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Traykov V, Marchov D, Martinov E, El Abbady A, Gelev V, Dichtl W. Ongoing substrate-driven atrial fibrillation "boxed" in the left atrial posterior wall with ablation: a case report. Front Cardiovasc Med 2023; 10:1251874. [PMID: 37790595 PMCID: PMC10542893 DOI: 10.3389/fcvm.2023.1251874] [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: 07/02/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Patients undergoing valve surgery for rheumatic heart disease are expected to develop significant atrial arrhythmogenic substrates outside of the pulmonary veins, which sometimes require complex ablation techniques for the treatment of symptomatic arrhythmias. We describe, herein, the case of a 76-year-old male undergoing endocardial ablation for the treatment of symptomatic persistent atrial fibrillation which developed after aortic and mitral valve replacement with a simultaneous tricuspid ring annuloplasty. Following pulmonary vein isolation, the patient's atrial fibrillation was converted into cavotricuspid isthmus-dependent atrial flutter. After a successful cavotricuspid isthmus ablation, the arrhythmia reverted back to a left atrial tachyarrhythmia originating from the posterior wall. A linear left atrial lesion led to the electrical isolation of a large area, which included the posterior wall, as well as the containment of the ongoing fibrillatory activity, while sinus rhythm was restored in the rest of the atria. In conclusion, successful left atrial posterior wall isolation can be achieved in the setting of severe scarring due to previous atriotomy by creating a linear lesion on the atrial roof, in conjunction with pulmonary vein isolation, sparing the patient from requiring bottom-line ablation, and avoiding possible esophageal injury. Such compartmentalization of the left atrium may effectively contain local fibrillatory activity, while allowing for the restoration of sinus rhythm.
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Affiliation(s)
- Vassil Traykov
- Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Daniel Marchov
- Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Emiliyan Martinov
- Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Asmaa El Abbady
- Cardiac Electrophysiology Department, National Heart Institute, Giza, Egypt
| | - Valeri Gelev
- Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Wolfgang Dichtl
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
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2
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Sohns C, Bergau L, El-Hamriti M, Fox H, Molatta S, Braun M, Khalaph M, Imnadze G, Sommer P. Posterior wall substrate modification using optimized and contiguous lesions in patients with atrial fibrillation. Cardiol J 2022; 29:917-926. [PMID: 33346368 PMCID: PMC9788747 DOI: 10.5603/cj.a2020.0180] [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: 07/08/2020] [Accepted: 10/13/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Radiofrequency (RF) linear ablation at the left atrial (LA) roof and bottom to isolate the LA posterior wall using contiguous and optimized RF lesions was evaluated. Achieving isolation of the LA posterior wall is challenging as two continuous linear lesion sets are necessary. METHODS Forty consecutive patients with symptomatic atrial fibrillation (AF) and arrhythmia substrates affecting the LA posterior wall underwent posterior wall isolation by linear lesions across the roof and bottom. The cohort was divided into two groups: group 1 (20 patients) linear ablation guided by contact force (CF) only; group 2 (20 patients) guided by ablation index (AI) and interlesion distance. RESULTS Bidirectional block across the LA roof and bottom was achieved in 40/40 patients. Additional endocardial RF applications in 5 patients from group 1 vs. 3 patients from group 2 resulted in posterior wall isolation in all patients. Procedure duration was almost equal in both groups. CF and AI were significantly higher in group 2 for the roof line, whereas no statistical difference was found for the bottom line. AI-guided LA posterior wall isolation led to a significantly lower maximum temperature increase. The mean AI value as well as the mean value for catheter-to-tissue CF for the roof line were significantly higher when AI-guided ablation was performed. Standard deviation in group 2 showed a remarkably lower dispersion. CONCLUSIONS Ablation index guided posterior wall isolation for substrate modification is safe and effective. AI guided application of the posterior box lesion allows improved lesion formation.
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Affiliation(s)
- Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Leonard Bergau
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mustapha El-Hamriti
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Thoracic and Cardiovascular Surgery and Heart Failure Department, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Stephan Molatta
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Martin Braun
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Moneeb Khalaph
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Guram Imnadze
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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Li DL, El‐harasis M, Montgomery JA, Richardson TD, Kanagasundram A, Estrada JC, Lean M, Benjamin Shoemaker M, Saavedra PJ, Touchton S, Patel B, Herrmann T, John RM, Michaud GF. Durable pulmonary vein isolation with diffuse posterior left atrial ablation using low‐flow, median power, short‐duration strategy. J Cardiovasc Electrophysiol 2022; 33:1655-1664. [DOI: 10.1111/jce.15550] [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: 02/09/2022] [Revised: 03/29/2022] [Accepted: 04/13/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Dan L. Li
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | - Majd El‐harasis
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | - Jay A. Montgomery
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | - Travis D. Richardson
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | - Arvindh Kanagasundram
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | - Juan Carlos Estrada
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | | | - M. Benjamin Shoemaker
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | - Pablo J. Saavedra
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
| | | | | | | | - Roy M. John
- Division of Cardiology, Department of Medicine, Stanford UniversityStanfordCA
| | - Gregory F. Michaud
- Division of CardiologyDepartment of MedicineVanderbilt University Medical CenterNashvilleTN
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4
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Jiang X, Liao J, Ling Z, Meyer C, Sommer P, Futyma P, Martinek M, Schratter A, Acou WJ, Wang J, Zhu L, Kiuchi MG, Pürerfellner H, Schmidt B, Chun JKR, Yin Y, Chen S. Adjunctive Left Atrial Posterior Wall Isolation in Treating Atrial Fibrillation: Insight From a Large Secondary Analysis. JACC Clin Electrophysiol 2022; 8:605-618. [PMID: 35589173 DOI: 10.1016/j.jacep.2022.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/14/2022] [Accepted: 02/02/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES This study evaluated the role of adjunctive left atrium posterior wall isolation (PWI) in preventing atrial fibrillation (AF) recurrence. BACKGROUND The left atrium posterior wall is an arrhythmogenic substrate that contributes to the development of AF. METHODS This was an updated pooled analysis that included clinical data regarding PWI plus pulmonary vein isolation (PVI) in treating AF. The primary outcome was recurrence of atrial tachyarrhythmias. RESULTS A total of 26 studies with 3,287 patients with AF (age 61.7 ± 10.8 years) were included. Mean follow-up was 15.2 ± 8.4 months. Procedural success to achieve PWI was 92.8%. In paroxysmal AF, adjunctive PWI did not reduce the recurrence of all atrial arrhythmias (P = 0.21) or AF (P = 0.37); however, in persistent AF, adjunctive PWI was associated with substantially lower recurrence of all atrial arrhythmias (risk ratio: 0.74; P < 0.001) and AF (risk ratio: 0.67; P = 0.01), particularly when randomized data were included. Subgroup analyses based on meta-regression demonstrated that patients with older age, a larger left atrial diameter, and persistent AF benefited more significantly from the adjunctive PWI. Adjunctive PWI using either radiofrequency or a cryoballoon reduced AF recurrence, whereas using radiofrequency seemed to be associated with higher recurrence rate of atrial tachycardias and/or atrial flutter. Non-BOX adjunctive PWI rather than BOX PWI was associated with significantly lower recurrence of AF. The incidence of procedural adverse events between the PVI+PWI (3.2%) and PVI (2.8%) groups was low and similar. PVI+PWI needed longer ablation and/or procedural time but had similar fluoroscopy time. CONCLUSIONS Adjunctive PWI can be achieved in most patients without compromising safety. Patients with persistent AF appear to benefit from this approach. The ablation technology and/or approach may affect the clinical outcome of PWI.
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Affiliation(s)
- Xi Jiang
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Liao
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Christian Meyer
- Department of Cardiology, Angiology, Intensive Care, NEP, Cardiac Neuro- and Electrophysiology Research Consortium, Evangelisches Krankenhaus (EVK) Düsseldorf, Düsseldorf, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Institute of Neural and Sensory Physiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp Sommer
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Piotr Futyma
- St. Joseph's Heart Rhythm Center, Medical College at University of Rzeszów, Rzeszów, Poland
| | - Martin Martinek
- Department für Kardiologie und Elektrophysiologie, Akademisches Lehrkrankenhaus, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | | | | | - Jiazhi Wang
- Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Lin Zhu
- Medizinisch-Geriatrische Klinik, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | - Márcio Galindo Kiuchi
- School of Medicine-Royal Perth Hospital Unit, University of Western Australia, Perth, Western Australia, Australia
| | - Helmut Pürerfellner
- Department für Kardiologie und Elektrophysiologie, Akademisches Lehrkrankenhaus, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany; Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shaojie Chen
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Cardioangiologisches Centrum Bethanien, Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany; Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany; Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany.
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5
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Thiyagarajah A, Mahajan R, Iwai S, Gupta A, Linz D, Chim I, Emami M, Kadhim K, O'Shea C, Middeldorp ME, Lau DH, Sanders P. Single Ring Isolation For Atrial Fibrillation Ablation: Impact of the Learning Curve. J Cardiovasc Electrophysiol 2022; 33:608-617. [DOI: 10.1111/jce.15387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Anand Thiyagarajah
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Lyell McEwin HospitalAdelaideAustralia
| | - Shinsuke Iwai
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Aashray Gupta
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Ivana Chim
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Catherine O'Shea
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Melissa E. Middeldorp
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Dennis H. Lau
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of AdelaideAdelaideAustralia
- Department of Cardiology, Royal Adelaide HospitalAdelaideAustralia
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6
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Aryana A. Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation. J Innov Card Rhythm Manag 2021; 12:4633-4646. [PMID: 34476116 PMCID: PMC8384303 DOI: 10.19102/icrm.2021.120801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
There is strong evidence in support of pulmonary vein isolation (PVI) with concomitant left atrial (LA) posterior wall (PW) isolation (PWI) for the treatment of patients with persistent atrial fibrillation (persAF). While this may be achieved using surgical and catheter-based strategies, there is growing interest in performing this approach using the cryoballoon. There are several potential advantages to this strategy. First, lesions created using the current-generation cryoballoons are typically large and durable. Second, cryoballoon ablation offers a simple technique to directly ablate and debulk the LAPW. Moreover, some consider cryoenergy a safer modality specifically with regard to collateral structures (ie, the esophagus). Based on the available data, cryoballoon PVI + PWI is associated with greater intraprocedural AF terminations and reductions in long-term AF recurrence (typically by ~20%), as compared to PVI alone in patients with persAF, but with similar rates of adverse events. As such, PVI + PWI has emerged as a significant predictor of freedom from recurrent AF (odds ratio: 3.67, 95% confidence interval: 1.44-9.34; p = 0.006) as well as all atrial arrhythmias (hazard ratio: 2.04, 95% confidence interval: 1.15-3.61; p = 0.015). Adjunct radiofrequency ablation to complete PWI is required in at least one-third of the patients, and this need is highly predicted by the LA size (significantly increased with an LA diameter > 48 mm). LAPW reconnection also seems to be associated with LA dimension, particularly an LA diameter greater than 48 mm (negative predictive value: 89.7%). Nevertheless, based on the analysis of patients who underwent repeat electrophysiology study for arrhythmia recurrences, cryoballoon PVI + PWI yields acceptable long-term durability (> 80%).
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Affiliation(s)
- Arash Aryana
- Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
- Cardiac Catheterization Laboratory, Mercy General Hospital, Sacramento, CA, USA
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7
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Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation. Circ Arrhythm Electrophysiol 2020; 13:e009288. [DOI: 10.1161/circep.120.009288] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background:
The limited effectiveness of endocardial catheter ablation (CA) for persistent and long-standing persistent atrial fibrillation (AF) treatment led to the development of a minimally invasive epicardial/endocardial ablation approach (Hybrid Convergent) to achieve a more comprehensive lesion set with durable transmural lesions. The multicenter randomized controlled CONVERGE trial (Convergence of Epicardial and Endocardial Ablation for the Treatment of Symptomatic Persistent AF) evaluated the safety of Hybrid Convergent and compared its effectiveness to CA for persistent and long-standing persistent AF treatment.
Methods:
One-hundred fifty-three patients were randomized 2:1 to Hybrid Convergent versus CA. Primary effectiveness was freedom from AF/atrial flutter/atrial tachycardia absent new/increased dosage of previously failed/intolerant class I/III antiarrhythmic drugs through 12 months. Primary safety was major adverse events through 30 days. CONVERGE permitted left atrium size up to 6 cm and imposed no limits on AF duration, making it the only ablation trial to substantially include long-standing persistent–AF, that is, 42% patients with long-standing persistent–AF.
Results:
Of 149 evaluable patients at 12 months, primary effectiveness was achieved in 67.7% (67/99) patients with Hybrid Convergent and 50.0% (25/50) with CA (
P
=0.036) on/off previously failed antiarrhythmic drugs and in 53.5% (53/99) versus 32.0% (16/50;
P
=0.0128) respectively off antiarrhythmic drugs. At 18 months using 7-day Holter, 74.0% (53/72) Hybrid Convergent and 55% (23/42) CA patients experienced ≥90% AF burden reduction. A total of 2.9% (3/102) patients had primary safety events within 7 days, and 4.9% (5/102) between 8 and 30 days postprocedure. No deaths, cardiac perforations, or atrioesophageal fistulas occurred. All but one primary safety event resolved.
Conclusions:
The Hybrid Convergent procedure has superior effectiveness compared to the CA for the treatment of persistent and long-standing persistent atrial fibrillation.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01984346.
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8
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Kawajiri K, Fukamizu S, Kitamura T, Hojo R. One-point posterior ablation for complete isolation of the posterior left atrium. HeartRhythm Case Rep 2020; 6:738-740. [PMID: 33101944 PMCID: PMC7573377 DOI: 10.1016/j.hrcr.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Kohei Kawajiri
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Takeshi Kitamura
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
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9
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Fujito T, Mochizuki A, Kamiyama N, Koyama M, Nagahara D, Miura T. Is Incomplete Left Atrial Posterior Wall Isolation Associated With Recurrence of Atrial Fibrillation After Radiofrequency Catheter Ablation? Circ Rep 2020; 2:648-656. [PMID: 33693191 PMCID: PMC7937498 DOI: 10.1253/circrep.cr-20-0044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: Complete left atrial posterior wall isolation (LAPI) is not always achieved. We examined whether incomplete LAPI has an effect on outcomes after catheter ablation (CA). Methods and Results: This study enrolled 75 consecutive patients (mean [±SD] age 62.6±8.9 years, 74.7% male) who underwent LAPI by radiofrequency CA for persistent atrial fibrillation (AF). The median follow-up period was 541 days (interquartile range 338-840 days). Incomplete LAPI was defined as the presence of a successfully created roof or floor linear lesion. The rate of complete LAPI was 41.3% (31/75). Either a roof or floor linear lesion was created in 38 patients, whereas neither was created in 6. Multivariate Cox proportional hazards regression analysis revealed that female sex (hazard ratio [HR] 5.29; 95% confidence interval [CI] 1.81-16.8; P=0.002) and complete or incomplete LAPI (HR 0.17; 95% CI 0.03-0.79; P=0.027) were independent predictors of AF recurrence. Kaplan-Meier curves indicated that better outcome was associated with at least one rather than no successful linear lesion (86.5% vs. 50.0% at 1 year; P=0.043). There were no significant differences in outcomes between the complete LAPI and incomplete LAPI groups. Conclusions: Complete LAPI is unachievable in a significant percentage of patients with persistent AF. However, incomplete LAPI, as a result of aiming for complete LAPI, may have a benefit comparable to that of complete LAPI.
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Affiliation(s)
- Takefumi Fujito
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Atsushi Mochizuki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Naoyuki Kamiyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Masayuki Koyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Daigo Nagahara
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine Sapporo Japan
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10
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Aryana A, Pujara DK, Allen SL, Baker JH, Espinosa MA, Buch EF, Srivatsa U, Ellis E, Makati K, Kowalski M, Lee S, Tadros T, Baykaner T, Al-Ahmad A, d'Avila A, Di Biase L, Okishige K, Natale A. Left atrial posterior wall isolation in conjunction with pulmonary vein isolation using cryoballoon for treatment of persistent atrial fibrillation (PIVoTAL): study rationale and design. J Interv Card Electrophysiol 2020; 62:187-198. [PMID: 33009645 DOI: 10.1007/s10840-020-00885-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is growing evidence in support of pulmonary vein isolation (PVI) with concomitant posterior wall isolation (PWI) for the treatment of patients with symptomatic persistent atrial fibrillation (persAF). However, there is limited data on the safety and efficacy of this approach using the cryoballoon. OBJECTIVE The aim of this multicenter, investigational device exemption trial (G190171) is to prospectively evaluate the acute and long-term outcomes of PVI versus PVI+PWI using the cryoballoon in patients with symptomatic persAF. METHODS The PIVoTAL is a prospective, randomized controlled study ( ClinicalTrials.gov : NCT04505163) in which patients with symptomatic persAF refractory/intolerant to ≥ 1 class I-IV antiarrhythmic drug, undergoing first-time catheter ablation, will be randomized to PVI (n = 183) versus PVI+PWI (n = 183) using the cryoballoon in a 1:1 fashion. The design will be double-blind until randomization immediately after PVI, beyond which the design will transform into a single-blind. PVI using cryoballoon will be standardized using a pre-specified dosing algorithm. Other empiric ablations aside from documented arrhythmias/arrhythmias spontaneously induced during the procedure will not be permitted. The primary efficacy endpoint is defined as AF recurrence at 12 months, after a single procedure and a 90-day blanking period. Arrhythmia outcomes will be assessed by routine electrocardiograms and 7-14 day ambulatory electrocardiographic monitoring at 3, 6, and 12 months post-ablation. CONCLUSION The PIVoTAL is a prospective, randomized controlled trial designed to evaluate the outcomes of PVI alone versus PVI+PWI using the cryoballoon, in patients with symptomatic persAF. We hypothesize that PVI+PWI will prove to be superior to PVI alone for prevention of AF recurrence.
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Affiliation(s)
- Arash Aryana
- Cardiovascular Services, Mercy General Hospital and Dignity Health Heart and Vascular Institute, 3941 J Street, Suite #350, Sacramento, CA, 95819, USA.
| | | | - Shelley L Allen
- Cardiovascular Services, Mercy General Hospital and Dignity Health Heart and Vascular Institute, 3941 J Street, Suite #350, Sacramento, CA, 95819, USA
| | | | | | - Eric F Buch
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - Uma Srivatsa
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Ethan Ellis
- UCHealth Medical Center, Fort Collins, CO, USA
| | | | | | - Sung Lee
- MedStar Georgetown University Hospital and Medical Center, Washington, DC, USA
| | | | - Tina Baykaner
- Stanford University Medical Center, Stanford, CA, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - André d'Avila
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Luigi Di Biase
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
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11
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Aryana A, Chierchia GB, de Asmundis C. Recurrent Atrial Fibrillation After Cryoballoon Ablation: What to Expect! Card Electrophysiol Clin 2020; 12:199-208. [PMID: 32451104 DOI: 10.1016/j.ccep.2020.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atrial fibrillation (AF) recurrence following cryoballoon ablation may occur as a consequence of pulmonary vein (PV) reconnection, which can be treated effectively by performing repeat PV isolation. Alternatively, AF recurrence can manifest in presence of bilateral antral PV isolation. In such circumstances, one may pursue catheter ablation of AF triggers, if present, or proceed with empiric posterior left atrial wall ablation. Although traditionally, focal radiofrequency ablation has been used for this, cryoballoon ablation, itself, may also be used for ablation/isolation of certain structures such as the superior vena cava, the left atrial appendage and even the posterior left atrial wall.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Suite #350, 3941 J Street, Sacramento, CA 95819, USA.
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Thiyagarajah A, Kadhim K, Lau DH, Emami M, Linz D, Khokhar K, Munawar DA, Mishima R, Malik V, O’Shea C, Mahajan R, Sanders P. Feasibility, Safety, and Efficacy of Posterior Wall Isolation During Atrial Fibrillation Ablation. Circ Arrhythm Electrophysiol 2019; 12:e007005. [DOI: 10.1161/circep.118.007005] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background:
The posterior left atrium is an arrhythmogenic substrate that contributes to the initiation and maintenance of atrial fibrillation (AF); however, the feasibility, safety, and efficacy of posterior wall isolation (PWI) as an AF ablation strategy has not been widely reported.
Methods:
We undertook a systematic review and meta-analysis of studies performing PWI to assess (1) acute procedural success including the ability to achieve PWI and the number of procedure-related complications, (2) Long-term, clinical success including rates of arrhythmia recurrence and posterior wall reconnection, and (3) The efficacy of PWI compared with pulmonary vein isolation on preventing arrhythmia recurrence. MEDLINE, EMBASE, and Web of Science databases were searched in May 2018 to retrieve relevant studies. Results were pooled using a random effects model.
Results:
Seventeen studies (13 box isolation, 3 single ring isolation, and 1 debulking ablation) comprising 1643 patients (31.3% paroxysmal AF, left atrial diameter 41±3.1 mm) were included in the final analysis. In studies focusing specifically on PWI, the acute procedural success rate for achieving PWI was 94.1% (95% CI, 87.2%–99.3%). Single-procedure 12-month freedom from atrial arrhythmia was 65.3% (95% CI, 57.7%–73.9%) overall and 61.9% (54.2%–70.8%) for persistent AF. Randomized control trials comparing PWI to pulmonary vein isolation (3 studies, 444 patients) yielded conflicting results and could not confirm an incremental benefit to PWI. Fifteen major complications (0.1%), including 2 atrio-esophageal fistulas, were reported.
Conclusions:
PWI as an end point of AF ablation can be achieved in a large proportion of cases with good rates of 12-month freedom from atrial arrhythmia. Although the procedure-related complication rate is low, it did not eliminate the risk of atrio-esophageal fistula.
Registration:
URL:
http://www.crd.york.ac.uk/prospero
. PROSPERO registration number: CRD42018107212.
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Affiliation(s)
- Anand Thiyagarajah
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Kadhim Kadhim
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Dennis H. Lau
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Dominik Linz
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Kashif Khokhar
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Dian A. Munawar
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Ricardo Mishima
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Lyell McEwin Health Service, Adelaide, Australia (R.M.)
| | - Varun Malik
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Catherine O’Shea
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., R.M., V.M., C.O., R.M., P.S.)
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia (A.T., K. Kadhim, D.H.L., M.E., D.L., K. Khokhar, D.A.M., V.M., C.O., R.M., P.S.)
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Aryana A, Baker JH, Espinosa Ginic MA, Pujara DK, Bowers MR, O'Neill PG, Ellenbogen KA, Di Biase L, d'Avila A, Natale A. Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: A multicenter experience. Heart Rhythm 2019; 15:1121-1129. [PMID: 30060879 DOI: 10.1016/j.hrthm.2018.05.014] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) in conjunction with isolation of the posterior left atrial wall (PVI+PWI) is associated with improved clinical outcomes in certain patients with atrial fibrillation (AF). OBJECTIVE The purpose of this multicenter study was to evaluate the acute and long-term outcomes of PVI+PWI vs PVI alone performed using cryoballoon ablation in patients with persistent AF (persAF). METHODS We examined the procedural safety and efficacy and short- and long-term outcomes in 390 consecutive patients with persAF who underwent a first-time cryoballoon ablation procedure using PVI+PWI (n = 222 [56.9%]) vs PVI alone (n = 168 [43.1%]). RESULTS Acute isolation was achieved in 99.7% of all pulmonary veins (PVI+PWI = 99.8% vs PVI alone = 99.3%; P = .23) using 6.3 ± 1.4 applications and 17 ± 2 minutes of cryoablation. PWI was achieved using 13.7 ± 3.2 applications and 34 ± 10 minutes of cryoablation. Adjunct radiofrequency ablation was required in 1.8% of patients to complete PVI (4 ± 2 minutes) and in 32.4% to complete PWI (5 ± 2 minutes). PVI+PWI yielded significantly greater posterior wall (77.2% ± 6.4% vs 40.6% ± 4.9%; P < .001) and total left atrial (53.3% ± 4.2% vs 36.3% ± 3.8%; P < .001) isolation. In addition, PVI+PWI was associated with greater AF termination (19.8% vs 8.9%; P = .003) and conversion to atrial flutters (12.2% vs 5.4%; P = .02). Adverse events were similar in both groups, whereas recurrence of AF and all atrial arrhythmias was lower with PVI+PWI at 12 months of follow-up. Moreover, in a Cox regression analysis, PVI+PWI emerged as a significant predictor of freedom from recurrent atrial arrhythmias (hazard ratio: 2.04; 95% confidence interval: 1.15-3.61; P = .015). CONCLUSION PVI+PWI can be achieved safely and effectively using the cryoballoon. This approach appears superior to PVI alone in patients with persAF.
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Affiliation(s)
- Arash Aryana
- Dignity Health Heart and Vascular Institute, Mercy General Hospital, Sacramento, California.
| | | | | | - Deep K Pujara
- University of Texas School of Public Health, Houston, Texas
| | - Mark R Bowers
- Dignity Health Heart and Vascular Institute, Mercy General Hospital, Sacramento, California
| | - P Gearoid O'Neill
- Dignity Health Heart and Vascular Institute, Mercy General Hospital, Sacramento, California
| | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore Hospital, Bronx, New York
| | - André d'Avila
- Cardiac Arrhythmia Research Institute, Cardiac Hospital of Florianopolis, Florianopolis, Santa Catarina, Brazil
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
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Higuchi S, Ejima K, Shoda M, Yamamoto E, Iwanami Y, Yagishita D, Hagiwara N. Impact of a prolonged interatrial conduction time for predicting the recurrence of atrial fibrillation after circumferential pulmonary vein isolation of persistent atrial fibrillation. Heart Vessels 2018; 34:616-624. [PMID: 30291411 DOI: 10.1007/s00380-018-1272-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 09/28/2018] [Indexed: 11/26/2022]
Abstract
There are some cases that are difficult to cure with only circumferential pulmonary vein isolation (CPVI) of persistent atrial fibrillation (PerAF). Recently, prolonged interatrial conduction times (IACTs), which seem to be associated with progressive remodeled atria, have been reported as a predictor of new-onset AF. This study aimed to investigate the prognostic value of a prolonged IACT for predicting AF recurrences after CPVI of PerAF. One hundred thirteen patients who underwent CPVI without an empirical substrate modification of PerAF were retrospectively analyzed. The IACT was defined as the interval from the earliest P-wave onset on the ECG to the latest activation in the coronary sinus and was measured after achieving the CPVI and conversion to sinus rhythm. During a mean 22.7-month follow-up after the initial procedure, 56 patients (50%) had AF recurrences. Patients with AF recurrence had a longer IACT than those without AF recurrence (p < 0.001). The best discriminative cut-off value for the IACT was 123 ms (sensitivity 53%, specificity 85%). In a Cox multivariate analysis, a prolonged IACT of ≥ 123 ms was the only independent predictor (hazard ratio: 2.38; 95% confidence interval: 1.36-4.16, p = 0.002) of being associated with the incidence of an AF recurrence. Even after multiple CPVI procedures, patients with an IACT ≥ 123 ms had a higher AF recurrence rate than those with an IACT < 123 ms (p = 0.002). In conclusion, a prolonged IACT of ≥ 123 ms may be a useful marker for predicting AF recurrences after both initial and multiple CPVI procedures for PerAF.
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Affiliation(s)
- Satoshi Higuchi
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Koichiro Ejima
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Morio Shoda
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Eri Yamamoto
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yuji Iwanami
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Daigo Yagishita
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women'S Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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