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Calvert P, Mills MT, Xydis P, Essa H, Ding WY, Koniari I, Farinha JM, Harding M, Mahida S, Snowdon R, Waktare J, Borbas Z, Modi S, Todd D, Ashrafi R, Luther V, Gupta D. Cost, Efficiency and Outcomes of Pulsed Field Ablation versus Thermal Ablation for Atrial Fibrillation: A Real World Study. Heart Rhythm 2024:S1547-5271(24)02574-8. [PMID: 38763378 DOI: 10.1016/j.hrthm.2024.05.032] [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: 04/14/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND With the exponential growth of catheter ablation (CA) for atrial fibrillation (AF), there is increasing interest in associated healthcare costs. Pulsed field ablation (PFA) using a single-shot pentaspline multi-electrode catheter has been shown to be safe and effective for AF CA, but its cost efficiency compared to conventional thermal ablation modalities (cryoballoon [CB] or radiofrequency [RF]) has not been evaluated. OBJECTIVE To compare cost, efficiency, effectiveness and safety between PFA, CB and RF for AF ablation. METHODS We studied 707 consecutive patients (208 PFA, 325 CB, 174 RF) undergoing first-time AF ablation. Individual procedural costs were calculated, including equipment, lab utilisation and hospital stay, and compared between ablation modalities, as effectiveness and safety. RESULTS Skin-to-skin times and catheter lab times were significantly shorter with PFA (68min/102min) vs CB (91min/122min) and RF (89min/123 min); p<0.001. General anaesthesia utilisation differed across modalities (PFA 100%, CB 10.2%, RF 61.5%); p<0.001. Major complications occurred in 1% of cases, with no significant differences between modalities. Shorter procedural times resulted in lower staffing and lab costs with PFA, but these savings were offset by substantially higher equipment costs, resulting in higher overall median costs with PFA (£10,010) vs CB (£8,106) and RF (£8,949); p<0.001. CONCLUSION In this contemporary real-world study of the three major AF CA modalities used concurrently, PFA had shorter skin-to-skin and catheter lab times than CB and RF, with similarly low rates of complications. However, PFA procedures were considerably more expensive, largely due to higher equipment cost.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, UK L14 3PE
| | - Mark T Mills
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, UK L14 3PE
| | - Panagiotis Xydis
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Hani Essa
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Ioanna Koniari
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Jose Maria Farinha
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, UK L14 3PE
| | - Mike Harding
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, UK L14 3PE
| | - Saagar Mahida
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Richard Snowdon
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Johan Waktare
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Zoltan Borbas
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Simon Modi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Derick Todd
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Reza Ashrafi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Vishal Luther
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, UK L14 3PE.
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Katritsis G, Kailey B, Luther V, Jamil Copley S, Koa-Wing M, Balasundram A, Malcolme-Lawes L, Qureshi N, Boon Lim P, Ng FS, Cortez Diaz N, Carpinteiro L, de Sousa J, Martin R, Das M, Murray S, Chow A, Peters NS, Whinnett Z, Linton NWF, Kanagaratnam P. Characterization of conduction system activation in the postinfarct ventricle using ripple mapping. Heart Rhythm 2024; 21:571-580. [PMID: 38286246 DOI: 10.1016/j.hrthm.2024.01.038] [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: 11/11/2023] [Revised: 01/14/2024] [Accepted: 01/18/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Three-dimensional (3D) mapping of the ventricular conduction system is challenging. OBJECTIVE The purpose of this study was to use ripple mapping to distinguish conduction system activation to that of adjacent myocardium in order to characterize the conduction system in the postinfarct left ventricle (LV). METHODS High-density mapping (PentaRay, CARTO) was performed during normal rhythm in patients undergoing ventricular tachycardia ablation. Ripple maps were viewed from the end of the P wave to QRS onset in 1-ms increments. Clusters of >3 ripple bars were interrogated for the presence of Purkinje potentials, which were tagged on the 3D geometry. Repeating this process allowed conduction system delineation. RESULTS Maps were reviewed in 24 patients (mean 3112 ± 613 points). There were 150.9 ± 24.5 Purkinje potentials per map, at the left posterior fascicle (LPF) in 22 patients (92%) and at the left anterior fascicle (LAF) in 15 patients (63%). The LAF was shorter (41.4 vs 68.8 mm; P = .0005) and activated for a shorter duration (40.6 vs 64.9 ms; P = .002) than the LPF. Fourteen of 24 patients had left bundle branch block (LBBB), with 11 of 14 (78%) having Purkinje potential-associated breakout. There were fewer breakouts from the conduction system during LBBB (1.8 vs 3.4; 1.6 ± 0.6; P = .039) and an inverse correlation between breakout sites and QRS duration (P = .0035). CONCLUSION We applied ripple mapping to present a detailed electroanatomic characterization of the conduction system in the postinfarct LV. Patients with broader QRS had fewer LV breakout sites from the conduction system. However, there was 3D mapping evidence of LV breakout from an intact conduction system in the majority of patients with LBBB.
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Affiliation(s)
- George Katritsis
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Balrik Kailey
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Vishal Luther
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Michael Koa-Wing
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Anu Balasundram
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Norman Qureshi
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | | | - Ruairidh Martin
- Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Moloy Das
- Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Stephen Murray
- Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Nicholas S Peters
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zachary Whinnett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nick W F Linton
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Prapa Kanagaratnam
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.
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Calvert P, Ding WY, Mills MT, Snowdon R, Borbas Z, Modi S, Hall M, Morgan M, Clarkson N, Chackochen S, Barton J, Kemp I, Luther V, Gupta D. Durability of Thermal Pulmonary Vein Isolation in Persistent Atrial Fibrillation Assessed by Mandated Repeat Invasive Study. Heart Rhythm 2024:S1547-5271(24)02388-9. [PMID: 38636929 DOI: 10.1016/j.hrthm.2024.04.061] [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: 02/13/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND No study has assessed durability of pulmonary vein isolation (PVI) with radiofrequency (RF) and Cryoballoon (CB) in patients with persistent AF. These data are especially lacking for those with significantly diseased left atria (LA). OBJECTIVE To assess PVI durability in patients with significant LA disease and compare reconnection rates between RF and CB. METHODS 44 Patients (mean age 63, 77% male, median time since AF diagnosis 22.5 months, median indexed LA volume 36 ml/m2) were randomised 1:1 to RF (StablePoint catheter, Boston Scientific) or CB (Arctic Front Advance, Medtronic) PVI. A redo procedure using ultra high-density electroanatomic mapping (Rhythmia, Boston Scientific) was mandated at 2 months, where PV reconnections were identified and re-isolated. RESULTS 38 patients underwent both procedures (n=17 CB, n=21 RF). Index RF procedures were longer (median 158 vs 97min; p<0.001) but required less fluoroscopy (9.5 vs 23min; p<0.001). At the index RF procedure, median 47% of LA myocardium had voltage <0.5mV, suggesting half of the mapped LA comprised scar. PV reconnection was observed in 73/152 (48.0%) PVs and was more frequent with CB (58.8%) vs RF (39.3%), p=0.022. Reconnection of at least 1 PV was detected in >75% of patients. Significantly more ablation was required at redo to reisolate PVs in the CB arm (median 10.8 vs 1.2min; p<0.001). CONCLUSION PVI durability may be poor in those with significant LA scarring and dilatation, even with modern thermal ablation technologies. RF resulted in significantly better PVI durability than CB in this complex population. CLINICAL TRIAL REGISTRATION NCT04111731.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Wern Yew Ding
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Mark T Mills
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Simon Modi
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Maureen Morgan
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | | | | | - Janet Barton
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Ian Kemp
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, UK; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.
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Calvert P, Koniari I, Mills MT, Ashrafi R, Snowdon R, Gupta D, Luther V. Lesion metrics and 12-month outcomes of very-high power short duration radiofrequency ablation (90W/4 s) under mild conscious sedation. J Cardiovasc Electrophysiol 2024. [PMID: 38571287 DOI: 10.1111/jce.16269] [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: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) is often performed under general anaesthesia (GA) or deep sedation. Anaesthetic availability is limited in many centers, and deep sedation is prohibited in some countries without anaesthetic support. Very high-power short duration (vHPSD-90W/4 s) PVI using the Q-Dot catheter is generally well tolerated under mild conscious sedation (MCS) though an understanding of catheter stability and long-term effectiveness is lacking. We analyzed lesion metrics and 12-month freedom from atrial arrythmia with this approach. METHODS Our approach to radiofrequency (RF) PVI under MCS is standardized and includes a single catheter approach with a steerable sheath. We identified patients undergoing Q-Dot RF PVI between March 2021 and December 2022 in our center, comparing those undergoing vHPSD ablation under MCS (90W/MCS) against those undergoing 50 W ablation under GA (50 W/GA) up to 12 months of follow-up. Data were extracted from clinical records and the CARTO system. RESULTS Eighty-three patients met our inclusion criteria (51 90W/MCS; 32 50 W/GA). Despite shorter ablation times (353 vs. 886 s; p < .001), the 90 W/MCS group received more lesions (median 87 vs. 58, p < .001), resulting in similar procedure times (149.3 vs. 149.1 min; p = .981). PVI was achieved in all cases, and first pass isolation rates were similar (left wide antral circumferential ablation [WACA] 82.4% vs. 87.5%, p = .758; right WACA 74.5% vs. 78.1%, p = .796; 90 W/MCS vs. 50 W/GA respectively). Analysis of 6647 ablation lesions found similar mean impedance drops (10.0 ± 1.9 Ω vs. 10.0 ± 2.2 Ω; p = .989) and mean contact force (14.6 ± 2.0 g vs. 15.1 ± 1.6 g; p = .248). Only median 2.5% of lesions in the 90 W/MCS cohort failed to achieve ≥ 5 Ω drop. In the 90 W/MCS group, there were no procedural related complications, and 12-month freedom from atrial arrhythmia was observed in 78.4%. CONCLUSION vHPSD PVI is feasible under MCS, with encouraging acute and long-term procedural outcomes. This provides a compelling option for centers with limited anaesthetic support.
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Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | | | | | | | | | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
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Grade Santos J, Mills MT, Calvert P, Worthington N, Phenton C, Modi S, Ashrafi R, Todd D, Waktare J, Mahida S, Gupta D, Luther V. Delineating postinfarct ventricular tachycardia substrate with dynamic voltage mapping in areas of omnipolar vector disarray. Heart Rhythm O2 2024; 5:224-233. [PMID: 38690145 PMCID: PMC11056467 DOI: 10.1016/j.hroo.2024.02.006] [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: 05/02/2024] Open
Abstract
Background Defining postinfarct ventricular arrhythmic substrate is challenging with voltage mapping alone, though it may be improved in combination with an activation map. Omnipolar technology on the EnSite X system displays activation as vectors that can be superimposed onto a voltage map. Objective The study sought to optimize voltage map settings during ventricular tachycardia (VT) ablation, adjusting them dynamically using omnipolar vectors. Methods Consecutive patients undergoing substrate mapping were retrospectively studied. We categorized omnipolar vectors as uniform when pointing in one direction, or in disarray when pointing in multiple directions. We superimposed vectors onto voltage maps colored purple in tissue >1.5 mV, and the voltage settings were adjusted so that uniform vectors appeared within purple voltages, a process termed dynamic voltage mapping (DVM). Vectors in disarray appeared within red-blue lower voltages. Results A total of 17 substrate maps were studied in 14 patients (mean age 63 ± 13 years; mean left ventricular ejection fraction 35 ± 6%, median 4 [interquartile range 2-8.5] recent VT episodes). The DVM mean voltage threshold that differentiated tissue supporting uniform vectors from disarray was 0.27 mV, ranging between patients from 0.18 to 0.50 mV, with good interobserver agreement (median difference: 0.00 mV). We found that VT isthmus components, as well as sites of latest activation, isochronal crowding, and excellent pace maps colocated with tissue along the DVM border zone surrounding areas of disarray. Conclusion DVM, guided by areas of omnipolar vector disarray, allows for individualized postinfarct ventricular substrate characterization. Tissue bordering areas of disarray may harbor greater arrhythmogenic potential.
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Affiliation(s)
- Joao Grade Santos
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Mark T. Mills
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Peter Calvert
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Simon Modi
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Reza Ashrafi
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Derick Todd
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Johan Waktare
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Saagar Mahida
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vishal Luther
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
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Luther V. What Is the Best Approach to Treat Patients With De Novo Atypical Flutter? JACC Clin Electrophysiol 2024; 10:249-250. [PMID: 38180433 DOI: 10.1016/j.jacep.2023.11.019] [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: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom.
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Calvert P, Ding WY, Griffin M, Bisson A, Koniari I, Fitzpatrick N, Snowdon R, Modi S, Luther V, Mahida S, Waktare J, Borbas Z, Ashrafi R, Todd D, Gupta D. Silent pulmonary veins at redo ablation for atrial fibrillation: Implications and approaches. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01750-w. [PMID: 38261098 DOI: 10.1007/s10840-024-01750-w] [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] [Accepted: 01/14/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. METHODS Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. RESULTS A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p<0.001), had more persistent AF (62.5% vs 41.1%; p=0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p=0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p=0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35-3.96]; p=0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56-6.62]; p=0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20-2.08]; p=0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30-2.72]; p<0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. CONCLUSIONS Patients with silent PVs at redo AF ablation have worse clinical outcomes.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Michael Griffin
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Arnaud Bisson
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Ioanna Koniari
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Noel Fitzpatrick
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Simon Modi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Johan Waktare
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Reza Ashrafi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
- Department of Cardiology, Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE, UK.
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Denham N, Ding WY, Campbell T, Modi S, Luther V, Todd D, Kumar S, Agarwal S, Mahida S. UltraSOUND-based characterization of ventricular tachycardia SCAR and arrhythmogenic substrate: The SOUNDSCAR study. Heart Rhythm 2024; 21:45-53. [PMID: 38176771 DOI: 10.1016/j.hrthm.2023.10.022] [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: 02/27/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Intracardiac echocardiography (ICE) represents a valuable image integration technique, with the unique advantage of dynamic real-time scar characterization. OBJECTIVES The goals of this study were to assess the correlation between ICE-defined and electroanatomic mapping (EAM)-defined scar in patients with ischemic cardiomyopathy and to define the outcomes of ICE-guided ventricular tachycardia (VT) ablation. METHODS Thirty-eight patients with ischemic cardiomyopathy (SOUNDSCAR cohort) underwent full left ventricular (LV) ICE imaging and EAM. ICE-defined scar parameters (end-diastolic and end-systolic wall diameter [EDWD and ESWD], end-systolic wall thickening [percentage difference between EDWD and ESWD with respect to EDWD], slope [end-diastole to end-systole wall thickening], and American Heart Association wall motion scoring) were correlated with EAM-defined scar (voltage <1.5 mV). In a separate cohort (n = 21), outcomes of an ICE-guided VT ablation approach (EAM focused to ICE-defined scar regions) were compared with those of conventional ablation (full left ventricular mapping with EAM only; n = 21). RESULTS In the 38 SOUNDSCAR patients (mean age 67 ± 11 years; 35 male [92%]; left ventricular ejection fraction 31% ± 10%; 2474 ICE segments; 524 ICE sectors), all ICE-defined parameters strongly predicted EAM-defined scar (area under the curve: American Heart Association score 0.873; ESWD 0.880; EDWD 0.827; slope 0.855; percentage difference between EDWD and ESWD with respect to EDWD, 0.851). All ICE-defined parameters had large effect sizes for predicting EAM-defined scar (logistic regression, P < .001). A detailed topographical comparison of ICE-defined (slope) and EAM-defined scar was possible in 25 patients and demonstrated 88% ± 10% overlap. Compared with conventional VT ablation, ICE-guided ablation was associated with shorter procedure times and comparable VT-free survival (ICE-guided vs conventional: procedure time 240 ± 20 minutes vs 298 ± 39 minutes; P < .001; VT recurrence 3 [14%] vs 7 [31%]; P = .19). CONCLUSION ICE-defined scar demonstrates a strong correlation with EAM-defined scar. ICE-guided VT ablation is associated with enhanced procedural efficiency.
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Affiliation(s)
- Nathan Denham
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Wern Yew Ding
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Liverpool Centre for Cardiovascular Science, Liverpool, United Kingdom
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Simon Modi
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Vishal Luther
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Derick Todd
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Sharad Agarwal
- Department of Cardiac Electrophysiology, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Saagar Mahida
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Reddy RK, Howard JP, Ahmad Y, Shun-Shin MJ, Simader FA, Miyazawa AA, Saleh K, Naraen A, Samways JW, Katritsis G, Mohal JS, Kaza N, Porter B, Keene D, Linton NWF, Francis DP, Whinnett ZI, Luther V, Kanagaratnam P, Arnold AD. Catheter Ablation for Ventricular Tachycardia After MI: A Reconstructed Individual Patient Data Meta-analysis of Randomised Controlled Trials. Arrhythm Electrophysiol Rev 2023; 12:e26. [PMID: 38124803 PMCID: PMC10731517 DOI: 10.15420/aer.2023.07] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/24/2023] [Indexed: 12/23/2023] Open
Abstract
Background The prognostic impact of ventricular tachycardia (VT) catheter ablation is an important outstanding research question. We undertook a reconstructed individual patient data meta-analysis of randomised controlled trials comparing ablation to medical therapy in patients developing VT after MI. Methods We systematically identified all trials comparing catheter ablation to medical therapy in patients with VT and prior MI. The prespecified primary endpoint was reconstructed individual patient assessment of all-cause mortality. Prespecified secondary endpoints included trial-level assessment of all-cause mortality, VT recurrence or defibrillator shocks and all-cause hospitalisations. Prespecified subgroup analysis was performed for ablation approaches involving only substrate modification without VT activation mapping. Sensitivity analyses were performed depending on the proportion of patients with prior MI included. Results Eight trials, recruiting a total of 874 patients, were included. Of these 874 patients, 430 were randomised to catheter ablation and 444 were randomised to medical therapy. Catheter ablation reduced all-cause mortality compared with medical therapy when synthesising individual patient data (HR 0.63; 95% CI [0.41-0.96]; p=0.03), but not in trial-level analysis (RR 0.91; 95% CI [0.67-1.23]; p=0.53; I2=0%). Catheter ablation significantly reduced VT recurrence, defibrillator shocks and hospitalisations compared with medical therapy. Sensitivity analyses were consistent with the primary analyses. Conclusion In patients with postinfarct VT, catheter ablation reduces mortality.
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Affiliation(s)
- Rohin K Reddy
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale UniversityNew Haven, CT, US
| | | | | | | | - Keenan Saleh
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Akriti Naraen
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Jack W Samways
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - George Katritsis
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Jagdeep S Mohal
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Nandita Kaza
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Bradley Porter
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | | | - Darrel P Francis
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | | | - Vishal Luther
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | | | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College LondonLondon, UK
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10
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Mills MT, Luther V. Five scar patterns to reclassify the ventricular tachycardia substrate. J Cardiovasc Electrophysiol 2023; 34:2283-2285. [PMID: 37752727 DOI: 10.1111/jce.16088] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Mark T Mills
- Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Vishal Luther
- Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
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11
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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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12
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Coyle C, Koutsoftidis S, Kim MY, Porter B, Keene D, Luther V, Handa B, Kay J, Lim E, Malcolme-Lawes L, Koa-Wing M, Lim PB, Whinnett ZI, Ng FS, Qureshi N, Peters NS, Linton NWF, Drakakis E, Kanagaratnam P. Feasibility of mapping and ablating ectopy-triggering ganglionated plexus reproducibly in persistent atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01517-9. [PMID: 36867371 DOI: 10.1007/s10840-023-01517-9] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Ablation of autonomic ectopy-triggering ganglionated plexuses (ET-GP) has been used to treat paroxysmal atrial fibrillation (AF). It is not known if ET-GP localisation is reproducible between different stimulators or whether ET-GP can be mapped and ablated in persistent AF. We tested the reproducibility of the left atrial ET-GP location using different high-frequency high-output stimulators in AF. In addition, we tested the feasibility of identifying ET-GP locations in persistent atrial fibrillation. METHODS Nine patients undergoing clinically-indicated paroxysmal AF ablation received pacing-synchronised high-frequency stimulation (HFS), delivered in SR during the left atrial refractory period, to compare ET-GP localisation between a custom-built current-controlled stimulator (Tau20) and a voltage-controlled stimulator (Grass S88, SIU5). Two patients with persistent AF underwent cardioversion, left atrial ET-GP mapping with the Tau20 and ablation (Precision™, Tacticath™ [n = 1] or Carto™, SmartTouch™ [n = 1]). Pulmonary vein isolation (PVI) was not performed. Efficacy of ablation at ET-GP sites alone without PVI was assessed at 1 year. RESULTS The mean output to identify ET-GP was 34 mA (n = 5). Reproducibility of response to synchronised HFS was 100% (Tau20 vs Grass S88; [n = 16] [kappa = 1, SE = 0.00, 95% CI 1 to 1)][Tau20 v Tau20; [n = 13] [kappa = 1, SE = 0, 95% CI 1 to 1]). Two patients with persistent AF had 10 and 7 ET-GP sites identified requiring 6 and 3 min of radiofrequency ablation respectively to abolish ET-GP response. Both patients were free from AF for > 365 days without anti-arrhythmics. CONCLUSIONS ET-GP sites are identified at the same location by different stimulators. ET-GP ablation alone was able to prevent AF recurrence in persistent AF, and further studies would be warranted.
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Affiliation(s)
- Clare Coyle
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | | | - Min-Young Kim
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Bradley Porter
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Daniel Keene
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Vishal Luther
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Balvinder Handa
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Jamie Kay
- NHLI, Imperial College London, London, UK
| | - Elaine Lim
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | | | - Michael Koa-Wing
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Phang Boon Lim
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Zachary I Whinnett
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Fu Siong Ng
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Norman Qureshi
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nicholas S Peters
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nicholas W F Linton
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Prapa Kanagaratnam
- NHLI, Imperial College London, London, UK.
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
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13
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Khanra D, Calvert P, Hughes S, Waktare J, Modi S, Hall M, Todd D, Mahida S, Gupta D, Luther V. An approach to help differentiate postinfarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation. J Cardiovasc Electrophysiol 2023; 34:664-672. [PMID: 36478627 DOI: 10.1111/jce.15766] [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: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50 mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate postinfarct scar from conducting borderzone (BZ) during ventricular tachycardia (VT) ablation. METHODS Fifteen consecutive patients (left ventricular ejection fraction 30 ± 7%) underwent endocardial left ventricle pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50 mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50 mV defined the RM-BZ. RESULTS RM-scar was significantly smaller than the traditional 0.50 mV cutoff (median 4% vs. 12% shell area, p < .001). 65 ± 16% of tissue <0.50 mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from BZ tissue was 0.22 ± 0.07 mV, though this ranged widely (from 0.12 to 0.35 mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs. 347 ms, p = .001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs. 1.2, p = .013) with faster RM-BZ conduction speed (0.72 vs. 0.34 m/s, p = .001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367 ± 38 ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs. 3.2, p = .059), and slower RM-BZ conduction speed (0.36 vs. 0.63 m/s, p = .036). RM guided ablation collocated within 66 ± 20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes preablation vs. 0 post, p < .001) at 11 ± 6 months follow-up. CONCLUSION Postinfarct scars appear significantly smaller than traditional 0.50 mV cut-offs suggest, with voltage thresholds unique to each patient.
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Affiliation(s)
| | - Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
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14
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Chu G, Calvert P, Sidhu B, Mavilakandy A, Kotb A, Tovmassian L, Kozhuharov N, Biermé C, Denham N, Pius C, O'Brien J, Ding WY, Luther V, Snowdon RL, Ng GA, Gupta D. Patient experience of very high power short duration radiofrequency ablation for atrial fibrillation under mild conscious sedation. J Interv Card Electrophysiol 2023; 66:445-453. [PMID: 35997848 PMCID: PMC9396586 DOI: 10.1007/s10840-022-01351-5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Very high power short duration (vHPSD) radiofrequency ablation (RFA) may reduce ablation times and improve patient tolerability, permitting pulmonary vein isolation (PVI) under mild conscious sedation (mCS) and promoting same day discharge (SDD). METHODS First, a retrospective feasibility study was performed at 2 tertiary cardiac centres in the UK. Consecutive cases of first-time PVI using vHPSD ablation with 90 W lesions for up to 4 s were compared against cases performed using standard RF (sRF) and cryoballoon (Cryo) therapy. Subsequently, a prospective study of patients who had vHPSD or Cryo exclusively under mCS was undertaken. Questionnaires based on Likert and visual analogue scales (VAS) were used to measure anxiety, discomfort and pain. RESULTS In total, 182 patients (59 vHPSD, 62 sRF and 61 Cryo) were included in the retrospective study, with 53 (90%) of vHPSD cases successfully performed under mCS. PVI ablation time in the vHPSD group (5.8 ± 1.7 min) was shorter than for sRF (16.5 ± 6.3 min, p < 0.001) and Cryo (17.5 ± 5.9 min, p < 0.001). Fifty-one vHPSD and 52 Cryo patients were included in the prospective study. PVI ablation time in the vHPSD group was shorter than for the Cryo group (6.4 ± 2.9 min vs 17.9 ± 5.7 min, p < 0.001), but overall procedure duration was longer (121 ± 39 min vs 95 ± 20 min, p < 0.001). There were no differences in the patient experience of anxiety, discomfort or pain. SDD rates were the same in both groups (61% vs 67%, p = 0.49). CONCLUSIONS vHPSD RFA for PVI can be performed under mCS to achieve SDD rates comparable to cryoablation, without compromising patient experience.
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Affiliation(s)
- Gavin Chu
- Lancashire Cardiac Centre, Blackpool, UK
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Peter Calvert
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Bharat Sidhu
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Akash Mavilakandy
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ahmed Kotb
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Lilith Tovmassian
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Nikola Kozhuharov
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Cédric Biermé
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Nathan Denham
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Charlene Pius
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Jim O'Brien
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Wern Yew Ding
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Vishal Luther
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Richard L Snowdon
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - G André Ng
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
- Glenfield Hospital, Leicester, UK
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
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15
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Pavitt C, Luther V, Lefroy D, Tanner M. Retrograde venography to navigate an occluded subclavian vein to achieve cardiac resynchronization therapy upgrade via His bundle pacing: a case report. Eur Heart J Case Rep 2023; 7:ytad016. [PMID: 36819886 PMCID: PMC9927565 DOI: 10.1093/ehjcr/ytad016] [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: 05/03/2022] [Revised: 07/13/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Background Guidelines support upgrade to cardiac resynchronization therapy (CRT) through His-bundle pacing (HBP) in pacing-induced cardiomyopathy and moderate left ventricular systolic dysfunction (LVSD). Lead-related venous occlusion can represent an obstacle to upgrade procedures. We describe a technique to overcome venous occlusion through direct puncture of a collateral vein facilitating upgrade to HBP. Case summary An 84-year-old man with a right ventricular (RV) pacemaker was referred with New York Heart Association (NYHA) Class III breathlessness secondary to moderate LVSD (left ventricular ejection fraction [LVEF] 45%). Device interrogation revealed 100% RV pacing and AV-dyssynchrony. To optimize atrioventricular (AV) and interventricular (VV) synchrony a CRT upgrade with HBP was planned. Venography revealed an occluded left subclavian vein which was probed in a retrograde manner using a 6F MPA catheter from right femoral venous access. We were able to direct the catheter distal to the left brachio-cephalic vein and define the occlusion using contrast. A collateral branch was identified, a J-wire was left in this branch and venous access was secured at this medial subclavian site using the Seldinger technique. A right atrial lead was deployed and 69 cm ISI-1 His lead was deployed via a C315 sheath at the His-bundle. The resulted in non-selective HBP (Stim-QRS end 146 ms). There were no procedural complications. Two months later both symptoms and LV function (LVEF 55%) improved. Discussion Lead-related venous occlusion occurs frequently and can be probed in a retrograde manner from femoral venous access using contrast, facilitating direct percutaneous puncture of collateral venous branches to allow upgrade to CRT via HBP.
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Affiliation(s)
| | - Vishal Luther
- Cardiology Department, Hammersmith Hospital, Imperial College NHS Foundation Trust, 72 Du Cane Road, London W12 0HS, UK
| | - David Lefroy
- Cardiology Department, Hammersmith Hospital, Imperial College NHS Foundation Trust, 72 Du Cane Road, London W12 0HS, UK
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16
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Ding WY, Khanra D, Kozhuharov N, Shaw M, Luther V, Ashrafi R, Borbas Z, Mahida S, Modi S, Hall M, Snowdon R, Waktare J, Todd D, Gupta D. Incidence of vascular complications for electrophysiology procedures in the ultrasound era: a single-centre experience over 10,000 procedures in the long term. J Interv Card Electrophysiol 2022; 66:693-700. [PMID: 36214805 DOI: 10.1007/s10840-022-01386-8] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ultrasound (US) is being increasingly used to guide vascular access for electrophysiology (EP) procedures in many centres. Nonetheless, the incidence and predictors of vascular complications in the US era are limited. In this study, we describe our experience of vascular access-related complications associated with EP procedures which were performed with the routine use of US-guided vascular access. METHODS A total of 10,158 consecutive EP procedures in 8361 patients performed from April 2014 (when our centre moved to a policy of routine US-guided vascular access for EP procedures) to March 2022 were included. The outcome of interest was any vascular access-related complication that occurred within 7 days of the procedure; these were classified as severe if surgical intervention and/or blood transfusion was required, major if non-surgical intervention or delayed hospital discharge was required, or minor if it did not fulfil the criteria for severe or major. RESULTS During the study period, 2 (0.02%) severe vascular complications occurred, including 1 pseudo-aneurysm requiring surgery and 1 retroperitoneal haemorrhage requiring blood transfusion. Nine (0.09%) major complications occurred, including 6 hematomas managed by compression devices, 1 type B aortic dissection, 1 AV fistula managed conservatively and 1 haematoma managed conservatively but delayed hospital discharge. Eighteen (0.18%) minor haematomas were seen that did not require any intervention or delayed hospital discharge. On multivariable analysis, female sex [OR (95% CI): 2.5 (1.2, 5.4)] and use of an arterial access [OR (95% CI): 19.3 (7.1, 52.3)] were seen to be independent predictors of the 29 vascular complications. CONCLUSION With the use of US-guided vascular access in EP procedures, major vascular complications are exceedingly rare, particularly those needing surgical intervention. Our results provide additional evidence for scientific guidelines to support US use.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | | | | | - Matthew Shaw
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Reza Ashrafi
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | - Derick Todd
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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17
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Pius C, Ahmad H, Snowdon R, Ashrafi R, Waktare JE, Borbas Z, Luther V, Mahida S, Modi S, Hall M, Gupta D, Todd D. Impact of COVID-19 on patients awaiting ablation for atrial fibrillation. Open Heart 2022; 9:openhrt-2022-001969. [PMID: 35697474 PMCID: PMC9195158 DOI: 10.1136/openhrt-2022-001969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/11/2022] [Indexed: 12/21/2022] Open
Abstract
Objective Atrial fibrillation (AF) ablation services were significantly affected by the COVID-19 pandemic. We aimed to evaluate a symptom-based clinician prioritisation scheme for waiting list management compared with patient-completed quality of life (QoL) scores. We also sought to understand factors influencing QoL, particularly the impact of COVID-19, on patients awaiting AF ablation, via a bespoke questionnaire. Methods Patients awaiting AF ablation were sent two QoL questionnaires (Atrial Fibrillation Effect on QualiTy of Life (AFEQT) and EuroQol 5D (EQ5D-5L)) and the bespoke questionnaire. At a separate time point, patients were categorised as C1—urgent, C2—priority or C3—routine by their cardiologist based on review of clinic letters. Results There were 118 patients included with priority categorisation available for 86 patients. Median AFEQT scores were lower in C2 (30.4; 17.2–51.9) vs C3 patients (56.5; 32.1–74.1; p<0.01). Unplanned admission occurred in 3 patients in C3 with AFEQT scores of <40. Although 65 patients had AF symptoms during the pandemic, 43.1% did not seek help where they ordinarily would have. An exercise frequency of ≥3–4 times a week was associated with higher AFEQT (56.5; 41.2–74.1; p<0.001) and EQ5D (0.84; 0.74–0.88; p<0.0001) scores. Conclusion The QoL of patients awaiting AF ablation is impaired and AFEQT helps to identify patients at risk of admission, over and above physician assessment. COVID-19 influenced patients seeking medical attention with symptomatic AF when they normally would. Regular exercise is associated with better QoL in patients awaiting AF ablation.
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Affiliation(s)
- Charlene Pius
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Hasan Ahmad
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Richard Snowdon
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Reza Ashrafi
- Adult Congenital Heart Disease, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Johan Ep Waktare
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Zoltan Borbas
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Vishal Luther
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Saagar Mahida
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Simon Modi
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mark Hall
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Dhiraj Gupta
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Derick Todd
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
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18
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Khanra D, Calvert P, Wright P, Hughes S, Mahida S, Hall M, Todd D, Gupta D, Luther V. Differentiating border-zone tissue from post-infarct scar using ripple mapping during VT ablation. Europace 2022. [DOI: 10.1093/europace/euac053.352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Areas of post-infarct ventricular scar and border-zone slow conduction are often highlighted on a bipolar voltage map with generalized values 0.5mV–1.5mV. The true voltage that differentiates regions of conducting from non-conducting tissue is unknown. Ripple Mapping (RM)displays allows conducting tissue to be seen as areas supporting Ripple activation, and non-conducting tissue as areas devoid of Ripple activation.
Purpose
We describe application of Ripple Maps to differentiate areas of scar from conducting tissue during ischemic VT ablation.
Methods
Dense bipolar voltage maps were created (Pentaray catheter, pacing 80-100bpm) and presented as a single value (e.g. 0.5mV-0.5mV) to binarize the color display (red and purple). RMs were superimposed on the voltage map and played above a pre-set noise threshold (>0.05mV). The voltage map mV limit was sequentially reduced ("border-zone threshold") until only those areas devoid of Ripple bars appeared red. The surrounding border-zone supporting ripple activation thus appeared purple. We performed off-line analysis of border-zone voltage thresholds from a series of RM guided VT ablations.
Results
10 consecutive patients (LVEF 32.3±7.5%) with remote myocardial infarction underwent VT ablation (median 19days (IQR 8-33) since last VT). Bipolar voltage mapping (5873±2841 points, median shell area 224cm2), revealed voltages<0.5mV covered a median 11% (IQR 7-17%) of the shell. The border-zone voltage threshold was median 0.2mV (range 0.12mV - 0.3mV). Non-conducting tissue below this value covered only median 5% (IQR 3-7%) of the entire shell. VT was mappable in 4 patients, and the isthmus was bordered by tissue below the same border-zone threshold as found in normal rhythm. The border-zone was homogenized with ablation(40-50W, median 29 mins (IQR 22-33), and clinical VT was non-inducible in all, and 9 pts (91%) remain sustained VT-free at median 90-day follow-up (IQR 23-139), 2-weeks blanking period).
Picture 1 presents an infero-lateral LV infarct collected in an RV paced rhythm (7340points) and displayed at conventional bipolar voltage settings 0.5-1.5mV. Tissue with voltages<0.5mV appear red and cover 30% of the total area. In this case, this border-zone voltage threshold was defined as 0.25mV. Non-conducting tissue, seen as areas devoid of ripple bars below this value, now appeared as red, and covered only 11% of the total area. Picture 2 demonstrates the morphologies of 4 poorly tolerated induced VTs during this case. Each had near perfect pacemaps to the exit sites of border-zone tissue defined using this approach, and were targets for ablation resulting in complete non-inducibility and no VT recurrence in early follow-up.
Conclusion
The bipolar voltage that differentiates putative scar from bordering conducting tissue is unique to each patient, and far lower than 0.5mV-1.5mV. RM presents a practical approach to visualize the border-zone activation to guide ablation.
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Affiliation(s)
- D Khanra
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - P Calvert
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - P Wright
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - S Hughes
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - S Mahida
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - M Hall
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - D Todd
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - D Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - V Luther
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
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19
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Katritsis G, Luther V, Kailey B, Jamil-Copley S, Koa-Wing M, Malcolme-Lawes L, Qureshi NA, Lim PB, Ng FS, Dias NC, Ribeiro dos Santos Carpinteiro LM, De Sousa J, MARTIN RUAIRIDH, Das M, Murray S, Chow AW, Peters NS, Linton NF, Kanagaratnam P. PO-684-03 CHARACTERISATION OF FASCICULAR ACTIVATION IN THE POST-INFARCT VENTRICLE USING RIPPLE MAPPING. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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20
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Kim MY, Coyle C, Tomlinson DR, Sikkel MB, Sohaib A, Luther V, Leong KM, Malcolme-Lawes L, Low B, Sandler B, Lim E, Todd M, Fudge M, Wright IJ, Koa-Wing M, Ng FS, Qureshi NA, Whinnett ZI, Peters NS, Newcomb D, Wood C, Dhillon G, Hunter RJ, Lim PB, Linton NWF, Kanagaratnam P. Ectopy-triggering ganglionated plexuses ablation to prevent atrial fibrillation: GANGLIA-AF study. Heart Rhythm 2022; 19:516-524. [PMID: 34915187 PMCID: PMC8976158 DOI: 10.1016/j.hrthm.2021.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND The ganglionated plexuses (GPs) of the intrinsic cardiac autonomic system may play a role in atrial fibrillation (AF). OBJECTIVE We hypothesized that ablating the ectopy-triggering GPs (ET-GPs) prevents AF. METHODS GANGLIA-AF (ClinicalTrials.gov identifier NCT02487654) was a prospective, randomized, controlled, 3-center trial. ET-GPs were mapped using high frequency stimulation, delivered within the atrial refractory period and ablated until nonfunctional. If triggered AF became incessant, atrioventricular dissociating GPs were ablated. We compared GP ablation (GPA) without pulmonary vein isolation (PVI) against PVI in patients with paroxysmal AF. Follow-up was for 12 months including 3-monthly 48-hour Holter monitors. The primary end point was documented ≥30 seconds of atrial arrhythmia after a 3-month blanking period. RESULTS A total of 102 randomized patients were analyzed on a per-protocol basis after GPA (n = 52; 51%) or PVI (n = 50; 49%). Patients who underwent GPA had 89 ± 26 high frequency stimulation sites tested, identifying a median of 18.5% (interquartile range 16%-21%) of GPs. The radiofrequency ablation time was 22.9 ± 9.8 minutes in GPA and 38 ± 14.4 minutes in PVI (P < .0001). The freedom from ≥30 seconds of atrial arrhythmia at 12-month follow-up was 50% (26 of 52) with GPA vs 64% (32 of 50) with PVI (log-rank, P = .09). ET-GPA without atrioventricular dissociating GPA achieved 58% (22 of 38) freedom from the primary end point. There was a significantly higher reduction in antiarrhythmic drug usage postablation after GPA than after PVI (55.5% vs 36%; P = .05). Patients were referred for redo ablation procedures in 31% (16 of 52) after GPA and 24% (12 of 50) after PVI (P = .53). CONCLUSION GPA did not prevent atrial arrhythmias more than PVI. However, less radiofrequency ablation was delivered to achieve a higher reduction in antiarrhythmic drug usage with GPA than with PVI.
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Affiliation(s)
- Min-Young Kim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Clare Coyle
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - David R Tomlinson
- Cardiology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Markus B Sikkel
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Afzal Sohaib
- Cardiology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Vishal Luther
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Kevin M Leong
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louisa Malcolme-Lawes
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Benjamin Low
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Belinda Sandler
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Elaine Lim
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michelle Todd
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Fudge
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ian J Wright
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Koa-Wing
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Norman A Qureshi
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zachary I Whinnett
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas S Peters
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Daniel Newcomb
- Cardiology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Cherith Wood
- Cardiology Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Gurpreet Dhillon
- Cardiology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ross J Hunter
- Cardiology Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas W F Linton
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom; Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
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21
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Calvert P, Chu G, Rao A, Gupta D, Luther V. Ventricular tachycardia ablation in a patient with Ehlers-Danlos syndrome. HeartRhythm Case Rep 2021; 8:84-88. [PMID: 35242544 PMCID: PMC8858776 DOI: 10.1016/j.hrcr.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Gavin Chu
- Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Archana Rao
- Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Address reprint requests and correspondence: Dr Vishal Luther, Consultant Cardiologist & Electrophysiologist, Cardiology Department, Liverpool Heart & Chest Hospital, Thomas Dr, Liverpool, L14 3PE UK.
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22
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Affiliation(s)
| | - Damanpreet Dev
- Cardiology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Daniel M Sado
- Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Vishal Luther
- Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK .,Liverpool Centre for Cardiovascular Science, Livepool, UK
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23
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Luther V, Kailey B, Dev DS. Is virtual cardiology training here to stay in the post-COVID era? Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In April 2020, face-face UK cardiology training was paused due to COVID-19. We adapted by utilising a video-conferencing platform to continue some form of education on a national scale (CardioWebinar). We studied the effectiveness of delivering virtual Cardiology education 1 year into the COVID pandemic.
Methods
Expert speakers throughout the UK were sought after via social media and “word of mouth”. Weekly webinars were organised and advertised (Canva posters) on social media (Twitter), as well as via the British Cardiovascular Society and British Junior Cardiologists' Association (BJCA) media links. Each webinar was scheduled mid-week at 17:30 (UK). Interested attendees registered for free using an online ticketing platform (Eventbrite). Webinars were delivered using an online video conferencing platform (Zoom) which required a £14.99 monthly subscription. Each webinar consisted of a 40-minute presentation followed by Q&A (20mins). All webinars were recorded and later accessible for free on the BJCA TV Gallery. A Learning Management System (LMS) collected feedback after each session and generated certificates of attendance.
We systematically reviewed the LMS feedback from 6 consecutive webinars delivered between Jan-Feb 2021. We further surveyed our most recent (March 2021) attendees via an extended questionnaire exploring their experiences of our virtual education.
Results
55 CardioWebinars have been delivered since April 2020. The speakers have been predominantly Consultant Cardiologists from the UK. Some of the recordings have had >1000 views. Other than the video platform subscription, no cost was incurred in the delivery of this entire programme.
We collected feedback from 392 respondents (∼65 live attendees per webinar) from each session between Jan-Feb 2021. The sessions were rated as “very good-excellent” by 97%. We collected a further 145 extended responses from March 2021 attendees. 90% rated the whole series as “very good –excellent” in supporting their cardiology education during the Covid pandemic, and 84% felt the programme sufficiently covered even the more challenging areas of the curriculum (e.g. aortopathies). 90% of the respondents felt that their work-life schedule allowed them to join the live webinars. The respondents where predominantly from the UK (91%), though included an international audience (9%). Whilst 74% of attendees were cardiology trainees, the remaining 26% included physiologists, nurses, consultants and other junior doctors. 99% felt that virtual education should continue to play a formal part in their training after the COVID pandemic.
Conclusion
Webinars allow everyone interested in cardiac care across the world the opportunity to hear experts teach, and without a travel cost. They are cheap and easy to organise. This study suggests that webinars will remain an integral part of the post-COVID era.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- V Luther
- Liverpool Heart and Chest Hospital, Cardiology, Liverpool, United Kingdom
| | - B Kailey
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - D S Dev
- Kettering General Hospital, Kettering, United Kingdom
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24
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Katritsis G, Luther V, Jamil-Copley S, Koa-Wing M, Qureshi N, Whinnett Z, Lim PB, Ng FS, Malcolme-Lawes L, Peters NS, Fudge M, Lim E, Linton NWF, Kanagaratnam P. Postinfarct ventricular tachycardia substrate: Characterization and ablation of conduction channels using ripple mapping. Heart Rhythm 2021; 18:1682-1690. [PMID: 34004345 DOI: 10.1016/j.hrthm.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/12/2021] [Revised: 04/27/2021] [Accepted: 05/11/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Conduction channels have been demonstrated within the postinfarct scar and seem to be co-located with the isthmus of ventricular tachycardia (VT). Mapping the local scar potentials (SPs) that define the conduction channels is often hindered by large far-field electrograms generated by healthy myocardium. OBJECTIVE The purpose of this study was to map conduction channel using ripple mapping to categorize SPs temporally and anatomically. We tested the hypothesis that ablation of early SPs would eliminate the latest SPs without direct ablation. METHODS Ripple maps of postinfarct scar were collected using the PentaRay (Biosense Webster) during normal rhythm. Maps were reviewed in reverse, and clusters of SPs were color-coded on the geometry, by timing, into early, intermediate, late, and terminal. Ablation was delivered sequentially from clusters of early SPs, checking for loss of terminal SPs as the endpoint. RESULTS The protocol was performed in 11 patients. Mean mapping time was 65 ± 23 minutes, and a mean 3050 ± 1839 points was collected. SP timing ranged from 98.1 ± 60.5 ms to 214.8 ± 89.8 ms post QRS peak. Earliest SPs were present at the border, occupying 16.4% of scar, whereas latest SPs occupied 4.8% at the opposing border or core. Analysis took 15 ± 10 minutes to locate channels and identify ablation targets. It was possible to eliminate latest SPs in all patients without direct ablation (mean ablation time 16.3 ± 11.1 minutes). No VT recurrence was recorded (mean follow-up 10.1 ± 7.4 months). CONCLUSION Conduction channels can be located using ripple mapping to analyze SPs. Ablation at channel entrances can eliminate the latest SPs and is associated with good medium-term results.
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Affiliation(s)
| | - Vishal Luther
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | - Norman Qureshi
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | - Michael Fudge
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
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O'Brien J, Obeidat M, Kozhuharov N, Ding WY, Tovmassian L, Bierme C, Chin SH, Chu GS, Luther V, Snowdon RL, Gupta D. Procedural efficiencies, lesion metrics, and 12-month clinical outcomes for Ablation Index-guided 50 W ablation for atrial fibrillation. Europace 2021; 23:878-886. [PMID: 33693677 DOI: 10.1093/europace/euab031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/09/2020] [Accepted: 01/28/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS The safety of Ablation Index (AI)-guided 50 W ablation for atrial fibrillation (AF) remains uncertain, and mid-term clinical outcomes have not been described. The interplay between AI and its components at 50 W has not been reported. METHODS AND RESULTS Eighty-eight consecutive AF patients (44% paroxysmal) underwent AI-guided 50 W ablation. Procedural and 12-month clinical outcomes were compared with 93 consecutive controls (65% paroxysmal) who underwent AI-guided ablation using 35-40 W. Posterior wall isolation (PWI) was performed in 44 (50%) and 23 (25%) patients in the 50 and 35-40 W groups, respectively, P < 0.001. The last 10 patients from each group underwent analysis of individual lesions (n = 1230) to explore relationships between different powers and the AI components. Pulmonary vein isolation was successful in all patients. Posterior wall isolation was successful in 41/44 (93.2%) and 22/23 (95.7%) in the 50 and 35-40 W groups, respectively (P = 0.685). Radiofrequency times (20 vs. 26 min, P < 0.001) and total procedure times (130 vs. 156 min, P = 0.002) were significantly lower in the 50 W group. No complication or steam pop was seen in either group. Twelve-month freedom from arrhythmia was similar (80.2% vs. 82.8%, P = 0.918). A higher proportion of lesions in the 50 W group were associated with impedance drop >7 Ω (54.6% vs. 45.5%, P < 0.001). Excessive ablation (AI >600 anteriorly, >500 posteriorly) was more frequent in the 50 W group (9.7% vs. 4.3%, P < 0.001). CONCLUSION Ablation Index-guided 50 W AF ablation is as safe and effective as lower powers and results in reduced ablation and procedure times. Radiofrequency lesions are more likely to be therapeutic, but there is a higher risk of delivering excessive ablation.
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Affiliation(s)
- Jim O'Brien
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Mohammed Obeidat
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Nikola Kozhuharov
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.,Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wern Yew Ding
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Lilith Tovmassian
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Cedric Bierme
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Shui Hao Chin
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Gavin S Chu
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Vishal Luther
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Richard L Snowdon
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Dhiraj Gupta
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
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Katritsis G, Luther V, Jamil-Copley S, Koa-Wing M, Fudge M, Lim E, Qureshi NA, Whinnett ZI, Lim PB, Siong Ng F, Lefroy DC, Malcolme-Lawes L, Peters NS, Linton NF, Kanagaratnam P. B-PO02-128 MAPPING AND ABLATION OF CONDUCTION CHANNELS IN THE ISCHEMIC VENTRICULAR SCAR USING RIPPLE MAPPING. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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27
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Pius C, Ahmad H, Snowdon R, Ashrafi R, Waktare J, Borbas Z, Luther V, Mahida S, Modi S, Hall M, Gupta D, Todd D. Assessing atrial fibrillation ablation priority during COVID-19 -does use of patient questionnaires help in stratification above physician assessment? Europace 2021. [PMCID: PMC8194591 DOI: 10.1093/europace/euab116.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Funding Acknowledgements Type of funding sources: None. Introduction Catheter ablation for atrial fibrillation (AF) is largely offered for symptomatic relief. The ORBIT registry has shown that patients with a higher EHRA class and lower quality of life (QoL) scores (AFEQT score <65.7) are more likely to suffer emergency hospital admissions. To help prevent unplanned AF admissions and to best utilise the reduced capacity for elective work during the COVID-19 pandemic, it has become even more important to prioritise the most symptomatic AF patients for ablation. Purpose: To evaluate the accuracy of a subjective symptom-based clinician prioritisation schema compared to objective patient-completed quality of life (QoL) scores. Methods: In July 2020, all elective cases awaiting AF ablation at our institution were categorised by their cardiologist as either category 1 (C1-urgent), category 2 (C2–priority, procedure to be done during the ongoing COVID-19 pandemic) or category 3 (C3–routine, procedure may be delayed until post pandemic). This categorisation was based on review of clinic letters where EHRA AF symptom class or PROMS are not routinely recorded. All patients in C2 and C3 were then posted an AF specific (AFEQT) and a generic (EQ5D) QoL questionnaire to complete. Physicians were blinded to patient responses on the QoL questionnaires. Results: Details of physician prioritisation and completed questionnaires were available for 85 patients (62 ± 10 years, PAF in 61%, males 66%). The 18 patients that had been categorised in C2 (priority) group were found to have a significantly lower AFEQT score (30.4, IQR 17.2-51.9) compared to the 67 patients classed in C3 (routine) group (56.5, IQR 32.1-74.1; p < 0.01)(Figure 1a). EQ5D scores also tended to be lower in the C2 patients (0.7, IQR 0.4-0.8) compared to C3 (0.8, IQR 0.6-0.9; p = 0.056) (Figure 1c). 16 (89%) patients in C2 had significant AF-related impact on QoL (as defined as AFEQT score <65.7) compared to 42 (63%) of patients in C3. However, there was significant overlap between groups (Figure 1b). 4 patients in C3 had unplanned AF related hospital admissions while awaiting ablation, as compared to none in C2. The median AFEQT score of these 4 patients was 23.3, indicating that they were highly symptomatic despite being classified in C3 by their cardiologist. Conclusion : Physician assessments are moderately accurate in prioritising patients awaiting AF ablation. The addition of formal patient-completed QoL assessment such as with AFEQT, helps to identify the most symptomatic patients at risk of emergency hospital admission, and physicians should consider using these as part of routine assessment, especially during the COVID pandemic.
Abstract Figure 1 ![]()
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Affiliation(s)
- C Pius
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - H Ahmad
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - R Snowdon
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - R Ashrafi
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - J Waktare
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - Z Borbas
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - V Luther
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - S Mahida
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - S Modi
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - M Hall
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - D Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
| | - D Todd
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom of Great Britain & Northern Ireland
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Katritsis G, Luther V, Cortez-Dias N, Carpinteiro L, de Sousa J, Lim PB, Whinnett Z, Ng FS, Koa-Wing M, Qureshi N, Chow A, Agarwal S, Jamil-Copley S, Peters NS, Linton N, Kanagaratnam P. Electroanatomic Characterization and Ablation of Scar-Related Isthmus Sites Supporting Perimitral Flutter. JACC Clin Electrophysiol 2021; 7:578-590. [PMID: 33516707 DOI: 10.1016/j.jacep.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 09/03/2020] [Revised: 10/24/2020] [Accepted: 10/24/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The authors reviewed 3-dimensional electroanatomic maps of perimitral flutter to identify scar-related isthmuses and determine their effectiveness as ablation sites. BACKGROUND Perimitral flutter is usually treated by linear ablation between the left lower pulmonary vein and mitral annulus. Conduction block can be difficult to achieve, and recurrences are common. METHODS Patients undergoing atrial tachycardia ablation using CARTO3 (Biosense Webster Inc., Irvine, California) were screened from 4 centers. Patients with confirmed perimitral flutter were reviewed for the presence of scar-related isthmuses by using CARTO3 with the ConfiDense and Ripple Mapping modules. RESULTS Confirmed perimitral flutter was identified in 28 patients (age 65.2 ± 8.1 years), of whom 26 patients had prior atrial fibrillation ablation. Scar-related isthmus ablation was performed in 12 of 28 patients. Perimitral flutter was terminated in all following correct identification of a scar-related isthmus using ripple mapping. The mean scar voltage threshold was 0.11 ± 0.05 mV. The mean width of scar-related isthmuses was 8.9 ± 3.5 mm with a conduction speed of 31.8 ± 5.5 cm/s compared to that of normal left atrium of 71.2 ± 21.5 cm/s (p < 0.0001). Empirical, anatomic ablation was performed in 16 of 28, with termination in 10 of 16 (63%; p = 0.027). Significantly less ablation was required for critical isthmus ablation compared to empirical linear lesions (11.4 ± 5.3 min vs. 26.2 ± 17.1 min; p = 0.0004). All 16 cases of anatomic ablation were reviewed with ripple mapping, and 63% had scar-related isthmus. CONCLUSIONS Perimitral flutter is usually easy to diagnose but can be difficult to ablate. Ripple mapping is highly effective at locating the critical isthmus maintaining the tachycardia and avoiding anatomic ablation lines. This approach has a higher termination rate with less radiofrequency ablation required.
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Affiliation(s)
| | | | | | | | | | | | | | - Fu Siong Ng
- Imperial College Healthcare, London, United Kingdom
| | | | | | | | | | | | | | - Nick Linton
- Imperial College Healthcare, London, United Kingdom
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29
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Kim MY, Sandler BC, Sikkel MB, Cantwell CD, Leong KM, Luther V, Malcolme-Lawes L, Koa-Wing M, Ng FS, Qureshi N, Sohaib A, Whinnett ZI, Fudge M, Lim E, Todd M, Wright I, Peters NS, Lim PB, Linton NWF, Kanagaratnam P. Anatomical Distribution of Ectopy-Triggering Plexuses in Patients With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2020; 13:e008715. [PMID: 32718187 DOI: 10.1161/circep.120.008715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Min-Young Kim
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom
| | - Belinda C Sandler
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom
| | - Markus B Sikkel
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Christopher D Cantwell
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom
| | - Kevin M Leong
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Vishal Luther
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Louisa Malcolme-Lawes
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Michael Koa-Wing
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Fu Siong Ng
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Norman Qureshi
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Afzal Sohaib
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.).,Department of Cardiology, Barts Health NHS Trust, London, United Kingdom (A.S.)
| | - Zachary I Whinnett
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Michael Fudge
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Elaine Lim
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Michelle Todd
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Ian Wright
- Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Nicholas S Peters
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Phang Boon Lim
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Nicholas W F Linton
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom.,Imperial Centre for Cardiac Engineering (M.-Y.K., B.C.S., M.B.S., C.D.C., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.), Imperial College London, United Kingdom.,Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (M.B.S., K.M.L., V.L., L.M.-L., M.K.-W., F.S.N., N.Q., A.S., Z.I.W., M.F., M.F., E.L., M.T., I.W., N.S.P., P.B.L., N.W.F.L.)
| | - Prapa Kanagaratnam
- Myocardial Function Section, Imperial Centre for Translational and Experimental Medicine (M.-Y.K., B.C.S., M.B.S., C.D.C., F.S.N., N.S.P., P.B.L., N.W.F.L., P.K.), Imperial College London, United Kingdom
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Kim MY, Sandler B, Sikkel MB, Cantwell CD, Leong KM, Luther V, Malcolme-Lawes L, Koa-Wing M, Ng FS, Qureshi N, Sohaib A, Whinnett ZI, Fudge M, Lim E, Todd M, Wright I, Peters NS, Lim PB, Linton NWF, Kanagaratnam P. The ectopy-triggering ganglionated plexuses in atrial fibrillation. Auton Neurosci 2020; 228:102699. [PMID: 32769021 PMCID: PMC7511599 DOI: 10.1016/j.autneu.2020.102699] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 12/28/2019] [Revised: 06/27/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Epicardial ganglionated plexuses (GP) have an important role in the pathogenesis of atrial fibrillation (AF). The relationship between anatomical, histological and functional effects of GP is not well known. We previously described atrioventricular (AV) dissociating GP (AVD-GP) locations. In this study, we hypothesised that ectopy triggering GP (ET-GP) are upstream triggers of atrial ectopy/AF and have different anatomical distribution to AVD-GP. OBJECTIVES We mapped and characterised ET-GP to understand their neural mechanism in AF and anatomical distribution in the left atrium (LA). METHODS 26 patients with paroxysmal AF were recruited. All were paced in the LA with an ablation catheter. High frequency stimulation (HFS) was synchronised to each paced stimulus for delivery within the local atrial refractory period. HFS responses were tagged onto CARTO™ 3D LA geometry. All geometries were transformed onto one reference LA shell. A probability distribution atlas of ET-GP was created. This identified high/low ET-GP probability regions. RESULTS 2302 sites were tested with HFS, identifying 579 (25%) ET-GP. 464 ET-GP were characterised, where 74 (16%) triggered ≥30s AF/AT. Median 97 (IQR 55) sites were tested, identifying 19 (20%) ET-GP per patient. >30% of ET-GP were in the roof, mid-anterior wall, around all PV ostia except in the right inferior PV (RIPV) in the posterior wall. CONCLUSION ET-GP can be identified by endocardial stimulation and their anatomical distribution, in contrast to AVD-GP, would be more likely to be affected by wide antral circumferential ablation. This may contribute to AF ablation outcomes.
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Affiliation(s)
- Min-Young Kim
- Myocardial Function Section, NHLI, Imperial College London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Belinda Sandler
- Myocardial Function Section, NHLI, Imperial College London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Markus B Sikkel
- Myocardial Function Section, NHLI, Imperial College London, UK; Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Christopher D Cantwell
- Myocardial Function Section, NHLI, Imperial College London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Kevin M Leong
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Vishal Luther
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Louisa Malcolme-Lawes
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Michael Koa-Wing
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Fu Siong Ng
- Myocardial Function Section, NHLI, Imperial College London, UK; Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Norman Qureshi
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Afzal Sohaib
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK; Barts Health NHS Trust, UK
| | - Zachary I Whinnett
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Michael Fudge
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Elaine Lim
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Michelle Todd
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Ian Wright
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Nicholas S Peters
- Myocardial Function Section, NHLI, Imperial College London, UK; Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Phang Boon Lim
- Myocardial Function Section, NHLI, Imperial College London, UK; Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Nicholas W F Linton
- Myocardial Function Section, NHLI, Imperial College London, UK; Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Prapa Kanagaratnam
- Myocardial Function Section, NHLI, Imperial College London, UK; Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK; Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
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Luther V, Agarwal S, Chow A, Koa-Wing M, Cortez-Dias N, Carpinteiro L, de Sousa J, Balasubramaniam R, Farwell D, Jamil-Copley S, Srinivasan N, Abbas H, Mason J, Jones N, Katritsis G, Lim PB, Peters NS, Qureshi N, Whinnett Z, Linton NW, Kanagaratnam P. Ripple-AT Study. Circ Arrhythm Electrophysiol 2019; 12:e007394. [DOI: 10.1161/circep.118.007394] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Ripple mapping (RM) is an alternative approach to activation mapping of atrial tachycardia (AT) that avoids electrogram annotation. We tested whether RM is superior to conventional annotation based local activation time (LAT) mapping for AT diagnosis in a randomized and multicenter study.
Methods:
Patients with AT were randomized to either RM or LAT mapping using the CARTO3v4 CONFIDENSE system. Operators determined the diagnosis using the assigned 3D mapping arm alone, before being permitted a single confirmatory entrainment manuever if needed. A planned ablation lesion set was defined. The primary end point was AT termination with delivery of the planned ablation lesion set. The inability to terminate AT with this first lesion set, the use of more than one entrainment manuever, or the need to crossover to the other mapping arm was defined as failure to achieve the primary end point.
Results:
One hundred five patients from 7 centers were recruited with 22 patients excluded due to premature AT termination, noninducibility or left atrial appendage thrombus. Eighty-three patients (pts; RM=42, LAT=41) completed mapping and ablation within the 2 groups of similar characteristics (RM versus LAT: prior ablation or cardiac surgery n=35 [83%] versus n=35 [85%],
P
=0.80). The primary end point occurred in 38/42 pts (90%) in the RM group and 29/41pts (71%) in the LAT group (
P
=0.045). This was achieved without any entrainment in 31/42 pts (74%) with RM and 18/41 pts (44%) with LAT (
P
=0.01). Of those patients who failed to achieve the primary end point, AT termination was achieved in 9/12 pts (75%) in the LAT group following crossover to RM with entrainment, but 0/4 pts (0%) in the RM group crossing over to LAT mapping with entrainment (
P
=0.04).
Conclusions:
RM is superior to LAT mapping on the CARTO3v4 CONFIDENSE system in guiding ablation to terminate AT with the first lesion set and with reduced entrainment to assist diagnosis.
Clinical Trials Registration:
https://www.clinicaltrials.gov
. Unique identifier: NCT02451995.
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Affiliation(s)
- Vishal Luther
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | | | - Anthony Chow
- Barts Heart Centre, London, United Kingdom (A.C., N.S., H.A.)
| | - Michael Koa-Wing
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Nuno Cortez-Dias
- Hospital de Santa Maria, Lisbon, Portugal (N.C.-D., L.C., J.d.S.)
| | - Luís Carpinteiro
- Hospital de Santa Maria, Lisbon, Portugal (N.C.-D., L.C., J.d.S.)
| | - João de Sousa
- Hospital de Santa Maria, Lisbon, Portugal (N.C.-D., L.C., J.d.S.)
| | | | | | | | - Neil Srinivasan
- Barts Heart Centre, London, United Kingdom (A.C., N.S., H.A.)
| | - Hakam Abbas
- Barts Heart Centre, London, United Kingdom (A.C., N.S., H.A.)
| | - James Mason
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Nikki Jones
- Royal Bournemouth & Christchurch Hospital (R.B., N.J.)
| | - George Katritsis
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Phang Boon Lim
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Nicholas S. Peters
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Norman Qureshi
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Zachary Whinnett
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Nick W.F. Linton
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
| | - Prapa Kanagaratnam
- Imperial College Healthcare, London (V.L., M.K.-W., G.K., P.B.L., N.S.P., N.Q., Z.W., N.W.F.L., P.K.)
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32
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Qureshi NA, Kim SJ, Cantwell CD, Afonso VX, Bai W, Ali RL, Shun-Shin MJ, Malcolme-Lawes LC, Luther V, Leong KMW, Lim E, Wright I, Nagy S, Hayat S, Ng FS, Wing MK, Linton NWF, Lefroy DC, Whinnett ZI, Davies DW, Kanagaratnam P, Peters NS, Lim PB. Voltage during atrial fibrillation is superior to voltage during sinus rhythm in localizing areas of delayed enhancement on magnetic resonance imaging: An assessment of the posterior left atrium in patients with persistent atrial fibrillation. Heart Rhythm 2019; 16:1357-1367. [PMID: 31170484 PMCID: PMC6722483 DOI: 10.1016/j.hrthm.2019.05.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Indexed: 11/30/2022]
Abstract
Background Bipolar electrogram voltage during sinus rhythm (VSR) has been used as a surrogate for atrial fibrosis in guiding catheter ablation of persistent atrial fibrillation (AF), but the fixed rate and wavefront characteristics present during sinus rhythm may not accurately reflect underlying functional vulnerabilities responsible for AF maintenance. Objective The purpose of this study was determine whether, given adequate temporal sampling, the spatial distribution of mean AF voltage (VmAF) better correlates with delayed-enhancement magnetic resonance imaging (MRI-DE)–detected atrial fibrosis than VSR. Methods AF was mapped (8 seconds) during index ablation for persistent AF (20 patients) using a 20-pole catheter (660 ± 28 points/map). After cardioversion, VSR was mapped (557 ± 326 points/map). Electroanatomic and MRI-DE maps were co-registered in 14 patients. Results The time course of VmAF was assessed from 1–40 AF cycles (∼8 seconds) at 1113 locations. VmAF stabilized with sampling >4 seconds (mean voltage error 0.05 mV). Paired point analysis of VmAF from segments acquired 30 seconds apart (3667 sites; 15 patients) showed strong correlation (r = 0.95; P <.001). Delayed enhancement (DE) was assessed across the posterior left atrial (LA) wall, occupying 33% ± 13%. VmAF distributions were (median [IQR]) 0.21 [0.14–0.35] mV in DE vs 0.52 [0.34–0.77] mV in non-DE regions. VSR distributions were 1.34 [0.65–2.48] mV in DE vs 2.37 [1.27–3.97] mV in non-DE. VmAF threshold of 0.35 mV yielded sensitivity of 75% and specificity of 79% in detecting MRI-DE compared with 63% and 67%, respectively, for VSR (1.8-mV threshold). Conclusion The correlation between low-voltage and posterior LA MRI-DE is significantly improved when acquired during AF vs sinus rhythm. With adequate sampling, mean AF voltage is a reproducible marker reflecting the functional response to the underlying persistent AF substrate.
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Affiliation(s)
- Norman A Qureshi
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | | | | | - Wenjia Bai
- Imperial College London, London, United Kingdom
| | | | - Matt J Shun-Shin
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | - Vishal Luther
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Kevin M W Leong
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Ian Wright
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Szabi Nagy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Sajad Hayat
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Michael Koa Wing
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nick W F Linton
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - David C Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Zachary I Whinnett
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - D Wyn Davies
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S Peters
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.
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Luther V, Wright I, Lefroy D, Ng FS. A narrow complex tachycardia with variable R-R intervals: What is the mechanism? J Cardiovasc Electrophysiol 2018; 29:1174-1176. [DOI: 10.1111/jce.13618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/14/2018] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Vishal Luther
- Imperial College Healthcare NHS Trust & Imperial College London; London United Kingdom
| | - Ian Wright
- Imperial College Healthcare NHS Trust & Imperial College London; London United Kingdom
| | - David Lefroy
- Imperial College Healthcare NHS Trust & Imperial College London; London United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust & Imperial College London; London United Kingdom
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34
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Sikkel MB, Luther V, Sau A, Guerrero F, Ng FS, Lim PB. High-Density Electroanatomical Mapping to Identify Point of Epicardial to Endocardial Breakthrough in Perimitral Flutter. JACC Clin Electrophysiol 2018; 3:637-639. [PMID: 29759439 DOI: 10.1016/j.jacep.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/20/2016] [Accepted: 11/28/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Markus B Sikkel
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Electrophysiology, Imperial College Healthcare National Health Service Trust, Hammersmith Hospital, London, United Kingdom.
| | - Vishal Luther
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Electrophysiology, Imperial College Healthcare National Health Service Trust, Hammersmith Hospital, London, United Kingdom
| | - Arunashis Sau
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Fu Siong Ng
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Phang Boon Lim
- Myocardial Function Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom; Department of Electrophysiology, Imperial College Healthcare National Health Service Trust, Hammersmith Hospital, London, United Kingdom
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Luther V, Qureshi N, Lim PB, Koa-Wing M, Jamil-Copley S, Ng FS, Whinnett Z, Davies DW, Peters NS, Kanagaratnam P, Linton N. Isthmus sites identified by Ripple Mapping are usually anatomically stable: A novel method to guide atrial substrate ablation? J Cardiovasc Electrophysiol 2018; 29:404-411. [PMID: 29341322 DOI: 10.1111/jce.13425] [Citation(s) in RCA: 6] [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: 11/01/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postablation reentrant ATs depend upon conducting isthmuses bordered by scar. Bipolar voltage maps highlight scar as sites of low voltage, but the voltage amplitude of an electrogram depends upon the myocardial activation sequence. Furthermore, a voltage threshold that defines atrial scar is unknown. We used Ripple Mapping (RM) to test whether these isthmuses were anatomically fixed between different activation vectors and atrial rates. METHODS We studied post-AF ablation ATs where >1 rhythm was mapped. Multipolar catheters were used with CARTO Confidense for high-density mapping. RM visualized the pattern of activation, and the voltage threshold below which no activation was seen. Isthmuses were characterized at this threshold between maps for each patient. RESULTS Ten patients were studied (Map 1 was AT1; Map 2: sinus 1/10, LA paced 2/10, AT2 with reverse CS activation 3/10; AT2 CL difference 50 ± 30 ms). Point density was similar between maps (Map 1: 2,589 ± 1,330; Map 2: 2,214 ± 1,384; P = 0.31). RM activation threshold was 0.16 ± 0.08 mV. Thirty-one isthmuses were identified in Map 1 (median 3 per map; width 27 ± 15 mm; 7 anterior; 6 roof; 8 mitral; 9 septal; 1 posterior). Importantly, 7 of 31 (23%) isthmuses were unexpectedly identified within regions without prior ablation. AT1 was treated following ablation of 11/31 (35%) isthmuses. Of the remaining 20 isthmuses, 14 of 16 isthmuses (88%) were consistent between the two maps (four were inadequately mapped). Wavefront collision caused variation in low voltage distribution in 2 of 16 (12%). CONCLUSIONS The distribution of isthmuses and nonconducting tissue within the ablated left atrium, as defined by RM, appear concordant between rhythms. This could guide a substrate ablative approach.
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Katritsis G, Luther V, Kanagaratnam P, Linton NW. Arrhythmia Mechanisms Revealed by Ripple Mapping. Arrhythm Electrophysiol Rev 2018; 7:261-264. [PMID: 30588314 DOI: 10.15420/aer.2018.44.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 07/27/2018] [Accepted: 08/13/2018] [Indexed: 11/04/2022] Open
Abstract
Ripple mapping is a novel method of 3D intracardiac electrogram visualisation that allows activation of the myocardium to be tracked visually without prior assignment of local activation times and without interpolation into unmapped regions. It assists in the identification of tachycardia mechanism and optimal ablation site, without the need for an experienced computer-operating assistant. This expert opinion presents evidence demonstrating the benefit of Ripple Mapping, compared with traditional electroanatomic mapping techniques, for the diagnosis and management of atrial and ventricular tachyarrhythmias during electrophysiological procedures.
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Affiliation(s)
- George Katritsis
- Department of Cardiac Electrophysiology, Imperial College Healthcare London, UK
| | - Vishal Luther
- Department of Cardiac Electrophysiology, Imperial College Healthcare London, UK
| | - Prapa Kanagaratnam
- Department of Cardiac Electrophysiology, Imperial College Healthcare London, UK
| | - Nick Wf Linton
- Department of Bioengineering, Imperial College London UK
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Sau A, Sikkel MB, Luther V, Wright I, Guerrero F, Koa-Wing M, Lefroy D, Linton N, Qureshi N, Whinnett Z, Lim PB, Kanagaratnam P, Peters N, Davies DW. 148The sawtooth EKG pattern of typical atrial flutter is not related to differences in conduction velocity around the flutter circuit. Europace 2017. [DOI: 10.1093/europace/eux283.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Luther V, Cortez-Dias N, Carpinteiro L, de Sousa J, Balasubramaniam R, Sopher M, Babu G, Till R, Jones N, Farwell D, Tan S, Chow A, Lowe M, Lane J, Agarwal S, Linton N, Kanagaratnam P. 2A multi-centre study into the use of Ripple Mapping to differentiate atrial scar from conducting tissue during tachycardia ablation. Europace 2017. [DOI: 10.1093/europace/eux283.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sau A, Sikkel MB, Luther V, Wright I, Guerrero F, Koa-Wing M, Lefroy D, Linton N, Qureshi N, Whinnett Z, Lim PB, Kanagaratnam P, Peters NS, Davies DW. The sawtooth EKG pattern of typical atrial flutter is not related to slow conduction velocity at the cavotricuspid isthmus. J Cardiovasc Electrophysiol 2017; 28:1445-1453. [DOI: 10.1111/jce.13323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/13/2017] [Accepted: 08/15/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Arunashis Sau
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Markus B. Sikkel
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Vishal Luther
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Ian Wright
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | | | - Michael Koa-Wing
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - David Lefroy
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Nicholas Linton
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Norman Qureshi
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Zachary Whinnett
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Phang Boon Lim
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Prapa Kanagaratnam
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - Nicholas S. Peters
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
| | - D. Wyn Davies
- Imperial Centre for Translational and Experimental Medicine; Imperial College London; London UK
- Department of Cardiology; Imperial College Healthcare NHS Trust; London UK
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Luther V, Cortez-Dias N, Carpinteiro L, de Sousa J, Balasubramaniam R, Agarwal S, Farwell D, Sopher M, Babu G, Till R, Jones N, Tan S, Chow A, Lowe M, Lane J, Pappachan N, Linton N, Kanagaratnam P. Ripple mapping: Initial multicenter experience of an intuitive approach to overcoming the limitations of 3D activation mapping. J Cardiovasc Electrophysiol 2017; 28:1285-1294. [PMID: 28776822 DOI: 10.1111/jce.13308] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 05/26/2017] [Revised: 07/07/2017] [Accepted: 07/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ripple mapping (RM) displays electrograms as moving bars over a three-dimensional surface displaying bipolar voltage, and has shown in a single-center series to be effective for atrial tachycardia (AT) mapping without annotation of local activation time or window-of-interest assignment. We tested the reproducibility of these findings in operators naïve to RM, using it for the first time in postablation AT. METHODS Maps were collected with multielectrode catheters and CARTO ConfiDENSE. A diagnosis of the tachycardia mechanism was made using RM and an assessment of operator confidence was made according to a three-grade scale (1 highest-3 lowest). RESULTS The first 20 patients (64 ± 9 years, median two previous ablations) undergoing RM-guided AT ablation across five sites were studied. High-density maps (2,935 ± 1,328 points) in AT (CL = 296 ± 95 milliseconds) were collected. Macroreentrant ATs bordered by scar or anatomical obstacles were identified in n = 12 (60%), small reentrant ATs around scar in n = 3 (15%), and focal ATs from scar in n = 5 (25%). Diagnostic confidence with RM was grade 1 in n = 13 (65%), where operators felt confident to proceed to ablation without entrainment. Ablation offered the correct diagnosis n = 18 (90%). Retrospective review of the accompanying LAT maps demonstrated potential sources for error related to the window of interest selection, interpolation, and differentiating regions of scar during tachycardia on the voltage map. CONCLUSION RM was easy to adopt by operators using it for the first time, and identified the correct target for ablation with high diagnostic confidence in most cases of complex AT.
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Affiliation(s)
- Vishal Luther
- Cardiac Electrophysiology Laboratories, Imperial College Healthcare, London, UK
| | - Nuno Cortez-Dias
- Department of Cardiac Electrophysiology, Hospital de Santa Maria, Lisbon, Portugal
| | - Luís Carpinteiro
- Department of Cardiac Electrophysiology, Hospital de Santa Maria, Lisbon, Portugal
| | - João de Sousa
- Department of Cardiac Electrophysiology, Hospital de Santa Maria, Lisbon, Portugal
| | - Richard Balasubramaniam
- Cardiac Electrophysiology Laboratories, Royal Bournemouth & Christchurch Hospital, Bournemouth, UK
| | - Sharad Agarwal
- Cardiac Electrophysiology Laboratories, Papworth Hospital, Cambridge, UK
| | - David Farwell
- Cardiac Electrophysiology Laboratories, Essex Cardiothoracic Centre, Basildon, UK
| | - Mark Sopher
- Cardiac Electrophysiology Laboratories, Royal Bournemouth & Christchurch Hospital, Bournemouth, UK
| | - Girish Babu
- Cardiac Electrophysiology Laboratories, Royal Bournemouth & Christchurch Hospital, Bournemouth, UK
| | - Richard Till
- Cardiac Electrophysiology Laboratories, Royal Bournemouth & Christchurch Hospital, Bournemouth, UK
| | - Nikki Jones
- Cardiac Electrophysiology Laboratories, Royal Bournemouth & Christchurch Hospital, Bournemouth, UK
| | - Stuart Tan
- Cardiac Electrophysiology Laboratories, Essex Cardiothoracic Centre, Basildon, UK
| | - Anthony Chow
- Department of Cardiac Electrophysiology, Barts Heart Centre, London, UK
| | - Martin Lowe
- Department of Cardiac Electrophysiology, Barts Heart Centre, London, UK
| | - Jem Lane
- Department of Cardiac Electrophysiology, Barts Heart Centre, London, UK
| | - Naveen Pappachan
- Cardiac Electrophysiology Laboratories, Imperial College Healthcare, London, UK
| | - Nicholas Linton
- Cardiac Electrophysiology Laboratories, Imperial College Healthcare, London, UK
| | - Prapa Kanagaratnam
- Cardiac Electrophysiology Laboratories, Imperial College Healthcare, London, UK
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Luther V, Linton NWF, Jamil-Copley S, Koa-Wing M, Lim PB, Qureshi N, Ng FS, Hayat S, Whinnett Z, Davies DW, Peters NS, Kanagaratnam P. A Prospective Study of Ripple Mapping the Post-Infarct Ventricular Scar to Guide Substrate Ablation for Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004072. [PMID: 27307519 DOI: 10.1161/circep.116.004072] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [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: 02/08/2016] [Accepted: 05/12/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Post-infarct ventricular tachycardia is associated with channels of surviving myocardium within scar characterized by fractionated and low-amplitude signals usually occurring late during sinus rhythm. Conventional automated algorithms for 3-dimensional electro-anatomic mapping cannot differentiate the delayed local signal of conduction within the scar from the initial far-field signal generated by surrounding healthy tissue. Ripple mapping displays every deflection of an electrogram, thereby providing fully informative activation sequences. We prospectively used CARTO-based ripple maps to identify conducting channels as a target for ablation. METHODS AND RESULTS High-density bipolar left ventricular endocardial electrograms were collected using CARTO3v4 in sinus rhythm or ventricular pacing and reviewed for ripple mapping conducting channel identification. Fifteen consecutive patients (median age 68 years, left ventricular ejection fraction 30%) were studied (6 month preprocedural implantable cardioverter defibrillator therapies: median 19 ATP events [Q1-Q3=4-93] and 1 shock [Q1-Q3=0-3]). Scar (<1.5 mV) occupied a median 29% of the total surface area (median 540 points collected within scar). A median of 2 ripple mapping conducting channels were seen within each scar (length 60 mm; initial component 0.44 mV; delayed component 0.20 mV; conduction 55 cm/s). Ablation was performed along all identified ripple mapping conducting channels (median 18 lesions) and any presumed interconnected late-activating sites (median 6 lesions; Q1-Q3=2-12). The diastolic isthmus in ventricular tachycardia was mapped in 3 patients and colocated within the ripple mapping conducting channels identified. Ventricular tachycardia was noninducible in 85% of patients post ablation, and 71% remain free of ventricular tachycardia recurrence at 6-month median follow-up. CONCLUSIONS Ripple mapping can be used to identify conduction channels within scar to guide functional substrate ablation.
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Affiliation(s)
- Vishal Luther
- From the Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Nick W F Linton
- From the Imperial College Healthcare NHS Trust, London, United Kingdom.
| | | | - Michael Koa-Wing
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Norman Qureshi
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sajad Hayat
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zachary Whinnett
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - D Wyn Davies
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas S Peters
- From the Imperial College Healthcare NHS Trust, London, United Kingdom
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Luther V, Sikkel M, Bennett N, Guerrero F, Leong K, Qureshi N, Ng FS, Hayat SA, Sohaib SMA, Malcolme-Lawes L, Lim E, Wright I, Koa-Wing M, Lefroy DC, Linton NWF, Whinnett Z, Kanagaratnam P, Davies DW, Peters NS, Lim PB. Visualizing Localized Reentry With Ultra-High Density Mapping in Iatrogenic Atrial Tachycardia: Beware Pseudo-Reentry. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004724. [PMID: 28356307 DOI: 10.1161/circep.116.004724] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [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: 10/20/2016] [Accepted: 03/01/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The activation pattern of localized reentry (LR) in atrial tachycardia remains incompletely understood. We used the ultra-high density Rhythmia mapping system to study activation patterns in LR. METHODS AND RESULTS LR was suggested by small rotatory activations (carousels) containing the full spectrum of the color-coded map. Twenty-three left-sided atrial tachycardias were mapped in 15 patients (age: 64±11 years). 16 253±9192 points were displayed per map, collected over 26±14 minutes. A total of 50 carousels were identified (median 2; quartiles 1-3 per map), although this represented LR in only n=7 out of 50 (14%): here, rotation occurred around a small area of scar (<0.03 mV; 12±6 mm diameter). In LR, electrograms along the carousel encompassed the full tachycardia cycle length, and surrounding activation moved away from the carousel in all directions. Ablating fractionated electrograms (117±18 ms; 44±13% of tachycardia cycle length) within the carousel interrupted the tachycardia in every LR case. All remaining carousels were pseudo-reentrant (n=43/50 [86%]) occurring in areas of wavefront collision (n=21; median 0.5; quartiles 0-2 per map) or as artifact because of annotation of noise or interpolation in areas of incomplete mapping (n=22; median 1, quartiles 0-2 per map). Pseudo-reentrant carousels were incorrectly ablated in 5 cases having been misinterpreted as LR. CONCLUSIONS The activation pattern of LR is of small stable rotational activations (carousels), and this drove 30% (7/23) of our postablation atrial tachycardias. However, this appearance is most often pseudo-reentrant and must be differentiated by interpretation of electrograms in the candidate circuit and activation in the wider surrounding region.
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Affiliation(s)
- Vishal Luther
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Markus Sikkel
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Nathan Bennett
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Fernando Guerrero
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Kevin Leong
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Norman Qureshi
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Fu Siong Ng
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Sajad A Hayat
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - S M Afzal Sohaib
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Louisa Malcolme-Lawes
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Elaine Lim
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Ian Wright
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Michael Koa-Wing
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - David C Lefroy
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Nick W F Linton
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Zachary Whinnett
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Prapa Kanagaratnam
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - D Wyn Davies
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Nicholas S Peters
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.)
| | - Phang Boon Lim
- From the Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom (V.L., M.S., K.L., N.Q., F.S.N., S.A.H., S.M.A.S., L.M.-L., E.L., I.W., M.K.-W., D.C.L., N.W.F.L., Z.W., P.K., D.W.D., N.S.P., P.B.L.); and Boston Scientific Ltd, Marlborough, MA (N.B., F.G.).
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Affiliation(s)
- Fu Siong Ng
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College London, London, United Kingdom
| | | | - Vishal Luther
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Markus Sikkel
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College London, London, United Kingdom
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Luther V, Nijjer SS, Lefroy DC. Management of ventricular tachycardia. Br J Hosp Med (Lond) 2017; 78:C6-C9. [PMID: 28067552 DOI: 10.12968/hmed.2017.78.1.c6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vishal Luther
- BHF Clinical Research Fellow and Cardiology Specialist Registrar, Augustus Waller Department of Electrophysiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
| | - Sukhjinder S Nijjer
- Consultant in Interventional Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London
| | - David C Lefroy
- Consultant in Cardiology and Cardiac Electrophysiology, Augustus Waller Department of Electrophysiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London
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Affiliation(s)
- Sukhjinder S Nijjer
- Consultant in Interventional Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London
| | - Vishal Luther
- BHF Clinical Research Fellow and Cardiology Specialist Registrar, Augustus Waller Department of Electrophysiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
| | - David C Lefroy
- Consultant in Cardiology and Cardiac Electrophysiology, Augustus Waller Department of Electrophysiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London
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Varanasi S, Wright I, Hussain W, Bowers R, Slater T, Sengupta A, Porter B, Hussein A, Chu G, Siddiqui M, Man S, Somani R, Sandilands A, Stafford P, Ng G, Luther V, Young Kim M, Benfield A, Tanner M, Lefroy D, Koa-Wing M, Lim P, Linton N, Davies D, Peters N, Kanagaratnam P, Moore P, Whinnett Z, Thakrar D, Iacovides S, Paisey J, Balasubramaniam R, Sopher SM, Saunderson C, Moyles C, Blackburn Y, Morley C, Jamil H, Schlosshan D, Kearney M, Witte K, Lambden C, Woodcock T, Matthew D, Hashmy S, Kaur M, Kaba A, Grant R, Unger-Graeber B, Khan S, Das M, Wynn G, Morgan M, Waktare J, Hall M, Modi S, Snowdon R, Todd D, Gupta D. MODERATED POSTERS (1)43P WAVE DURATION & SPECTRAL ANALYSIS OF SIGNAL AVERAGED P WAVE: CAN THIS PREDICT RECURRENCE OF PARAOXYSMAL ATRIAL FIBRILLATION AFTER PULMONARY VEIN SIOLATION? A PROSPECTIVE STUDY44ATP INDUCED SLOW VF - A MECHANISM TO EXPLAIN THE ASSOCIATION BETWEEN ATP AND INCREASED MORTALITY45THE USE OF A HANDHELD DEVICE IN IDENTIFYING ATRIAL FIBRILLATION PATIENTS DURING FLU VACCINATION CLINICS46DELIVERY OF A FULL EP SERVICE FROM A DISTRICT GENERAL HOSPITAL SETTING: OUTCOMES FROM A SINGLE CENTRE47THE PREVALENCE OF SODIUM AND FLUID DEPLETION IN PATIENTS WITH RECURRENT SYNCOPE OF PRESUMED HYPOTENSIVE ORIGIN: A SINGLE CENTRE EXPERIENCE48ECHOCARDIOGRAPHY AND RISK STRATIFICATION FOR ICD IMPLANTATION AFTER ST-ELEVATION MYOCARDIAL INFARCTION:OPPORTUNITIES FOR IMPROVEMENT49THE QUALITY AND OUTCOMES FRAMEWORK DATA UNDERESTIMATES AF PREVALENCE AND OVERESTIMATES RATES OF APPROPRIATE THROMBOEMBOLIC PROPHYLAXIS50THE RELATIONSHIP BETWEEN THE EFFECTIVE REFRACTORY PERIOD OF RECONNECTED PULMONARY VEINS AT REPEAT ELECTROPHYSIOLOGY STUDY AND RECURRENCE OF ATRIAL TACHYCARRHYTHMIA BEYOND ONE MONTH AFTER PULMONARY VEIN ISOLATION. Europace 2016. [DOI: 10.1093/europace/euw268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Martin C, Papageorgiou N, Srinivasan N, Luther V, Ang R, Saberwal B, Sawhney V, Martin C, Orini M, Srinivasan N, Bhar-Amato J, Chow A, Lowe M, Simon R, Lambiase P, Providência R, Srinivasan N, Bronis K, Moscoso Costa F, Cavaco D, Adragao P, Tousoulis D, Hunter R, Schilling R, Segal O, Chow A, Rowland E, Lowe M, Lambiase P, Orini M, Providencia R, Simon R, Khan F, Segal O, Ahsan S, Chow A, Lowe M, Schilling R, Taggart P, Lambiase P, Linton N, Jamil-Copley S, Koa-Wing M, Lim P, Qureshi N, Whinnett Z, Davies D, Peters N, Kanagaratnam P, Opel A, Ullah W, Baker V, Finlay M, Dhinoja M, Earley M, Sporton S, Hunter R, Schilling R, Roy A, Perera D, Sporton S, Dhinoja M, Segal O, Lambiase P, Lowe M, Chow A, Hunter R, Rowland E, Khan F, Ezzat V, Providencia R, Earley M, Finlay M, Schilling R, Ahsan S, Bacuetes EB, Wray MW, Dhinoja MD, Earley ME, Schilling RJS, Sporton SS, Curtain J, Gajendragadkar P, Begley D, Fynn S, Grace A, Heck P, Virdee M, Salaunkey K, Agarwal S. MODERATED POSTERS (2)51GLOBAL HIGH DENSITY MAPPING OF RE-ENTRY VULNERABILITY INDEX INDENTIFIES SITES OF RIGHT VENTRICULAR ARRHYTHMIA INITIATION IN BRUGADA SYNDROME AND ARVC52THE ROLE OF ADENOSINE-GUIDED PULMONARY VEIN ISOLATION IN PATIENTS UNDERGOING ATRIAL FIBRILLATION ABLATION:AN UPDATED META-ANALYSIS53FIRST EVIDENT THAT T-PEAK AND TPEAK-TEND CORRELATE WITH RIGHT TO LEFT AND TRANSMURAL DYNAMIC DISPERSION OF REPOLARIZATION IN THE INTACT HUMAN HEART54RIPPLE MAPPING VENTRICULAR SCAR TO CHARACTERIZE CHANNELS SUPPORTING RE-ENTRANT TACHYCARDIA AS A GUIDE TO ABLATION55LONG TERM DURABILITY OF PULMONARY VEIN ISOLATION: INSIGHTS FROM A RANDOMISED TRIAL OF CRYOBALLOON VERSUS RADIOFREQUENCY ABLATION FOR A COMBINED APPROACH56A SINGLE-CENTRE EXPERIENCE OF THE CONVERGENT PROCEDURE FOR THE TREATMENT OF LONG-STANDING PERSISTENT ATRIAL FIBRILLATION57MODERATE SEDATION IN THE CARDIAC ELECTROPHYSIOLOGY LABORATORY: A RETROSPECTIVE ANALYSIS TO ASSESS SAFETY58USE OF GENERAL ANAESTHESIA IN CATHETER ABLATION OF PERSISTENT AF: IMPROVED OUTCOME AND COST EFFECTIVENESS:. Europace 2016. [DOI: 10.1093/europace/euw269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Luther V, Sikkel MB, Wright I, Faulkner M, Qureshi N, Lefroy DC. A Collapsed Sportsman With a Shock Advised in Sinus Rhythm: The Importance of Automated External Defibrillator Rhythm Strip Retrieval Prior to Defibrillator Implantation. Circ Arrhythm Electrophysiol 2016; 9:e003914. [PMID: 26987568 DOI: 10.1161/circep.116.003914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Vishal Luther
- From the Department of Cardiac Electrophysiology, Imperial College Healthcare NHS Trust (V.L., M.B.S., I.W., N.Q., D.C.L.) and London Ambulance Service (M.F.), London, United Kingdom.
| | - Markus B Sikkel
- From the Department of Cardiac Electrophysiology, Imperial College Healthcare NHS Trust (V.L., M.B.S., I.W., N.Q., D.C.L.) and London Ambulance Service (M.F.), London, United Kingdom
| | - Ian Wright
- From the Department of Cardiac Electrophysiology, Imperial College Healthcare NHS Trust (V.L., M.B.S., I.W., N.Q., D.C.L.) and London Ambulance Service (M.F.), London, United Kingdom
| | - Mark Faulkner
- From the Department of Cardiac Electrophysiology, Imperial College Healthcare NHS Trust (V.L., M.B.S., I.W., N.Q., D.C.L.) and London Ambulance Service (M.F.), London, United Kingdom
| | - Norman Qureshi
- From the Department of Cardiac Electrophysiology, Imperial College Healthcare NHS Trust (V.L., M.B.S., I.W., N.Q., D.C.L.) and London Ambulance Service (M.F.), London, United Kingdom
| | - David C Lefroy
- From the Department of Cardiac Electrophysiology, Imperial College Healthcare NHS Trust (V.L., M.B.S., I.W., N.Q., D.C.L.) and London Ambulance Service (M.F.), London, United Kingdom
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Leong KMW, Chow JJ, Ng FS, Yates S, Wright I, Luther V, David L, Qureshi N, Koa-Wing M, Whinnett Z, Linton NW, Davies DW, Lim PB, Peters NS, Kanagaratnam P, Varnava A. 145 Risk Stratification in Hypertrophic Cardiomyopathy: Evaluation of the European Society of Cardiology Sudden Cardiac Death Risk Scoring System. Heart 2016. [DOI: 10.1136/heartjnl-2016-309890.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Luther V, Linton N, Jamil-Copley S, Koa-Wing M, Qureshi N, Ng F, Lim PB, Whinnett Z, Davies DW, Peters N, Kanagaratnam P. 68 Ripple Mapping the Ventricular Scar: A Novel Approach to Substrate Ablation of Post-infarct Ventricular Tachycardia to Prevent Implantable Defibrillator Therapy. Heart 2016. [DOI: 10.1136/heartjnl-2016-309890.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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