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Markman TM, Marchlinski FE, Callans DJ, Frankel DS. Programmed Ventricular Stimulation: Risk Stratification and Guiding Antiarrhythmic Therapies. JACC Clin Electrophysiol 2024:S2405-500X(24)00182-8. [PMID: 38661601 DOI: 10.1016/j.jacep.2024.02.034] [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: 01/16/2024] [Accepted: 02/13/2024] [Indexed: 04/26/2024]
Abstract
Electrophysiologic testing with programmed ventricular stimulation (PVS) has been utilized to induce ventricular tachycardia (VT), thereby improving risk stratification for patients with ischemic and nonischemic cardiomyopathies and determining the effectiveness of antiarrhythmic therapies, especially catheter ablation. A variety of procedural aspects can be modified during PVS in order to alter the sensitivity and specificity of the test including the addition of multiple baseline pacing cycle lengths, extrastimuli, and pacing locations. The definition of a positive result is also critically important, which has varied from exclusively sustained monomorphic VT (>30 seconds) to any ventricular arrhythmia regardless of morphology. In this review, we discuss the history of PVS and evaluate its role in sudden cardiac death risk stratification in a variety of patient populations. We propose an approach to future investigations that will capitalize on the unique ability to vary the sensitivity and specificity of this test. We then discuss the application of PVS during and following catheter ablation. The strategies that have been utilized to improve the efficacy of intraprocedural PVS are highlighted during a discussion of the limitations of this probabilistic strategy. The role of noninvasive programmed stimulation is also reviewed in predicting recurrent VT and informing management decisions including repeat ablations, modifications in antiarrhythmic drugs, and implantable cardioverter-defibrillator programming. Based on the available evidence and guidelines, we propose an approach to future investigations that will allow clinicians to optimize the use of PVS for risk stratification and assessment of therapeutic efficacy.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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2
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Kawamura I, Wang BJ, Nies M, Watanabe K, Chaudhry HW, Maejima Y, Sasano T, Gordon R, Dukkipati SR, Reddy VY, Koruth J. Ultrastructural insights from myocardial ablation lesions from microsecond pulsed field vs radiofrequency energy. Heart Rhythm 2024; 21:389-396. [PMID: 38159790 DOI: 10.1016/j.hrthm.2023.12.017] [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: 11/19/2023] [Revised: 12/19/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Ultrastructural findings immediately after pulsed field ablation (PFA) of the myocardium have not been described. OBJECTIVES The purpose of this study was to elucidate ultrastructural characteristics and differences between microsecond PFA at the 1- and 4-hour timepoints after pulse delivery and to compare them to irrigated radiofrequency ablation (RFA) lesions. METHODS Healthy swine underwent endocardial PFA or RFA followed by necropsy. Discrete microsecond PFA and irrigated RFA lesions were created in the ventricles with a lattice tip ablation catheter. Lesions were delivered in a manner so as to allow sampling to occur 1 and 4 hours after ablation. All lesions were located at necropsy, and samples were carefully obtained from within the lesion core, lesion periphery, and adjacent healthy myocardium. Transmission electron microscopic assessment was performed after fixation using paraformaldehyde and glutaraldehyde. RESULTS One hour after microsecond PFA delivery, myocytes were noted to be significantly and uniformly disrupted. Clustered, misaligned, swollen mitochondria coupled with degenerating nuclei and condensed chromatin were visualized. These findings progressed over the subsequent few hours with worsening edema. Similar changes were seen with RFA but reduced in severity. However, there was prominent extravasation of red blood cells with occlusion of capillaries that was not seen in PFA. At the lesion periphery, an abrupt change in the degree of myocyte damage was observed with PFA but not RFA. CONCLUSION Transmission electron microscopy demonstrates evidence of widespread destruction of myocytes as early as an hour after PFA and corroborates known histologic features such as sparing of vessels and sharp lesion margins.
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Affiliation(s)
- Iwanari Kawamura
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Bingyan J Wang
- Cardiovascular Regenerative Medicine, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Moritz Nies
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Keita Watanabe
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hina W Chaudhry
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan; Department of Cell Biology and Molecular Medicine, Cardiovascular Research Institute, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ronald Gordon
- Pathology, Molecular and Cell based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jacob Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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Buschmann E, Van Steenkiste G, Boussy T, Vernemmen I, Schauvliege S, Decloedt A, van Loon G. Three-dimensional electro-anatomical mapping and radiofrequency ablation as a novel treatment for atrioventricular accessory pathway in a horse: A case report. J Vet Intern Med 2023; 37:728-734. [PMID: 36866668 DOI: 10.1111/jvim.16668] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 02/07/2023] [Indexed: 03/04/2023] Open
Abstract
We describe the diagnosis and treatment of an atrioventricular accessory pathway (AP) in a horse using 3-dimensional electro-anatomical mapping (3D EAM) and radiofrequency catheter ablation (RFCA). During routine evaluation of the horse, intermittent ventricular pre-excitation was identified on the ECG, characterized by a short PQ interval and abnormal QRS morphology. A right cranial location of the AP was suspected from the 12-lead ECG and vectorcardiography. After precise localization of the AP using 3D EAM, ablation was performed and AP conduction was eliminated. Immediately after recovery from anesthesia an occasional pre-excited complex still was observed, but a 24-hour ECG and an ECG during exercise 1 and 6 weeks after the procedure showed complete disappearance of pre-excitation. This case shows the feasibility of 3D EAM and RFCA to identify and treat an AP in horses.
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Affiliation(s)
- Eva Buschmann
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Glenn Van Steenkiste
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Tim Boussy
- Department of Cardiology, AZ Groeninge, Kortrijk, Belgium
| | - Ingrid Vernemmen
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Stijn Schauvliege
- Department of Large Animal Surgery, and Anaesthesia and Orthopaedics, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Annelies Decloedt
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Gunther van Loon
- Equine Cardioteam Ghent, Department of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
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4
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Pérez JJ, Berjano E, González-Suárez A. How far the zone of heat-induced transient block extends beyond the lesion during RF catheter cardiac ablation. Int J Hyperthermia 2023; 40:2163310. [PMID: 36592987 DOI: 10.1080/02656736.2022.2163310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE While radiofrequency catheter ablation (RFCA) creates a lesion consisting of the tissue points subjected to lethal heating, the sublethal heating (SH) undergone by the surrounding tissue can cause transient electrophysiological block. The size of the zone of heat-induced transient block (HiTB) has not been quantified to date. Our objective was to use computer modeling to provide an initial estimate. METHODS AND MATERIALS We used previous experimental data together with the Arrhenius damage index (Ω) to fix the Ω values that delineate this zone: a lower limit of 0.1-0.4 and upper limit of 1.0 (lesion boundary). An RFCA computer model was used with different power-duration settings, catheter positions and electrode insertion depths, together with dispersion of the tissue's electrical and thermal characteristics. RESULTS The HiTB zone extends in depth to a minimum and maximum distance of 0.5 mm and 2 mm beyond the lesion limit, respectively, while its maximum width varies with the energy delivered, extending to a minimum of 0.6 mm and a maximum of 2.5 mm beyond the lesion, reaching 3.5 mm when high energy settings are used (25 W-20s, 500 J). The dispersion of the tissue's thermal and electrical characteristics affects the size of the HiTB zone by ±0.3 mm in depth and ±0.5 mm in maximum width. CONCLUSIONS Our results suggest that the size of the zone of heat-induced transient block during RFCA could extend beyond the lesion limit by a maximum of 2 mm in depth and approximately 2.5 mm in width.
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Affiliation(s)
- Juan J Pérez
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- School of Engineering, University of Galway, Galway, Ireland.,Translational Medical Device Lab, University of Galway, Galway, Ireland
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5
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Zhou B, Yu J, Ju W, Li X, Zhang F, Chen H, Li M, Gu K, Xie X, Cheng D, Wang X, Wu Y, Zhou J, Zhang B, Kojodjojo P, Cao K, Yang B, Chen M. Bipolar Catheter Ablation Strategies for Outflow Tract Ventricular Arrhythmias Refractory to Unipolar Ablation. J Cardiovasc Electrophysiol 2022; 33:1769-1778. [PMID: 35634859 DOI: 10.1111/jce.15579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/02/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Benjun Zhou
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
- Department of CardiologyThe Affiliated Jiangning Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Jinbo Yu
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Weizhu Ju
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Xiaorong Li
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Fengxiang Zhang
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Hongwu Chen
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Mingfang Li
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Kai Gu
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Xin Xie
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Dian Cheng
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Xuecheng Wang
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Yizhang Wu
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Jian Zhou
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Baowei Zhang
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Pipin Kojodjojo
- Department of CardiologyNg Teng Fong General HospitalSingaporeSingapore
| | - Kejiang Cao
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
| | - Bing Yang
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
- Department of Cardiology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Minglong Chen
- Department of CardiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingP.R. China
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6
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Buja LM, Schoen FJ. The pathology of cardiovascular interventions and devices for coronary artery disease, vascular disease, heart failure, and arrhythmias. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Decroocq M, Rousselet L, Riant M, Norberciak L, Viart G, Guyomar Y, Graux P, Maréchaux S, Germain M, Menet A. Periprocedural, early, and long-term risks of pacemaker implantation after atrioventricular nodal re-entry tachycardia ablation: a French nationwide cohort. Europace 2021; 22:1526-1536. [PMID: 32785702 DOI: 10.1093/europace/euaa151] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023] Open
Abstract
AIMS Pacemaker implantation (PI) after atrioventricular nodal re-entry tachycardia (AVNRT) ablation is a dreadful complication. We aimed to assess periprocedural, early, and late risks for PI. METHODS AND RESULTS All 27 022 patients who underwent latest AVNRT ablation in France from 2009 to 2017, were identified in the nationwide medicalization database. A control group of 305 152 patients hospitalized for arm, leg, or skin injuries with no history of AVNRT or supraventricular tachycardia were selected. After propensity score matching, both groups had mean age of 53 ± 18 years and were predominantly female (64%). During this 9-year period, 822 of 27 022 (3.0%) AVNRT patients underwent PI, with significant higher risk in propensity-matched AVNRT patients compared to propensity-matched controls [2.9% vs. 0.9%; hazard ratio 3.4 (2.9-3.9), P < 0.0001]. This excess risk was significant during all follow-up, including periprocedural (1st month), early (1-6 months), and late (>6 months) risk periods. Annualized late risk per 100 AVNRT patients was 0.2%. In comparison to controls, excess risk was 0.2% in <30-year-old AVNRT patients; 0.7% in 30-50-year-old; 1.1% in 50-70-year-old and 6.5% over 70-year-olds. Risk for PI was also significantly different according to three procedural factors: centres, experience, and ablation date, with a 30% decrease since 2015. CONCLUSION Periprocedural, early, and late risks for PI were higher after AVNRT ablation compared to propensity-matched controls. Longer follow-up is needed as the excess risk seems to persist late after AVNRT ablation.
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Affiliation(s)
- Marie Decroocq
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Cardiologie, Université Catholique de Lille, F-59000 Lille, France
| | - Louis Rousselet
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département d'Information Médicale, Université Catholique de Lille, F-59000 Lille, France
| | - Margaux Riant
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Recherche Médicale, Université Catholique de Lille, F-59000 Lille, France
| | - Laurène Norberciak
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Recherche Médicale, Université Catholique de Lille, F-59000 Lille, France
| | - Guillaume Viart
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Cardiologie, Université Catholique de Lille, F-59000 Lille, France
| | - Yves Guyomar
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Cardiologie, Université Catholique de Lille, F-59000 Lille, France
| | - Pierre Graux
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Cardiologie, Université Catholique de Lille, F-59000 Lille, France
| | - Sylvestre Maréchaux
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Cardiologie, Université Catholique de Lille, F-59000 Lille, France
| | - Marysa Germain
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département d'Information Médicale, Université Catholique de Lille, F-59000 Lille, France
| | - Aymeric Menet
- GCS-Groupement des hôpitaux de l'institut Catholique de Lille/Faculté Libre de Médecine, Département de Cardiologie, Université Catholique de Lille, F-59000 Lille, France
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8
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Calkins H, Gache L, Frame D, Boo LM, Ghaly N, Schilling R, Deering T, Duytschaever M, Packer DL. Predictive value of atrial fibrillation during the postradiofrequency ablation blanking period. Heart Rhythm 2020; 18:366-373. [PMID: 33242668 DOI: 10.1016/j.hrthm.2020.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/30/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recurrent arrhythmia following catheter ablation of atrial fibrillation (AF) may present early, during a standard 3-month blanking period. Early recurrence has been correlated to late recurrence, but the degree to which its absence predicts longer-term success has not been quantified. OBJECTIVE The purpose of this study was to explore and quantify the relationship between early and late arrhythmia recurrence, specifically the negative predictive value, that is, the degree to which absence of blanking period recurrence predicts absence of late recurrence. METHODS A systematic literature review and meta-analysis were conducted using statistical methods of a diagnostic test accuracy review. Studies of AF ablation using point-by-point radiofrequency, with repeated monitoring of arrhythmia recurrence including asymptomatic recurrence, and with separate data by AF type, were eligible. RESULTS Nine studies met the prespecified eligibility criteria. For paroxysmal AF, 89% (confidence interval [CI] 82%-94%) of patients free from early recurrence remained free from late recurrence. The estimate for persistent AF was similar (91%; CI 75%-97%). This finding was robust in sensitivity analyses. Patients with early recurrence had a wider range of likely outcomes with longer-term follow-up. CONCLUSION Freedom from AF recurrence during the blanking period is highly predictive of longer-term success in catheter ablation. Clinical trials in this area may be able to leverage these findings to more quickly assess the potential utility of new ablation technologies and methods, for example, by using early surrogate measures of success.
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Affiliation(s)
- Hugh Calkins
- Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
| | - Larry Gache
- Real World Evidence, CTI Clinical Trial and Consulting Services, Covington, Kentucky
| | - Diana Frame
- Real World Evidence, CTI Clinical Trial and Consulting Services, Covington, Kentucky
| | - Lee Ming Boo
- Clinical Science and External Research, Biosense Webster, Inc, Irvine, California
| | - Nader Ghaly
- Medical Affairs, Biosense Webster, Inc, Irvine, California
| | - Richard Schilling
- Department of Cardiology, St Bartholomew's Hospital, London, United Kingdom
| | - Thomas Deering
- Department of Cardiology, Piedmont Heart Institute, Atlanta, Georgia
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9
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Candemir B, Baskovski E, Duzen V, Coskun F, Vurgun K, Goksuluk H, Ozyuncu N, Kurklu ST, Altin T, Akyurek O, Erol C. Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation. Indian Pacing Electrophysiol J 2019; 19:114-118. [PMID: 30822513 PMCID: PMC6531642 DOI: 10.1016/j.ipej.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/10/2019] [Accepted: 02/14/2019] [Indexed: 12/02/2022] Open
Abstract
Ablation of premature ventricular complexes (PVCs) originating from left ventricular outflow tract (LVOT)/left ventricular summit (LVS) is challenging with considerable rate of failure. Recently, in a novel approach to ablation of these arrythmias, application of radiofrequency energy to anatomically opposite sites of presumed origin of arrythmia, has been associated with moderate procedure success. Although late elimination of PVCs that are persistent following an ablation procedure has been previously reported, this observation has not been studied sufficiently. In this report, firstly, we present three cases of lately eliminated LVS PVCs, then, we discuss possible mechanism of this observation and conclude that after an initial failed attempt of anatomic ablation, operators may choose a period of watchful waiting before attempting a redo procedure.
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Affiliation(s)
- Basar Candemir
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Emir Baskovski
- Ankara University, Cardiology Department, Ankara, Turkiye.
| | - Veysel Duzen
- Gaziantep Ersin Arslan Research Hospital, Cardiology Department, Gaziantep, Turkiye
| | - Firat Coskun
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Kutay Vurgun
- Ankara University, Cardiology Department, Ankara, Turkiye
| | | | - Nil Ozyuncu
- Ankara University, Cardiology Department, Ankara, Turkiye
| | | | - Timucin Altin
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Omer Akyurek
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Cetin Erol
- Ankara University, Cardiology Department, Ankara, Turkiye
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10
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Shirai Y, Liang JJ, Santangeli P, Arkles JS, Schaller RD, Supple GE, Lin D, Nazarian S, Deo R, Dixit S, Epstein AE, Callans DJ, Marchlinski FE, Frankel DS. Long-term outcome and mode of recurrence following noninducibility during noninvasive programmed stimulation after ventricular tachycardia ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:333-340. [PMID: 30656717 DOI: 10.1111/pace.13605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/21/2018] [Accepted: 01/14/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Noninducibility of ventricular tachycardia (VT) at noninvasive programmed stimulation performed shortly following ablation (negative NIPS) predicts low risk of the medium-term recurrence. This study aimed to evaluate long-term rate and mode of recurrence following negative NIPS. METHODS We extended follow-up on patients in whom no VT could be induced at NIPS following ablation between 2008 and 2010. Recurrent VTs were categorized as "Original clinical" if they matched VT that had occurred spontaneously prior to the index ablation; "Original nonclinical" if they matched VT that was induced during the index ablation but had not occurred spontaneously; or "New." Among those undergoing repeat ablation, the area ablated to treat the recurrent VT was categorized as "Targeted initial scar" if it was targeted during the index procedure; "Untargeted initial scar" if it was present but not targeted during the index procedure; or "New scar" if it was not present during the index procedure. RESULTS Of 60 patients with negative NIPS, 18 (30%) had recurrent VT and nine underwent repeat ablation over (4.1 ± 3.2) years follow-up. Of 23 recurrent VTs, 18 (78%) were "New." During repeat ablations, six (46%) of the 13 recurrent VTs were ablated in "untargeted initial scar" and four (31%) in "new scar." CONCLUSIONS When spontaneous or inducible VTs are eliminated with ablation and no longer inducible during NIPS, these VTs are unlikely to recur during long-term follow-up. More commonly, new VTs occur, which are either associated with areas of scar not present or not targeted during the initial ablation.
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Affiliation(s)
- Yasuhiro Shirai
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson J Liang
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Arkles
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rajat Deo
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew E Epstein
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Krahn PRP, Singh SM, Ramanan V, Biswas L, Yak N, Anderson KJT, Barry J, Pop M, Wright GA. Cardiovascular magnetic resonance guided ablation and intra-procedural visualization of evolving radiofrequency lesions in the left ventricle. J Cardiovasc Magn Reson 2018; 20:20. [PMID: 29544514 PMCID: PMC5856306 DOI: 10.1186/s12968-018-0437-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 02/15/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Radiofrequency (RF) ablation has become a mainstay of treatment for ventricular tachycardia, yet adequate lesion formation remains challenging. This study aims to comprehensively describe the composition and evolution of acute left ventricular (LV) lesions using native-contrast cardiovascular magnetic resonance (CMR) during CMR-guided ablation procedures. METHODS RF ablation was performed using an actively-tracked CMR-enabled catheter guided into the LV of 12 healthy swine to create 14 RF ablation lesions. T2 maps were acquired immediately post-ablation to visualize myocardial edema at the ablation sites and T1-weighted inversion recovery prepared balanced steady-state free precession (IR-SSFP) imaging was used to visualize the lesions. These sequences were repeated concurrently to assess the physiological response following ablation for up to approximately 3 h. Multi-contrast late enhancement (MCLE) imaging was performed to confirm the final pattern of ablation, which was then validated using gross pathology and histology. RESULTS Edema at the ablation site was detected in T2 maps acquired as early as 3 min post-ablation. Acute T2-derived edematous regions consistently encompassed the T1-derived lesions, and expanded significantly throughout the 3-h period post-ablation to 1.7 ± 0.2 times their baseline volumes (mean ± SE, estimated using a linear mixed model determined from n = 13 lesions). T1-derived lesions remained approximately stable in volume throughout the same time frame, decreasing to 0.9 ± 0.1 times the baseline volume (mean ± SE, estimated using a linear mixed model, n = 9 lesions). CONCLUSIONS Combining native T1- and T2-based imaging showed that distinctive regions of ablation injury are reflected by these contrast mechanisms, and these regions evolve separately throughout the time period of an intervention. An integrated description of the T1-derived lesion and T2-derived edema provides a detailed picture of acute lesion composition that would be most clinically useful during an ablation case.
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Affiliation(s)
- Philippa R. P. Krahn
- Department of Medical Biophysics, University of Toronto, Toronto, ON Canada
- Sunnybrook Research Institute, Toronto, ON Canada
| | - Sheldon M. Singh
- Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON Canada
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | | | | | - Nicolas Yak
- Sunnybrook Research Institute, Toronto, ON Canada
| | | | | | - Mihaela Pop
- Department of Medical Biophysics, University of Toronto, Toronto, ON Canada
- Sunnybrook Research Institute, Toronto, ON Canada
- Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON Canada
| | - Graham A. Wright
- Department of Medical Biophysics, University of Toronto, Toronto, ON Canada
- Sunnybrook Research Institute, Toronto, ON Canada
- Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON Canada
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12
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Ju W, Gu K, Yang B, Zhang F, Chen H, Yang G, Li M, Shi L, Yu J, Xiao F, Xu Q, Chu M, Shen W, Cao K, Chen M. Late cure of focal ventricular arrhythmias post-catheter ablation: electrophysiological characteristics and long-term outcome. J Interv Card Electrophysiol 2018; 52:31-37. [PMID: 29460233 DOI: 10.1007/s10840-018-0328-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 02/06/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Late cure after a previously failed ablation of ventricular arrhythmias (VAs) is a relatively common phenomenon. The present study sought to delineate the incidence and electrophysiological characteristics of late cure in idiopathic VA patients. METHODS Totally, 45 idiopathic VA cases (mean age 44 ± 18 years, 27 males) either failed acutely or recurred within 12 h were enrolled in this study. Based on intensive clinical observations in the acute period, 19 (42%) patients demonstrated late cure in the first week after the procedure. RESULTS The late cure patients had significantly better acute and cumulative ablation effects during the procedure than did those without a late cure. Additionally, they had a prediction that originated from the right ventricular outflow tract, aortic-mitral continuum, and left summit area relative to other sites (13/18 vs 6/27, p < 0.01). In a median follow-up of 24 [14, 46] months, 7/19 (37%) patients had their VAs recurred. The late cure group had significantly more patients cured at long-term follow-up than those without (12/19 vs 0/26, p < 0.01). A cutoff value of the "time to eliminate VAs" > 7.0 s was able to predict a long-term recurrence of the VAs with 62.5% sensitivity and 85.7% specificity. CONCLUSIONS The late cure of VAs occurs in more than one third of patients who have a seemingly unsuccessful ablation session, which is clustered in the first week after the procedure. However, long-term recurrence of VAs occurred in 37% of the late cure patients, emphasizing the importance of long-term follow-up.
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Affiliation(s)
- Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Bing Yang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Linsheng Shi
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Jinbo Yu
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Fangyi Xiao
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Qiang Xu
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Ming Chu
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Wenzhi Shen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Kejiang Cao
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road, Nanjing, 210029, China.
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13
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Abreu LADS, Damasceno-Ferreira JA, Costa WS, Pereira-Sampaio MA, Sampaio FJB, de Souza DB. Glomerular Loss After Renal Radiofrequency Ablation Are Comparable to 30 Minutes of Warm Ischemia. J Endourol 2017; 31:517-521. [PMID: 28326799 DOI: 10.1089/end.2016.0899] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To compare, with stereological methods, the glomerular loss in kidneys submitted to radiofrequency ablation (RFA) or warm ischemia. MATERIALS AND METHODS Twenty-six male pigs were divided into three groups. Eight animals were allocated in the sham group, which was submitted to laparoscopic dissection of the left renal hilum, without renal ischemia. Eight animals were allocated in the ischemia group, which had the left renal hilum clamped for 30 minutes under laparoscopic access. Ten animals were submitted to RFA of the left kidney lower pole, under laparoscopic visualization. Animals were euthanized 21 days after surgery, when kidneys were collected. Fragments of the upper pole of the left kidney were processed for morphometric analysis. Right kidney was used as self-controls for each animal. Glomerular volumetric density (Vv[glom]); volume-weighted glomerular volume (VWGV); and glomerular density were quantified by stereological methods and compared by Student's t-test and one-way-analysis of variance with Dunnett's post-test. RESULTS Three animals in the RFA group developed postoperative complications (Urinoma/Hydronephrosis) and were excluded from the analysis. No difference was found among the kidneys submitted to RFA and warm ischemia for all parameters. However, these kidneys showed lower Vv[glom] and glomerular density when compared to its self-controls (right kidneys), and when compared to sham-operated animals (p < 0.05). No difference was observed in regards to VWGV among the groups. CONCLUSION RFA in pigs determines a significant reduction of glomerular density in the remaining parenchyma. This alteration was comparable to that observed in kidneys submitted to 30 minutes of warm ischemia.
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Affiliation(s)
- Leonardo Albuquerque Dos Santos Abreu
- 1 Urogenital Research Unit, State University of Rio de Janeiro , Rio de Janeiro, Brazil .,2 Faculty of Medicine, Estacio de Sá University , Rio de Janeiro, Brazil
| | - José Aurelino Damasceno-Ferreira
- 1 Urogenital Research Unit, State University of Rio de Janeiro , Rio de Janeiro, Brazil .,3 Department of Veterinary Clinical Pathology, Fluminense Federal University , Niterói, Brazil
| | - Waldemar Silva Costa
- 1 Urogenital Research Unit, State University of Rio de Janeiro , Rio de Janeiro, Brazil
| | - Marco Aurélio Pereira-Sampaio
- 1 Urogenital Research Unit, State University of Rio de Janeiro , Rio de Janeiro, Brazil .,4 Department of Morphology, Fluminense Federal University , Niterói, Brazil
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Pathak RK, Garcia FC. Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia. Card Electrophysiol Clin 2017; 9:99-106. [PMID: 28167090 DOI: 10.1016/j.ccep.2016.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Endocardial and epicardial electroanatomical mapping and ablation is a safe and effective therapy in the treatment of right ventricle arrhythmias occurring in the setting of arrhythmogenic right ventricular cardiomyopathy (ARVD). Careful mapping and ablation plans must be tailored for each patient based on comorbidities and ventricular tachycardia morphologies. This review focuses on the catheter ablation for ventricular arrhythmias in patients with ARVD.
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Affiliation(s)
- Rajeev K Pathak
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Fermin C Garcia
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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15
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Buja L, Schoen F. The Pathology of Cardiovascular Interventions and Devices for Coronary Artery Disease, Vascular Disease, Heart Failure, and Arrhythmias. Cardiovasc Pathol 2016. [DOI: 10.1016/b978-0-12-420219-1.00032-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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16
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Double Ventricular Responses Leading to Reversible Cardiomyopathy as Late Complication after Slow-Pathway Ablation. Case Rep Cardiol 2015; 2015:326576. [PMID: 26491571 PMCID: PMC4605263 DOI: 10.1155/2015/326576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/14/2015] [Accepted: 09/16/2015] [Indexed: 11/18/2022] Open
Abstract
Double ventricular response is a rare arrhythmia that results from simultaneous antegrade conduction over the fast and slow pathways of AV node. Double ventricular responses may lead to arrhythmia-related cardiomyopathy. As far as we know, there is not any reported reversible cardiomyopathy development that resulted from double ventricular responses to one atrial impulse after slow pathway ablation. We report a unique case of double ventricular response cardiomyopathy that has been developed 5 years after slow pathway ablation.
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17
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Wu Z, Kumon RE, Laughner JI, Efimov IR, Deng CX. Electrophysiological changes correlated with temperature increases induced by high-intensity focused ultrasound ablation. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:432-448. [PMID: 25516446 PMCID: PMC4297512 DOI: 10.1016/j.ultrasmedbio.2014.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 08/30/2014] [Accepted: 09/04/2014] [Indexed: 06/04/2023]
Abstract
To gain better understanding of the detailed mechanisms of high-intensity focused ultrasound (HIFU) ablation for cardiac arrhythmias, we investigated how the cellular electrophysiological (EP) changes were correlated with temperature increases and thermal dose (cumulative equivalent minutes [CEM43]) during HIFU application using Langendorff-perfused rabbit hearts. Employing voltage-sensitive dye di-4-ANEPPS, we measured the EP and temperature during HIFU using simultaneous optical mapping and infrared imaging. Both action potential amplitude (APA) and action potential duration at 50% repolarization (APD50) decreased with temperature increases, and APD50 was more thermally sensitive than APA. EP and tissue changes were irreversible when HIFU-induced temperature increased above 52.3 ± 1.4°C and log10(CEM43) above 2.16 ± 0.51 (n = 5), but were reversible when temperature was below 50.1 ± 0.8°C and log10(CEM43) below -0.9 ± 0.3 (n = 9). EP and temperature/thermal dose changes were spatially correlated with HIFU-induced tissue necrosis surrounded by a transition zone.
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Affiliation(s)
- Ziqi Wu
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Ronald E Kumon
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Jacob I Laughner
- Department of Biomedical Engineering, Washington University at Saint Louis, MO, USA
| | - Igor R Efimov
- Department of Biomedical Engineering, Washington University at Saint Louis, MO, USA
| | - Cheri X Deng
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
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18
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Keller MW, Schuler S, Wilhelms M, Lenis G, Seemann G, Schmitt C, Dössel O, Luik A. Characterization of radiofrequency ablation lesion development based on simulated and measured intracardiac electrograms. IEEE Trans Biomed Eng 2014; 61:2467-78. [PMID: 24816474 DOI: 10.1109/tbme.2014.2322515] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Radiofrequency ablation (RFA) therapy is the gold standard in interventional treatment of many cardiac arrhythmias. A major obstacle is nontransmural lesions, leading to recurrence of arrhythmias. Recent clinical studies have suggested intracardiac electrogram (EGM) criteria as a promising marker to evaluate lesion development. Seeking for a deeper understanding of underlying mechanisms, we established a simulation approach for acute RFA lesions. Ablation lesions were modeled by a passive necrotic core surrounded by a borderzone with properties of heated myocardium. Herein, conduction velocity and electrophysiological properties were altered. We simulated EGMs during RFA to study the relation between lesion formation and EGM changes using the bidomain model. Simulations were performed on a three-dimensional setup including a geometrically detailed representation of the catheter with highly conductive electrodes. For validation, EGMs recorded during RFA procedures in five patients were analyzed and compared to simulation results. Clinical data showed major changes in the distal unipolar EGM. During RFA, the negative peak amplitude decreased up to 104% and maximum negative deflection was up to 88% smaller at the end of the ablation sequence. These changes mainly occurred in the first 10 s after ablation onset. Simulated unipolar EGMs reproduced the clinical changes, reaching up to 83% negative peak amplitude reduction and 80% decrease in maximum negative deflection for transmural lesions. In future studies, the established model may enable the development of further EGM criteria for transmural lesions even for complex geometries in order to support clinical therapy.
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19
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Liao JN, Hu YF, Wu TJ, Fong AN, Lin WS, Lin YJ, Chang SL, Lo LW, Tuan TC, Chang HY, Li CH, Chao TF, Chung FP, Hanafy DA, Lin WY, Huang JL, Huang CC, Leu HB, Lee PC, Chiang CE, Chen SA. Permanent pacemaker implantation for late atrioventricular block in patients receiving catheter ablation for atrioventricular nodal reentrant tachycardia. Am J Cardiol 2013; 111:569-73. [PMID: 23219174 DOI: 10.1016/j.amjcard.2012.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 11/03/2012] [Accepted: 11/03/2012] [Indexed: 10/27/2022]
Abstract
The present study investigated the incidence and predictors of permanent pacemaker (PPM) implantation for late atrioventricular block (AVB) in patients with atrioventricular nodal reentrant tachycardia (AVNRT) who received ablation. The data from 3,442 patients with AVNRT who received ablation were analyzed. Those who developed late AVB (>1 month after ablation) and received a PPM were identified. The incidence of PPM implantation in 1,148 matched patients with Wolff-Parkinson-White syndrome and in the whole population of Taiwan were compared. Of the patients with AVNRT receiving ablation (mean follow-up duration 128.3 ± 62.5 months), 15 (0.4%) received PPM implantation for late AVB (mean interval after catheter ablation 95.4 ± 55.0 months). Only age (odds ratio 1.05, p = 0.02) and transient AVB (odds ratio 8.55, p = 0.01) during the procedure were independently associated with PPM implantation for late AVB. The patients with AVNRT had a greater incidence of PPM implantation due to late AVB compared to the matched patients with Wolff-Parkinson-White syndrome. The annual incidence of PPM implantation for AVB was also greater in the patients with AVNRT than in the general population. In conclusion, the incidence of PPM implantation for late AVB in patients with AVNRT who received catheter ablation was low but still greater than that in patients with Wolff-Parkinson-White syndrome and the general population in Taiwan.
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20
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Eyerly SA, Bahnson TD, Koontz JI, Bradway DP, Dumont DM, Trahey GE, Wolf PD. Intracardiac acoustic radiation force impulse imaging: a novel imaging method for intraprocedural evaluation of radiofrequency ablation lesions. Heart Rhythm 2012; 9:1855-62. [PMID: 22772134 PMCID: PMC3483372 DOI: 10.1016/j.hrthm.2012.07.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arrhythmia recurrence after cardiac radiofrequency ablation (RFA) for atrial fibrillation has been linked to conduction through discontinuous lesion lines. Intraprocedural visualization and corrective ablation of lesion line discontinuities could decrease postprocedure atrial fibrillation recurrence. Intracardiac acoustic radiation force impulse (ARFI) imaging is a new imaging technique that visualizes RFA lesions by mapping the relative elasticity contrast between compliant-unablated and stiff RFA-treated myocardium. OBJECTIVE To determine whether intraprocedure ARFI images can identify RFA-treated myocardium in vivo. METHODS In 8 canines, an electroanatomical mapping-guided intracardiac echo catheter was used to acquire 2-dimensional ARFI images along right atrial ablation lines before and after RFA. ARFI images were acquired during diastole with the myocardium positioned at the ARFI focus (1.5 cm) and parallel to the intracardiac echo transducer for maximal and uniform energy delivery to the tissue. Three reviewers categorized each ARFI image as depicting no lesion, noncontiguous lesion, or contiguous lesion. For comparison, 3 separate reviewers confirmed RFA lesion presence and contiguity on the basis of functional conduction block at the imaging plane location on electroanatomical activation maps. RESULTS Ten percent of ARFI images were discarded because of motion artifacts. Reviewers of the ARFI images detected RFA-treated sites with high sensitivity (95.7%) and specificity (91.5%). Reviewer identification of contiguous lesions had 75.3% specificity and 47.1% sensitivity. CONCLUSIONS Intracardiac ARFI imaging was successful in identifying endocardial RFA treatment when specific imaging conditions were maintained. Further advances in ARFI imaging technology would facilitate a wider range of imaging opportunities for clinical lesion evaluation.
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Affiliation(s)
- Stephanie A Eyerly
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708, USA
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21
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Caforio ALP, Marcolongo R, Jahns R, Fu M, Felix SB, Iliceto S. Immune-mediated and autoimmune myocarditis: clinical presentation, diagnosis and management. Heart Fail Rev 2012; 18:715-32. [DOI: 10.1007/s10741-012-9364-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Dos Santos LF, Antonio EL, Serra AJ, Venturini G, Montemor J, Okada M, Araújo S, Tucci P, de Paola A, Fenelon G. Thermotolerance does not reduce the size or remodeling of radiofrequency lesions in the rat myocardium. J Interv Card Electrophysiol 2012; 36:5-11; discussion 11. [PMID: 23080332 DOI: 10.1007/s10840-012-9746-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 09/14/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Late lesion extension may be involved in the genesis of delayed radiofrequency (RF) effects. Because RF lesion is thermally mediated, we hypothesized that induction of heat shock response (thermotolerance) would modulate lesion healing. We evaluated the effects of thermotolerance on the dimensions and remodeling of RF lesions in a rat model of heart failure. METHODS Wistar rats (weight 300 g) subjected to heat stress (n = 22, internal temperature of 42 °C for 10 min) were compared to controls (n = 22, internal temperature of 37 °C for 10 min). After 48 h (peak of HSP70 myocardial concentration), a modified unipolar RF lesion (customized catheter, tip 4.5 mm in diameter; 12 W; 10 s) was created on the left ventricular free wall. Animals were sacrificed 2 h (n = 10 per group) and 4 weeks (n = 12 per group) after ablation for lesion analysis. An echocardiogram was obtained at 4 weeks. RESULTS There was no difference between groups regarding the size of acute (controls 27 ± 2 vs. treated 27 ± 3 mm(2)) and chronic lesions (controls 17 ± 1 vs. treated 19 ± 1 mm(2)). Histology of lesions did not differ between groups. The echocardiogram revealed dilation of the cavities and moderate systolic dysfunction without difference between groups. Acute lesion dimensions were similar between control and treated animals over time (ablation undertaken 3, 12, 24, 48, and 72 h after hyperthermia) and also using a conventional ablation catheter (50 °C; 15 W; 10 s). CONCLUSION Thermotolerance does not reduce the size or remodeling of RF lesions in the rat myocardium.
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Affiliation(s)
- Luís Felipe Dos Santos
- Discipline of Cardiology, Paulista School of Medicine, Federal University of São Paulo, Pedro de Toledo 781, 10th Floor (Cardiology), São Paulo, SP 04039-032, Brazil
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Canpolat U, Şahiner L, Aytemir K, Oto A. Recovery of atrioventricular block with teophylline and methylprednisolone occurring few days after slow pathway radiofrequency ablation. Int J Cardiol 2012; 160:e33-4. [PMID: 22340984 DOI: 10.1016/j.ijcard.2012.01.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 01/22/2012] [Indexed: 11/30/2022]
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24
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Frankel DS, Mountantonakis SE, Zado ES, Anter E, Bala R, Cooper JM, Deo R, Dixit S, Epstein AE, Garcia FC, Gerstenfeld EP, Hutchinson MD, Lin D, Patel VV, Riley MP, Robinson MR, Tzou WS, Verdino RJ, Callans DJ, Marchlinski FE. Noninvasive programmed ventricular stimulation early after ventricular tachycardia ablation to predict risk of late recurrence. J Am Coll Cardiol 2012; 59:1529-35. [PMID: 22516442 DOI: 10.1016/j.jacc.2012.01.026] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/15/2011] [Accepted: 01/02/2012] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The goal of this study was to evaluate the ability of noninvasive programmed stimulation (NIPS) after ventricular tachycardia (VT) ablation to identify patients at high risk of recurrence. BACKGROUND Optimal endpoints for VT ablation are not well defined. METHODS Of 200 consecutive patients with VT and structural heart disease undergoing ablation, 11 had clinical VT inducible at the end of ablation and 11 recurred spontaneously. Of the remaining 178 patients, 132 underwent NIPS through their implantable cardioverter-defibrillator 3.1 ± 2.1 days after ablation. At 2 drive cycle lengths, single, double, and triple right ventricular extrastimuli were delivered to refractoriness. Clinical VT was defined by comparison with 12-lead electrocardiograms and stored implantable cardioverter-defibrillator electrograms from spontaneous VT episodes. Patients were followed for 1 year. RESULTS Fifty-nine patients (44.7%) had no VT inducible at NIPS; 49 (37.1%) had inducible nonclinical VT only; and 24 (18.2%) had inducible clinical VT. Patients with inducible clinical VT at NIPS had markedly decreased 1-year VT-free survival compared to those in whom no VT was inducible (<30% vs. >80%; p = 0.001), including 33% recurring with VT storm. Patients with inducible nonclinical VT only, had intermediate 1-year VT-free survival (65%). CONCLUSIONS When patients with VT and structural heart disease have no VT or nonclinical VT only inducible at the end of ablation or their condition is too unstable to undergo final programmed stimulation, NIPS should be considered in the following days to further define risk of recurrence. If clinical VT is inducible at NIPS, repeat ablation may be considered because recurrence over the following year is high.
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Affiliation(s)
- David S Frankel
- Cardiovascular Division, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Chan NY, Mok NS, Choy CC, Lau CL, Chu PS, Yuen HC, Lau ST. Treatment of atrioventricular nodal re-entrant tachycardia by cryoablation with an 8-mm-tip catheter versus radiofrequency ablation. J Interv Card Electrophysiol 2012; 34:295-301. [DOI: 10.1007/s10840-012-9670-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 01/23/2012] [Indexed: 11/28/2022]
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DOS SANTOS LUISF, ANTONIO EDNEI, SERRA ANDREY, VENTURINI GABRIELA, OKADA MIEKO, ARAÚJO SERGIO, TUCCI PAULO, DE PAOLA ANGELO, FENELON GUILHERME. Radiofrequency Ablation Does Not Induce Apoptosis in the Rat Myocardium. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:449-55. [DOI: 10.1111/j.1540-8159.2011.03306.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Choi JI, Pak HN, Park JS, Kwak JJ, Nagamoto Y, Lim HE, Park SW, Hwang C, Kim YH. Clinical significance of early recurrences of atrial tachycardia after atrial fibrillation ablation. J Cardiovasc Electrophysiol 2011; 21:1331-7. [PMID: 20586828 DOI: 10.1111/j.1540-8167.2010.01831.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND atrial tachycardia (AT) commonly recurs within 3 months after radiofrequency catheter ablation for atrial fibrillation (AF). However, it remains unclear whether early recurrence of atrial tachycardia (ERAT) predicts late recurrence of AF or AT. METHODS of 352 consecutive patients who underwent circumferential pulmonary vein isolation with or without linear ablation(s) for AF, 56 patients (15.9%) with ERAT were identified by retrospective analysis. ERAT was defined as early relapse of AT within a 3-month blanking period after ablation. RESULTS during 21.7 ± 12.5 months, the rate of late recurrence was higher in patients with ERAT (41.1%) compared with those without ERAT (11.8%, P < 0.001). In a multivariable model, positive inducibility of AF or AT immediately after ablation (65.2% vs 36.4%, P = 0.046; odd ratio, 3.9; 95% confidence interval, 1.0-14.6) and the number of patients who underwent cavotricuspid isthmus (CTI) ablation (73.9% vs 42.4%, P = 0.042; odd ratio, 4.5; 95% confidence interval, 1.1-19.5) were significantly related to late recurrence in the ERAT group. The duration of ablation (174.3 ± 62.3 vs 114.7 ± 39.5 minutes, P = 0.046) and the procedure time (329.3 ± 83.4 vs 279.2 ± 79.7 minutes, P = 0.027) were significantly longer in patients with late recurrence than in those without late recurrence following ERAT. CONCLUSIONS the late recurrence rate is higher in the patients with ERAT compared with those without ERAT following AF ablation, and is more often noted in the patients who underwent CTI ablation and had a prolonged procedure time. Furthermore, inducibility of AF or AT immediately after ablation independently predicts late recurrence in patients with ERAT.
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Affiliation(s)
- Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea Yonsei University Health System, Seoul, Republic of Korea Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Andrade JG, Khairy P, Verma A, Guerra PG, Dubuc M, Rivard L, Deyell MW, Mondesert B, Thibault B, Talajic M, Roy D, Macle L. Early recurrence of atrial tachyarrhythmias following radiofrequency catheter ablation of atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 35:106-16. [PMID: 22054110 DOI: 10.1111/j.1540-8159.2011.03256.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The use of blanking periods, the immediate period postablation during which transient tachyarrhythmia episodes are not considered recurrences, has been predicated on the assumption that not all early recurrences of atrial tachyarrhythmias (ERAT) will lead to later recurrences and, as such, does not necessarily represent treatment failure. While ERAT can be expected to occur in approximately 38% of patients within the first 3 months of atrial fibrillation (AF) ablation, only half of these patients will manifest later recurrences. Clinical features related to the patient's history of AF, the index ablation procedure, and particularities of the ERAT can help identify patients at higher risk of later recurrence in whom aggressive attempts to control rhythm, including early cardioversion and reintervention, may be justified.
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Affiliation(s)
- Jason G Andrade
- Electrophysiology Service, Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
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Castaño A, Crawford T, Yamazaki M, Avula UMR, Kalifa J. Coronary artery pathophysiology after radiofrequency catheter ablation: review and perspectives. Heart Rhythm 2011; 8:1975-80. [PMID: 21740881 DOI: 10.1016/j.hrthm.2011.07.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 07/04/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) has proven to be an effective and safe treatment in patients with ventricular and atrial tachyarrhythmias. Among complications arising after RFA, the incidence of coronary artery (CA) injury is exceedingly low. When CA injury does occur, however, it can be clinically devastating. The proximity of CAs to common ablation sites suggests that the relationship between RFA and CA perfusion pathophysiology is important for optimal lesion formation and safe arrhythmia treatments. OBJECTIVE Although others have described the presentation and outcomes of patients with CA injury after ablation, a review that consolidates the mechanisms of CA injury after RFA has yet to be presented in the cardiology literature. METHODS We conducted an extensive literature search of studies published over the past 30 years that relate the biophysics of RFA with CA perfusion pathophysiology and injury. RESULTS We present a review of the dynamic relationship between RFA and CA perfusion. We describe RFA lesion pathology, mechanisms of CA injury from RFA, and factors that influence lesion formation, such as convective cooling and the shadow effect. CONCLUSION We summarize methods to mitigate CA injury after RFA and propose new research avenues to optimize lesion formation and safe arrhythmia treatments when tissue is ablated in the vicinity of CAs.
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Affiliation(s)
- Adam Castaño
- Department of Internal Medicine, Columbia University Medical Center, New York, New York, USA
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Chang SL, Tsao HM, Lin YJ, Lo LW, Hu YF, Tuan TC, Suenari K, Tai CT, Li CH, Chao TF, Lin YK, Tsai CF, Wu TJ, Chen SA. Characteristics and significance of very early recurrence of atrial fibrillation after catheter ablation. J Cardiovasc Electrophysiol 2011; 22:1193-8. [PMID: 21615812 DOI: 10.1111/j.1540-8167.2011.02095.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Early restoration of sinus rhythm following ablation of atrial fibrillation (AF) facilitates reverse atrial remodeling and improves the long-term outcome. The purpose of this study was to determine the predictors and outcome in patients with very early AF recurrences (< 2 days). METHODS AND RESULTS Ablation was performed in 339 consecutive AF patients (paroxysmal AF = 262). Biatrial voltage was mapped during sinus rhythm. If recurrent AF occurred within 2 days following the ablation, electrical cardioversion was performed to restore sinus rhythm. Very early recurrences of AF occurred in 39 (15%) patients with paroxysmal AF and 26 (34%) with nonparoxysmal AF. Patients with very early recurrence had a higher incidence of nonparoxysmal AF (40% vs 18.6%, P< 0.001), requirement of electrical cardioversion during procedure, larger left atrial (LA) diameter (43 ± 7 vs 39 ± 6 mm, P< 0.001), lower left ventricular ejection fraction (54 ± 10% vs 59 ± 7, P< 0.001), longer procedural time, and lower LA voltage (1.5 ± 0.7 vs 1.9 ± 0.8 mV, P< 0.001). A multivariate analysis revealed that the independent predictors of a very early recurrence were a longer procedural time and lower LA voltage. During a follow-up of 13 ± 5 months, a very early recurrence did not predict the long-term outcome of a single procedure recurrence in the patients with paroxysmal AF, but was associated with a late recurrence in the nonparoxysmal AF patients. CONCLUSION Very early recurrence occurred in patients with paroxysmal AF is not associated with long-term recurrence. Nonparoxysmal AF is an independent predictor of late recurrence of AF in patients with very early recurrence.
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Affiliation(s)
- Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Chan NY, Mok NS, Lau CL, Lo YK, Choy CC, Lau ST, Choi YC. Treatment of atrioventricular nodal re-entrant tachycardia by cryoablation with a 6 mm-tip catheter vs. radiofrequency ablation. Europace 2009; 11:1065-70. [DOI: 10.1093/europace/eup121] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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HAINES DAVIDE. Radiofrequency Catheter Ablation with Large Lesion Technologies: What is the Right Formula? J Cardiovasc Electrophysiol 2008; 20:336-7. [DOI: 10.1111/j.1540-8167.2008.01349.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Calkins H, Brugada J, Packer DL, Cappato R, Chen SA, Crijns HJG, Damiano RJ, Davies DW, Haines DE, Haissaguerre M, Iesaka Y, Jackman W, Jais P, Kottkamp H, Kuck KH, Lindsay BD, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Natale A, Pappone C, Prystowsky E, Raviele A, Ruskin JN, Shemin RJ. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007; 4:816-61. [PMID: 17556213 DOI: 10.1016/j.hrthm.2007.04.005] [Citation(s) in RCA: 886] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Sarubbi B, D'Alto M, Calvanese R, Russo MG, Calabrò R. Late cure after radiofrequency catheter ablation in a pediatric patient. J Cardiovasc Med (Hagerstown) 2007; 7:356-61. [PMID: 16645415 DOI: 10.2459/01.jcm.0000223259.54803.3f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 12-year-old female with the Wolff-Parkinson-White syndrome underwent an electrophysiologic study followed by radiofrequency catheter ablation of the left-lateral accessory pathway. After several unsuccessful attempts, the procedure was stopped because of early recurrence of accessory pathway conduction. Twenty-four hours after the procedure, the patient was found without ventricular pre-excitation pattern on the electrocardiogram. During a 12-month follow-up, the Wolff-Parkinson-White pattern was no longer present. A transesophageal electrophysiologic study showed no further tachycardia induction and the patient is still asymptomatic. This report raises the issue that ablation-induced lesions may evolve considerably during the first few days after ablation, leading to either recurrent accessory pathway conduction or long-lasting complete cure.
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Affiliation(s)
- Berardo Sarubbi
- Division of Cardiology, University of Naples, Monaldi Hospital, Naples, Italy.
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Callans DJ, Jacobson JT. Nonpharmacologic Treatment of Tachyarrhythmias. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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36
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Gupta D, Al-Lamee RK, Earley MJ, Kistler P, Harris SJ, Nathan AW, Sporton SC, Schilling RJ. Cryoablation compared with radiofrequency ablation for atrioventricular nodal re-entrant tachycardia: analysis of factors contributing to acute and follow-up outcome. ACTA ACUST UNITED AC 2006; 8:1022-6. [PMID: 17101629 DOI: 10.1093/europace/eul124] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIMS The efficacy of transvenous Cryoablation (Cryo), for the treatment of atrioventricular nodal re-entry tachycardia (AVNRT), when compared with radiofrequency (RF) ablation, requires further investigation. METHODS AND RESULTS We sought to compare the acute- and follow-up results of 71 cases each of Cryo and RF for AVNRT using a retrospective matched case-control study design and aimed at identifying patient and procedural factors that may predict success with each strategy. Primary failure of Cryo (thus necessitating RF at the same sitting) was seen in 11 (15.4%) cases, whereas there were two (2.8%) primary failures with RF (P<0.01). Patients in the Cryo group had significantly higher arrhythmia recurrence [14 (19.8%)] when compared with the RF group [4 (5.6%)] (P<0.01). The incidence of recurrence following Cryo was significantly higher if an echo beat was still inducible after ablation than if complete slow pathway block was achieved (7/19, vs. 4/46, P<0.001). The median number of Cryo lesions was significantly lower in patients who had recurrence compared with those who did not (1.5 vs. 3.0, P=0.02). CONCLUSION We have observed a much higher primary failure and recurrence rate with Cryo when compared with RF for AVNRT. It may be possible to decrease this high recurrence rate by aiming to achieve complete slow pathway block and by increasing the number of Cryo lesions.
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Affiliation(s)
- Dhiraj Gupta
- Department of Cardiology, First Floor, Dominion House, 60 Bartholomew Close, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
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Kovoor P, Daly M, Mikhail M, Eipper V, Dewsnap B, Ross DL. Change in Size of Lesions Over 3 Weeks After Radiofrequency Ablation of Left Ventricle. J Cardiovasc Electrophysiol 2006; 17:411-4. [PMID: 16643365 DOI: 10.1111/j.1540-8167.2006.00428.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The initial success or failure of radiofrequency ablation (RFA) does not always reflect the long-term outcome that can lead to complications such as late atrioventricular block or recurrence of accessory pathways. We hypothesize that these occurrences may be due to a change in lesion size over time. METHODS AND RESULTS Intramural RFAs were performed on five greyhounds at thoracotomy using an epicardial approach into the left ventricular (LV) wall. Twenty-one gauge needle electrode ablations were created in the anterior aspect of the left ventricle. Radiofrequency energy was delivered at 600 Hz for 60 seconds and at an electrode temperature of 90 degrees C. Eight ablations were created in each greyhound and the chest was closed. After 3 weeks, a further eight ablations were created under the same conditions in the lateral aspect of the LV, ensuring they were well away from the chronic lesions, and the dogs were sacrificed an hour later. All lesions were removed, stained with Gomori Trichrome and measured. There was no significant difference in lesion size detected in the 1-hour-old lesions compared with 3-week-old lesions. Acute lesions were well demarcated by an area of fibrous scar and a central necrotic region. Chronic lesions showed chronic inflammatory cells and strands of collagen. CONCLUSIONS This study shows no change in lesion dimension over time and hence a change in size may not contribute to a change in RFA outcome over time.
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Affiliation(s)
- Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia.
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Wagner AA, Solomon SB, Su LM. Treatment of renal tumors with radiofrequency ablation. J Endourol 2005; 19:643-52; discussion 652-3. [PMID: 16053352 DOI: 10.1089/end.2005.19.643] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Radiofrequency (RF) energy has been investigated as a minimally invasive modality for ablating small renal tumors. Recent advances in the application of this technology have improved its safety and effectiveness. MATERIALS AND METHODS We describe the technology of RF application and review the current delivery systems as applied to renal tumor ablation. We also review relevant animal studies, which have revealed the natural history of ablated renal tissue. Finally, we examine recent human trials with an emphasis on longer-term follow-up, imaging, complications, and successful ablation according to tumor location within the kidney; i.e., central v peripheral. RESULTS Radiofrequency ablation can be performed safely in a minimally invasive fashion either percutaneously or laparoscopically. Energy delivery varies, and available systems include dry, wet, cooled-tip, and bipolar electrodes. Heat rise and subsequent charring in the tissue adjacent to the electrode is limited by temperature or impedance-based feedback systems. In animal studies, ablation results in complete cell kill, as judged by nicotinamide adenine dinucleotide diaphorase staining. Clinical trials with intermediate follow-up show excellent success rates. Tumors >3 cm and central tumors have a higher recurrence rate after RFA than smaller, more peripheral tumors. CONCLUSIONS The current literature suggests that RFA is a promising minimally invasive method of treating small renal tumors. Nevertheless, long-term follow-up is still required, and questions remain regarding the optimal delivery system, duration of ablation, and method of surveillance.
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Affiliation(s)
- Andrew A Wagner
- Department of Urology, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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Khoury DS, Rao L, Ding C, Sun H, Youker KA, Panescu D, Nagueh SF. Localizing and quantifying ablation lesions in the left ventricle by myocardial contrast echocardiography. J Cardiovasc Electrophysiol 2005; 15:1078-87. [PMID: 15363083 DOI: 10.1046/j.1540-8167.2004.04087.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The inability to determine the extent and intramural depth of ablation lesions can hamper the success of catheter ablation. The study tested the feasibility of differentiating radiofrequency ablation lesions from normal myocardium and quantifying their dimensions by myocardial contrast echocardiography (MCE). METHODS AND RESULTS In 11 normal dogs, we created 14 focal and 4 linear lesions at different left ventricular sites. MCE was performed both before and after ablation by using an intracardiac echocardiography catheter (9 MHz) and infusing contrast microbubbles through the left coronary artery. We initially used two-dimensional MCE to image focal lesions and subsequently three-dimensional MCE to image linear lesions. An independent observer examined the lesion pathology. We found that intracardiac echocardiography alone could not delineate lesion dimensions. However, after ablation, MCE localized the lesions as well-defined, low-contrast areas within the normally opacified myocardium. Lesion dimensions by MCE immediately after ablation and 30 minutes later were similar. In 12 focal lesions, the average maximum depth (5.55 +/- 1.38 mm) and average maximum diameter (10.38 +/- 2.09 mm) by MCE were in excellent agreement with the pathologic depth (5.20 +/- 1.45 mm) and diameter (10.61 +/- 1.67 mm). Two focal lesions could not be detected by MCE and later were found to be superficial. Three-dimensional MCE correctly reconstructed the extent and shape of linear lesions compared to pathology (length: 18.7 +/- 5.7 vs 18.5 +/- 5.6 mm; maximum longitudinal cross-sectional area: 81.2 +/- 9.6 vs 76.0 +/- 10.3 mm2). CONCLUSION MCE accurately localized and quantified radiofrequency ablation lesions in the normal left ventricle. This new application of MCE may advance ablation for managing ventricular arrhythmias that involve intramural or epicardial regions by providing instantaneous anatomic feedback on the effects of ablation during catheterization.
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Affiliation(s)
- Dirar S Khoury
- Center for Experimental Cardiac Electrophysiology, Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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Wittkampf FHM, van Oosterhout MF, Loh P, Derksen R, Vonken EJ, Slootweg PJ, Ho SY. Where to draw the mitral isthmus line in catheter ablation of atrial fibrillation: histological analysis. Eur Heart J 2005; 26:689-95. [PMID: 15637084 DOI: 10.1093/eurheartj/ehi095] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS A linear lesion between the left inferior pulmonary vein orifice and mitral annulus, the so-called mitral isthmus, may improve the success of catheter ablation for atrial fibrillation. Gaps in the lesion line, however, may facilitate left atrial flutter. The aim of the study was to determine the optimal location of the lesion line by serial sectioning of the isthmus area. METHODS AND RESULTS In a post-mortem study of 16 patients with normal left atria, serial sections of the isthmus area from 10 mm superior to and 30 mm inferior to the isthmus were studied by light microscopy. The length of the isthmus was 35+/-7 mm. On average, the muscle sleeve around the coronary sinus ended 10 mm inferior to the isthmus. The prevalence of a ramus circumflexus <5 mm from the endocardial surface, decreased from 60% in the most superior section to 0% in the most inferior section. Atrial arteries were frequently present in all sections. CONCLUSIONS The thickness of atrial myocardium, the ramus circumflexus sometimes very close to the endocardium, a myocardial sleeve around the coronary sinus, and local cooling by atrial arteries and veins may complicate the creation of conduction block in the mitral isthmus.
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Affiliation(s)
- Fred H M Wittkampf
- Heart Lung Center Utrecht, University Medical Center E03-406, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Inoue Y, Kiso I, Takahashi R, Mori A, Motogami K. Beating-heart epicardial radiofrequency ablation: optimal temperature setting. Ann Thorac Surg 2004; 78:308-11; discussion 312. [PMID: 15223450 DOI: 10.1016/s0003-4975(03)01163-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2003] [Indexed: 12/13/2022]
Abstract
PURPOSE Pulmonary vein isolation is a simple procedure, which has recently been reported as an effective treatment for the termination of atrial fibrillation. Although there are several clinical reports of beating-heart epicardial ablation, the optimal temperature has not been experimentally investigated. We evaluated the effective temperature for the placement of circular lesions around the pulmonary vein-left atrial junction. DESCRIPTION Twelve swine underwent epicardial ablation to create linear conduction block lesions around the pulmonary vein-left atrial junction by a seven-electrode ablation catheter. The ablation was performed at 60 degrees C (group I), 70 degrees C (group II), 80 degrees C (group III), and 90 degrees C (group IV) for 120 seconds. The creation of a firm conduction block across the ablated lesion under pacing was compared. EVALUATION Complete conduction block was observed in all groups except group I. However, heat injury to adjacent structures in group IV and transient discoloration of the tissue surrounding coronary arteries in groups III and IV were observed. CONCLUSIONS The effective temperature for epicardial radiofrequency pulmonary vein isolation was 120 minutes and above 70 degrees C.
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Affiliation(s)
- Yoshito Inoue
- Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya, Tochigi, Japan.
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Kovoor P, Daly M, Campbell C, Dewsnap B, Eipper V, Uther J, Ross D. Intramural Radiofrequency Ablation:. Effects of Electrode Temperature and Length. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:719-25. [PMID: 15189525 DOI: 10.1111/j.1540-8159.2004.00519.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to evaluate intramural temperature-controlled radiofrequency ablation by determining the intramural temperature profile during ablation and by correlating lesion geometry with intramural electrode size and temperature. Intramural ablation might be useful to create deeper lesions for ventricular tachycardia secondary to underlying heart disease. Intramural radiofrequency ablation was performed in 17 greyhounds at thoracotomy, from an epicardial approach, using a 21-gauge needle electrode. Sixty-eight lesions were created in 11 dogs at electrode temperatures of 70 degrees C, 80 degrees C, 90 degrees C, and 100 degrees C for 60 seconds. Intramural thermocouples at 1-, 2-, 3-, 4-, and 5-mm distances were used to identify simultaneous intramural temperature profile. An epicardial approach was used to ensure accurate positioning of the ablating and temperature monitoring needles within the myocardium with fixed interneedle distances. Ninety-nine radiofrequency ablations were performed in six greyhounds using three different intramural electrode lengths (1 mm, 2.5 mm, and 5.5 mm). Lesions were created at 70 degrees C, 80 degrees C, and 90 degrees C for 60 seconds. All lesions were measured after staining with Gomori Trichrome. Lesion dimensions increased in a highly predictable manner with increasing electrode temperature or length. There was no popping or charring, even with target electrode temperature of 100 degrees C. There was significant correlation between intramural temperature 4 mm from the ablating electrode and lesion width (P < 0.001, R2= 0.45) and depth (P = 0.02, R2= 0.08). Feedback control of electrode temperature enables reliable intramural radiofrequency ablation without impedance rise even with target electrode temperature of 100 degrees C. Increasing the length of the intramural ablating electrode to > or = 5.5 mm and increasing temperatures to 90 degrees C-100 degrees C creates the largest lesions.
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Affiliation(s)
- Pramesh Kovoor
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Austalia.
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Delacretaz E, Soejima K, Brunckhorst CB, Maisel WH, Friedman PL, Stevenson WG. Assessment of Radiofrequency Ablation Effect From Unipolar Pacing Threshold. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2003; 26:1993-6. [PMID: 14516340 DOI: 10.1046/j.1460-9592.2003.00307.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Methods for determining if an ablation lesion has been created by RF current application are limited, but needed. This study sought to determine if a change in pacing threshold at the ablation site might be used to assess creation of an ablation lesion. Peak-to-peak amplitude of the bipolar electrogram (EGM) and the unipolar pacing threshold were determined before and after creation of RF lesions using irrigated tip (63 lesions in 11 patients) or conventional ablation catheters (33 lesions in 9 patients) in infarct scars for ablation of ventricular tachycardia. The threshold was measured during continuous pacing at a cycle length of 600 ms by a decrementing output current at a pulse width of 2 ms. The unipolar pacing threshold increased by 254 +/- 248% (from 5.7 +/- 3.5 to 15.1 +/- 6.7 mA, P<0.001) after irrigated tip ablation and by 155 +/- 144% (from 5.9 +/- 3.4 to 12.3 +/- 5.7 mA, P<0.001) after conventional ablation (P<0.05 for irrigated tip vs conventional). EGM amplitude decreased by 17 +/- 27% (from 0.39 +/- 0.32 to 0.30 +/- 0.21 mV) after irrigated tip ablation and by 16 +/- 24%(from 0.48 +/- 0.27 to 0.41 +/- 0.20 mV) after conventional ablation (irrigated tip vs conventional, P=NS). There was no correlation between the change in bipolar EGM amplitude and the pacing threshold. An increase in unipolar pacing threshold is a marker of lesion creation. In regions of infarction, the relative change in threshold produced by ablation is substantially larger than the change in bipolar electrogram amplitude. The greater increase in pacing threshold after irrigated tip ablation compared to conventional ablation suggests that the magnitude of change reflects lesion size.
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Affiliation(s)
- Etienne Delacretaz
- Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Avitall B, Urboniene D, Rozmus G, Lafontaine D, Helms R, Urbonas A. New cryotechnology for electrical isolation of the pulmonary veins. J Cardiovasc Electrophysiol 2003; 14:281-6. [PMID: 12716111 DOI: 10.1046/j.1540-8167.2003.02357.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Creation of radiofrequency lesions to isolate the pulmonary veins (PV) and ablate atrial fibrillation (AF) has been complicated by stenosis of the PVs. We tested a cryoballoon technology that can create electrical isolation of the PVs, with the hypothesis that cryoenergy will not result in PV stenosis. METHODS AND RESULTS Lesions were created in 9 dogs (weight 31-37 kg). Cryoenergy was applied to the PV-left atrial (LA) interface. Data collected before and after ablation included PV orifice size, arrhythmia inducibility, electrogram activity, and pacing threshold in the PVs. Tissue examination was performed immediately after ablation in 3 dogs and after 3 months (4.8 +/- 1.0) in 6 dogs. After ablation there was no localized P wave activity in the ablation zone and no LA-PV conduction. Before ablation, the pacing threshold was 1.9 +/- 1.1 mA in each PV. After ablation, the pacing threshold increased significantly to 7.2 +/- 1.8 mA, or capture was not possible. Burst pacing did not induce any sustained arrhythmias. Most dogs had hemoptysis during the first 24 to 48 hours. Acute tissue examination revealed hemorrhagic injury of the atrial-PV junction that extended into the lung parenchyma. After recovery, the lesions were circumferential and soft with no PV stenosis. Histologic examination revealed fibrous tissue with no PV-LA interface thickening. CONCLUSION This new cryoballoon technology effectively isolates the PVs from LA tissue. No PV stenosis was noted. Acute tissue hemorrhage and hemoptysis are short-term complications of this procedure. After 3 months of recovery, cryoablated tissue exhibits no collagen or cartilage formation.
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Affiliation(s)
- Boaz Avitall
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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Thomas SP, Guy DJR, Boyd AC, Eipper VE, Ross DL, Chard RB. Comparison of epicardial and endocardial linear ablation using handheld probes. Ann Thorac Surg 2003; 75:543-8. [PMID: 12607670 DOI: 10.1016/s0003-4975(02)04314-x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal technique for producing linear radiofrequency thermal lesions in myocardial tissue is unclear. We compared epicardial ablation on the beating heart with endocardial ablation after cardioplegia. METHODS Radiofrequency lesions were produced using a multielectrode malleable handheld probe in ovine myocardium with three wall thicknesses. Detailed analysis of lesion dimensions was used to assess the effects of site of ablation, muscle thickness, and duration of ablation. RESULTS After epicardial atrial ablation, myocardial lesions were detected in all sections without macroscopically visible epicardial fat (n = 10), but only 43% (6/14) of sections with epicardial fat. Three of 24 atrial epicardial sections (13%) and 92% (23/25) of endocardial atrial lesion sections were clearly transmural. In thicker tissues lesion depth was independent of endocardial (right ventricle: 3.9 +/- 1.1 mm, left ventricle: 3.8 +/- 0.7 mm) or epicardial (right ventricle: 3.4 +/- 0.6 mm, left ventricle: 4.3 +/- 0.9 mm) ablation site. Epicardial lesions are less deep in thinner areas of myocardium (p = 0.003). Lesions were all wider than they were deep. There was no significant increase in lesion depth with the increase in ablation duration from 1 to 2 minutes. CONCLUSIONS Lesions were unlikely to be transmural with either technique when the wall thickness was greater than about 4 mm. Epicardial fat has an important negative effect on epicardial lesion formation. Where epicardial fat is absent epicardially produced lesions penetrate less deeply when the wall thickness is small, possibly due to endocardial cooling by circulating blood. Prolongation of the duration of ablation from 1 to 2 minutes does not significantly increase lesion depth.
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Affiliation(s)
- Stuart P Thomas
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.
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Takahashi M, Mitsuhashi T, Hashimoto T, Ebisawa K, Fujikawa H, Ikeda U, Shimada K. Transient complete atrioventricular block occurring 1 week after radiofrequency ablation for the treatment of atrioventricular nodal re-entrant tachycardia. Circ J 2002; 66:1073-5. [PMID: 12419945 DOI: 10.1253/circj.66.1073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Atrioventricular (AV) block following radiofrequency (RF) ablation for the treatment of AV nodal re-entrant tachycardia (AVNRT) is a rare but serious complication of this procedure. Almost all such cases occur during or immediately after radiofrequencey (RF) energy application, followed by prompt recovery. The present report describes a 22-year-old woman with first-degree AV block on electrocardiography, who developed complete AV block 1 week after RF ablation for the treatment of the uncommon form of AVNRT (slow/slow). The patient's complete AV block persisted for another 1 week before she recovered.
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Oral H, Knight BP, Ozaydin M, Tada H, Chugh A, Hassan S, Scharf C, Lai SWK, Greenstein R, Pelosi F, Strickberger SA, Morady F. Clinical significance of early recurrences of atrial fibrillation after pulmonary vein isolation. J Am Coll Cardiol 2002; 40:100-4. [PMID: 12103262 DOI: 10.1016/s0735-1097(02)01939-3] [Citation(s) in RCA: 267] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purposes of this study were to describe the prevalence of early recurrences of atrial fibrillation (ERAF) that occur within two weeks after pulmonary vein (PV) isolation, and to determine whether ERAF is predictive of long-term outcome after PV isolation. BACKGROUND Atrial fibrillation (AF) sometimes recurs within days after PV isolation and may prompt an early repeat intervention. METHODS Segmental PV isolation was performed using radiofrequency energy in 110 consecutive patients (mean age 53 +/- 11 years) with paroxysmal (93 patients) or persistent (17 patients) AF. Three to four PVs were targeted for isolation in all patients. Pulmonary vein isolation was complete in 338 of the 358 PVs that were targeted (94%). RESULTS Early recurrences of AF occurred in 39 of 110 patients (35%) at a mean of 3.7 +/- 3.5 days after the procedure. The prevalence of ERAF was similar in patients with paroxysmal and persistent AF (33% and 47%, respectively, p = 0.4). Beyond the first two weeks, at 208 +/- 125 days of follow-up, 60 of the 71 patients without ERAF (85%) and 12 of the 39 patients with ERAF (31%) were free of recurrent AF in the absence of antiarrhythmic drug therapy (p < 0.001). CONCLUSIONS Early recurrences of AF occur in approximately 35% of patients within two weeks after isolation of three to four PVs, and are associated with a lower long-term success rate than in patients without ERAF. However, approximately 30% of patients with ERAF have no further symptomatic AF during long-term follow-up. Therefore, temporary antiarrhythmic drug therapy may be more appropriate than early repeat ablation in patients with ERAF.
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Affiliation(s)
- Hakan Oral
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Hayes DL, Charboneau JW, Lewis BD, Asirvatham SJ, Dupuy DE, Lexvold NY. Radiofrequency treatment of hepatic neoplasms in patients with permanent pacemakers. Mayo Clin Proc 2001; 76:950-2. [PMID: 11560308 DOI: 10.4065/76.9.950] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Clinicians who provide care for patients with implantable devices for rhythm management, ie, pacemakers and internal cardioverter defibrillators, must be aware of sources of interference that could affect device function. Intracardiac radiofrequency is a recognized source of potential interference. However, radiofrequency to extracardiac sites that are relatively close to the implanted device has not been investigated thoroughly. We present 2 patients with permanent pacemakers undergoing intrahepatic radiofrequency for the treatment of metastatic disease. No interference was documented in either patient. Additional in vitro and in vivo studies are needed to determine definite clinical guidelines for such patients.
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Affiliation(s)
- D L Hayes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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Ware DL, Boor P, Yang C, Gowda A, Motamedi M. Ventricular arrhythmias following thermal damage of epicardial tissue: possible causes and clinical implications. Pacing Clin Electrophysiol 2000; 23:1375-80. [PMID: 11025893 DOI: 10.1111/j.1540-8159.2000.tb00965.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Epicardial heating may be used for ventricular tachycardia (VT) ablation and transmyocardial revascularization. However, the potential risks of thermal epicardial injury, including arrhythmia, have not been fully explored. This study relates the pathologic and arrhythmic sequellae of epicardial heating when applied with a diode laser at varying doses. Acute pathology and dosimetry were determined in a group of normal dogs using 2-3 W over 30-90 seconds. Another group received a similar dose range before undergoing 24-hour monitoring, and electrophysiological testing was done at 4 weeks. In this group, four dogs each received 12 lesions (90-180 J) according to a randomized block design. Another dog received nine lower dose lesions (30-120 J). Acute lesions measured 2.5-8.0-mm wide by 4-8.5-mm deep. Charring and vaporization were common when 3 W were applied over 45 seconds. Within 24 hours, VT with features of abnormal automaticity occurred in all dogs receiving this dose. The dog in whom lower doses induced coagulation only had no VT. Four weeks later, electrophysiological study induced no VT. At this time fibrosis and granulation tissue were organizing the contraction band necrosis seen acutely, and some lesion borders were becoming calcified. No major vessels had been damaged. Abnormal automaticity and VT may occur if thermal damage of the epicardium exceeds coagulation. This could be related to tissue injury caused by sudden water vaporization, and may have clinical relevance given the growing indications for myocardial heating.
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Affiliation(s)
- D L Ware
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, TX 77555-0553, USA.
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Mitchell MA, McRury ID, Everett TH, Li H, Mangrum JM, Haines DE. Morphological and physiological characteristics of discontinuous linear atrial ablations during atrial pacing and atrial fibrillation. J Cardiovasc Electrophysiol 1999; 10:378-86. [PMID: 10210501 DOI: 10.1111/j.1540-8167.1999.tb00686.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Linear atrial ablations are thought to be necessary to accomplish successful catheter ablation of atrial fibrillation. In order to investigate the conduction characteristics of atrial myocardium in regions of linear lesion discontinuity (gaps), we performed activation sequence mapping in gap regions during atrial pacing and atrial fibrillation. METHODS AND RESULTS In seven dogs, a linear epicardial ablation was created on the right atrial free wall with a discontinuous segment (gap) in the mid-portion of the lesion. A plaque electrode was used to measure conduction across the gap. Conduction was assessed during (1) atrial pacing from the edge of the plaque electrode during sinus rhythm, and (2) during atrial fibrillation. After each series of measurements, the lesion gap was decreased by creating additional radiofrequency ablations and repeat conduction maps were obtained. The process was repeated until conduction block was observed during atrial pacing. Gap lengths ranged from 0 to 25 mm. During atrial pacing, gaps as narrow as 2 mm demonstrated normal conduction and gaps as large as 5 mm demonstrated block during pacing. Although conduction block was never present across gaps greater than 5 mm, the ability to predict conduction block as a function of gap width was difficult for lesions < or = 5 mm due to a significant degree of overlap between normal conduction and conduction block in this gap range. During atrial fibrillation, 1/175 (0.6%) mapped wavelets conducted across gaps that demonstrated block during pacing; whereas, 411/600 (68.5%; P < 0.0001) wavelets conducted across gaps that did not demonstrate block during pacing (P = NS compared to preablation measurements). Histologically normal atrial myocytes were observed within gaps exhibiting conduction block. CONCLUSIONS Visible gaps > 5 mm rarely demonstrate conduction block during atrial pacing and atrial fibrillation; whereas, gaps < or = 5 mm in length may demonstrate block. Lesion gaps that do not demonstrate conduction block during atrial pacing have no higher rate of functional conduction block during atrial fibrillation than fibrillating atria without ablation lesions.
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Affiliation(s)
- M A Mitchell
- Department of Internal Medicine, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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