín
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
| | - David Filgueiras-Rama
- From the Myocardial Pathophysiology Area, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain (J.G.Q., J.M.A.-A., J.J., D.F.-R.).,Arrhythmia Unit, Cardiology Department, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain (J.G.Q., N.P.-C., J.P.-V., D.F.-R.).,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.G.Q., N.P.-C., J.J., J.P.-V., D.F.-R.)
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5
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Zaman JAB, Baykaner T, Clopton P, Swarup V, Kowal RC, Daubert JP, Day JD, Hummel J, Schricker AA, Krummen DE, Mansour M, Tomassoni GF, Wheelan KR, Vishwanathan M, Park S, Wang PJ, Narayan SM, Miller JM. Recurrent Post-Ablation Paroxysmal Atrial Fibrillation Shares Substrates With Persistent Atrial Fibrillation : An 11-Center Study. JACC Clin Electrophysiol 2019; 3:393-402. [PMID: 28596994 DOI: 10.1016/j.jacep.2016.10.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The role of atrial fibrillation (AF) substrates is unclear in patients with paroxysmal AF (PAF) that recurs after pulmonary vein isolation (PVI). We hypothesized that patients with recurrent post-ablation (redo) PAF despite PVI have electrical substrates marked by rotors and focal sources, and structural substrates that resemble persistent AF more than patients with (de novo) PAF at first ablation. METHODS In 175 patients at 11 centers, we compared AF substrates in both atria using 64 pole-basket catheters and phase mapping, and indices of anatomical remodeling between patients with de novo or redo PAF and first ablation for persistent AF. RESULTS Sources were seen in all patients. More patients with de novo PAF (78.0%) had sources near PVs than patients with redo PAF (47.4%, p=0.005) or persistent AF (46.9%, p=0.001). The total number of sources per patient (p=0.444), and number of non-PV sources (p=0.701) were similar between groups, indicating that redo PAF patients had residual non-PV sources after elimination of PV sources by prior PVI. Structurally, left atrial size did not separate de novo from redo PAF (49.5±9.5 vs. 49.0±7.1mm, p=0.956) but was larger in patients with persistent AF (55.2±8.4mm, p=0.001). CONCLUSIONS Patients with paroxysmal AF despite prior PVI show electrical substrates that resemble persistent AF more closely than patients with paroxysmal AF at first ablation. Notably, these subgroups of paroxysmal AF are indistinguishable by structural indices. These data motivate studies of trigger versus substrate mechanisms for patients with recurrent paroxysmal AF after PVI.
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Affiliation(s)
| | - Tina Baykaner
- Stanford University, Stanford.,San Diego VA Medical Center
| | | | | | | | | | - John D Day
- Intermountain Medical Center, Salt Lake City
| | | | | | | | | | | | | | | | | | | | | | - John M Miller
- Indiana University School of Medicine, Indianapolis, United States
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6
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Long-term mode and timing of premature ventricular complex recurrence following successful catheter ablation. J Interv Card Electrophysiol 2019; 55:153-160. [PMID: 30734139 DOI: 10.1007/s10840-019-00520-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Catheter ablation of premature ventricular contractions (PVCs) is highly successful and has become the hallmark treatment for symptomatic or highly prevalent cases. However, few studies exist that evaluate the outcomes of ablation and likely mechanisms of PVC recurrence beyond 1 year of follow-up. METHODS This study is a retrospective analysis of patients who underwent catheter ablation for symptomatic PVCs with acute procedural success and had clinical follow-up ≥ 12 months. RESULTS Forty-four patients (24 women; age 53.5 ± 4.8 years) following acutely successful PVC ablation with long-term follow-up were studied. At a mean of 36 ± 6 months, overall long-term ablation success was 75% (33/44 patients). Notably, recurrence of the targeted PVC focus was low (6.8%, 3/44 patients); the majority of recurrences were from a new source location (18.2%, 8/44 patients). The time course for targeted versus de novo PVC recurrences was significantly different: recurrence of a PVC similar to the targeted PVC morphology occurred at a mean of 5.0 ± 2.0 months, while recurrence of a PVC different from the index case occurred at a mean of 35.8 ± 17.1 months (p = 0.01). Non-ischemic cardiomyopathy was associated with increased risk of PVC recurrence (odds ratio [OR] 14.50 (95% confidence interval [CI] 1.92-109.33, p = 0.01)) and was a significant negative prognostic factor in multivariate analysis for PVC recurrence survival (hazard ratio [HR] 4.63, 95% CI 1.03-20.74, p = 0.04). CONCLUSIONS The majority of long-term PVC recurrences occur late in follow-up, at locations remote from the targeted PVC source or sources. Such sites may represent ongoing substrate evolution; additional work is required to determine the precise substrate alterations which promote such arrhythmogenic changes.
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7
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Boyle PM, Hakim JB, Zahid S, Franceschi WH, Murphy MJ, Prakosa A, Aronis KN, Zghaib T, Balouch M, Ipek EG, Chrispin J, Berger RD, Ashikaga H, Marine JE, Calkins H, Nazarian S, Spragg DD, Trayanova NA. The Fibrotic Substrate in Persistent Atrial Fibrillation Patients: Comparison Between Predictions From Computational Modeling and Measurements From Focal Impulse and Rotor Mapping. Front Physiol 2018; 9:1151. [PMID: 30210356 PMCID: PMC6123380 DOI: 10.3389/fphys.2018.01151] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/31/2018] [Indexed: 12/19/2022] Open
Abstract
Focal impulse and rotor mapping (FIRM) involves intracardiac detection and catheter ablation of re-entrant drivers (RDs), some of which may contribute to arrhythmia perpetuation in persistent atrial fibrillation (PsAF). Patient-specific computational models derived from late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) has the potential to non-invasively identify all areas of the fibrotic substrate where RDs could potentially be sustained, including locations where RDs may not manifest during mapped AF episodes. The objective of this study was to carry out multi-modal assessment of the arrhythmogenic propensity of the fibrotic substrate in PsAF patients by comparing locations of RD-harboring regions found in simulations and detected by FIRM (RDsim and RDFIRM) and analyze implications for ablation strategies predicated on targeting RDs. For 11 PsAF patients who underwent pre-procedure LGE-MRI and FIRM-guided ablation, we retrospectively simulated AF in individualized atrial models, with geometry and fibrosis distribution reconstructed from pre-ablation LGE-MRI scans, and identified RDsim sites. Regions harboring RDsim and RDFIRM were compared. RDsim were found in 38 atrial regions (median [inter-quartile range (IQR)] = 4 [3; 4] per model). RDFIRM were identified and subsequently ablated in 24 atrial regions (2 [1; 3] per patient), which was significantly fewer than the number of RDsim-harboring regions in corresponding models (p < 0.05). Computational modeling predicted RDsim in 20 of 24 (83%) atrial regions identified as RDFIRM-harboring during clinical mapping. In a large number of cases, we uncovered RDsim-harboring regions in which RDFIRM were never observed (18/22 regions that differed between the two modalities; 82%); we termed such cases “latent” RDsim sites. During follow-up (230 [180; 326] days), AF recurrence occurred in 7/11 (64%) individuals. Interestingly, latent RDsim sites were observed in all seven computational models corresponding to patients who experienced recurrent AF (2 [2; 2] per patient); in contrast, latent RDsim sites were only discovered in two of four patients who were free from AF during follow-up (0.5 [0; 1.5] per patient; p < 0.05 vs. patients with AF recurrence). We conclude that substrate-based ablation based on computational modeling could improve outcomes.
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Affiliation(s)
- Patrick M Boyle
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Joe B Hakim
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sohail Zahid
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - William H Franceschi
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael J Murphy
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Adityo Prakosa
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | | | - Tarek Zghaib
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Muhammed Balouch
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Esra G Ipek
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Jonathan Chrispin
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Ronald D Berger
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hiroshi Ashikaga
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Joseph E Marine
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Saman Nazarian
- Penn Heart & Vascular Center, University of Pennsylvania, Philadelphia, PA, United States
| | - David D Spragg
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
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8
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Shukla G, Zimmerman J, Shir Z, Shah R, Hasanaj E. Long-term clinical outcomes of magnetically navigated rotor ablation as an adjunct to conventional pulmonary vein isolation. Europace 2018; 20:ii40-ii47. [PMID: 29722856 DOI: 10.1093/europace/euy003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/06/2018] [Indexed: 02/01/2023] Open
Abstract
Aims The objective of this study is to evaluate the outcomes of magnetically guided ablation of atrial fibrillation (AF) rotors in conjunction with magnetically guided pulmonary vein isolation (PVI) in a large consecutive series of patients. Methods and results A total of 110 consecutive patients with drug-refractory AF underwent rotor ablation followed by conventional PVI and ablation of other spontaneous arrhythmias, all of which were performed with remote magnetic navigation (RMN). The patients were followed to assess the recurrence of atrial arrhythmia. Patients had a mean age of 62.5 ± 9.9 years, 64.5% had persistent AF, and 36.4% had a prior failed PVI. All patients had mapped rotors (3.9 ± 1.5 per patient), with right atrial (RA) rotors in 77.3% (85/110) of patients. After a mean follow-up of 17.6 ± 9.5 months, 90.9% (100/110) were in stable sinus rhythm including patients on previously ineffective antiarrhythmic drugs (AADs). 69.1% (76/110) were in stable sinus rhythm without any AADs. Outcome did not differ between patients with persistent or paroxysmal AF (69.2% vs. 69.0%; P = 0.75), failed prior ablation or those undergoing an initial ablation (77.5% vs. 64.3%; P = 0.193), or patients with and without intra-procedural AF termination (67.3% vs. 70.5%; P = 0.723). Conclusion Ablation of rotors in combination with PVI using RMN was associated with a high success rate in this large cohort of consecutive patients. Significant proportion of patients exhibited RA rotors, which was associated with persistent AF, obstructive sleep apnoea, and obesity.
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Affiliation(s)
- Gunjan Shukla
- Heart and Vascular Center at Hackensack University Medical Center, Seton Hall- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - John Zimmerman
- Heart and Vascular Center at Hackensack University Medical Center, Seton Hall- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Zoya Shir
- Heart and Vascular Center at Hackensack University Medical Center, Seton Hall- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Roshan Shah
- Heart and Vascular Center at Hackensack University Medical Center, Seton Hall- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Edmund Hasanaj
- Heart and Vascular Center at Hackensack University Medical Center, Seton Hall- Hackensack Meridian School of Medicine, Hackensack, NJ, USA
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9
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Boyle PM, Hakim JB, Zahid S, Franceschi WH, Murphy MJ, Vigmond EJ, Dubois R, Haïssaguerre M, Hocini M, Jaïs P, Trayanova NA, Cochet H. Comparing Reentrant Drivers Predicted by Image-Based Computational Modeling and Mapped by Electrocardiographic Imaging in Persistent Atrial Fibrillation. Front Physiol 2018; 9:414. [PMID: 29725307 PMCID: PMC5917348 DOI: 10.3389/fphys.2018.00414] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 04/04/2018] [Indexed: 02/06/2023] Open
Abstract
Electrocardiographic mapping (ECGI) detects reentrant drivers (RDs) that perpetuate arrhythmia in persistent AF (PsAF). Patient-specific computational models derived from late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) identify all latent sites in the fibrotic substrate that could potentially sustain RDs, not just those manifested during mapped AF. The objective of this study was to compare RDs from simulations and ECGI (RDsim/RDECGI) and analyze implications for ablation. We considered 12 PsAF patients who underwent RDECGI ablation. For the same cohort, we simulated AF and identified RDsim sites in patient-specific models with geometry and fibrosis distribution from pre-ablation LGE-MRI. RDsim- and RDECGI-harboring regions were compared, and the extent of agreement between macroscopic locations of RDs identified by simulations and ECGI was assessed. Effects of ablating RDECGI/RDsim were analyzed. RDsim were predicted in 28 atrial regions (median [inter-quartile range (IQR)] = 3.0 [1.0; 3.0] per model). ECGI detected 42 RDECGI-harboring regions (4.0 [2.0; 5.0] per patient). The number of regions with RDsim and RDECGI per individual was not significantly correlated (R = 0.46, P = ns). The overall rate of regional agreement was fair (modified Cohen's κ0 statistic = 0.11), as expected, based on the different mechanistic underpinning of RDsim- and RDECGI. nineteen regions were found to harbor both RDsim and RDECGI, suggesting that a subset of clinically observed RDs was fibrosis-mediated. The most frequent source of differences (23/32 regions) between the two modalities was the presence of RDECGI perpetuated by mechanisms other than the fibrotic substrate. In 6/12 patients, there was at least one region where a latent RD was observed in simulations but was not manifested during clinical mapping. Ablation of fibrosis-mediated RDECGI (i.e., targets in regions that also harbored RDsim) trended toward a higher rate of positive response compared to ablation of other RDECGI targets (57 vs. 41%, P = ns). Our analysis suggests that RDs in human PsAF are at least partially fibrosis-mediated. Substrate-based ablation combining simulations with ECGI could improve outcomes.
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Affiliation(s)
- Patrick M Boyle
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Joe B Hakim
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Sohail Zahid
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - William H Franceschi
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Michael J Murphy
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Edward J Vigmond
- L'Institut de RYthmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France
| | - Rémi Dubois
- L'Institut de RYthmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France
| | - Michel Haïssaguerre
- L'Institut de RYthmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France.,Centre Hospitalier Universitaire de Bordeaux, Pessac-Bordeaux, France
| | - Mélèze Hocini
- L'Institut de RYthmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France.,Centre Hospitalier Universitaire de Bordeaux, Pessac-Bordeaux, France
| | - Pierre Jaïs
- L'Institut de RYthmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France.,Centre Hospitalier Universitaire de Bordeaux, Pessac-Bordeaux, France
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Hubert Cochet
- L'Institut de RYthmologie et Modélisation Cardiaque (IHU-LIRYC), Pessac-Bordeaux, France.,Centre Hospitalier Universitaire de Bordeaux, Pessac-Bordeaux, France
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10
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Navara R, Leef G, Shenasa F, Kowalewski C, Rogers AJ, Meckler G, Zaman JAB, Baykaner T, Park S, Turakhia MP, Zei P, Viswanathan M, Wang PJ, Narayan SM. Independent mapping methods reveal rotational activation near pulmonary veins where atrial fibrillation terminates before pulmonary vein isolation. J Cardiovasc Electrophysiol 2018; 29:687-695. [PMID: 29377478 DOI: 10.1111/jce.13446] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To investigate mechanisms by which atrial fibrillation (AF) may terminate during ablation near the pulmonary veins before the veins are isolated (PVI). INTRODUCTION It remains unstudied how AF may terminate during ablation before PVs are isolated, or how patients with PV reconnection can be arrhythmia-free. We studied patients in whom PV antral ablation terminated AF before PVI, using two independent mapping methods. METHODS We studied patients with AF referred for ablation, in whom biatrial contact basket electrograms were studied by both an activation/phase mapping method and by a second validated mapping method reported not to create false rotational activity. RESULTS In 22 patients (age 60.1 ± 10.4, 36% persistent AF), ablation at sites near the PVs terminated AF (77% to sinus rhythm) prior to PVI. AF propagation revealed rotational (n = 20) and focal (n = 2) patterns at sites of termination by mapping method 1 and method 2. Both methods showed organized sites that were spatially concordant (P < 0.001) with similar stability (P < 0.001). Vagal slowing was not observed at sites of AF termination. DISCUSSION PV antral regions where ablation terminated AF before PVI exhibited rotational and focal activation by two independent mapping methods. These data provide an alternative mechanism for the success of PVI, and may explain AF termination before PVI or lack of arrhythmias despite PV reconnection. Mapping such sites may enable targeted PV lesion sets and improved freedom from AF.
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Affiliation(s)
- Rachita Navara
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - George Leef
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Fatemah Shenasa
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Christopher Kowalewski
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.,Friedrich-Alexander Universitaet Erlangen-Nürnberg, Erlangen, Germany
| | - Albert J Rogers
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabriela Meckler
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Junaid A B Zaman
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.,Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Tina Baykaner
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Shirley Park
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mintu P Turakhia
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paul Zei
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Mohan Viswanathan
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul J Wang
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Sanjiv M Narayan
- Division of Cardiology, Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
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11
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Baykaner T, Zaman JAB, Rogers AJ, Navara R, AlHusseini M, Borne RT, Park S, Wang PJ, Krummen DE, Sauer WH, Narayan SM. Spatial relationship of sites for atrial fibrillation drivers and atrial tachycardia in patients with both arrhythmias. Int J Cardiol 2017; 248:188-195. [PMID: 28733070 PMCID: PMC5865446 DOI: 10.1016/j.ijcard.2017.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 06/21/2017] [Accepted: 07/03/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) often converts to and from atrial tachycardia (AT), but it is undefined if these rhythms are mechanistically related in such patients. We tested the hypothesis that critical sites for AT may be related to regional AF sources in patients with both rhythms, by mapping their locations and response to ablation on transitions to and from AF. METHODS From 219 patients undergoing spatial mapping of AF prior to ablation at 3 centers, we enrolled 26 patients in whom AF converted to AT by ablation (n=19) or spontaneously (n=7; left atrial size 42±6cm, 38% persistent AF). Both atria were mapped in both rhythms by 64-electrode baskets, traditional activation maps and entrainment. RESULTS Each patient had a single mapped AT (17 reentrant, 9 focal) and 3.7±1.7 AF sources. The mapped AT spatially overlapped one AF source in 88% (23/26) of patients, in left (15/23) or right (8/23) atria. AF transitioned to AT by 3 mechanisms: (a) ablation anchoring AF rotor to AT (n=13); (b) residual, unablated AF source producing AT (n=6); (c) spontaneous slowing of AF rotor leaving reentrant AT at this site without any ablation (n=7). Electrogram analysis revealed a lower peak-to-peak voltage at overlapping sites (0.36±0.2mV vs 0.49±0.2mV p=0.03). CONCLUSIONS Mechanisms responsible for AT and AF may arise in overlapping atrial regions. This mechanistic inter-relationship may reflect structural and/or functional properties in either atrium. Future work should delineate how acceleration of an organized AT may produce AF, and whether such regions can be targeted a priori to prevent AT recurrence post AF ablation.
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Affiliation(s)
- Tina Baykaner
- Stanford University Medical Center, Palo Alto, CA, United States.
| | - Junaid A B Zaman
- Stanford University Medical Center, Palo Alto, CA, United States
| | - Albert J Rogers
- Stanford University Medical Center, Palo Alto, CA, United States
| | - Rachita Navara
- Stanford University Medical Center, Palo Alto, CA, United States
| | | | - Ryan T Borne
- University of Colorado School of Medicine, Denver, CO, United States
| | - Shirley Park
- Stanford University Medical Center, Palo Alto, CA, United States
| | - Paul J Wang
- Stanford University Medical Center, Palo Alto, CA, United States
| | - David E Krummen
- University of California San Diego and Veterans Affairs Medical Center, La Jolla, CA, United States
| | - William H Sauer
- University of Colorado School of Medicine, Denver, CO, United States
| | - Sanjiv M Narayan
- Stanford University Medical Center, Palo Alto, CA, United States
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12
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Narayan SM, Vishwanathan MN, Kowalewski CAB, Baykaner T, Rodrigo M, Zaman JAB, Wang PJ. The continuous challenge of AF ablation: From foci to rotational activity. Rev Port Cardiol 2017; 36 Suppl 1:9-17. [PMID: 29126896 DOI: 10.1016/j.repc.2017.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/18/2017] [Accepted: 09/11/2017] [Indexed: 11/24/2022] Open
Abstract
Pulmonary vein isolation (PVI) is central to ablation approaches for atrial fibrillation (AF), yet many patients still have arrhythmia recurrence after one or more procedures despite the latest technology for PVI. Ablation of rotational or focal sources for AF, which lie outside the pulmonary veins in many patients, is a practical approach that has been shown to improve success by many groups. Localized sources lie in atrial regions shown mechanistically to sustain AF in optical mapping and clinical studies of human AF, as well as computational and animal studies. Because they arise in localized atrial regions, AF sources may explain central paradoxes in clinical practice - such as how limited ablation in patient specific sites can terminate persistent AF yet extensive anatomical ablation at stereotypical locations, which should extinguish disordered waves, does not improve success in clinical trials. Ongoing studies may help to resolve many controversies in the field of rotational sources for AF. Studies now verify rotational activation by multiple mapping approaches in the same patients, at sites where ablation terminates persistent AF. However, these studies also show that certain mapping methods are less effective for detecting AF sources than others. It is also recognized that the success of AF source ablation is technique dependent. This review article provides a mechanistic and clinical rationale to ablate localized sources (rotational and focal), and describes successful techniques for their ablation as well as pitfalls to avoid. We hope that this review will serve as a platform for future improvements in the patient-tailored ablation for complex arrhythmias.
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Affiliation(s)
| | | | | | | | | | | | - Paul J Wang
- Stanford University, Palo Alto, CA, United States
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13
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Narayan SM, Vishwanathan MN, Kowalewski CA, Baykaner T, Rodrigo M, Zaman JA, Wang PJ. The continuous challenge of AF ablation: From foci to rotational activity. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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14
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Ablation of Focal Impulses and Rotational Sources: What Can Be Learned from Differing Procedural Outcomes? CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0552-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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15
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Balouch M, Gucuk Ipek E, Chrispin J, Bajwa RJ, Zghaib T, Berger RD, Ashikaga H, Nazarian S, Marine JE, Calkins H, Spragg DD. Impact of rotor temperospatial stability on acute and one-year atrial fibrillation ablation outcomes. Clin Cardiol 2017; 40:383-389. [PMID: 28120392 DOI: 10.1002/clc.22674] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 11/29/2016] [Accepted: 12/20/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The utility of rotor ablation using commercially available systems as an adjunct to pulmonary vein isolation (PVI) is controversial. Variable results may stem from heterogeneous practice patterns. We investigated whether a prespecified protocol to determine temperospatial rotor stability improved acute and intermediate outcomes following rotor ablation. HYPOTHESIS Protocolized rotor mapping and ablation, with prespecified metrics to determine temporal rotor stability prior to ablation, will improve short- and long-term PVI/rotor ablation outcomes. METHODS Patients undergoing PVI plus rotor ablation at Johns Hopkins during 2015 were included. The first cohort underwent rotor mapping and ablation at the operator's discretion, whereas the second cohort underwent protocolized rotor mapping, with ablation limited to temperospatially stable rotors. Both cohorts underwent PVI. Acute results (rotor elimination, atrial fibrillation [AF] termination), procedural data, and 1-year outcomes were assessed. RESULTS Twenty-seven patients underwent ablation (mean age, 64.4 ± 9 years, male 81.5%, persistent AF 85.2%, long-standing persistent AF 14.8%, mean AF duration 4.4 ± 4 years, repeat cases 51.8%, and mean LA size 4.6 ± 0.8 cm). In the protocolized cohort, rotors were reproducible in 83% (10/12) of cases in at least 1 chamber. Acute rhythm change was achieved in 8/27 (29.6%) patients. Sinus rhythm on presentation (62.5% vs 15.8%, P = 0.03) and higher total targeted rotors (3.8 ± 1.7 vs 2.5 ± 1.0, P = 0.02) predicted acute change. At 12 months, freedom from AF/atrial tachycardia was achieved in 5/15 (33.3%) patients in the first cohort and 5/11 patients in the protocolized cohort (45.5%; P = 0.53 for comparison). CONCLUSIONS Acute and intermediate results did not change with protocolized mapping designed to identify temperospatially stable rotors. Outcomes at 12 months were similar in both groups.
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Affiliation(s)
- Muhammad Balouch
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Esra Gucuk Ipek
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Jonathan Chrispin
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Rizma J Bajwa
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Tarek Zghaib
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ronald D Berger
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Hiroshi Ashikaga
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Saman Nazarian
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph E Marine
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Hugh Calkins
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - David D Spragg
- Johns Hopkins Hospital Heart and Vascular Institute, Division of Cardiology, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
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