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Wei HQ, Liu F, Xue Y, Wu S, Zhan X. A case report of entrapment of PentaRay catheter in the mechanical mitral valve: a known complication experienced anew. Eur Heart J Case Rep 2024; 8:ytae194. [PMID: 38707525 PMCID: PMC11065343 DOI: 10.1093/ehjcr/ytae194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 05/07/2024]
Abstract
Background Complex atrial tachycardia (AT) is commonly observed in patients with cardiac surgery. High-density mapping is widely adopted for catheter ablation of complex AT in patients with cardiac surgery. Several case reports have described that PentaRay mapping catheter can be trapped in the mechanical valve and sheared off and successful retrieval of the spline by a snare system. We described a rare case in which PentaRay mapping catheter spline was successfully retrieved from the distal anterior tibial artery by direct syringe suction via the diagnostic catheter following entrapment in the mechanical mitral valve (MV) and rupture of the spline. Case summary A 70-year-old female with mechanical bileaflet MV underwent catheter ablation for AT. During mapping in left atrium, the catheter was entrapped in mechanical MV and sheared off. We attempted to release the entrapped the spline by advancing the ablation catheter towards the stuck disc and pushing on the hinge portion of the disc with the catheter tip. The stuck and closed disc was opened, and the deeply entrapped spline was released. However, the entrapped PentaRay spline floated through the Valsalva sinus and strayed into the distal left anterior tibial artery. Fortunately, we successfully retrieved the spline from the distal anterior tibial artery by direct syringe suction instead of a snare system. Discussion The possibility of the entrapment and subsequent rupture of the spline should always be considered during mapping the site close to mechanical valve. A rapid retrieval of embolized material should be carried out. If the spline strays into the distal and small artery in which the snare system is difficult to advance, a direct syringe suction via the diagnostic catheter may be attempted.
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Affiliation(s)
- Hui-Qiang Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan 2nd Road, Yuexiu District, 510000 Guangzhou, China
| | - Fangzhou Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan 2nd Road, Yuexiu District, 510000 Guangzhou, China
| | - Yumei Xue
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan 2nd Road, Yuexiu District, 510000 Guangzhou, China
| | - Shulin Wu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan 2nd Road, Yuexiu District, 510000 Guangzhou, China
| | - Xianzhang Zhan
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhongshan 2nd Road, Yuexiu District, 510000 Guangzhou, China
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Vasireddi SK, Badhwar M, Schott G, Scheinman M. Supraventricular tachycardia with a variable RP relationship but without a change in the cycle length: What is the mechanism? Heart Rhythm 2024:S1547-5271(24)02369-5. [PMID: 38604588 DOI: 10.1016/j.hrthm.2024.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/04/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Affiliation(s)
- Sunil K Vasireddi
- Cardiovascular Medicine, University of Wisconsin, Madison, Wisconsin; Cardiovascular Medicine, Stanford University, Palo Alto, California.
| | - Mannat Badhwar
- Cardiovascular Medicine, University of Wisconsin, Madison, Wisconsin
| | - Gerilyn Schott
- Cardiovascular Medicine, Stanford University, Palo Alto, California
| | - Melvin Scheinman
- Division of Cardiology, University of California, San Francisco, California
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Zhang J, Cheng G, Deng C, Zhao A. Electrophysiologic mechanism and ablation strategy for macroreentrant bi atrial tachycardias after Cox-maze procedures. Heart Rhythm 2024:S1547-5271(24)02331-2. [PMID: 38604587 DOI: 10.1016/j.hrthm.2024.03.1819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Different types of recurrent atrial tachycardia (AT) after Cox-maze procedures have been reported, whereas biatrial tachycardia (BiAT) has not been systematically analyzed. OBJECTIVE In this study, we retrospectively investigated the electrophysiologic characteristics of BiAT after Cox-maze procedures by use of an ultrahigh-density mapping system. METHODS Of a consecutive 76 patients who underwent catheter ablation of AT after Cox-maze procedures, 12 BiATs were identified. High-density activation mapping was performed in both the left atrium and right atrium in combination with entrainment pacing to confirm the circuit. RESULTS We classified these BiATs into 2 groups. In group 1 (7 patients), the bidirectional block of maze linear lesions to prevent the macroreentrant AT was achieved; the posterior interatrial connections were involved in the circuit. In group 2 (5 patients), the bidirectional block of maze linear lesions was not blocked, and the most common gap was located at the end of the linear lesion near the annulus. In group 1, all the ATs were terminated by targeting the corresponding left atrium end of the posterior interatrial connections. In group 2, the ATs were terminated by targeting the gap near the annulus. CONCLUSION The optimal ablation strategy for BiATs after the maze procedure should be based on detailed demonstration of the circuit by high-density mapping.
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Affiliation(s)
- Jinlin Zhang
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China.
| | - Guanghui Cheng
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China
| | - Chenggang Deng
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China
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Yang JD, Gao Y, Guo XG, Zhou GB, Liu X, Chen K, Ma J, Sun Q. Focal atrial tachycardias originating from the aorta-mitral continuity: Anatomical and electrophysiological characteristics. Heart Rhythm 2024:S1547-5271(24)02328-2. [PMID: 38588992 DOI: 10.1016/j.hrthm.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The aorta-mitral annulus conjunction (AMC) is an uncommon site of origin of focal atrial tachycardias (ATs). Hence, the electrophysiological and ablation target characteristics are poorly described. OBJECTIVE The purpose of this study was to describe the characteristics of AMC AT in detail. METHODS The study enrolled 650 patients with AT, 21 (3.2%) of whom had AT originating from the AMC. A comprehensive evaluation, including electrocardiography, electrophysiology study, computed tomography scan, and intracardiac echocardiography, was performed. RESULTS The majority (90.5%) of ATs occurred spontaneously. The mean age of this group was 48.9 ± 21.6 years, with 12 being female (57.1%). Seventeen patients had a typical biphasic P wave with a prominent positive component. The earliest activation site in the right atrium was near the His bundle, with average activation -10.3 ± 6.0 ms preceding the P wave. The successful ablation targets were distributed as follows: 1 case at 9 o'clock, 6 cases at 10 o'clock, 7 cases at 11 o'clock, 6 cases at 12 o'clock, and 1 case in the left coronary cusp. The local AMC potential differed from the commonly perceived annular potential and was characterized by a large A and a small V (atrial-to-ventricular ratio > 1). The angle of encroachment on the left atrial anterior wall, compressed by the left coronary cusp, was significantly smaller in the AMC AT group than in the control group, which may have contributed to the arrhythmia substrate (141.7° ± 11.5° vs 155.2° ± 13.9°; P = .026). CONCLUSION A new strategy for mapping AMC ATs has been introduced. The ablation target should have an atrial-to-ventricular ratio of >1.
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Affiliation(s)
- Jian-du Yang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Gao
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Gang Guo
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gong-Bu Zhou
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Xu Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China, (4)Department of Cardiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Ma
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Sun
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Zhang M, Cao X, Zhang Y. Combination of electrophysiological mapping, radiofrequency catheter ablation, and atrial appendectomy in a 5-year-old girl with tachycardia-induced cardiomyopathy: a case report. J Cardiothorac Surg 2024; 19:169. [PMID: 38566062 PMCID: PMC10986129 DOI: 10.1186/s13019-024-02693-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/24/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Atrial tachycardia (AT) originating from the left atrial appendage (LAA) is uncommon and the most difficult arrhythmia to eliminate. Therefore, we present the case of a 5-year-old girl with tachycardia-induced cardiomyopathy (TIC) caused by AT originating from the LAA and successfully treated with RFCA associated to left atrial appendectomy. With resolution of AT, we observed a progressive improvement of LV function. The effectiveness and safety of this combination therapy were evaluated over a one-month follow-up period. CASE PRESENTATION A 5 -year-old female was evaluated for three days of incessant cough and a syncopal episode. Surface echocardiography and 24-hour monitoring showed that the infant had persistent atrial tachycardia. Echocardiography revealed an enlarged tele diastolic diameter (46.1 mm) and malfunctioning (EF 28.53%) left ventricle. The location of the lesion at the apex of the LAA was further confirmed by electrophysiological study and RFCA. After RFCA, the infant's ECG monitor showed that sinus rhythm was maintained for up to 22 h. Subsequently, atrial tachycardia recurred and sinus rhythm disappeared. Finally, atrial appendectomy was performed and sinus rhythm returned to normal. CONCLUSIONS The heart function of the infant improved and sinus rhythm was maintained, further demonstrating the safety and effectiveness of combined treatment with RFCA and atrial appendectomy after electrophysiological localization of AT from LAA to TIC.
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Affiliation(s)
- Min Zhang
- Wuhan Women and Children Medical care center, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science & Technology, 100 Hongkong Road, Jiangan District, Wuhan, Hubei, China.
| | - Xiaoxiao Cao
- Wuhan Women and Children Medical care center, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science & Technology, 100 Hongkong Road, Jiangan District, Wuhan, Hubei, China
| | - Yong Zhang
- Wuhan Women and Children Medical care center, Tongji Medical College, Wuhan Children's Hospital, Huazhong University of Science & Technology, 100 Hongkong Road, Jiangan District, Wuhan, Hubei, China
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Choi JH, Kwon CH. Timing of critical isthmus from end of P wave and usefulness of activation mapping with window of interest from end to end of P wave in reentrant atrial tachycardia. Heart Vessels 2024; 39:319-327. [PMID: 38015232 DOI: 10.1007/s00380-023-02335-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023]
Abstract
In activation mapping of reentrant atrial tachycardia (AT), there was no reference for window of interest (WOI). We examined the timing of a successful termination site from end of the P wave and attempted to determine whether the critical isthmus can be identified using activation mapping when WOI was set as end to end of the P wave. Forty patients with 54 reentrant AT who underwent 3D electroanatomic mapping and radiofrequency catheter ablation were evaluated retrospectively. The critical isthmus was defined as a successful termination site. We evaluate critical isthmus timing from end of the P wave and percentage of critical isthmus timing from end of the P wave to tachycardia cycle length. In 54 reentrant AT, Macro-reentry was identified in 46 (85.2%) and micro-reentry was identified in eight (14.8%). The timing of the critical isthmus site from end of the P wave was - 4.0 ± 31.1 ms (Macro-reentry vs. Micro-reentry; - 8.9 ± 29.4 ms vs. 24.0 ± 26.7 ms; P = 0.005). The percentage of critical isthmus timing from end of the P wave/tachycardia cycle length was - 1.4 ± 10.5% (Macro-reentry vs. Micro-reentry; - 3.1 ± 9.8% vs. 8.3 ± 9.3%, P = 0.004) The critical isthmus of reentrant AT is located within 10% backward and forward from end of the P wave to tachycardia cycle length. Setting the WOI from end to end of the P wave is useful for identification of the critical isthmus through activation mapping.
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Affiliation(s)
- Ji-Hoon Choi
- Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul, 05030, Korea
| | - Chang Hee Kwon
- Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul, 05030, Korea.
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Gunawardene MA, Harloff T, Jularic M, Dickow J, Wahedi R, Anwar O, Wohlmuth P, Gessler N, Hartmann J, Willems S. Contemporary catheter ablation of complex atrial tachycardias after prior atrial fibrillation ablation: pulsed field vs. radiofrequency current energy ablation guided by high-density mapping. Europace 2024; 26:euae072. [PMID: 38513110 PMCID: PMC11034699 DOI: 10.1093/europace/euae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS Catheter ablation (CA) of post-ablation left atrial tachycardias (LATs) can be challenging. So far, pulsed field ablation (PFA) has not been compared to standard point-by-point radiofrequency current (RFC) energy for LAT ablation. To compare efficacy of PFA vs. RFC in patients undergoing CA for LAT. METHODS AND RESULTS Consecutive patients undergoing LAT-CA were prospectively enrolled (09/2021-02/2023). After electro-anatomical high-density mapping, ablation with either a pentaspline PFA catheter or RFC was performed. Patients were matched 1:1. Ablation was performed at the assumed critical isthmus site with additional ablation, if necessary. Right atrial tachycardia (RAT) was ablated with RFC. Acute and chronic success were assessed. Fifty-six patients (n = 28 each group, age 70 ± 9 years, 75% male) were enrolled.A total of 77 AT (n = 67 LAT, n = 10 RAT; 77% macroreentries) occurred with n = 32 LAT in the PFA group and n = 35 LAT in the RFC group. Of all LAT, 94% (PFA group) vs. 91% (RFC group) successfully terminated to sinus rhythm or another AT during ablation (P = 1.0). Procedure times were shorter (PFA: 121 ± 41 vs. RFC: 190 ± 44 min, P < 0.0001) and fluoroscopy times longer in the PFA group (PFA: 15 ± 9 vs. RFC: 11 ± 6 min, P = 0.04). There were no major complications. After one-year follow-up, estimated arrhythmia free survival was 63% (PFA group) and 87% (RFC group), [hazard ratio 2.91 (95% CI: 1.11-7.65), P = 0.0473]. CONCLUSION Pulsed field ablation of post-ablation LAT using a pentaspline catheter is feasible, safe, and faster but less effective compared to standard RFC ablation after one year of follow-up. Future catheter designs and optimization of the electrical field may further improve practicability and efficacy of PFA for LAT.
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Affiliation(s)
- Melanie A Gunawardene
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Tim Harloff
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Mario Jularic
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Jannis Dickow
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Rahin Wahedi
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Omar Anwar
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Peter Wohlmuth
- Asklepios Proresearch Research Insitute, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
| | - Nele Gessler
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
- Asklepios Proresearch Research Insitute, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
| | - Jens Hartmann
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
| | - Stephan Willems
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmuehlenstrasse 5, 20099 Hamburg, Germany
- Semmelweis University Budapest Hungary, Asklepios Campus Hamburg, Lohmuehlenstrasse 5, 20099 Hamburg and Ülloi ut 26, 1085 Budapest
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
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Shah MM, Cunnane RT, Liang JJ. Interatrial septal pressure: A novel technique to facilitate safe ablation of periphrenic right atrial tachycardias. Heart Rhythm 2024:S1547-5271(24)00244-3. [PMID: 38461921 DOI: 10.1016/j.hrthm.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Muazzum M Shah
- Section of Electrophysiology, Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan. https://twitter.com/muazzumshah
| | - Ryan T Cunnane
- Section of Electrophysiology, Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan. https://twitter.com/CunnaneRyan
| | - Jackson J Liang
- Section of Electrophysiology, Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.
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Dittrich S, Scheurlen C, van den Bruck JH, Filipovic K, Wörmann J, Erlhöfer S, Schipper JH, Lüker J, Steven D, Sultan A. The omnipolar mapping technology-a new mapping tool to overcome "bipolar blindness" resulting in true high-density maps. J Interv Card Electrophysiol 2024; 67:399-408. [PMID: 37227537 PMCID: PMC10901967 DOI: 10.1007/s10840-023-01562-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Omnipolar mapping (OT) is a novel tool to acquire omnipolar signals for electro-anatomical mapping, displaying true voltage and real-time wavefront direction and speed independent of catheter orientation. The aim was to analyze previously performed left atrial (LA) and left ventricular (LV) maps for differences using automated OT vs. standard bipolar settings (SD) and HD wave (HDW) algorithm. METHODS Previously obtained SD and HDW maps of the LA and LV using a 16-electrode, grid-shaped catheter were retrospectively analyzed by applying automated OT, comparing voltage, point density, pulmonary vein (PV) gaps, and LV scar area. RESULTS In this analysis, 135 maps of 45 consecutive patients (30 treated for LA, 15 for LV arrhythmia) were included. Atrial maps revealed significantly higher point densities using OT (21471) vs. SD (6682) or HDW (12189, p < 0.001). Mean voltage was significantly higher using OT (0.75 mV) vs. SD (0.61 mV) or HDW (0.64 mV, p < 0.001). OT maps detected significantly more PV gaps per patient vs. SD (4 vs. 2), p = 0.001. In LV maps, OT revealed significantly higher point densities (25951) vs. SD (8582) and HDW (17071), p < 0.001. Mean voltage was significantly higher for OT (1.49 mV) vs. SD (1.19 mV) and HDW (1.2 mV), p < 0.001. Detected scar area was significantly smaller using OT (25.3%) vs. SD (33.9%, p < 0.001). CONCLUSION OT mapping leads to significantly different substrate display, map density, voltage, detection of PV gaps, and scar size, compared to SD and HDW in LA and LV procedures. Successful CA might be facilitated due to true HD maps.
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Affiliation(s)
- Sebastian Dittrich
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany.
| | - Cornelia Scheurlen
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | | | - Karlo Filipovic
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Jonas Wörmann
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Susanne Erlhöfer
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Jan-Hendrik Schipper
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Jakob Lüker
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Daniel Steven
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Arian Sultan
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
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Chou A, Jongnarangsin K, Yokokawa M, Ghannam M, Liang JJ, Oral H, Morady F, Chugh A. Posterior left atrial isolation is associated with a lower incidence of atrial tachycardia in patients with persistent atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01769-z. [PMID: 38411857 DOI: 10.1007/s10840-024-01769-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/08/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Patients may develop atrial tachycardia (AT) after left atrial (LA) ablation of persistent atrial fibrillation (AF). METHODS The population consisted of 101 consecutive patients (age = 64.3 ± 8.7 years, 70 males (69%), LA = 4.6 ± 0.8 cm, ejection fraction = 48.5 ± 16%) undergoing their initial procedure for persistent AF. After pulmonary vein isolation, patients either underwent posterior LA isolation (n = 50; study group) or linear ablation at the LA roof with verification of conduction block (n = 51; control group). RESULTS A repeat procedure was performed in 17 (34%) and 28 (55%) patients in the study and control groups, respectively (p = 0.02). Patients in the study group were less likely to develop AT (9/50 [18%] vs. 18/51 [35%]; p = 0.02), roof-dependent (1/50 [2%] vs. 8/51 [16%]; p = 0.008), and multi-loop AT (6/50 [12%] vs. 14/51 [27%]; p = 0.03) as compared to controls. Among various factors, only posterior LA isolation was associated with a lower likelihood of AT recurrence and roof tachycardia at redo procedure (OR, 0.37; 95% CI, 0.1 to 1.00, p = 0.05, and OR, 0.1, 95% CI, 0.01 to 0.96; p < 0.05, respectively). CONCLUSIONS In patients with persistent AF, posterior LA isolation is associated with a lower risk of a redo procedure, roof-dependent macro-reentry, and post-ablation AT in general as compared to controls who only received roof ablation. Posterior LA isolation also obviates the need for pacing maneuvers, and may be a more definitive endpoint than linear ablation at the LA roof.
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Affiliation(s)
- Andrew Chou
- Division of Cardiology, University of Michigan Medical Center, Ann Arbor, MI, 48109, USA
| | - Krit Jongnarangsin
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Miki Yokokawa
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Michael Ghannam
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jackson J Liang
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Hakan Oral
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Fred Morady
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aman Chugh
- Section of Cardiac Electrophysiology, University of Michigan Medical Center, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Yamashita K, Furuya K, Sato Y, Kinebuchi Y, Funayama K, Masano T, Maeda M, Kumazawa D, Mizuno Y, Onodera K, Nomura T. Intracardiac electrogram-based atrial pace mapping for detecting the earliest activation site in atrial arrhythmias. Heart Rhythm 2024:S1547-5271(24)00199-1. [PMID: 38369035 DOI: 10.1016/j.hrthm.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/27/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Kennosuke Yamashita
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan.
| | - Kenichi Furuya
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Yasuhiro Sato
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Yasuhiro Kinebuchi
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Keisuke Funayama
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Tomohisa Masano
- Department of Clinical Engineering, Sendai Kosei Hospital, Miyagi, Japan
| | - Manabu Maeda
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Daiki Kumazawa
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Yosuke Mizuno
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Kosuke Onodera
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Takehiro Nomura
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
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12
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Sonoda K, Fukushima T, Takei A, Otsuka K, Hata S, Shinboku H, Muroya T, Maemura K. Association between left atrial low-voltage area and induction and recurrence of macroreentrant atrial tachycardia in pulmonary vein isolation for atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01760-8. [PMID: 38321306 DOI: 10.1007/s10840-024-01760-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/24/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The relationship between induction and recurrence due to atrial tachycardia (AT) and left atrial (LA) matrix progression after atrial fibrillation (AF) ablation remains unclear. METHODS One hundred fifty-two consecutive patients with paroxysmal and persistent AF who underwent pulmonary vein isolation (PVI) and cavo-tricuspid isthmus (CTI) ablation and achieved sinus rhythm before the procedure were classified into three groups according to the AT pattern induced after the procedure: group N (non-induced), F (focal pattern), and M (macroreentrant pattern) in 3D mapping. RESULTS The total rate of AT induction was 19.7% (30/152) in groups F (n = 13) and M (n = 17). Patients in group M were older than those in groups N and F, with higher CHADS2/CHA2DS2-VASc values, left atrial enlargement, and low-voltage area (LVA) size of LA. The receiver operating characteristic curve determined that the cut-off LVA for macroreentrant AT induction was 8.8 cm2 (area under the curve [AUC]: 0.86, 95% confidence interval [CI]: 0.75-0.97). The recurrence of AT at 36 months in group N was 4.1% (5/122), and at the second ablation, all patients had macroreentrant AT. Patients with AT recurrence in group N had a wide LVA at the first ablation, and the cut-off LVA for AT recurrence was 6.5 cm2 (AUC 0.94, 95%CI 0.88-0.99). Adjusted multivariate analysis showed that only LVA size was associated with the recurrence of macroreentrant AT (odds ratio 1.21, 95%CI 1.04-1.51). CONCLUSIONS It is important to develop a therapeutic strategy based on the LVA size to suppress the recurrence of AT in these patients.
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Affiliation(s)
- Koichiro Sonoda
- Department of Cardiology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo, 857-8511, Japan.
| | - Tadatomo Fukushima
- Department of Cardiology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo, 857-8511, Japan
| | - Asumi Takei
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Kaishi Otsuka
- Department of Cardiology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo, 857-8511, Japan
| | - Shiro Hata
- Department of Cardiology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo, 857-8511, Japan
| | - Hiroki Shinboku
- Department of Cardiology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo, 857-8511, Japan
| | - Takahiro Muroya
- Department of Cardiology, Sasebo City General Hospital, 9-3 Hirase-cho, Sasebo, 857-8511, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Yamashita K, Maeda M, Kumazawa D, Mizuno Y, Onodera K, Nomura T. Novel simultaneous mapping technique to treat multifocal atrial tachycardia. J Cardiol Cases 2024; 29:67-72. [PMID: 38362575 PMCID: PMC10865130 DOI: 10.1016/j.jccase.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/14/2023] [Accepted: 10/11/2023] [Indexed: 02/17/2024] Open
Abstract
Although a high-resolution three-dimensional mapping system has made it possible to treat complicated atrial tachyarrhythmia (AT), there remain cases that are difficult to diagnose and treat. However, when multiple different ATs alternately appear, mapping and diagnosis of those are more difficult. Parallel mapping module is well known as a good option to simultaneously map two or more different ATs when they alternately appear. When performing parallel mapping of two different ATs, one bipolar signal of the reference catheter is used as a timing reference and a cycle length filter is used for differentiating AT1, AT2, and others, including sinus rhythm, fusion beats, or catheter-induced premature atrial complex. Therefore, it has some limitations for differentiating multifocal ATs. We present a case wherein multifocal ATs were successfully eliminated by combining parallel mapping module and dual-chamber intra-cardiac pattern matching technique that we have previously reported. Learning objective ▪Parallel mapping is a useful tool when two or more tachycardias alternately occur; however, it has some limitations.▪Dual-chamber intra-cardiac pattern matching technique, which combines right atrial and coronary sinus potentials, provides better discrimination than coronary sinus reference alone.▪By combining parallel mapping and dual-chamber intra-cardiac pattern matching, two or more atrial tachycardias could be automatically and simultaneously mapped.
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Affiliation(s)
- Kennosuke Yamashita
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Manabu Maeda
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Daiki Kumazawa
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Yosuke Mizuno
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Kosuke Onodera
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
| | - Takehiro Nomura
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Miyagi, Japan
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Maslova V, Demming T, Nonnenmacher M, Voges I, Lyan E. Ablation of atrial flutter in a patient after Fontan procedure: a case report of challenging access to the common atrium. Eur Heart J Case Rep 2024; 8:ytae048. [PMID: 38332919 PMCID: PMC10852018 DOI: 10.1093/ehjcr/ytae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/07/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
Background In patients with a total cavopulmonary connection in Fontan circulation, the access to the common atrium (CA) during a catheter ablation can be challenging, even in the presence of fenestration in an intra-atrial lateral tunnel (IALT). In our department, the fenestration is typically marked with metal clips (MCs). To the best of our knowledge, there is no previous report of balloonoplasty of clipped fenestration. Case summary A 19-year-old male with hypoplastic left heart syndrome (HLHS) was scheduled for catheter ablation of recurrent atrial tachycardia. He was diagnosed with HLHS prenatally and underwent a stepwise surgical palliation. Fontan circulation was completed with the creation of a fenestrated IALT. The fenestration was marked by four MCs. During the ablation procedure, the passage of the steerable sheath with mapping catheter to the CA was prevented by a small fenestration size and rigidness of the edges of the fenestration caused by the MCs. Multiple attempts to dilate the fenestration using a peripheric angioplasty balloon failed. Only angioplasty with the 'balloon-against-dilator' technique was finally successful. Activation map showed a counterclockwise atrial flutter in the CA; successful ablation was performed. Discussion We present a case of challenging access to the CA through a clipped fenestration in a polytetrafluoroethylene baffle for atrial tachycardia ablation. Even though a tunnel fenestration in Fontan patients facilitates access to the CA, the passage of a steerable introducer with a mapping catheter may be challenging due to diameter mismatch and the rigidity of its edges caused by MCs. The balloon-against-dilator technique might be helpful when conventional balloon angioplasty fails.
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Affiliation(s)
- Vera Maslova
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Thomas Demming
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Marc Nonnenmacher
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Evgeny Lyan
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
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15
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Lehmann HI, Chugh A. Alcohol ablation of the vein of Marshall in a patient with persistent atrial fibrillation and prior surgical ligation of the ligament of Marshall. HeartRhythm Case Rep 2024; 10:151-154. [PMID: 38404976 PMCID: PMC10885713 DOI: 10.1016/j.hrcr.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- H. Immo Lehmann
- Jean and Samuel Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - Aman Chugh
- Jean and Samuel Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
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16
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Zado ES, Garg L, Tschabrunn C, Santangeli P, Hyman M, Kumareswaran R, Arkles J, Marchlinski FE. Risk of atrial arrhythmias in patients with ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 2024; 21:133-140. [PMID: 37956774 DOI: 10.1016/j.hrthm.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND In arrhythmogenic right ventricular cardiomyopathy (ARVC), risk of atrial arrhythmias (AAs) persists after ventricular tachycardia (VT) ablation. OBJECTIVE The purpose of this study was to determine the type, prevalence, outcome, and risk correlates of AA in ARVC in patients undergoing VT ablation. METHODS Prospectively collected procedural and clinical data on ARVC patients undergoing VT ablation were analyzed. Risk score for typical atrial flutter was determined from univariate logistic regression analysis. RESULTS Of 119 consecutive patients with ARVC and VT ablation, 40 (34%) had AA: atrial fibrillation (AF) in 31, typical isthmus-dependent atrial flutter (AFL) in 27, and atrial tachycardia/atypical flutter (AT) in 10. Seventeen patients (43%) with AA experienced inappropriate defibrillator therapy, with 15 patients experiencing shocks. Ablation was performed for typical AFL in 21 (53%), AT in 5 (13%), and pulmonary vein isolation for AF in 4 (10%) patients and prevented AA in 78% and all AFL during additional mean follow-up of 65 months. Risk score for typical flutter included age >40 years (1 point), ≥moderate right ventricular dysfunction (2 points), ≥moderate tricuspid regurgitation (2 points), ≥moderate right atrial dilation (2 points), and right ventricular volume >250 cc (3points), with score >4 identifying 50% prevalence of typical flutter. CONCLUSION AAs are common in patients with ARVC and VT, can result in inappropriate implantable cardioverter-defibrillator shocks, and typically are controlled with atrial ablation. A risk score can be used to identify patients at high risk for typical AFL who may be considered for isthmus ablation at the time of VT ablation.
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Affiliation(s)
- Erica S Zado
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lohit Garg
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cory Tschabrunn
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Hyman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramanan Kumareswaran
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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17
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Wang J, Zhang QQ, Lin J, Yuan W, Wang LC, Wu YC. Treatment strategy for heart failure complicated with complete left bundle branch block and atrial tachycardia: a case report. J Med Case Rep 2024; 18:33. [PMID: 38279155 PMCID: PMC10821233 DOI: 10.1186/s13256-024-04343-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/29/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND For patients with heart failure combined with complete left bundle branch block, cardiac resynchronization therapy is an important therapeutic method. If these patients also have atrial tachycardia, how to choose a treatment strategy deserves discussion. CASE PRESENTATION A Chinese woman in her early 70s was admitted due to recurrent episodes of chest distress and asthma for 1 year. Physical and laboratory examinations showed filling of the jugular vein, lung rales, left enlargement of the heart boundary, edema of the lower limbs and elevation of N-terminal pro b-type natriuretic peptide. An electrocardiogram showed atrial tachycardia and a left bundle branch block. An echocardiography revealed enlargement of the left ventricle and left ventricular systolic dysfunction. After obtaining informed consent, the treatment strategy decided upon by the team was to use biventricular cardiac resynchronization therapy treatment and to not intervene for the atrial tachycardia, with left bundle branch area pacing as a backup. Due to twisted and narrow coronary vein branches, traditional biventricular pacing failed, and then, left bundle branch area pacing was attempted successfully. A follow-up echocardiography at 1 year showed improved systolic function. The outcomes for this patient are favorable, but the choice of interventional strategy is worthy of discussion in this case. CONCLUSION For patients with heart failure combined with left bundle branch block and atrial tachycardia, left bundle branch area pacing can replace traditional biventricular pacing for cardiac resynchronization therapy treatment, and the therapeutic effect is significant. However, multiple factors need to be considered when formulating strategies, including whether there is bundle branch block under sinus rhythm, the success and recurrence rate of atrial tachycardia ablation, the response of cardiac resynchronization therapy, the costs of different strategies, and instrument implantation issues.
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Affiliation(s)
- Jian Wang
- Department of Cardiology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, No. 366 Taihu Road, Taizhou, 225300, Jiangsu Province, China
| | - Qing-Qing Zhang
- Department of Endocrinology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, 225300, Jiangsu Province, China
| | - Jie Lin
- Department of Cardiology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, No. 366 Taihu Road, Taizhou, 225300, Jiangsu Province, China
| | - Wei Yuan
- Department of Cardiology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, No. 366 Taihu Road, Taizhou, 225300, Jiangsu Province, China
| | - Li-Chun Wang
- Department of Cardiology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, No. 366 Taihu Road, Taizhou, 225300, Jiangsu Province, China.
| | - Yu-Cheng Wu
- Department of Cardiology, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, No. 366 Taihu Road, Taizhou, 225300, Jiangsu Province, China.
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18
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Mizuno Y, Kumazawa D, Maeda M, Onodera K, Nomura T, Yamashita K. Optimal treatment of bi atrial tachycardia diagnosed by one-chamber mapping within an ultrahigh-resolution mapping system. J Cardiol Cases 2024; 29:19-22. [PMID: 38188324 PMCID: PMC10770096 DOI: 10.1016/j.jccase.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 01/09/2024] Open
Abstract
Biatrial tachycardia (BiAT) is a rare arrhythmia, and identification of the re-entry circuit is often complicated. By creating an activation map of the right atrium, left atrium, and coronary sinus as a single chamber, the LUMIPOINT module of the Rhythmia mapping system (Boston Scientific, Marlborough, MA, USA) can be used in real time to make an accurate diagnosis. Ablation of the Bachmann bundle is a feasible way to terminate BiAT, but might cause interatrial conduction delay and electrical isolation of the left atrial appendage. Chemical ablation into the vein of Marshall might be the more beneficial treatment, avoiding any potential interatrial conduction delay.
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Affiliation(s)
- Yosuke Mizuno
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Sendai-shi, Miyagi, Japan
| | - Daiki Kumazawa
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Sendai-shi, Miyagi, Japan
| | - Manabu Maeda
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Sendai-shi, Miyagi, Japan
| | - Kosuke Onodera
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Sendai-shi, Miyagi, Japan
| | - Takehiro Nomura
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Sendai-shi, Miyagi, Japan
| | - Kennosuke Yamashita
- Heart Rhythm Center, Department of Cardiovascular Medicine, Sendai Kosei Hospital, Sendai-shi, Miyagi, Japan
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19
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Tamura S, Shimeno K, Hayashi Y, Naruko T, Fukuda D. Effective ablation of atrial tachycardia with an epicardial circuit-insights from endocardial scars sites: a case study. J Interv Card Electrophysiol 2024; 67:1-3. [PMID: 37991668 DOI: 10.1007/s10840-023-01687-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
A previous study reported primary macroreentrant atrial tachycardia (AT) in the left atrium (LA), including the epicardial circuit on a left atrial anterior wall (LAAW) scar, without any prior cardiac intervention (Miyazawa et al. in J Cardiovasc Electrophysiol 2019; 30: 263-264). However, determining the target for terminating macroreentrant ATs is challenging. The mapping revealed a centrifugal pattern but did not fully elucidate the AT circuit. The reentrant mechanism of these ATs was confirmed using entrainment pacing. The earliest excitation site (EES) was traditionally selected as the ablation site, typically located in healthy tissue. However, our two cases provide new insights into AT termination, including the epicardial bridge across the endocardial LAAW scar, using minimum ablation points, without the need to ablate the healthy EES.
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Affiliation(s)
- Shota Tamura
- Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-Ku, Osaka, 534-0021, Japan
| | - Kenji Shimeno
- Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-Ku, Osaka, 534-0021, Japan.
| | - Yusuke Hayashi
- Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-Ku, Osaka, 534-0021, Japan
| | - Takahiko Naruko
- Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-Ku, Osaka, 534-0021, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abenoku, Osaka, 545-8585, Japan
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Yoshida M, Tanaka T, Sakuma H, Sato T, Yamashiro K. Atrial balloon septoplasty facilitates trans-subclavian approach for left atrial tachycardia in a patient with hemiazygos continuation of inferior vena cava. HeartRhythm Case Rep 2024; 10:81-85. [PMID: 38264108 PMCID: PMC10801016 DOI: 10.1016/j.hrcr.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Affiliation(s)
- Masaharu Yoshida
- Heart Rhythm Center, Takatsuki General Hospital, Takatsuki, Japan
| | - Tomomi Tanaka
- Heart Rhythm Center, Takatsuki General Hospital, Takatsuki, Japan
| | - Hiroki Sakuma
- Heart Rhythm Center, Takatsuki General Hospital, Takatsuki, Japan
| | - Taiki Sato
- Heart Rhythm Center, Takatsuki General Hospital, Takatsuki, Japan
| | - Kohei Yamashiro
- Heart Rhythm Center, Takatsuki General Hospital, Takatsuki, Japan
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21
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Tolani D, Ramdat Misier NL, Alqahtani M, Tindel K, de Groot NMS, Scott WA, Nguyen HH. Early experience with ivabradine for focal atrial tachycardia in pediatric patients with congenital heart disease. Heart Rhythm 2024; 21:115-116. [PMID: 37852564 DOI: 10.1016/j.hrthm.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/05/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Drishti Tolani
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
| | - Nawin L Ramdat Misier
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas; Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Manal Alqahtani
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
| | - Kaitlin Tindel
- Department of Pharmacy, Dallas Children's Medical Center, Dallas, Texas
| | | | - William A Scott
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
| | - Hoang H Nguyen
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas; Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands.
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22
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Cao X, Zhong X, Yu W, Xiong J. Ultrasonography of pericardial synovial sarcoma: A rare case report. Asian J Surg 2023; 46:5889-5890. [PMID: 37709617 DOI: 10.1016/j.asjsur.2023.08.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Affiliation(s)
- Xiying Cao
- Department of Thoracic Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.
| | - Xiangkun Zhong
- The First People's Hospital of Nankang District, Ganzhou, China.
| | - Wenbo Yu
- Gannan Medical University, Ganzhou, China.
| | - Jianxian Xiong
- Department of Cardiovascular Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, China.
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Gardziejczyk P, Wlazłowska-Struzik E, Skowrońska M, Baran J. Pulsed-field ablation using pentaspline catheter as a bail-out strategy for perimitral flutter related to the left atrium anterior wall scar. HeartRhythm Case Rep 2023; 9:906-909. [PMID: 38204828 PMCID: PMC10774522 DOI: 10.1016/j.hrcr.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Piotr Gardziejczyk
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wlazłowska-Struzik
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Skowrońska
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
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24
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Masuda M, Matsuda Y, Uematsu H, Mano T. Remote entrainment pacing from multiple distant areas to identify a slow conduction isthmus of a reentrant circuit in scar-related atrial tachycardia. HeartRhythm Case Rep 2023; 9:883-885. [PMID: 38204830 PMCID: PMC10774521 DOI: 10.1016/j.hrcr.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Masaharu Masuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | | | | | - Toshiaki Mano
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
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25
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Gagyi RB, Yap SC, Noten AME, Wijchers S, Szili-Torok T. The performance of dipole charge density mapping integrated with robotic magnetic navigation in the treatment of atrial tachycardias. J Interv Card Electrophysiol 2023; 66:2103-2111. [PMID: 37076739 PMCID: PMC10694103 DOI: 10.1007/s10840-023-01552-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/14/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Catheter ablation (CA) has become a well-established first-line therapy for a broad spectrum of arrhythmias, including atrial tachycardias (ATs). In this study we aimed to assess the performance of the integrated novel high-resolution new generation noncontact mapping system (AcQMap) with robotic magnetic navigation (RMN) system in CA procedures for patients with ATs including comparing patient subgroups based on the utilized mapping modality, arrhythmia mechanism, localization and type of procedure. METHODS All patients undergoing CA for AT using the AcQMap-RMN system were included. Procedural safety and efficacy were characterized by intra- and post-procedural complications. Acute procedural success and the long-term outcome were assessed in the overall group and in the subgroups. RESULTS A total number of 70 patients were referred for CA with atrial arrhythmias including 67 AT/AFL (mean age 57.1 ± 14.4 years), and 3 additional patients with inappropriate sinus tachycardia. Thirty-eight patients had de novo AT, 24 had post-PVI AT including 2 patients with perinodal AT, and 5 had post-MAZE AT. Two patients (2.9%) suffered post-procedural complications including 1 patient with groin hematoma and 1 patient with a transient ischemic attack. Acute success was achieved in 63/67 (94.0%) procedures. Thirteen patients (19.4%) had documented recurrence at the end of the 12-months follow-up period. The performance of AcQMap was equally good in focal vs. reentry mechanisms (p = 0.61, acute success), in the left and right atrium (p = 0.21). CONCLUSIONS AcQMap-RMN integration might improve success rates in CA of ATs with low number of complications.
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Affiliation(s)
- Rita B Gagyi
- Thoraxcenter, Department of Clinical Electrophysiology, Postbus 2040, 3000 CA Rotterdam, Molewaterplein 40, 3015 GD Rotterdam, Erasmus, MC, The Netherlands
| | - Sing-Chien Yap
- Thoraxcenter, Department of Clinical Electrophysiology, Postbus 2040, 3000 CA Rotterdam, Molewaterplein 40, 3015 GD Rotterdam, Erasmus, MC, The Netherlands
| | - Anna M E Noten
- Thoraxcenter, Department of Clinical Electrophysiology, Postbus 2040, 3000 CA Rotterdam, Molewaterplein 40, 3015 GD Rotterdam, Erasmus, MC, The Netherlands
| | - Sip Wijchers
- Thoraxcenter, Department of Clinical Electrophysiology, Postbus 2040, 3000 CA Rotterdam, Molewaterplein 40, 3015 GD Rotterdam, Erasmus, MC, The Netherlands
| | - Tamas Szili-Torok
- Thoraxcenter, Department of Clinical Electrophysiology, Postbus 2040, 3000 CA Rotterdam, Molewaterplein 40, 3015 GD Rotterdam, Erasmus, MC, The Netherlands.
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26
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Sivasubramanian BP, Ravikumar DB, Vyas B, Panchal V, Puli S, Kiernan G, Venkata VS. Role of POCUS in the Management of New-onset Tachyarrhythmia in the Setting of SARS-CoV-2: A Case Report. J Community Hosp Intern Med Perspect 2023; 13:50-53. [PMID: 38596561 PMCID: PMC11000831 DOI: 10.55729/2000-9666.1261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 04/11/2024] Open
Abstract
Introduction SARS-CoV-2 infection is associated with myocardial inflammation, new onset cardiomyopathy, and arrhythmias. Here, we describe the utilization of POCUS and management of concurrent new onset atrial tachycardia and heart failure with reduced ejection fraction (HfrEF) in a patient with SARS-CoV-2 infection. Presentation An 80-year-old female with multiple medical problems presented with sudden onset of shortness of breath and cough. She tested positive for SARS-CoV-2. Initially, she was hypoxic on room air and her heart rhythm was sinus tachycardia. CT angiogram of the chest showed consolidation, pleural effusion, and absence of pulmonary embolism. Because of persistent tachycardia, repeat EKGs and POCUS were performed. Subsequent EKGs showed intermittent atrial tachycardia and sinus tachycardia. Initially, home beta blockers were continued on admission, and additional dosages were considered for rate control, but Cardiac POCUS revealed HfrEF and was subsequently confirmed by comprehensive cardiac echocardiogram, consistent with SARS-CoV-2 infection-related cardiomyopathy. Beta blockers were discontinued, and treatment with amiodarone and furosemide showed improvement in symptoms. The patient was discharged with oral amiodarone and supplemental oxygen. Additionally, once the patient's hemodynamics improved, oral carvedilol was also started as part of GDMT for HfrEF. Follow-up echocardiogram 4 months later showed recovery of systolic EF to 60%. Conclusion It is essential to consider new onset HFrEF in the evaluation and management of new onset tachyarrhythmias since IV fluids and AV nodal blocking agents can be harmful in decompensated HFrEF. With the advent of POCUS, HFrEF can be quickly identified, and therapy can be tailored to that diagnosis.
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Affiliation(s)
- Barath P. Sivasubramanian
- Department of Infectious Diseases, University of Texas Health Science Centre, San Antonio, TX, 78229,
USA
| | - Diviya B. Ravikumar
- Department of Internal Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu,
India
| | - Bhavya Vyas
- Department of Medicine, Smt. N.H.L. Municipal Medical College and SVPISMR, Ahmedabad, Gujarat,
India
| | - Viraj Panchal
- Department of Medicine, Smt. N.H.L. Municipal Medical College and SVPISMR, Ahmedabad, Gujarat,
India
| | - Srikanth Puli
- Hospital Medicine Division, Cheshire Medical Center,
USA
| | - Gerard Kiernan
- Hospital Medicine Division, Cheshire Medical Center,
USA
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27
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Baskovski E, Altin AT, Akyurek O, Kuru B, Korkmaz K, Ersoy İ, Kozluca V, Akbulut IM, Tutar E. Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience. J Interv Card Electrophysiol 2023; 66:1901-1910. [PMID: 36811816 DOI: 10.1007/s10840-023-01513-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Despite being increasingly observed in daily practice, epicardial atrial tachycardias (Epi AT) have not been extensively characterized. In the present study, we retrospectively characterize electrophysiological properties, electroanatomic ablation targeting, and outcomes of this ablation strategy. METHODS Patients who underwent scar-based macro-reentrant left atrial tachycardia mapping and ablation patients with at least one Epi AT, which had a complete endocardial map, were selected for the inclusion. Based on current electroanatomical knowledge, Epi ATs were classified based by utilization of following epicardial structures: Bachmann's bundle, septopulmonary bundle, vein of Marshall. Endocardial breakthrough (EB) sites were analyzed as well as entrainment parameters. EB site was targeted for initial ablation. RESULTS Among seventy-eight patients undergoing scar-based macro-reentrant left atrial tachycardia ablation, fourteen (17.8%) patients met the inclusion criteria for Epi AT and were included in the study. Sixteen Epi ATs were mapped, four utilizing Bachmann's bundle, five utilizing septopulmonary bundle, and seven utilizing vein of Marshall. Fractionated, low amplitude signals were present at EB sites. Rf terminated the tachycardia in ten patients; activation changed in five patients and in one patient atrial fibrillation ensued. During the follow-up, there were three recurrences. CONCLUSIONS Epicardial left atrial tachycardias are a distinct type of macro-reentrant tachycardias that can be characterized by activation and entrainment mapping, without need for epicardial access. Endocardial breakthrough site ablation reliably terminates these tachycardias with good long-term success.
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Affiliation(s)
- Emir Baskovski
- Cardiology Department, Ankara University, Ankara, Turkey.
| | | | - Omer Akyurek
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Busra Kuru
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Kubra Korkmaz
- Cardiology Department, Ankara University, Ankara, Turkey
| | - İbrahim Ersoy
- Faculty of Medicine, Afyonkarahisar Science of Health University, Afyonkarahisar, Turkey
| | - Volkan Kozluca
- Cardiology Department, Ankara University, Ankara, Turkey
| | | | - Eralp Tutar
- Cardiology Department, Ankara University, Ankara, Turkey
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Kujiraoka H, Hojo R, Arai T, Takahashi M, Fukamizu S, Sasano T. Modification of the pulmonary vein antrum is associated with recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01668-9. [PMID: 37858001 DOI: 10.1007/s10840-023-01668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Although previous studies have shown the isolated areas after pulmonary vein isolation (PVI) using cryoballoons (CB) (CB-PVI), no studies have investigated the association between the isolated area and recurrence of atrial fibrillation (AF) and atrial tachycardia (AT). This single-center observational study investigated the association between the ablated area and recurrence rate after durable CB-PVI for paroxysmal AF. METHODS This study included 76 patients with paroxysmal AF who underwent CB-PVI and established durable PVI with a second procedure, regardless of AF/AT recurrence, 6 months after the first procedure. To compare the ablated zones, we quantified the left- and right-sided PV antral isolation areas and non-ablated posterior wall (PW) area. We examined non-ablated areas of the PW and AF/AT recurrence in the chronic phase. RESULTS In total, 16 of the 76 patients had AF/AT recurrence. The mean follow-up duration was 34 months. The non-ablated PW area (14.0 ± 4.6 cm2 vs. 11.5 ± 3.7 cm2; p = 0.0213) and the ratio of the non-ablated PW area to the whole PW area (NAPW) (52.9 ± 9.1% vs. 44.8 ± 9.8%; p = 0.003) were significantly higher in the AF/AT recurrence group than in the AF/AT non-recurrence group. NAPW > 50% was an independent predictor of AF/AT recurrence. CONCLUSION The NAPW after durable CB-PVI is associated with AF/AT recurrence. PW isolation or additional applications on the PV antrum with cryoballoon may be considered in addition to PVI in paroxysmal AF, especially in patients with dilated left atria.
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Affiliation(s)
- Hirofumi Kujiraoka
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, 2-34-10, Ebisu, Shibuya-Ku, Tokyo, 150-0013, Japan.
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, 2-34-10, Ebisu, Shibuya-Ku, Tokyo, 150-0013, Japan
| | - Tomoyuki Arai
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, 2-34-10, Ebisu, Shibuya-Ku, Tokyo, 150-0013, Japan
| | - Masao Takahashi
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, 2-34-10, Ebisu, Shibuya-Ku, Tokyo, 150-0013, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, 2-34-10, Ebisu, Shibuya-Ku, Tokyo, 150-0013, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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29
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Kailey B, Kemp I, Taylor M, Crooks J, Katritsis G, Koa-Wing M, Jamil-Copley S, Linton N, Kanagaratnam P, Gupta D, Luther V. Ripple AT Plus - isthmus-guided vs conventional ablation in the treatment of scar-related atrial tachycardia: study protocol for a randomised controlled trial. J Interv Card Electrophysiol 2023; 66:1533-1539. [PMID: 37594646 PMCID: PMC10547628 DOI: 10.1007/s10840-023-01607-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/11/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Catheter ablation is routinely used to treat scar-related atrial tachycardia (s-AT). Conventional ablation often involves creating anatomical "lines" that transect myocardial tissue supporting reentry. This can be extensive, creating iatrogenic scar as a nidus for future reentry, and may account for arrhythmia recurrence. High-density mapping may identify "narrower isthmuses" requiring less ablation, with ripple mapping proven to be an effective approach in identifying. This trial explores whether ablation of narrower isthmuses in s-AT, defined using ripple mapping, results in greater freedom from arrhythmia recurrence compared to conventional ablation. METHODS The Ripple-AT-Plus trial (registration ClinicalTrials.gov , NCT03915691) is a prospective, multicentre, single-blinded, randomised controlled trial with 12-month follow-up. Two hundred s-AT patients will be randomised in a 1:1 fashion to either "ripple mapping-guided isthmus ablation" vs conventional ablation on the CARTO3 ConfiDENSE system (Biosense Webster). The primary outcome will compare recurrence of any atrial arrhythmia. Multicentre data will be analysed over a secure web-based cloud-storage and analysis software (CARTONETTM). CONCLUSION This is the first trial that considers long-term patient outcomes post s-AT ablation, and whether targeting narrower isthmuses in the era of high density is optimal.
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Affiliation(s)
- Balrik Kailey
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Ian Kemp
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
| | - Martika Taylor
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
| | - Jennifer Crooks
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
| | | | - Michael Koa-Wing
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | | | - Nick Linton
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Prapa Kanagaratnam
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE UK
- Imperial College London, Imperial College Healthcare NHS Trust, London, UK
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30
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Peng X, Wang S, Ju W, Yang G, Gu K, Liu H, Li M, Chen H, Wang J, Chen M. Right atrial tachycardia after atrial fibrillation ablation: prevalence, clinical characteristics, electrophysiological mechanisms, and long-term outcomes. J Interv Card Electrophysiol 2023; 66:1641-1650. [PMID: 36692686 DOI: 10.1007/s10840-023-01482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/14/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND This study aims to evaluate the prevalence, clinical characteristics, electrophysiological mechanisms, and long-term outcomes of right atrial tachycardia (AT) in patients who underwent ablation for atrial fibrillation (AF). METHODS From March 2010 to December 2020, 220 consecutive patients undergoing index AF ablation were referred for post-ablation AT recurrence. Thirty-five patients (35/220, 15.9%) with right AT recurrence (25 men; mean age 59.3 ± 10.2 years) were enrolled. These patients were divided into groups with right ATs exclusively (group 1) and right combined with left ATs (group 2). RESULTS Fifty-three ATs were mapped in all patients, with thirty-nine ATs originating from the right atrium. The detailed distribution of all right ATs was 22 in the cavo-tricuspid isthmus (CTI), 6 in the ostium of superior vein cava (SVC), 4 in the right free wall, 4 in the right anterior atrial septum, 2 in coronary sinus ostium, and 1 in crista terminalis. Group 2 had a significantly higher incidence of typical atrial flutter (AFL) than group 1 (11/12, 90.9% vs. 12/24, 50.0%, P = 0.03). During the mean follow-up of 43.6 ± 25.2 months after the index AT ablation, the recurrence rate of AT/AF was 22.9% (8/35), and it was lower in group 1 than in group 2 (8.3% vs. 54.5%, P = 0.01). CONCLUSION Right AT is relatively less common post-AF ablation. The CTI-dependent AFL and the ostium of SVC-derived focal AT constituted the major components of right ATs, suggesting the importance of ablation- and anatomy-related arrhythmogenic effects in the right atrium.
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Affiliation(s)
- Xiafeng Peng
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Shixin Wang
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Weizhu Ju
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Gang Yang
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Kai Gu
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Hailei Liu
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Mingfang Li
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
| | - Hongwu Chen
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
| | - Jing Wang
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
| | - Minglong Chen
- Cardiology Division, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
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De Mattia L, Crosato M, Rebellato L, Nalli C, Calzolari V, Cernetti C. A storm in the desert: Ablation of a left atrial tachycardia in a heart transplant recipient. HeartRhythm Case Rep 2023; 9:720-722. [PMID: 38047187 PMCID: PMC10691953 DOI: 10.1016/j.hrcr.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Luca De Mattia
- Cardiology Department, “Ca’ Foncello” Hospital, Treviso, Italy
| | - Martino Crosato
- Cardiology Department, “Ca’ Foncello” Hospital, Treviso, Italy
| | - Luca Rebellato
- Cardiology Department, “Santa Maria della Misericordia” Hospital, Udine, Italy
| | - Chiara Nalli
- Cardiology Department, “Santa Maria della Misericordia” Hospital, Udine, Italy
| | | | - Carlo Cernetti
- Cardiology Department, “Ca’ Foncello” Hospital, Treviso, Italy
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32
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Harada S, Okada M, Mizutani A, Tanaka K, Hirao Y, Oka T, Tanaka N. Recurrence as isthmus-related atrial tachycardia: A cautionary point of low-voltage area homogenization of persistent atrial fibrillation. J Cardiol Cases 2023; 28:137-140. [PMID: 37818442 PMCID: PMC10562099 DOI: 10.1016/j.jccase.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/09/2023] [Accepted: 05/12/2023] [Indexed: 10/12/2023] Open
Abstract
A 66-year-old female underwent persistent atrial fibrillation ablation. After pulmonary vein isolation and homogenization of low-voltage areas (LVAs), atrial tachycardia (AT) was not induced at the first session; however, it recurred one year after the procedure. During the second session, the extensive LVAs were distributed in the same area of the left atrial anterior wall and expanded possibly due to the previous LVA homogenization. The activation map revealed a macroreentrant AT circuit with the critical isthmus between the isolated right superior pulmonary vein and homogenized LVAs. Although the Ripple map algorithm failed to visualize dynamic bars, extremely low voltage and fractionated potentials (amplitude, 0.04 mV) were observed at the isthmus. Currently, there are various procedural endpoints of LVA-guided ablation (e.g. local electrogram reduction > 50 % or <0.1 mV in amplitude). In this case, incomplete transmural lesions may have led to slow conduction, which could have become an AT substrate. In cases with extensive LVAs on the left atrial anterior wall, eliminating any potential channels may be important for preventing future iatrogenic ATs. LVA-guided ablation should be performed on an individual basis, considering the potential benefits and harms based on the extent and location of LVAs. Learning objective Currently, the procedural endpoint of low-voltage area (LVA)-guided ablation varies across studies. Because any low-voltage potentials, except scars, can cause slow conduction, LVA-guided ablation with an endpoint of local electrogram voltage reduction can unintentionally generate an iatrogenic slow conduction isthmus. LVA-guided ablation should be individually performed, considering the potential benefits and harms based on the extent and location of LVAs.
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Affiliation(s)
- Shinichi Harada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Masato Okada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Akinobu Mizutani
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Koji Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yuko Hirao
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Takafumi Oka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
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33
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Kahle AK, Alken FA, Scherschel K, Meyer C. Prognostic implications of baseline rhythm during catheter ablation for atrial tachycardia. Clin Res Cardiol 2023:10.1007/s00392-023-02292-3. [PMID: 37710016 DOI: 10.1007/s00392-023-02292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Atrial tachycardias (AT) occurring in patients after previous atrial fibrillation (AF) ablation are increasingly observed in clinical practice. Catheter ablation is the treatment of choice but an optimal workflow to improve patient outcome has not been defined. The purpose of this study was to assess procedural and clinical outcome depending on baseline rhythm at the beginning of AT ablation. METHODS A total of 380 patients (69 (61-75) years, 56.6% male) who underwent catheter ablation for consecutive AT after previous AF ablation were studied. RESULTS At the beginning of the procedure, 140 patients (36.8%) presented in sinus rhythm (SR), 208 (54.7%) with AT and 32 (8.4%) with AF. Patients in SR or with AT underwent shorter procedures (173 (132-213) minutes vs. 161 (120-203) minutes vs. 226 (154-249) minutes; p = 0.002) with more frequent termination to SR (87.9% vs. 81.3% vs. 56.3%; p < 0.001) than patients with AF. Acute procedural success did not differ between patients in SR or with AT but was higher compared to those with AF (96.4% vs. 97.1% vs. 87.5%; p = 0.033). During a follow-up of 290 (181-680) days, patients in baseline SR experienced arrhythmia recurrences less often (36.4% vs. 49.5% vs. 68.8%; p = 0.002) than patients with AT or AF. CONCLUSION Baseline rhythm during AT ablation predicts procedural and clinical outcome. Whereas acute procedural success does not differ between patients in SR or with AT, patients presenting in SR have a more favorable mid-term success rate.
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Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Fares-Alexander Alken
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Katharina Scherschel
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Christian Meyer
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany.
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany.
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Hurtado GM, Clarke JRD, Zimerman A, Maher T, Tavares L, d’Avila A. Speech-induced atrial tachycardia: A narrative review of putative mechanisms implicating the autonomic nervous system. Heart Rhythm O2 2023; 4:574-580. [PMID: 37744943 PMCID: PMC10513919 DOI: 10.1016/j.hroo.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Despite being uncommon, speech-induced atrial tachycardias carry significant morbidity and affect predominantly healthy individuals. Little is known about their mechanism, treatment, and prognosis. In this review, we seek to identify the underlying connections and pathophysiology between speech and arrhythmias while providing an informed approach to evaluation and management.
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Affiliation(s)
- Gabriel M.Pajares Hurtado
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - John-Ross D. Clarke
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andre Zimerman
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy Maher
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Liliana Tavares
- Department of Medicine, MetroWest Medical Center, Tufts School of Medicine, Framingham, Massachusetts
| | - Andre d’Avila
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Yorgun H, Çöteli C, Aytemir K. Atrial Late Activation Mapping Predicts the Critical Isthmus of Left Atrial Re-entrant Tachycardia. J Innov Card Rhythm Manag 2023; 14:5563-5564. [PMID: 37781723 PMCID: PMC10540876 DOI: 10.19102/icrm.2023.14092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/13/2023] [Indexed: 10/03/2023] Open
Abstract
Functional atrial mapping is an emerging mapping modality to predict potential critical sites with a role in the maintenance of tachycardia. We report a case of atrial late activation mapping under sinus rhythm predicting the critical isthmus of a left atrial tachycardia. Our findings demonstrate the utility of an atrial isochronal late-activation mapping approach to predict the critical isthmus of re-entry.
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Affiliation(s)
- Hikmet Yorgun
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Cem Çöteli
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Sasaki T, Nakamura K, Minami K, Naito S. Intra-septal radiofrequency ablation within the transseptal puncture hole targeting an interatrial connection during a bi- atrial tachycardia. Indian Pacing Electrophysiol J 2023; 23:166-169. [PMID: 37549787 PMCID: PMC10491961 DOI: 10.1016/j.ipej.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/27/2023] [Accepted: 08/04/2023] [Indexed: 08/09/2023] Open
Abstract
A 74-year-old man after multiple mitral valve surgeries underwent catheter ablation of a bi-atrial tachycardia (BiAT). Ultra-high resolution activation mapping exhibited a reentrant circuit propagating around the inferior to anterior mitral annulus and right atrial (RA) septum with two interatrial connections. At the transeptal puncture site, continuous fractionated electrograms were recorded during the BiAT, and entrainment pacing revealed a post-pacing interval similar to the tachycardia cycle length, which suggested that the interatrial conduction from the RA to the left atrium (LA) was located just at the transseptal puncture site. A radiofrequency application inside the transseptal puncture hole could successfully eliminate the BiAT. The ablation target for BiATs propagating around the mitral annulus and RA septum is generally the anatomical mitral isthmus (MI). Since the present case had multiple incisions on both the RA and LA septum due to mitral valve surgeries, there was the possibility of the occurrence of a BiAT including the RA and LA septum after performing an MI linear ablation. Therefore, the preferable ablation target for the BiAT in the present case appeared to be the interatrial connection. Ultra-high resolution detailed mapping not only on the atrial endocardium but also in the transseptal puncture hole may be useful for identifying a critical interatrial connection of BiAT circuits.
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Affiliation(s)
- Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan.
| | - Kentaro Minami
- Department of Cardiovascular Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi-machi, Maebashi City, Gunma, 371-0004, Japan
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Takigawa M, Kamakura T, Martin C, Derval N, Cheniti G, Duchateau J, Pambrun T, Sacher F, Cochet H, Hocini M, Negishi M, Yamamoto T, Ikenouchi T, Goto K, Shigeta T, Nishimura T, Tao S, Miyazaki S, Goya M, Sasano T, Haissaguierre M, Jais P. Detailed analysis of tachycardia cycle length aids diagnosis of the mechanism and location of atrial tachycardias. Europace 2023; 25:euad195. [PMID: 37428890 PMCID: PMC10403248 DOI: 10.1093/europace/euad195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/29/2023] [Indexed: 07/12/2023] Open
Abstract
AIMS Although the mechanism of an atrial tachycardia (AT) can usually be elucidated using modern high-resolution mapping systems, it would be helpful if the AT mechanism and circuit could be predicted before initiating mapping. OBJECTIVE We examined if the information gathered from the cycle length (CL) of the tachycardia can help predict the AT-mechanism and its localization. METHODS One hundred and thirty-eight activation maps of ATs including eight focal-ATs, 94 macroreentrant-ATs, and 36 localized-ATs in 95 patients were retrospectively reviewed. Maximal CL (MCL) and minimal CL (mCL) over a minute period were measured via a decapolar catheter in the coronary sinus. CL-variation and beat-by-beat CL-alternation were examined. Additionally, the CL-respiration correlation was analysed by the RhythmiaTM system. : Both MCL and mCL were significantly shorter in macroreentrant-ATs [MCL = 288 (253-348) ms, P = 0.0001; mCL = 283 (243-341) ms, P = 0.0012], and also shorter in localized-ATs [MCL = 314 (261-349) ms, P = 0.0016; mCL = 295 (248-340) ms, P = 0.0047] compared to focal-ATs [MCL = 506 (421-555) ms, mCL = 427 (347-508) ms]. An absolute CL-variation (MCL-mCL) < 24 ms significantly differentiated re-entrant ATs from focal-ATs with a sensitivity = 96.9%, specificity = 100%, positive predictive value (PPV) = 100%, and negative predictive value (NPV) = 66.7%. The beat-by-beat CL-alternation was observed in 10/138 (7.2%), all of which showed the re-entrant mechanism, meaning that beat-by-beat CL-alternation was the strong sign of re-entrant mechanism (PPV = 100%). Although the CL-respiration correlation was observed in 28/138 (20.3%) of ATs, this was predominantly in right-atrium (RA)-ATs (24/41, 85.7%), rather than left atrium (LA)-ATs (4/97, 4.1%). A positive CL-respiration correlation highly predicted RA-ATs (PPV = 85.7%), and negative CL-respiration correlation probably suggested LA-ATs (NPV = 84.5%). CONCLUSION Detailed analysis of the tachycardia CL helps predict the AT-mechanism and the active AT chamber before an initial mapping.
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Affiliation(s)
- Masateru Takigawa
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
- Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Tsukasa Kamakura
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Claire Martin
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- Cardiology Department, Royal Papworth Hospital, Cambridge CB2 0AY, UK
- Department of Medicine, Cambridge University, Cambridge CB2 0QQ, UK
| | - Nicolas Derval
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Ghassen Cheniti
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Josselin Duchateau
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Thomas Pambrun
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Frederic Sacher
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Meleze Hocini
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Miho Negishi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Takashi Ikenouchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Kentaro Goto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Takatoshi Shigeta
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Takuro Nishimura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Susumu Tao
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
- Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Masahiko Goya
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, 113-8510, Tokyo
| | - Michel Haissaguierre
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
| | - Pierre Jais
- Department of Cardiac Pacing and Electrophysiology, Bordeaux University Hospital (CHU), Av. Magellan, 33600 Pessac, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Univ. Bordeaux, Av. du Haut Lévêque, 33600 Pessac, France
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Spittler R, Witte N, Hoffmann BA, Marx A, Mollnau H, Quesada-Ocete B, Konrad T, Rostock T. Automated three-dimensional activation versus conventional mapping for catheter ablation of atrial tachycardia - A prospective randomized trial. Int J Cardiol Heart Vasc 2023; 47:101222. [PMID: 37252196 PMCID: PMC10220253 DOI: 10.1016/j.ijcha.2023.101222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023]
Abstract
Background The automated NavX Ensite Precision latency-map (LM) algorithm aims to identify atrial tachycardia (AT) mechanisms. However, data on a direct comparison of this algorithm with conventional mapping are scarce. Methods Patients scheduled for AT ablation were randomized to mapping with the LM- algorithm (LM group) or to conventional mapping (conventional only group: ConvO), using entrainment and local activation mapping techniques. Several outcomes were exploratively analyzed. Primary endpoint was intraprocedural AT Termination. If AT termination with only automated 3D-Mapping failed, additional conventional methods were applied (conversion). Results A total of 63 patients (mean 67 years, 34 % female) were enrolled. In the LM group (n = 31), the correct AT mechanism was identified in 14 patients (45 %) using the algorithm alone compared to 30 patients (94 %) with conventional methods. Time to termination of the first AT was not different between groups (LM group 34 ± 20 vs. ConvO 43.1 ± 28.3 min; p = 0.2). However, when AT termination did not occur with LM algorithm, time to termination prolonged significantly (65 ± 35 min; p = 0.01). After applying conventional methods (conversion), procedural termination rates did not differ between LM group (90 %) vs. ConvO (94 %) (p = 0.3). During a follow-up time of 20 ± 9 months, no differences were observed in clinical outcomes. Conclusion In this small prospective, randomized study, the use of the LM algorithm alone may lead to AT termination, but less accurate than conventional methods.
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Affiliation(s)
- Raphael Spittler
- Corresponding author at: Department of Cardiology II/Electrophysiology, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
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Miyamae K, Murase Y, Ogawa Y, Imai H, Kano N, Mamiya K, Ikeda T, Yamazoe S, Torii J, Yamanaka K, Kawaguchi K. Radiofrequency Ablation of Re-entrant Atrial Tachycardia Originating from the Superior Vena Cava with a High-resolution, 3-dimensional Mapping System. J Innov Card Rhythm Manag 2023; 14:5546-5551. [PMID: 38059260 PMCID: PMC10697111 DOI: 10.19102/icrm.2023.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/01/2023] [Indexed: 12/08/2023] Open
Abstract
An 80-year-old man with no previous history of catheter ablation or cardiac surgery underwent catheter ablation for atrial tachycardia (AT). We suspected that the mechanism causing AT was re-entry indicated by the entrainment phenomenon during AT and through activation mapping with a 3-dimensional mapping system (EnSite™ X EP system; Abbott, Chicago, IL, USA). We used a multipolar catheter (Advisor™ HD Grid Mapping Catheter; Abbott) inserted into the superior vena cava (SVC) to accomplish activation mapping. The AT circuit was localized inside the SVC with a fractionated potential recorded on its right lateral wall. A similar fractionated potential was observed in the surrounding area. These areas functioned as the critical isthmus of the AT. Radiofrequency (RF) catheter ablation at these sites eliminated the tachycardia. After RF delivery, no tachycardia was induced by programmed stimulation, even during isoproterenol infusion. Consequently, there was no recurrence of tachycardia even after catheter ablation.
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Affiliation(s)
- Kiichi Miyamae
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Yosuke Murase
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Yasuhiro Ogawa
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Hajime Imai
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Naoaki Kano
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Keita Mamiya
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Tomoyo Ikeda
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Shinji Yamazoe
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
| | - Jun Torii
- Department of Cardiology, Komaki City Hospital, Komaki, Japan
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Tóth P, Szilveszter B, Perge P, Fejér C, Gellér L, Nagy KV. Spinal osteophyte as a possible source of left atrial tachycardia. HeartRhythm Case Rep 2023; 9:456-460. [PMID: 37492045 PMCID: PMC10363472 DOI: 10.1016/j.hrcr.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Affiliation(s)
| | | | | | | | | | - Klaudia Vivien Nagy
- Address reprint requests and correspondence: Dr Klaudia Vivien Nagy, Heart and Vascular Center, Semmelweis University, 68 Városmajor utca, H-1122 Budapest, Hungary.
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Kong J, Ge X, Wu Y, Meng X, Rong B, Zhang K, Zhong J. Atrial tachycardia ablation at the pulmonary outflow tract in a patient with congenitally corrected transposition of the great arteries. HeartRhythm Case Rep 2023; 9:489-492. [PMID: 37492055 PMCID: PMC10363455 DOI: 10.1016/j.hrcr.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Affiliation(s)
- Jing Kong
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiao Ge
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yang Wu
- Department of Cardiology, Weihai Municipal Hospital, Weihai, China
| | - Xiao Meng
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bing Rong
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kai Zhang
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jingquan Zhong
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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Ganesan P, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Rogers AJ, Clopton P, Wang PJ, Zeemering S, Schotten U, Rappel WJ, Narayan SM. Quantifying a spectrum of clinical response in atrial tachyarrhythmias using spatiotemporal synchronization of electrograms. Europace 2023; 25:euad055. [PMID: 36932716 PMCID: PMC10227659 DOI: 10.1093/europace/euad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/19/2023] Open
Abstract
AIMS There is a clinical spectrum for atrial tachyarrhythmias wherein most patients with atrial tachycardia (AT) and some with atrial fibrillation (AF) respond to ablation, while others do not. It is undefined if this clinical spectrum has pathophysiological signatures. This study aims to test the hypothesis that the size of spatial regions showing repetitive synchronized electrogram (EGM) shapes over time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. METHODS AND RESULTS We studied n = 160 patients (35% women, 65.0 ± 10.4 years) of whom (i) n = 75 had AF terminated by ablation propensity matched to (ii) n = 75 without AF termination and (iii) n = 10 with AT. All patients had mapping by 64-pole baskets to identify areas of repetitive activity (REACT) to correlate unipolar EGMs in shape over time. Synchronized regions (REACT) were largest in AT, smaller in AF termination, and smallest in non-termination cohorts (0.63 ± 0.15, 0.37 ± 0.22, and 0.22 ± 0.18, P < 0.001). Area under the curve for predicting AF termination in hold-out cohorts was 0.72 ± 0.03. Simulations showed that lower REACT represented greater variability in clinical EGM timing and shape. Unsupervised machine learning of REACT and extensive (50) clinical variables yielded four clusters of increasing risk for AF termination (P < 0.01, χ2), which were more predictive than clinical profiles alone (P < 0.001). CONCLUSION The area of synchronized EGMs within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any predetermined mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.
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Affiliation(s)
- Prasanth Ganesan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Brototo Deb
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Ruibin Feng
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
| | - Samuel Ruiperez-Campillo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Albert J Rogers
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul Clopton
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Stef Zeemering
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Wouter-Jan Rappel
- Department of Physics, University of California, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
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Havranek S, Fingrova Z, Skala T, Reichenbach A, Dusik M, Jansa P, Ambroz D, Dytrych V, Klimes D, Hutyra M, Kautzner J, Linhart A, Wichterle D. Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study. Europace 2023:7161651. [PMID: 37178136 DOI: 10.1093/europace/euad131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/14/2023] [Indexed: 05/15/2023] Open
Abstract
AIMS Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias. METHODS AND RESULTS Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group. CONCLUSION Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov; NCT04053361.
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Affiliation(s)
- Stepan Havranek
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Zdenka Fingrova
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Tomas Skala
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Adrian Reichenbach
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Milan Dusik
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - David Ambroz
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Vladimir Dytrych
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dalibor Klimes
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Martin Hutyra
- First Department of Internal Medicine-Cardiology, Olomouc University Hospital, Olomouc, Czech Republic
| | - Josef Kautzner
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
| | - Dan Wichterle
- 2nd Department of Medicine-Department of Cardiovascular Medicine of the 1st Faculty of Medicine and General University Hospital in Prague, U Nemocnice 2, 12800 Prague, Czech Republic
- Cardiology Department, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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Korkmaz A, Özeke Ö, Cay S, Ozcan F, Kara M, Ozcan Cetin EH, Beton N, Aksoy A, Saribas H, Merovci I, Demirhan C, Aras D, Topaloglu S. Atrial Tachycardia with Cycle Length Alternans. J Innov Card Rhythm Manag 2023; 14:5436-5441. [PMID: 37216083 PMCID: PMC10193878 DOI: 10.19102/icrm.2023.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/26/2022] [Indexed: 05/24/2023] Open
Abstract
Tachycardia-induced tachycardia, or so-called double tachycardia, appears to be a relatively rare condition. The underlying mechanism for stable beat-to-beat cycle length variability (alternans) in atrial tachycardia has been sparsely reported.
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Affiliation(s)
- Ahmet Korkmaz
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Özcan Özeke
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Elif Hande Ozcan Cetin
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Nur Beton
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Atik Aksoy
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Halenur Saribas
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Idriz Merovci
- Department of Cardiology, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Can Demirhan
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Istanbul Medipol University, Istanbul, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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45
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Yagishita A, Sakama S, Ayabe K, Amino M, Ikari Y, Yoshioka K. Utility and limitations of coherent mapping algorithm utilizing vectors and global propagation patterns in atrial tachycardia. Int J Cardiol Heart Vasc 2023; 45:101193. [PMID: 36925726 PMCID: PMC10011740 DOI: 10.1016/j.ijcha.2023.101193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/07/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
Background A novel mapping algorithm utilizing vectors and global patterns of propagation (Coherent™, Biosense Webster) has been developed to help identify the mechanism of atrial tachycardia (AT). We aimed to determine the diagnostic accuracy of coherent mapping compared with that of ripple mapping. Methods and results This study included 41 consecutive patients with 84 ATs (47 reentrant and 37 focal ATs). Two independent electrophysiologists confirmed the diagnoses using coherent mapping before the ripple map-guided ablation. AT termination was achieved in 75 of 84 ATs (89%) at first ablation lesion set. Four of the remaining nine ATs, which were terminated before an index radiofrequency (RF) application, were non-inducible after RF delivery at the first lesion set, whereas the other five ATs were terminated at the second lesion set. Diagnostic agreement between coherent and ripple maps was achieved in 51 of 84 ATs (61%): 28 of the 47 macroreentrant ATs (60%) and 23 of the 37 focal ATs (62%; P = 0.826). In typical macroreentrant ATs, including left atrial roof, perimitral, and cavotricuspid isthmus-dependent ATs, coherent maps achieved diagnostic agreement in 23 of 29 ATs (79%), which was higher than that in other ATs (51%, P = 0.018): 13 of 26 macroreentrant ATs (50%) and 15 of 29 focal ATs (52%, P = 1.000). Conclusion Ripple map-guided AT ablation achieved a high termination rate in the first lesion set. Coherent mapping yielded a favorable diagnostic accuracy for typical macroreentrant ATs, though its value for diagnosing other ATs was limited.
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Affiliation(s)
- Atsuhiko Yagishita
- Corresponding author at: Shimokasuya 143, Isehara, Kanagawa #259-1193, Japan.
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46
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Ghannam M, Jongnarangsin K, Emami H, Yokokawa M, Liang JJ, Saeed M, Oral H, Morady F, Chugh A. Incidental Left Atrial Appendage Isolation after Catheter Ablation of Persistent Atrial Fibrillation: Mechanisms and Long-term Risk of Thromboembolism. J Cardiovasc Electrophysiol 2023; 34:1152-1161. [PMID: 36934394 DOI: 10.1111/jce.15889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/18/2023] [Accepted: 03/08/2023] [Indexed: 03/20/2023]
Abstract
BACKGROUND Incidental left atrial appendage (LAA) isolation may occur during radiofrequency ablation of persistent atrial fibrillation (AF). OBJECTIVE The study aims to describe the mechanisms and long-term thromboembolic risk related to incidental LAA isolation. METHODS Patients who experienced incidental LAA isolation after AF ablation were included. Culprit sites where ablation resulted in LAA isolation were identified. Thromboembolic risk despite oral anticoagulation (OAC) was compared to that in a propensity-matched control group without LAA isolation. RESULTS Forty-one patients with LAA isolation, and 82 matched patients without LAA isolation were included. The patient age, ejection fraction, LA diameter, and CHA2 DS2 -VASc score were 64±11 years, 55±12%, 45.0±7 mm and 2.62±1.5, respectively. Culprit sites included the LAA base, mitral isthmus, inferior LA, Bachmann's bundle, coronary sinus, and Marshall vein. After 4.2±3.6 years follow up, thromboembolism occurred in 7 of 41 patients (17%) with LAA isolation vs. 3 of 82 patients (4%) without isolation (log rank P<0.009, HR 5.14, 95% CI [1.32-19.94], P=0.02). Patients with and without thromboembolism had similar CHA2 DS2 -VASc scores (2.65±1.3 vs. 2.71±0.76, P=0.89). Thromboembolism occurred during noncompliance with or temporary discontinuation of OAC in 4 of the 7 patients. CONCLUSIONS Incidental LAA isolation may occur during ablation of atrial arrhythmias in the vicinity of, or even at sites remote from the appendage. Patients with incidental LAA isolation had higher rates of thromboembolism compared to patients without isolation. Since thromboembolism may occur despite prescription for OAC, the risks of LAA isolation must be weighed against clinical benefit and appendage occlusion devices should be considered in vulnerable patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Michael Ghannam
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Krit Jongnarangsin
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Hamed Emami
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Miki Yokokawa
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Jackson J Liang
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Mohammed Saeed
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Hakan Oral
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Fred Morady
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Aman Chugh
- From the section of Electrophysiology/Division of Cardiology, University of Michigan, Ann Arbor, Michigan
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47
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Xu X, Guo Y, Gao W, Huang M, Liu T, Li F. Ivabradine monotherapy in pediatric patients with focal atrial tachycardia: a single-center study. Eur J Pediatr 2023. [PMID: 36869903 DOI: 10.1007/s00431-023-04891-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 03/05/2023]
Abstract
This study investigated the efficacy of ivabradine monotherapy in pediatric patients with focal atrial tachycardia (FAT). We prospectively enrolled 12 pediatric patients (7.5 ± 4.5 years; six girls) with FAT who were resistant to conventional antiarrhythmics and received ivabradine as monotherapy. Patients were classified as having tachycardia-induced cardiomyopathy (TIC) if they had a left ventricular ejection fraction (LVEF) of < 50% and a left ventricular end-diastolic dimension (LVDD) z-score of > 2 due to tachycardia. Oral ivabradine was initiated at 0.1 mg/kg every 12 h, increased to 0.2 mg/kg every 12 h if no restoration of stable sinus rhythm was observed after two doses, and discontinued after 48 h if neither rhythm nor heart rate control was observed. Of these patients, six (50%) had incessant atrial tachycardia, and 6 had frequent short episodes of FAT. Six patients were diagnosed with TIC, and their mean LVEF and mean LVDD z-score were 36.2 ± 8.7% (range, 27-48%) and 4.2 ± 1.7 (range, 2.2-7.3), respectively. Finally, six patients achieved either rhythm (n = 3) or heart rate control (n = 3) within 48 h of ivabradine monotherapy. One patient achieved rhythm/heart rate control with ivabradine at a dose of 0.1 mg/kg every 12 h, while the others achieved rhythm/heart rate control at a dose of 0.2 mg/kg every 12 h. Five patients received ivabradine monotherapy for chronic therapy, one (20%) of whom had FAT breakthrough 1 month after discharge, and metoprolol was added. Neither FAT recurrence nor adverse effect (with or without beta-blocker) was observed during a median follow-up of 5 months. CONCLUSION Ivabradine is well-tolerated and may provide early heart rate control in pediatric FAT and can be considered early, especially in the presence of left ventricular dysfunction. Further investigations are deserved to confirm the optimal dose and long-term efficacy in this population. WHAT IS KNOWN • Focal atrial tachycardia (FAT) is the most common arrhythmia associated with tachycardia-induced cardiomyopathy (TIC) in children, and the efficacy of conventional antiarrhythmic medications in the treatment of FAT is poor. • Ivabradine is currently the only selective hyperpolarization-activated cyclic nucleotide-gated (HCN) inhibitor, which can effectively low HR without negative effect on blood pressure or inotropy. WHAT IS NEW • Ivabradine (0.1-0.2 mg/kg every 12 h) can effectively suppress focal atrial tachycardia in 50% of pediatric patients. • Ivabradine provides early control of heart rate and hemodynamic stabilization in children with severe left ventricular dysfunction due to atrial tachycardia within 48 h.
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48
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Zhang J, Ju W, Yang G, Tang C, Luo J, Xu J, Chen M. Epicardial ablation of refractory focal atrial tachycardia after a failed endocardial approach. Heart Rhythm 2023; 20:374-382. [PMID: 36410677 DOI: 10.1016/j.hrthm.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/30/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Endocardial ablation is effective for most focal atrial tachycardias (FATs). In rare circumstances, the FAT can originate from the epicardial side of the atrium. OBJECTIVE In the present study, we retrospectively assessed the percutaneous approach for epicardial ablation of FAT when standard endocardial ablation had failed. METHODS Among a consecutive 186 patients undergoing ablation for 198 FATs, epicardial mapping and ablation via a percutaneous subxiphoid approach were attempted in 10 patients because of failed endocardial ablation. RESULTS In 3 cases, the origin of FAT was at the epicardial side of the junction of the right atrial appendage and superior vena cava. In 3 cases, the origin of FAT was located in the epicardial region of the left atrial insertion of Bachmann bundle. In 2 cases, the FAT originated from the epicardial side of the right atrial free wall. In 1 case, the FAT was successfully ablated from the epicardial side of the right atrial appendage, and in the remaining case, the origin of FAT was located in the epicardial region of the vein of Marshall. All FATs were successfully eliminated by ablation at the epicardial earliest activation site. CONCLUSION Epicardial mapping and ablation can be considered as an effective and safe option for FAT resistant to endocardial ablation.
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Affiliation(s)
- Jinlin Zhang
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China.
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Cheng Tang
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China
| | - Jianfeng Luo
- The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Jian Xu
- The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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49
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Ramirez FD, Meo M, Dallet C, Krisai P, Vlachos K, Frontera A, Takigawa M, Nakatani Y, Nakashima T, André C, Kamakura T, Takagi T, Carapezzi A, Tixier R, Chauvel R, Cheniti G, Duchateau J, Pambrun T, Sacher F, Hocini M, Haïssaguerre M, Jaïs P, Dubois R, Derval N. High-resolution mapping of reentrant atrial tachycardias: Relevance of low bipolar voltage. Heart Rhythm 2023; 20:430-7. [PMID: 36368515 DOI: 10.1016/j.hrthm.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Bipolar voltage is widely used to characterize the atrial substrate but has been poorly validated, particularly during clinical tachycardias. OBJECTIVE The purpose of this study was to evaluate the diagnostic performance of voltage thresholds for identifying regions of slow conduction during reentrant atrial tachycardias (ATs). METHODS Thirty bipolar voltage and activation maps created during reentrant ATs were analyzed to (1) examine the relationship between voltage amplitude and conduction velocity (CV), (2) measure the diagnostic ability of voltage thresholds to predict CV, and (3) identify determinants of AT circuit dimensions. Voltage amplitude was categorized as "normal" (>0.50 mV), "abnormal" (0.05-0.50 mV), or "scar" (<0.05 mV); slow conduction was defined as <30 cm/s. RESULTS A total of 266,457 corresponding voltage and CV data points were included for analysis. Voltage and CV were moderately correlated (r = 0.407; P < .001). Bipolar voltage predicted regions of slow conduction with an area under the receiver operating characteristic curve of 0.733 (95% confidence interval 0.731-0.735). A threshold of 0.50 mV had 91% sensitivity and 35% specificity for identifying slow conduction, whereas 0.05 mV had 36% sensitivity and 87% specificity, with an optimal voltage threshold of 0.15 mV. Analyses restricted to the AT circuits identified weaker associations between voltage and CV and an optimal voltage threshold of 0.25 mV. CONCLUSION Widely used bipolar voltage amplitude thresholds to define "abnormal" and "scar" tissue in the atria are, respectively, sensitive and specific for identifying regions of slow conduction during reentrant ATs. However, overall, the association of voltage with CV is modest. No clinical predictors of AT circuit dimensions were identified.
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50
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Hu W, Zhou D, Ding X, Yang G, Liu H, Wang Z, Chen H, Ju W, Li M, Zhang F, Yang J, Han J, Wu X, Qiu Z, Zheng L, Chen M. Arrhythmogenesis of surgical atrial incisions and lesions in Maze procedure: insights from high-resolution mapping of atrial tachycardias. Europace 2023; 25:137-145. [PMID: 35851635 PMCID: PMC10112846 DOI: 10.1093/europace/euac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Atrial tachycardias (ATs) frequently develop after a surgical Maze procedure. We aimed to elucidate the electrophysiologic mechanisms and their arrhythmogenic substrates of these ATs. METHODS AND RESULTS We retrospectively reviewed 20 patients (14 females, mean age of 55.5 ± 8.6 years) with post-Maze ATs who underwent high-resolution mapping at three institutions. The slow conduction areas, reentry circuits, voltage signals, complex electrograms, and their correlation with the surgical incisions and lesions placed in the surgical Maze procedures were analyzed. Thirty-six ATs with a mean cycle length of 260.0 ± 67.6 ms were mapped in these patients. Among them, 22 (61.1%) were anatomical macro-reentrant ATs (AMAT), 12 (33.3%) non-AMATs (localized ATs), and 2 (5.6%) focal ATs, respectively. Epicardial conduction bridges were observed in 6/20 (30.0%) patients and 7/36 (19.4%) ATs. Different arrhythmogenic substrates were identified in these ATs, including slow conduction regions within the previous lesion areas or between the incisions and anatomical structures, the prolonged activation pathways caused by the short lesions connecting the tricuspid annulus, and the circuits around the long incisions and/or lesions. CONCLUSIONS Reentry is the main mechanism of the post-Maze ATs. The pro-arrhythmic substrates are most likely caused by surgical incisions and lesions. The slow conduction regions and the protected channels yielded from these areas are the major arrhythmogenic factors.
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Affiliation(s)
- Wei Hu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dongchen Zhou
- Cardiology Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiangwei Ding
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hailei Liu
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zidun Wang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizu Ju
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingfang Li
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Yang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Han
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xianhao Wu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaohui Qiu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liangrong Zheng
- Cardiology Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Minglong Chen
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Cardiology Department, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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