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Kueffer T, Stettler R, Maurhofer J, Madaffari A, Stefanova A, Iqbal SUR, Thalmann G, Kozhuharov NA, Galuszka O, Servatius H, Haeberlin A, Noti F, Tanner H, Roten L, Reichlin T. Pulsed-field vs cryoballoon vs radiofrequency ablation: Outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)02372-5. [PMID: 38614191 DOI: 10.1016/j.hrthm.2024.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patients with paroxysmal atrial fibrillation (AF). OBJECTIVE The purpose of this study was to compare the procedural and long-term outcomes in patients with persistent AF undergoing PVI using PFA, CBA, or RFA. METHODS Consecutive patients with persistent AF undergoing first PVI with PFA, CBA, or RFA were included. Patients underwent 7-day Holter electrocardiography at 3, 6, and 12 months postablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events. RESULTS A total of 533 patients with persistent AF underwent PVI using PFA (n = 214, 39%), CBA (n = 190, 36%), or RFA (n = 129, 24%). Procedures with PFA guided by fluoroscopy were shorter than those with CBA (median 60 minutes; interquartile range [IQR] 53-80 minutes vs 84 minutes; IQR 68-101 minutes; P ≤ .001), and procedures with PFA in combination with 3-dimensional electroanatomic mapping were shorter than those with RFA (median 101 minutes; IQR 85-126 minutes vs 171 minutes; IQR 141-204 minutes; P < .001). Acute safety events occurred in 2.3%, 2.6%, and 0.8% in the PFA, CBA, and RFA groups, respectively (P = .545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA, and 48.3% for RFA (CBA vs PFA: P = .79; CBA vs RFA: P = .009; PFA vs RFA: P = .010). CONCLUSION In patients with persistent AF undergoing first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA than with RFA.
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Affiliation(s)
- Thomas Kueffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; SITEM Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Bern, Switzerland
| | - Robin Stettler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Maurhofer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anita Stefanova
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salik Ur Rehman Iqbal
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregor Thalmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikola A Kozhuharov
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Oskar Galuszka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; SITEM Center for Translational Medicine and Biomedical Entrepreneurship, University of Bern, Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Espinosa T, Farrus A, Venturas M, Cano A, Vazquez-Calvo S, Pujol-Lopez M, Eulogio-Valenzuela F, Guichard JB, Falzone PV, Graterol FR, Freixa X, Tolosana JM, Guasch E, Porta-Sanchez A, Arbelo E, Brugada J, Sitges M, Mont L, Roca-Luque I, Althoff TF. Same-day discharge after atrial fibrillation ablation under a nurse-coordinated standardized protocol. Europace 2024; 26:euae083. [PMID: 38571291 PMCID: PMC11020282 DOI: 10.1093/europace/euae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/28/2024] [Indexed: 04/05/2024] Open
Abstract
AIMS Same-day discharge (SDD) after atrial fibrillation (AF) ablation is an effective means to spare healthcare resources. However, safety remains a concern, and besides structural adaptations, SDD requires more efficient logistics and coordination. Therefore, in this study, we implement a streamlined, nurse-coordinated SDD programme following a standardized protocol. METHODS AND RESULTS As a dedicated SDD coordinator, a nurse specialized in ambulatory cardiac interventions was in charge of the full SDD protocol, including eligibility, patient flow, in-hospital logistics, patient education, and discharge as well as early post-discharge follow-up by smartphone-based virtual visits. Patients planned for AF ablation were considered eligible if they had a left ventricular ejection fraction (LVEF) ≥35%, with basic support at home and accessibility of the hospital within 60 min also forming a part of the eligibility criteria. A total of 420 consecutive patients were screened by the SDD coordinator, of whom 331 were eligible for SDD. The reasons for exclusion were living remotely (29, 6.9%), lack of support at home (19, 4.5%), or LVEF <35% (17, 4.0%). Of the eligible patients, 300 (91%) were successfully discharged the same day. There were no major post-SDD complications. Rates of unplanned medical attention (19, 6.3%) and 30-day readmission (5, 1.6%) were extremely low and driven by femoral access-site complications. These were significantly reduced upon the introduction of compulsory ultrasound-guided punctures after the initial 150 SDD patients (P = 0.0145). Standardized SDD coordination resulted in efficient workflows and reduced the total workload of the medical staff. CONCLUSION Same-day discharge after AF ablation following a nurse-coordinated standardized protocol is safe and efficient. The concept of ambulatory cardiac intervention nurses functioning as dedicated coordinators may be key in the future transition of hospitals to SDD. Ultrasound-guided femoral puncture virtually eliminated relevant femoral access-site complications in our cohort and should therefore be a prerequisite for SDD.
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Affiliation(s)
- Teresa Espinosa
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Anna Farrus
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Montserrat Venturas
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Alba Cano
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Sara Vazquez-Calvo
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Margarida Pujol-Lopez
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Frida Eulogio-Valenzuela
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Jean-Baptiste Guichard
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Pasquale V Falzone
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Freddy R Graterol
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Xavier Freixa
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Jose M Tolosana
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Eduard Guasch
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Andreu Porta-Sanchez
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Elena Arbelo
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Josep Brugada
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
| | - Marta Sitges
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Lluis Mont
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Ivo Roca-Luque
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red, Cardiovascular Diseases (CIBERCV), Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Till F Althoff
- Department of Cardiology, Cardiovascular Institute (ICCV), CLÍNIC—Barcelona University Hospital, Carrer Villarroel 170, 08036 Barcelona, Catalonia, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Department of Arrhythmia Research, C/del Rosselló, 149, 08036 Barcelona, Catalonia, Spain
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Margolis G, Goldhaber O, Kazatsker M, Kobo O, Roguin A, Leshem E. Atrial Fibrillation Catheter Ablation among Cancer Patients: Utilization Trends and In-Hospital Outcomes. J Clin Med 2024; 13:1318. [PMID: 38592136 PMCID: PMC10932365 DOI: 10.3390/jcm13051318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Atrial fibrillation (AF) catheter ablation in cancer patients has been evaluated in very few studies. We aimed to investigate utilization trends and in-hospital outcomes of AF catheter ablation among cancer patients in a large US inpatient registry. Methods: Utilizing the National Inpatient Sample (NIS) database, patients who underwent AF catheter ablation between 2012 and 2019 were identified. Sociodemographic, clinical data, in-hospital procedures and outcomes were collected. Baseline characteristics and in-hospital outcomes were compared between patients with and without cancer. Results: An estimated total of 67,915 patients underwent AF catheter ablation between 2012 and 2019 in the US. Of them, 950 (1.4%) had a cancer diagnosis. Patients with a cancer diagnosis were older and had higher Charlson Comorbidity Index, CHA2DS2-VASc and ATRIA bleeding indices scores. A higher rate of total complications was observed in cancer patients (10.5% vs. 7.9, p < 0.001), driven mainly by more bleeding and infectious complications. However, no significant differences in cardiac or neurological complications as well as in-hospital mortality rates were observed and were relatively low in both groups. Conclusions: AF catheter ablation in cancer patients is associated with higher bleeding and infectious complication rates, but not with increased cardiac complications or in-hospital mortality in a US nationwide, all-comer registry.
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Affiliation(s)
- Gilad Margolis
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 38100, Israel; (O.G.); (M.K.); (O.K.); (A.R.); (E.L.)
- Cardiac Electrophysiology Unit, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Ofir Goldhaber
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 38100, Israel; (O.G.); (M.K.); (O.K.); (A.R.); (E.L.)
| | - Mark Kazatsker
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 38100, Israel; (O.G.); (M.K.); (O.K.); (A.R.); (E.L.)
- Cardiac Electrophysiology Unit, Hillel Yaffe Medical Center, Hadera 38100, Israel
| | - Ofer Kobo
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 38100, Israel; (O.G.); (M.K.); (O.K.); (A.R.); (E.L.)
| | - Ariel Roguin
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 38100, Israel; (O.G.); (M.K.); (O.K.); (A.R.); (E.L.)
| | - Eran Leshem
- Division of Cardiovascular Medicine, Hillel Yaffe Medical Center, The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 38100, Israel; (O.G.); (M.K.); (O.K.); (A.R.); (E.L.)
- Cardiac Electrophysiology Unit, Hillel Yaffe Medical Center, Hadera 38100, Israel
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Kataoka N, Imamura T, Koi T, Uchida K, Kinugawa K. Adverse Events Requiring Hospitalization Following Catheter Ablation for Atrial Fibrillation in Heart Failure with versus without Systolic Dysfunction. J Cardiovasc Dev Dis 2024; 11:35. [PMID: 38392249 PMCID: PMC10888582 DOI: 10.3390/jcdd11020035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND The safety and efficacy of atrial fibrillation (AF) ablation in individuals with heart failure (HF) with preserved ejection fraction (EF), particularly concerning the occurrence of post-procedural adverse events necessitating hospitalization, including anticoagulant-associated major bleeding, still lack conclusive determination. METHODS Data from patients with HF and AF who underwent catheter ablation for AF between 2019 and 2022 at our institution were retrospectively reviewed. All participants were divided into an EF < 50% group or an EF ≥ 50% group according to their baseline left ventricular EF. The composite incidence of the clinical events following catheter ablation was compared between the two groups: (1) all-cause death, (2) HF hospitalization, (3) stroke or systemic embolism, and (4) major bleeding. RESULTS A total of 122 patients (75 years old, 68 male) were included. Of them, 62 (50.8%) patients had an EF ≥ 50%. EF ≥ 50% was an independent predictor of the composite endpoint (adjusted odds ratio 6.07, 95% confidence interval 1.37-26.99, p = 0.018). The incidences of each adverse event were not significantly different between the two groups, except for a higher incidence of major bleeding in the EF ≥ 50% group (12.7% vs. 0%, p = 0.026). CONCLUSIONS Among patients with HF coupled with AF, the incidence of adverse events following AF ablation proved notably elevated in patients with EF ≥ 50% in contrast to their counterparts with EF < 50%. This disparity primarily stems from a heightened occurrence of major bleeding within the EF ≥ 50% cohort. The strategy to reduce adverse events, especially in patients with EF ≥ 50%, remains the next concern.
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Affiliation(s)
- Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Sugitani, Toyama 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Sugitani, Toyama 930-0194, Japan
| | - Takahisa Koi
- Second Department of Internal Medicine, University of Toyama, Sugitani, Toyama 930-0194, Japan
| | - Keisuke Uchida
- Second Department of Internal Medicine, University of Toyama, Sugitani, Toyama 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Sugitani, Toyama 930-0194, Japan
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5
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Piros K, Vida A, Szegedi N, Perge P, Salló Z, Ferencz AB, Nagy VK, Herczeg S, Ábrahám P, Csobay-Novák C, Drobni Z, Tahin T, Apponyi G, Merkely B, Gellér L, Osztheimer I. One-Day Interruption of NOAC Is Associated with Low Risk of Periprocedural Adverse Events during Pulmonary Vein Isolation If Combined with Left Atrial Thrombus Exclusion with Computed Tomography. Life (Basel) 2024; 14:133. [PMID: 38255747 PMCID: PMC10817453 DOI: 10.3390/life14010133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Safety, efficacy, and patient comfort are the expectations during pulmonary vein isolation (PVI). We aimed to validate the combined advantages of pre- and periprocedural anticoagulation with non-vitamin K anticoagulants (NOACs) and rigorous left atrial appendage thrombus (LAAT) exclusion with computed tomography (CT). METHODS This study included a population of consecutive patients, between March 2018 and June 2020, who underwent cardiac CT within 24 h before PVI to guide the ablation and rule out LAAT. NOAC was omitted 24 h before the ablation. RESULTS A total of 187 patients (63% male) underwent CT before PVI. None of the patients experienced stroke during or after the procedure. The complication rate was low, with no thromboembolic events and 2.1% of patients experiencing a major bleeding event. CONCLUSIONS Omitting NOAC 24 h before the ablation might be safe if combined with left atrial thrombus exclusion with computed tomography.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, Városmajor Street 68, 1122 Budapest, Hungary; (K.P.); (A.V.); (N.S.); (P.P.); (Z.S.); (A.B.F.); (V.K.N.); (S.H.); (P.Á.); (C.C.-N.); (Z.D.); (T.T.); (G.A.); (B.M.); (L.G.)
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6
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Mugnai G, Farkowski M, Tomasi L, Roten L, Migliore F, de Asmundis C, Conte G, Boveda S, Chun JKR. Prevention of venous thromboembolism in right heart-sided electrophysiological procedures: results of an European Heart Rhythm Association survey. Europace 2023; 26:euad364. [PMID: 38091971 PMCID: PMC10754160 DOI: 10.1093/europace/euad364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023] Open
Abstract
Limited data are available regarding venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), following right-sided ablations and electrophysiological (EP) studies. Compared to left-sided procedures, no guidelines on antithrombotic management strategies for the prevention of DVT and PE are available. The main purpose of the present European Heart Rhythm Association (EHRA) survey is to report the current management of right-sided EP procedures, focusing on anticoagulation and prevention of VTE. An online survey was conducted using the EHRA infrastructure. A total of 244 participants answered a 19-items questionnaire on the periprocedural management of EP studies and right-sided catheter ablations. The right femoral vein is the most common access for EP studies and right-sided procedures. An ultrasound-guided approach is employed by more than 2/3 of respondents. Intravenous heparin is not commonly given by the majority of participants. About 1/3 of participants (34%) routinely prescribe VTE prophylaxis during (mostly aspirin and low molecular weight heparin) and 1/4 of respondents (25%) commonly prescribe VTE prophylaxis after discharge (mostly aspirin). Of note, respectively 13% and 9% of participants observed at least one DVT and one PE related to right-sided ablation or EP study within the last year in their center. The present survey shows that only a minority of operators routinely gives intraprocedural intravenous heparin and prescribes VTE prophylaxis after right-sided EP procedures. Compared to left-sided procedures like atrial fibrillation (AF) ablation, there are no consistent systematic antithrombotic management strategies.
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Affiliation(s)
- Giacomo Mugnai
- Division of Cardiology, Cardio-Thoracic Department, School of Medicine, University Hospital of Verona, Piazzale Aristide Stefani 1, 37126 Verona, Italy
| | - Michal Farkowski
- Department of Cardiology, Ministry of Interior and Administration National Medical Institute, Warsaw, Poland
| | - Luca Tomasi
- Division of Cardiology, Cardio-Thoracic Department, School of Medicine, University Hospital of Verona, Piazzale Aristide Stefani 1, 37126 Verona, Italy
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico Migliore
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University Hospital of Padova, Padova, Italy
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Brussels, Belgium
| | - Giulio Conte
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien (CCB), Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt Am Main, Germany
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7
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Palmisano P, Parlavecchio A, Crea P, Guido A, Accogli M, Coluccia G. Superior approach from the pocket for atrioventricular junction ablation performed at the time of conduction system pacing implantation. Pacing Clin Electrophysiol 2023; 46:1652-1661. [PMID: 37864437 DOI: 10.1111/pace.14849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/07/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Conduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve outcomes in patients with symptomatic, refractory atrial fibrillation (AF). Superior approach (SA) from the pocket via axillary or subclavian vein has been proposed as an alternative to the conventional femoral venous access (FA) to perform AVJA. OBJECTIVE To assess the feasibility and safety of SA for AVJA performed simultaneously with CSP, and to compare this approach with FA. METHODS A prospective, observational study, enrolling consecutive patients with symptomatic, refractory AF undergoing simultaneous CSP and AVJA. RESULTS A total of 107 patients were enrolled: in 50, AVJA was primarily attempted with SA, in 69 from FA. AVJA with SA was successful in 38 patients (76.0%), while in 12 patients, a subsequent FA was required. AVJA from FA was successful in 68 patients (98.5%), while in one patient, a left-sided approach via femoral artery was required. Compared with FA, SA was associated with a significantly longer duration of ablation (238.0 ± 218.2 vs. 161.9 ± 181.9 s; p = .035), a significantly shorter procedure time (28.1 ± 19.8 vs. 19.8 ± 16.8 min; p = .018), an earlier ambulation (2.7 ± 3.2 vs. 19.8 ± 0.1 h; p < .001), and an earlier discharge from procedure completion (24.0 ± 2.7 vs. 27.1 ± 5.1 h; p < .001). After a median follow-up of 12 months, the rate of complications was similar in the two groups (2.0% in SA, 4.3% in FA; p = .483). CONCLUSION Simultaneous CSP and AVJA with SA is feasible, with a safety profile similar to FA. Compared to FA, this approach reduces the procedure times and allows earlier ambulation and discharge.
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Affiliation(s)
| | - Antonio Parlavecchio
- Cardiology Unit, "Card. G. Panico" Hospital, Tricase, Italy
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Pasquale Crea
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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8
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Müller J, Nentwich K, Berkovitz A, Sonne K, Kozlova O, Barth S, Deacanu A, Waechter C, Halbfass P, Lehrmann H, Deneke T. Recurrent Atrial Fibrillation Ablation after Initial Successful Pulmonary Vein Isolation. J Clin Med 2023; 12:7177. [PMID: 38002789 PMCID: PMC10672075 DOI: 10.3390/jcm12227177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is an effective treatment option for patients with symptomatic atrial fibrillation (AF). However, the electrical recovery of pulmonary veins (PVs) is the main trigger for AF recurrences. This study investigates the characteristics of patients admitted for redo AF ablation, the PV reconnection rates depending on previous ablation modalities and the impact of different ablation strategies for redo procedures. METHODS Consecutive patients undergoing first redo AF ablation were included. Patients were grouped according to the electrical recovery of at least one PV. The impacts of the technique for first AF ablation on PV reconnection rates and patients with and without PV reconnection were compared. Different ablation strategies for redo procedures were compared and its recurrence rates after a mean follow-up of 25 ± 20 months were investigated. RESULTS A total of 389 patients (68 ± 10 years; 57% male; 39% paroxysmal AF) underwent a first redo. The median time between the first and redo procedure was 40 ± 39 months. Radiofrequency was used in 278 patients, cryoballoon was used in 85 patients and surgical AF ablation was performed on 26 patients. In total, 325 patients (84%) had at least one PV reconnected, and the mean number of reconnected PVs was 2.0 ± 1.3, with significant differences between ablation approaches (p for all = 0.002); this was mainly due to differences in the left inferior PV and right superior PV reconnections. The presence of PV reconnection during redo was not associated with better long-term success compared to completely isolated PVs (67% vs. 67%; log-rank p = 0.997). Overall, the different ablation strategies for redos were comparable regarding AF recurrences during follow-up (p = 0.079), with the ablation approach having no impact in the case of left atrial low voltage or without. CONCLUSIONS PV reconnections after initial successful PVI are common among all techniques of AF ablation. Long-term rhythm control off antiarrhythmic drugs was possible in 2/3 of all patients after the redo procedure; however, different ablation strategies with extra-PV trigger ablation did not improve long-term success. Patients with recurrent AF after PVI constitute a challenging group of patients.
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Affiliation(s)
- Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, 79085 Freiburg im Breisgau, Germany;
| | - Karin Nentwich
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Artur Berkovitz
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Kai Sonne
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Olena Kozlova
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Sebastian Barth
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Alexandru Deacanu
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Christian Waechter
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Philipp Halbfass
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Heiko Lehrmann
- Department of Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, 79085 Freiburg im Breisgau, Germany;
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
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Schiavone M, Gasperetti A, Filtz A, Vantaggiato G, Gobbi C, Tondo C, Forleo GB. Safety and Efficacy of Uninterrupted Oral Anticoagulation in Patients Undergoing Catheter Ablation for Atrial Fibrillation with Different Techniques. J Clin Med 2023; 12:6533. [PMID: 37892671 PMCID: PMC10607349 DOI: 10.3390/jcm12206533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/30/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The safety and efficacy of an uninterrupted direct anticoagulation (DOAC) strategy during catheter ablation (CA) for atrial fibrillation (AF) has not been fully investigated with different ablation techniques. METHODS We evaluated consecutive AF patients undergoing catheter ablation with three different techniques. All patients were managed with an uninterrupted DOAC strategy. The primary endpoint was the rate of periprocedural thromboembolic and bleeding events. The secondary endpoints of the study were the rate of MACE and bleeding events at one-year follow-up. RESULTS In total, 162 patients were enrolled. Overall, 53 were female and the median age was 60 [55.5-69.5] years. The median CHA2DS2-VASc and HAS-BLED scores were 2 [1-4] and 2 [1-2], respectively. In total, 16 patients had a past stroke or TIA while 11 had a predisposition or a history of bleeding. The CA procedure was performed with different techniques: RF 43%, cryoballoon 37%, or laser-balloon 20%. Overall, 35.8% were on rivaroxaban, 20.4% were on edoxaban, 6.8% were on apixaban, and 3.7% were on dabigatran. All other patients were all naïve to DOACs; the first anticoagulant dose was given before the ablation procedure. As for periprocedural complications, we found three groin hematomas not requiring interventions, one ischemic stroke, and one systemic air embolism (the last two likely due to several catheter changes through the transeptal sheath). Five patients reached the secondary endpoints: one patient for a myocardial infarction while four patients experienced minor bleeding during 1-year follow-up. CONCLUSIONS Our results corroborate the safety and the efficacy of uninterrupted DOAC strategy in patients undergoing CA for AF, regardless of the ablation technique.
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Affiliation(s)
- Marco Schiavone
- Cardiology Unit, Luigi Sacco University Hospital, 20131 Milan, Italy; (A.F.); (G.V.); (G.B.F.)
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy;
- Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Alessio Gasperetti
- Cardiology Unit, Luigi Sacco University Hospital, 20131 Milan, Italy; (A.F.); (G.V.); (G.B.F.)
- Department of System Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Department of Cardiology, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Annalisa Filtz
- Cardiology Unit, Luigi Sacco University Hospital, 20131 Milan, Italy; (A.F.); (G.V.); (G.B.F.)
| | - Gaia Vantaggiato
- Cardiology Unit, Luigi Sacco University Hospital, 20131 Milan, Italy; (A.F.); (G.V.); (G.B.F.)
| | - Cecilia Gobbi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy;
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, 20138 Milan, Italy;
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
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10
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Turcsan M, Janosi KF, Debreceni D, Toth D, Bocz B, Simor T, Kupo P. Intracardiac Echocardiography Guidance Improves Procedural Outcomes in Patients Undergoing Cavotricuspidal Isthmus Ablation for Typical Atrial Flutter. J Clin Med 2023; 12:6277. [PMID: 37834921 PMCID: PMC10573340 DOI: 10.3390/jcm12196277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Atrial flutter (AFL) represents a prevalent variant of supraventricular tachycardia, distinguished by a macro-reentrant pathway encompassing the cavotricuspid isthmus (CTI). Radiofrequency (RF) catheter ablation stands as the favored therapeutic modality for managing recurring CTI-dependent AFL. Intracardiac echocardiography (ICE) has been proposed as a method to reduce radiation exposure during CTI ablation. This study aims to comprehensively compare procedural parameters between ICE-guided CTI ablation and fluoroscopy-only procedures. A total of 370 consecutive patients were enrolled in our single-center retrospective study. In 151 patients, procedures were performed using fluoroscopy guidance only, while 219 patients underwent ICE-guided CTI ablation. ICE guidance significantly reduced fluoroscopy time (73 (36; 175) s vs. 900 (566; 1179) s; p < 0.001), fluoroscopy dose (2.45 (0.6; 5.1) mGy vs. 40.5 (25.7; 62.9) mGy; p < 0.001), and total procedure time (70 (52; 90) min vs. 87.5 (60; 102.5) min; p < 0.001). Total ablation time (657 (412; 981) s vs. 910 (616; 1367) s; p < 0.001) and the time from the first to last ablation (20 (11; 36) min vs. 40 (25; 55) min; p < 0.01) were also significantly shorter in the ICE-guided group. Acute success rate was 100% in both groups, and no major complications occurred in either group. ICE-guided CTI ablation in patients with AFL resulted in shorter procedure times, reduced fluoroscopy exposure, and decreased ablation times, compared to the standard fluoroscopy-only approach.
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Affiliation(s)
| | | | | | | | | | | | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, Ifjusag utja 13, H-7624 Pecs, Hungary; (M.T.); (K.-F.J.); (D.D.); (D.T.); (B.B.); (T.S.)
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11
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
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12
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Hussain S, Sohrabi C, Providencia R, Ahsan S, Papageorgiou N. Catheter Ablation for the Management of Atrial Fibrillation: An Update of the Literature. Life (Basel) 2023; 13:1784. [PMID: 37629641 PMCID: PMC10455869 DOI: 10.3390/life13081784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Catheter ablation has been shown to be more effective at maintaining sinus rhythm and improving quality of life when compared to antiarrhythmic drugs. Radiofrequency and cryoablation are two effective methods. However, catheter-only ablation strategies have not consistently produced high success rates in treating longstanding and persistent AF patients. The emerging treatment of choice for such cases is hybrid ablation, which involves a multidisciplinary and minimally invasive approach to achieve surgical ablation of the direct posterior left atrial wall in combination with endocardial catheter ablation. Studies have shown promising results for the hybrid approach when compared with catheter ablation alone, but it is not without risks. Large and randomised studies are necessary to further evaluate these strategies for managing AF.
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Affiliation(s)
- Shahana Hussain
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Catrin Sohrabi
- Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rui Providencia
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St Bartholomew’s Hospital, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
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