Mapping of an atrial tachycardia after Epicor™ high-intensity focused ultrasound ablation: A case report

BACKGROUND

Surgical techniques, such as the application of high-intensity focused ultrasound (HIFU), can be used for pulmonary vein isolation (PVI).

CASE SUMMARY

We report a case of a 73-year old patient, in whom HIFU failed to achieve PVI but promoted the occurrence of a scar-related atrial tachycardia (AT). Voltage mapping of the left atrium revealed multiple gaps along the ablation line. Coherent mapping with visualization of velocity vectors allowed the correct interpretation and the targeted ablation of the AT.

DISCUSSION

Cardiac surgery can promote scar-related AT. The coherent mapping function could simplify the mapping of scar-related AT in the future.

Targeting Bachmann's bundle in hybrid ablation for long-standing persistent atrial fibrillation: a proof of concept study

BACKGROUND

Catheter-based or surgical procedures in patients with long-standing persistent atrial fibrillation (LSPAF) remain a challenge. As a result, different approaches including hybrid (surgical and endocardial) ablation have been developed. Bachmann's bundle (BB) is a mainly epicardial structure capable of sustaining arrhythmic reentry that could be involved in the development and perpetuation of atrial fibrillation. We investigated the efficacy and safety of an adjunctive BB ablation in LSPAF patients undergoing hybrid ablation.

METHODS

In a two-arm non-randomized study, consecutive LSPAF patients undergoing epicardial isolation of pulmonary veins with left atrial posterior wall (box lesion) with (n = 30, BB group) and without additional BB ablation (n = 30, CONV group) were enrolled in the study. All patients underwent an endocardial procedure within 6 weeks post-surgery to assess for potential lesion gaps and additional atrial substrate modification. The primary endpoint was freedom from AF through 12 months of follow-up.

RESULTS

The two-staged hybrid ablation was successfully completed in all patients. One-year freedom from atrial arrhythmias recurrence rates was 96.6% in the BB group vs 76.6% in the CONV group (p = 0.025). At procedure completion, 30 (100%) and 17 (56%) patients had a spontaneous cardioversion in BB and CONV group, respectively (p < 0.001). No significant differences in quality of life or complication rates were observed.

CONCLUSIONS

This initial experience shows, for the first time, that adjunctive BB ablation in the setting of hybrid ablation for LSPAF is a feasible and effective approach in increasing maintenance of sinus rhythm without increasing complication rates.

The combined application of the contrast-to-noise index and 80 kVp for cardiac CTA scanning before atrial fibrillation ablation reduces radiation dose exposure

INTRODUCTION

To compare the radiation dose, diagnostic accuracy, and the resultant ablation procedures using 80 and 120-kVp cardiac computed tomography angiography (CCTA) protocols with the same contrast-to-noise ratio in patients scheduled for atrial fibrillation (AF) ablation.

METHODS

This retrospective study was performed following institutional review board approval. We divided 140 consecutive patients who had undergone CCTA using a 64-MDCT scanner into two equal groups. Standard deviation (SD) of the CT number was set at 25 Hounsfield units (HU) for the 120-kVp protocol. To facilitate a reduction in radiation dose it was set at 40 HU for the 80 kVp protocol. We compared the two protocols with respect to the radiation dose, the diagnostic accuracy for detecting left atrial appendage (LAA) thrombi, matching for surface registration, and the resultant ablation procedures.

RESULTS

At 120 kVp, the dose length product (DLP) was 2.2 times that at 80 kVp (1269.0 vs 559.0 mGy cm, p < 0.01). The diagnostic accuracy for thrombus detection was 100% using both protocols. There was no difference between the two protocols with respect to matching for surface registration. The protocols did not differ with respect to the subsequent time required for the ablation procedures and the ablation fluoroscopy time, and the radiation dose (p = 0.54, 0.33, and 0.32, respectively).

CONCLUSION

For the same CNR, the DLP at 80 kVp (559.0 mGy cm) was 56% of that delivered at 120 kVp (1269.0 mGy cm). There was no reduction in diagnostic accuracy.

IMPLICATIONS FOR PRACTICE

Maintaining CNR allows for a reduction in the radiation dose without reducing the image quality.

Radiation exposure in cryoballoon ablation compared to radiofrequency ablation with three-dimensional electroanatomic mapping in atrial fibrillation patients

BACKGROUND

Catheter ablation for atrial fibrillation (AF) has become an established treatment to control symptoms. AF ablation either by cryoballoon or radiofrequency using three-dimensional (3D) electroanatomical mapping exposes patients and medical staff to increased doses of radiation.

AIM

To compare radiation exposure in patients during cryoballoon ablation compared to 3D electro-anatomic mapping catheter ablation in AF patients.

METHODS

A total of 30 patients referred for AF ablation underwent full history taking, 12-lead ECG, echocardiogram, and pulmonary vein isolation either by 3D mapping system or cryoballoon. Procedure duration and fluoroscopy time were collected and analyzed. Radiation exposure was measured using thermoluminescent dosimeters placed at different sites related to patients and medical staff.

RESULT

The procedural time was statistically significantly longer with 3D mapping compared to cryoballoon but showed no significant difference regarding fluoroscopy time. There was a significantly higher radiation skin dose at the right scapular area in the cryoballoon ablation group, in addition to higher peak skin dose compared to the 3D mapping ablation group. There was no statistically significant correlation between peak skin doses and fluoroscopy duration but a statistically significant correlation between peak skin dose and usage of high frame rate and the high dose area product.

CONCLUSION

Cryoballoon ablation was found to be associated with higher peak skin radiation doses especially in the right scapular area. Knowing dose area product and peak skin dose is more important than fluoroscopy time alone.

Safety and cost-effectiveness of same-day complex left atrial ablation

Background

Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.

Method

Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.

Results

A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.

Conclusions

Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

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We have previously reported same-day standard catheter ablation is safe, feasible and cost-effective. Data on same-day complex left-atrial ablation are limited.

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Our multi-centre cohort study of 967 consecutive elective complex left-atrial ablation procedures between January 2011 and December 2019 revealed same-day ablations using conscious sedation were safe and associated with very few complications and could have significant benefits to patients and cost-savings for healthcare providers worldwide.

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Same-day complex left-atrial ablation procedures can be performed safely without the need for overnight-stay. This has major implications for both patients and healthcare providers, especially given the current financial challenges and Covid-19 pandemic.

Esophageal cooling for protection: an innovative tool that improves the safety of atrial fibrillation ablation

This letter to the editor concerns the article: 'Innovative tools for atrial fibrillation ablation' by Rottner et al., published in the journal on 13th of May 2020. We read the article with great interest and congratulate the authors on an impressively detailed summary of the current tools and technological advances in atrial fibrillation ablation. Improving the safety of this procedure is very important due to widespread clinical practice and the increasing demand for this procedure. We would like to share further discussion with the authors and the journal's readership on current advances in improving the safety of this procedure - esophageal cooling. The results of a large randomized trial was recently presented, the IMPACT study (NCT03819946), which showed that a simple, standardized method of esophageal cooling with the ensoETM® device can significantly reduce esophageal thermal injury by 83.4%. Esophageal protection is important as esophageal injury has a high mortality rate to those that sustain this injury although the overall incidence is low. Rottner et al. discuss a much smaller study on esophageal cooling and the limitations of this study are also discussed.

The impact of left common pulmonary vein on cryoballoon ablation of atrial fibrillation. A meta-analysis

Introduction

Conflicting results regarding the impact of left common pulmonary vein (LCPV) on clinical outcome of atrial fibrillation (AF) ablation with cryoballoon technology have been reported.

Methods

We systematically searched PubMed and Cochrane library for articles that compared the arrhythmia recurrence rate after cryoballoon ablation between patients with normal pattern PVs and patients with LCPV. Studies of first ablation for persistent and paroxysmal AF using the 28 mm Arctic Front Advance, Medtronic cryoballoon (CB-A) reporting clinical success rates at a mean follow-up of ≥12 months were included. Data were analyzed by applying a random effects model.

Results

A total of 5 studies with a total of 1178 patients met our predefined inclusion criteria. After a mean follow-up of 18.4 months, the overall success rate of CB-A ablation among patients with persistent and paroxysmal AF was 57%; in the LCPV group the success rate was 46% and in the normal anatomical pattern group it was 61%. No significant heterogeneity was noted among the studies (I² = 35.8%; Q (df = 3) = 6.23 p-value = 0.18). Arrhythmia recurrence after CB-A ablation was not statistically significant between the two groups (LogOR 0.24; 95% CI [-0.16-0.63]; p-value = 0.23). No significant difference in PNI was observed between the two groups (p-value = 0.693).

Conclusion

The presence of LCPV does not affect the long-term outcome of paroxysmal and persistent atrial fibrillation ablation with 28 mm CB-A compared to normal left PVs pattern.

One-Year Course of Periprocedural Anticoagulation in Atrial Fibrillation Ablation: Results of a German Nationwide Survey

INTRODUCTION

Periprocedural oral anticoagulation (OAC) strategies for atrial fibrillation (AF) ablation procedures are changing rapidly.

OBJECTIVE

To assess the management and course of periprocedural OAC for AF ablation procedures in experienced electrophysiology (EP) centers in Germany over the last 12 months.

METHODS

The data are based on an electronic questionnaire, which was sent to 35 experienced EP centers in September 2018 and then exactly 1 year later. Participants provided information on their periprocedural OAC management, the handling with dual therapy (OAC plus single antiplatelet therapy), the availability of specific antidotes, the transseptal puncture approach, and noteworthy complications.

RESULTS

Responses were received from all 35 centers and represent 10,010 AF ablation procedures annually. In 2018, the administration of vitamin K antagonist (VKA) was continued throughout the procedure at all centers (100%). In contrast, the majority of centers used minimally interrupted periprocedural non-vitamin K antagonist oral anticoagulants (NOAC) (54.3%), 13 centers (37.2%) completely interrupted NOAC, and only 3 centers (8.5%) continued NOAC throughout the procedure. At the 1-year follow-up survey, 32 centers were found to have continued their previous strategy of periprocedural OAC and 3 changed from a minimally interrupted to a continued NOAC strategy. Of note, 30 centers (85.7%) performed transseptal puncture fluoroscopically without additional cardiac imaging. In the setting of uninterrupted periprocedural OAC management, no relevant complications were noted.

CONCLUSION

Our survey shows marked heterogeneous periprocedural OAC management at experienced EP centers in Germany. Whereas continuation of VKA has already been integrated into clinical practice, the majority of centers still use a minimally interrupted NOAC strategy.

Intra-procedural anticoagulation and post-procedural hemoglobin fall in atrial fibrillation ablation with minimally interrupted direct oral anticoagulants: comparisons across 4 drugs

PURPOSE

Thromboembolic or hemorrhagic complications related to atrial fibrillation (AF) ablation are rare, and thus, it is difficult to compare their frequency across different direct oral anticoagulants (DOACs). We aimed to compare the intra-ablation blood coagulability and post-procedural hemoglobin fall as alternatives to those complications across 4 DOACs.

METHODS

We enrolled AF patients younger than 65 years old in 3 cardiovascular centers who skipped a single dose of apixaban, dabigatran, edoxaban, and rivaroxaban, prior to the ablation. Endpoints included the activated clotting time (ACT), heparin requirement during the ablation, and drop in the hemoglobin level 24 h after the procedure.

RESULTS

The time-course curves of the ACT differed significantly across the patients with apixaban (N = 113), dabigatran (N = 130), edoxaban (N = 144), and rivaroxaban (N = 81), with its highest level in the dabigatran group (P < 0.001). The average ACT was greater in the dabigatran group than in the other groups (312.3 ± 34, 334.4 ± 44, 308.1 ± 41, and 305.8 ± 34.7 s; P < 0.001). A significant difference was noted in total heparin requirement across the patient groups (3990.2 ± 1167.9, 3890.4 ± 955.3, 4423.8 ± 1051.6, and 3972 ± 978.7 U/m²/h; P < 0.001), with its greatest amount in the edoxaban group. The reduction in the hemoglobin level was similar (- 0.93 ± 0.92, - 0.88 ± 0.79, - 0.89 ± 0.97, - 0.95 ± 1.23 g/dL; P = 0.94). No inter-group difference was noted in the rate of major or minor bleedings (0.9%, 2.3%, 1.4%, and 3.7%; P = 0.51), and no thromboembolic events were encountered.

CONCLUSION

A difference in DOACs may have an impact on intra-ablation anticoagulation; however, it may not be on the procedural blood loss in the setting of a single skip.

Comparison of peri-procedural anticoagulation with rivaroxaban and apixaban during radiofrequency ablation of atrial fibrillation

Introduction

Prospective studies on rivaroxaban and apixaban have shown the safety and efficacy of direct anticoagulation agents (DOAC)s used peri-procedurally during radiofrequency ablation (RFA) of atrial fibrillation (AF). Studies comparing the two agents have not been performed.

Methods

Consecutive patients from a prospective registry who underwent RFA of AF between April 2012 and March 2015 and were on apixaban or rivaroxaban were studied. Clinical variables and outcomes were noted.

Results

There were a total of 358 patients (n = 56 on apixaban and n = 302 on rivaroxaban). There were no differences in baseline characteristics between both groups. The last dose of rivaroxaban was administered the night before the procedure in 96% of patients. In patients on apixaban, 48% of patients whose procedure was in the afternoon took the medication on the morning of the procedure. TIA/CVA occurred in 2 patients (0.6%) in rivaroxaban group with none in apixaban group (p = 0.4). There was no difference in the rate of pericardial effusion between apixaban and rivaroxaban groups [1.7% vs 0.6% (p = 0.4)]. Five percent of patients in both groups had groin complications (p = 0.9). In apixaban group, all groin complications were small hematomas except one patient who had a pseudoaneurysm (1.6%). One pseudo-aneurysm, 1 fistula and 3 large hematomas were noted in patients on rivaroxaban (1.7%) with the rest being small hematomas. DOACs were restarted post procedure typically 4 h post hemostasis.

Conclusions

Peri-procedural uninterrupted use of apixaban and rivaroxaban during AF RFA is safe and there are no major differences between both groups.

Minimally invasive mitral valve replacement and concomitant Cox-Maze IV procedure using radiofrequency energy in situs inversus totalis: A case report

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Cardiac surgery in a patient with situs inversus totalis poses technical challenges.

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CT 3D-reconstruction helps operative planning.

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Minimally invasive approach is safe and effective for patients with SIT.

Introduction

Situs inversus totalis (SIT) is an uncommon congenital condition characterized by total transposition of abdominal and thoracic viscera. Performing minimally invasive cardiac surgery on individuals with SIT requires different surgical planning because of the unfamiliar positions of the heart and great vessels.

Presentation of case

A 52-year-old female was admitted to our center with palpitations and dyspnea on exertion. Chest X-ray showed dextrocardia. Echocardiography and chest computerized tomography (CT) revealed SIT with severe rheumatic mitral valve disease.

Discussion

Pre-operative three-dimensional (3D) chest CT reconstruction was helpful in surgical planning and management of cardiopulmonary bypass (CPB). Mitral valve replacement and concomitant atrial fibrillation (AF) ablation using radiofrequency (RF) energy via left mini-thoracotomy was successfully performed on the patient.

Conclusion

Minimally invasive approach can be safely and effectively employed in patients with SIT.

Assessing Atrial Fibrillation Substrates by P Wave Analysis: A Comprehensive Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Pharmacologic and non-pharmacologic rhythm control strategies impact on AF-related symptoms, while leaving largely unaffected the risk of stroke. Moreover, up to 20% of AF patients are asymptomatic during paroxysmal relapses of arrhythmia, thus underlying the need for early markers to identify at-risk patients and prevent cerebrovascular accidents. Indeed, non-invasive assessment of pre-clinical substrate changes that predispose to AF could provide early identification of at-risk patients and allow for tailored care paths. ECG-derived P wave analysis is a simple-to-use and inexpensive tool that has been successfully employed to detect AF-associated structural and functional atrial changes. Beyond standard electrocardiographic techniques, high resolution signal averaged electrocardiography (SAECG), by recording microvolt amplitude atrial signals, allows more accurate analysis of the P wave and possibly AF risk stratification. This review focuses on the evidence that support P wave analysis to assess AF substrates, predict arrhythmia relapses and guide rhythm-control interventions.

Expert opinion on continuous rhythm monitoring of patients with atrial fibrillation for candidates or patients who have already undergone ablation

BACKGROUND

Continuous monitoring by implantable loop recorder (ILR) can provide information relevant to rhythm control and oral anticoagulation (OAC) after atrial fibrillation (AF) ablation, but there is little agreement on patients' selection and appropriate management strategy.

METHODS

An expert panel (EP) made up of eight Italian electrophysiologists with expertise in AF ablation, gathered to define an algorithm to guide continuous rhythm monitoring in AF patients who have undergone ablation. The process included a review of the current literature and two EP face-to-face meetings. Between the two meetings, an on-line survey was sent to 50 Italian electrophysiologists practicing AF ablation. Agreement level was considered reached when ≥70% of respondents agreed or were neutral.

RESULTS

Two algorithms were developed to define patients for whom the ILR would be suggested support for (OAC) therapy discontinuation and rhythm management after AF ablation. Thirty-three out of 50 physicians responded to on-line survey (66% response rate). Together with EP members the responders accounted for electrophysiology centers performing about 50% of total yearly Italian AF ablation procedures. Agreement level was reached at the first survey round on all the questions, so the algorithms were not further modified and re-tested.

CONCLUSIONS

EP developed two algorithms for ECG monitoring to guide OAC therapy discontinuation and rhythm management after AF ablation. These suggestions, validated by wide feedback and consensus of physicians performing AF ablations, might support the decision on the choice and the use of ECG monitoring techniques, based on specific patient characteristics.

Cerebral thromboembolic risk in atrial fibrillation ablation: a direct comparison of vitamin K antagonists versus non-vitamin K-dependent oral anticoagulants

PURPOSE

Cerebral thromboembolic events are well-known complications of pulmonary vein isolation (PVI) and can manifest as stroke or silent cerebral embolic lesions. The aim of this study was to compare the incidence of cerebral embolic lesions (including silent cerebral embolism and stroke) after AF ablation in patients on vitamin K antagonists versus patients on non-vitamin K-dependent oral anticoagulants, and to identify corresponding clinical and procedural risk factors.

METHODS

A total of 421 patients undergoing PVI were prospectively included into the study. Of these, 43.7% were on VKA and 56.3% on NOAC treatment (dabigatran, rivaroxaban, apixaban, and edoxaban). In the NOAC group, 38% of patients had an interruption of anticoagulation for 24-36 h. All patients underwent pre- and postprocedural cerebral magnetic resonance imaging.

RESULTS

Periprocedural cerebral lesions occurred in 13.1% overall. Of these, three (0.7%) resulted in symptomatic cerebrovascular accidents and 52 (12.4%) in silent cerebral embolic lesions. Incidence of cerebral lesions was significantly higher in patients on NOAC compared with VKA (16% vs. 9.2%, respectively, p = 0.04), and in patients who had intraprocedural cardioversions compared with no cardivoersions (19.5% vs. 10.4%, respectively, p = 0.03). In multivariate analysis, both parameters were found to be independent risk factors for cerebral embolism. No significant difference between interrupted and uninterrupted NOAC administration could be detected.

CONCLUSIONS

In patients undergoing AF ablation, we identified the use of NOAC and intraprocedural cardioversion as independent risk factors for the occurrence of periprocedural cerebral embolic lesions.

Cerebral arterial air embolism secondary to iatrogenic left atrial-esophageal fistula: a case report

Background

Cerebral arterial air embolism is a life-threatening complication that can result in neurologic deficits or death. Sometimes it is iatrogenic, presented as a complication of invasive medical procedures. Here we describe a case of cerebral arterial air embolism secondary to iatrogenic left atrial-esophageal fistula, of which the diagnosis might be covered up by the complicated pathophysiologic changes.

Case presentation

A 68-year-old man presented with unconsciousness hours after aphasia and right hemiplegia, accompanied with hematemesis and fever. He had a history of atrial fibrillation, treated by radiofrequency catheter ablation 1 month ago. Brain CT displayed massive air embolism in left hemisphere, as well as right parietal lobe. Chest CT demonstrated a focus of air in the left atrium, which highly suggested an atrial-esophageal fistula. The patient received high flow (6 L/min) oxygen therapy. Intravenous antibiotics including imipenem and vancomycin were administered together with crystalloid rehydration. Supportive therapies were given including intubation, mechanical ventilation and vasopressor use. Because of the patient’s unstable condition and poor prognosis, surgical repair was considered but not pursued. The patient presented a very fast deterioration of cardiac function and circulatory failure, and finally died from cardiac arrest.

Conclusions

Clinicians must have a high index of suspicion for atrial-esophageal fistula for patients presenting with chest discomfort, new onset of stroke, upper gastrointestinal bleeding, and development of sepsis as long as 50 days after the ablation for atrial fibrillation. Urgent CT can ultimately establish the diagnosis in most cases.

Long-term left atrial remodeling after ablation of persistent atrial fibrillation: 7-year follow-up by cardiovascular magnetic resonance imaging

PURPOSE

Restoration of sinus rhythm in patients with persistent atrial fibrillation (ps. AF) induces reverse atrial remodeling and improvement of left ventricular function. We evaluated the effect of ablative treatment on cardiac remodeling after a long follow-up period of 7 years by cardiovascular magnetic resonance (CMR).

METHODS

Patients with symptomatic ps. AF underwent CMR within 7 days prior to the ablation procedure. Left atrial and ventricular volumes were measured. All patients underwent circumferential pulmonary vein isolation. At the end of follow-up (FU), a CMR and 7-day ECG registration were performed.

RESULTS

Forty-two patients (67 ± 9 years) were included. After a FU of 86 ± 13 months, 23 patients had a successful outcome. In these patients, LVEF improved from 56 ± 5 to 62 ± 4% (p = 0.02), but left atrial volume and ejection fraction (LAV, LAEF) remained unchanged (105 ± 25 to 98 ± 34, p = 0.44; 34 ± 10 to 36 ± 11, p = 0.6, respectively). In 14 patients with a BMI < 30 and no left ventricular hypertrophy (LVH), LAV decreased (104 ± 30 to 82 ± 26 ml, p = 0.01) and LAEF improved (33 ± 12 to 40 ± 11%, p = 0.03). In 9 patients with successful outcome and either BMI ≥ 30 or LVH, LAV increased (110 ± 26 to 125 ± 30 ml, p = 0.03) and LAEF deteriorated (35 ± 11 to 31 ± 10%, p = 0.04).

CONCLUSIONS

Successful ablative treatment of atrial fibrillation is associated with reverse left atrial remodeling and improvement of left atrial and ventricular function. In patients with a BMI ≥ 30 or left ventricular hypertrophy, further left atrial enlargement occurs despite successful outcome.

Cryoballoon pulmonary vein ablation and left atrial appendage closure combined procedure: A long-term follow-up analysis

BACKGROUND

The combined left atrial appendage closure (LAAC) and cryoenergy pulmonary vein isolation (PVI) procedure has been proven safe and effective in managing stroke in patients with nonvalvular atrial fibrillation (AF), although most data refer to procedures performed using radiofrequency as the main energy source.

OBJECTIVE

The purpose of this study was to evaluate long-term follow-up of patients with AF undergoing concomitant LAAC and cryoenergy PVI.

METHODS

Patients undergoing LAAC and cryoballoon PVI at our institution were enrolled. At 3, 6, and 24 months from the index procedure, we determined the atrial arrhythmia recurrence rate, the extent of LAAC, and the rate of cerebrovascular/bleeding events.

RESULTS

Forty-nine patients (mean age 69 ± 8 years; 32/49 (67%) men; CHA₂DS₂-VASc score 2.8 ± 1.2; HAS-BLED score 3 ± 1) with a guideline-recommended LAAC indication were included. Acute PVI and complete LAAC were achieved in 100% of patients. All patients completed at least 24 months of follow-up. At 8 weeks and 6 months, complete or satisfactory (<5 mm leak) LAAC rates were achieved in 40 (82%) and 9 (18%) and in 42 (86%) and 7 (14%) of patients, respectively. The overall freedom from atrial arrhythmia rate at 24 months was 29 (60%), and 45 (92%) of patients were off antithrombotic drugs. The observed annualized stroke and bleeding rates were 1% and 2%, respectively, a 71% and 60% risk reduction in comparison to event rates predicted from CHA₂DS₂-VASc and HAS-BLED scores.

CONCLUSION

Concomitant cryoballoon ablation and LAAC procedures appear safe and effective at long-term follow-up, with high antithrombotic drug withdrawal rates at 24 months.

A Case of Postablation Pericardial Effusion

Complications of atrial fibrillation ablation include pericardial effusion, which tends to occur acutely. Large and hemodynamically important effusions are uncommon, but a small effusion may be present at the end of the procedure in up to 22% of ablations. We monitor for pericardial effusions routinely after ablation with intracardiac echocardiography. However, the follow-up of a small effusion present immediately after ablation remains uncertain, especially with the use of dabigatran or another novel oral anticoagulant. There are no current recommendations on the follow-up of small pericardial effusions after ablation. We present a case and ask a panel of experts for their opinions.

Comparison of non-triggered magnetic resonance imaging and echocardiography for the assessment of left atrial volume and morphology

BACKGROUND

Advanced atrial fibrillation (AF) patients have persistent AF, failed previous catheter ablation and/or an enlarged left atrium (LA), which is associated with a reduced success of AF ablation. Transthoracic echocardiography (TTE) and contrast enhanced magnetic resonance angiography (CE-MRA) are available to assess LA volume. However, it is unknown how these modalities relate in patients with advanced AF. We therefore compared the reproducibility of TTE and non-triggered CE-MRA in advanced AF patients and their ability to select patients with successful thoracoscopic AF ablation.

METHODS

Two independent observers measured LA volumes on 65 TTE and CE-MRA exams of advanced AF patients prior to AF ablation. Patients were followed after AF ablation with rhythm monitoring every 3 months for 1 year to determine AF recurrence. Inter-modality, inter- and intra-observer variability were determined using intraclass correlation coefficients (ICC). Receiver-operating characteristic (ROC) analysis was performed to determine sensitivity and specificity of TTE and CE-MRA volume and CE-MRA dimensions to identify patients with AF recurrence during follow-up.

RESULTS

LA enlargement ≥ 34 ml/m2 was present in 60% of the patients. CE-MRA and TTE demonstrated a good correlation for LA volume assessment (intraclass correlation, ICC = 0.86; p < 0.001) with larger volumes consistently measured by CE-MRA. Major discrepancies were mostly attributed to TTE acquisition. Craniocaudal enlargement discriminated patients with AF recurrence (AUC 0.67 [95% CI 0.55-0.85], p = 0.01).

CONCLUSIONS

Non-triggered CE-MRA is a viable and reproducible 3D alternative for 2D TTE to assess LA volume in advanced AF patients. Craniocaudal enlargement was the only discriminator of AF recurrence after AF ablation.

Second-generation cryoballoon for pulmonary vein isolation in patients with pulmonary vein abnormality: Safety, efficacy and lessons from re-ablation procedures

Second generation cryoballoon (CB) has been shown to be effective for treatment of paroxysmal and persistent atrial fibrillation (AF). However, the fixed size of the non-compliant balloon may limit its use in patients with pulmonary vein (PV) abnormalities. In this study we investigated the acute success, procedural complications and long term outcome of CB based PV isolation (PVI) in patients with PV abnormality. A total of 238 patients [64.8 ± 11.1 years; 91 paroxysmal (38.2%), 147 persistent AF (61.8%)] underwent PVI using the second generation CB without preprocedural imaging. In 43/238 (18.1%) patients PV abnormality (left common PV in 26, right middle PV in 20) was observed. All targeted veins including abnormal PVs were isolated (100%). Transient phrenic nerve palsy (PNP) occurred in one (2.3%) patient in the PV anomalous group and 6 (3.0%) in the control group (p = NS). There was no other adverse event including PV stenosis, atrio-esophageal fistula or cerebrovascular events related to the procedure. During mean follow-up of 11.8 ± 5.4 month a total of 59 patients (24.7%) had atrial tachyarrhythmia (ATA) recurrence [27 (11.3%) had AT recurrence]. In the PV anomalous group, 20/43 (46.5%) patients had ATA recurrence compared to 39/195 (20%) in the control group (p < 0.001). AT recurrence was observed in 27 (11.3) patients [11 (25.5%) in the PV anomalous group and 16 (8.2%) in controls respectively, p = 0.003]. In patients with PV abnormality CB-based AF ablation results in a similar acute PVI rate but a higher ATA recurrence rate during follow up as compared to patients without PV abnormality.

A Decade of Information on the Use of Cardiac Implantable Electronic Devices and Interventional Electrophysiological Procedures in the European Society of Cardiology Countries: 2017 Report from the European Heart Rhythm Association

Aims

The aim of this analysis was to provide comprehensive information on invasive cardiac arrhythmia therapies in the European Society of Cardiology (ESC) area over the past 10 years.

Methods and results

The European Heart Rhythm Association (EHRA) has collected data on invasive arrhythmia therapies since 2008. This year 53 of the 56 ESC member countries provided data for the EHRA White Book. Here we present updated data on procedure rates together with information on demographics, economy, vital statistics, local healthcare systems and training activities. Considerable heterogeneity in the access to invasive arrhythmia therapies still exists across the five geographical ESC regions. In 2016, the device implantation rates per million population were 3-6 times higher in the Western region than in the non-European and Eastern ESC member countries. Catheter ablation activity was highest in the Western countries followed by the Northern and Southern areas. In the non-European countries, atrial fibrillation ablation rate was more than tenfold lower than in the European countries. On the other hand, the growth rate over the past ten years was highest in the non-European and Eastern countries. In some Eastern European countries with relative low gross domestic product the procedure rates exceeded the average values.

Conclusion

It was encouraging to note that during the past decade the growth in invasive arrhythmia therapies was greatest in the areas historically with relatively low activity. Nevertheless, there is substantial disparity and continued efforts are needed to improve harmonization of cardiac arrhythmia therapies in the ESC area.

Diabetes mellitus and atrial remodelling in patients with paroxysmal atrial fibrillation: Role of electroanatomical mapping and catheter ablation

Complex fractionated atrial electrograms (CFAEs) are related to atrial fibrosis, but their ablation has not yet shown superiority. The aim of the study was to compare, in terms of clinical outcome, two strategies of paroxysmal atrial fibrillation (AF) ablation in patients with type 1 diabetes mellitus (DM): pulmonary vein isolation (PVI) vs. PVI + CFAEs. Compared to an historical population of patient with paroxysmal AF and without DM, a higher percentage of patients with DM showed more than 25% of atrial area interested by CFAEs (study population, 58% vs historical group, 15%; p < 0.05). In PVI group, recurrences rate was similar in patients with HbA1c ⩽ 7.5% vs HbA1c > 7.5% (30% vs 22%; p = not significant), but a greater AF burden was observed in patients with HbA1c > 7.5% (6 ± 2 vs 1 ± 2; p < 0.05). In hazard ratios analysis PVI+CFAEs seems more effective than PVI alone in patients with HbA1c > 7.5% (hazard ratio, 1.28; p < 0.05), more than 25 years from DM diagnosis (hazard ratio, 1.25; p < 0.05) and more than five AF episodes/year (hazard ratio, 1.2; p < 0.05). Type 1 DM patients had complex atrial 'substrate', as documented by wider CFAEs areas. Despite this, 1-year follow-up recurrence rate was similar between two ablation approaches (PVI 27% vs. PVI+CFAEs 21%; p = not significant). In our study, only specific subgroups, like patients with disglycaemic state (HbA1c > 7.5%), long diabetes mellitus history and high AF burden, benefit from PVI+ CFAEs approach.

Iatrogenic atrio-esophageal fistula following a video-assisted thoracoscopic maze procedure: Is esophageal instrumentation justified even when the diagnosis is equivocal?

A 74-year-old female underwent an uneventful bilateral thoracoscopic maze procedure for persistent atrial fibrillation with continuous transesophageal echocardiographic (TEE) guidance. She presented six weeks later with persistent fever and focal neurological signs. Computed tomography of the thorax revealed air in the posterior LA, raising suspicion for an abscess versus an atrioesophageal fistula (AEF). Before undergoing an exploratory median sternotomy, an esophagogastroduodenoscopy (EGD) was performed by the surgeon to check for any esophageal pathology. This however, resulted in sudden hemodynamic compromise that required intensive treatment with vasopressors and inotropes. In this case-report, we review the various intraoperative risk factors associated with the development of AEF during cardiac ablation procedures as well as the potential hazards of esophageal instrumentation with TEE, naso- or oro- gastric devices, and/or an EGD when an AEF is suspected.

Five seconds of 50-60 W radio frequency atrial ablations were transmural and safe: an in vitro mechanistic assessment and force-controlled in vivo validation

Aims

Longer procedural time is associated with complications in radiofrequency atrial fibrillation ablation. We sought to reduce ablation time and thereby potentially reduce complications. The aim was to compare the dimensions and complications of 40 W/30 s setting to that of high-power ablations (50-80 W) for 5 s in the in vitro and in vivo models.

Methods and results

In vitro ablations-40 W/30 s were compared with 40-80 W powers for 5 s. In vivo ablations-40 W/30 s were compared with 50-80 W powers for 5 s. All in vivo ablations were performed with 10 g contact force and 30 mL/min irrigation rate. Steam pops and depth of lung lesions identified post-mortem were noted as complications. A total of 72 lesions on the non-trabeculated part of right atrium were performed in 10 Ovine. All in vitro ablations except for the 40 W/5 s setting achieved the critical lesion depth of 2 mm. For in vivo ablations, all lesions were transmural, and the lesion depths for the settings of 40 W/30 s, 50 W/5 s, 60 W/5 s, 70 W/5 s, and 80 W/5 s were 2.2 ± 0.5, 2.3 ± 0.5, 2.1 ± 0.4, 2.0 ± 0.3, and 2.3 ± 0.7 mm, respectively. The lesion depths of short-duration ablations were similar to that of the conventional ablation. Steam pops occurred in the ablation settings of 40 W/30 s and 80 W/5 s in 8 and 11% of ablations, respectively. Complications were absent in short-duration ablations of 50 and 60 W.

Conclusion

High-power, short-duration atrial ablation was as safe and effective as the conventional ablation. Compared with the conventional 40 W/30 s setting, 50 and 60 W ablation for 5 s achieved transmurality and had fewer complications.

Clinical and anatomic predictors of need for repeat atrial fibrillation ablation

AIM

To identify predictors of need for repeat procedures after initial atrial fibrillation (AF) ablation.

METHODS

We identified a cohort undergoing first time AF ablation at our institution from January 2004 to February 2014 who had cardiac magnetic resonance (CMR) imaging performed prior to ablation. Clinical variables and anatomic characteristics (determined from CMR) were assessed as predictors of need for repeat ablation. The decision regarding need for and timing of repeat ablation was at the discretion of the treating physician.

RESULTS

From a cohort of 331 patients, 142 patients (43%) underwent repeat ablation at a mean of 13.6 ± 18.4 mo after the index procedure. Both male gender (81% vs 71%, P = 0.05) and lower ejection fraction (57.4% ± 10.3% vs 59.8% ± 9.4%, P = 0.04) were associated with need for repeat ablation. On pre-ablation CMR, mean pulmonary vein (PV) diameters were significantly larger in all four PVs among patients requiring repeat procedures. In multivariate analysis, increased right superior PV diameter significantly predicted need for repeat ablation (odds ratio 1.08 per millimeter increase in diameter, 95%CI: 1.00-1.16, P = 0.05). There were also trends toward significance for increased left and right inferior PV sizes among those requiring repeat procedures.

CONCLUSION

Increased PV size predicts the need for repeat AF ablation, with each millimeter increase in PV diameter associated with an approximately 5%-10% increased risk of requiring repeat procedures.

Premature termination of radiofrequency delivery during pulmonary vein isolation due to oesophageal temperature alerts: impact on acute and chronic pulmonary vein reconnection

Aims

Oesophageal temperature monitoring is currently used during atrial fibrillation (AF) ablation to prevent atrio-oesophageal fistula. The aim of our study was to investigate if oesophageal temperature alerts, leading to early termination of radiofrequency (RF) energy and/or reduction in power during pulmonary vein isolation, can promote pulmonary vein reconnection (PVR).

Methods and results

Patients undergone two consecutive AF ablation procedures with a three-dimensional electro-anatomical mapping system and oesophageal temperature monitoring were studied. Any lesions causing oesophageal temperature rises >39°C during the index procedure, leading to premature cessation of RF and/or reduction in power, were labelled on the left atrial geometry in a different colour from standard uninterrupted RF lesions. Acute (at the time of the index procedure) and chronic (at the time of there-do procedure) PVR and the site of subsequent re-isolation were compared with the lesion markers for temperature alerts from the index procedure. Fifty-four patients were included (36 male, mean age 68 ± 8, 59% persistent AF). Forty-six PVs (21% of the total) in 30 patients (56%) had been subject to at least one temperature alert during the index procedure. In 12 patients, 23 PVs had acute PVR requiring further ablation. At the re-do procedure, 103 PVs were found to be reconnected in 44 patients. No correlation was found between the occurrence of temperature alerts at the index procedure and acute or chronic PVR in the associated PV.

Conclusion

Just over half of patients undergoing PV isolation will have an oesophageal temperature alert, however, precautionary oesophageal temperature monitoring does not compromise ablation efficacy.

Atrial Fibrillation Ablation Guided by a Novel Nonfluoroscopic Navigation System

INTRODUCTION AND OBJECTIVES

Rhythmia is a new nonfluoroscopic navigation system that is able to create high-density electroanatomic maps. The aim of this study was to describe the acute outcomes of atrial fibrillation (AF) ablation guided by this system, to analyze the volume provided by its electroanatomic map, and to describe its ability to locate pulmonary vein (PV) reconnection gaps in redo procedures.

METHODS

This observational study included 62 patients who underwent AF ablation with Rhythmia compared with a retrospective cohort who underwent AF ablation with a conventional nonfluoroscopic navigation system (Ensite Velocity).

RESULTS

The number of surface electrograms per map was significantly higher in Rhythmia procedures (12 125 ± 2826 vs 133 ± 21 with Velocity; P < .001), with no significant differences in the total procedure time. The Orion catheter was placed for mapping in 99.5% of PV (95.61% in the control group with a conventional circular mapping catheter; P = .04). There were no significant differences in the percentage of PV isolation between the 2 groups. In redo procedures, an ablation gap could be identified on the activation map in 67% of the reconnected PV (40% in the control group; P = .042). The measured left atrial volume was lower than that calculated by computed tomography (109.3 v 15.2 and 129.9 ± 13.2 mL, respectively; P < .001). There were no significant differences in the number of complications.

CONCLUSIONS

The Rhythmia system is effective for AF ablation procedures, with procedure times and safety profiles similar to conventional nonfluoroscopic navigation systems. In redo procedures, it appears to be more effective in identifying reconnected PV conduction gaps.

Figure-of-eight suture for venous hemostasis in fully anticoagulated patients after atrial fibrillation catheter ablation

Introduction

Limited data exists for types of venous closure and its associated complications in patients after atrial fibrillation (AF) catheter ablation. We evaluated the subcutaneous figure-of-eight closure (FO8) for achieving venous hemostasis after AF catheter ablation compared to manual pressure.

Methods

284 consecutive patients that underwent AF catheter ablation by two operators were included. All patients received continuous therapeutic warfarin or interrupted novel oral anticoagulants (NOAC) and heparin (ACT300-400 s) without reversal. Patients were divided into two groups: 1) sheaths were left in place and pulled once ACT < 180 s, with hemostasis being achieved with manual pressure (MP); and 2) a subcutaneous FO8 suture closed the venous access site immediately after the ablation on each groin site and sheaths were removed immediately after the ablation despite full anticoagulation with heparin and warfarin or interrupted NOAC. Sutures were removed after four hours, and the patients laid flat for an additional two hours.

Results

The MP group (n = 105) was similar to the FO8 group (n = 179). Time in bed was 573 ± 80 min for MP group vs. 373 ± 49 min for FO8 group (p < 0.0001). Eleven hematomas were seen in the MP group compared to seven in the FO8 group (P = 0.041).

Conclusions

In fully anticoagulated patients undergoing AF catheter ablation, excellent hemostasis was achieved with figure-of-eight sutures, with no major vascular complications, a lower hematoma rate, and a significantly shorter flat-time-in-bed compared to manual pressure.

Immediate discontinuation of ablation during pulmonary vein isolation remarkably decreases the incidence of esophageal thermal lesions even when using steerable sheaths

Background

Left atrial–esophageal fistulas (LAEFs) are serious complications with high mortality after atrial fibrillation radiofrequency ablation (AFRA). Decreasing the incidence of esophageal thermal lesions (EsoTLs) that may lead to LAEFs is important. The aim of this study was to suppress EsoTL development and determine the appropriate alarm setting for a temperature-monitoring probe by using steerable sheath (STS) methods.

Methods

We enrolled 82 consecutive patients (mean, 61.9±11.7 years; 75.6% men) who underwent AFRA, including pulmonary vein isolation for symptomatic, drug-refractory atrial fibrillation with esophageal temperature monitoring by using STS between January 2011 and April 2014. All patients underwent upper gastrointestinal endoscopy (UGE) 1–3 days after AFRA. The timing of ablation discontinuation in the first 17 patients was determined by each physician during AFRA (only monitoring group, OM). In the next 65 patients, physicians were to immediately discontinue ablation when an alarm set at 39 °C went off (instruction group, INS). We compared two groups with respect to the incidence of EsoTLs.

Results

Among the 82 patients, 5 (6.1%) had EsoTLs after AFRA. EsoTLs occurred in 3 of 17 patients (17.6%) and 2 of 65 patients (3.1%) in the OM and INS groups, respectively. The incidence of EsoTLs in the INS group was significantly lower than that in the OM group (p=0.0254). EsoTL did not occur at maximal temperature less than 39 °C, measured by using esophageal temperature-monitoring probe.

Conclusions

Immediate discontinuation of ablation during pulmonary vein isolation remarkably decreased the incidence of EsoTLs, even when using STS.

A 5-year clinical follow-up after duty-cycled phased RF ablation of paroxysmal atrial fibrillation

PURPOSE

Catheter radiofrequency ablation (RFA) is an effective treatment for symptomatic paroxysmal atrial fibrillation (AF). It has been demonstrated that the multielectrode pulmonary vein ablation catheter (PVAC) has favourable outcomes at 6-12 months post-ablation, but there are only few studies with a long-term follow-up.

METHODS

We retrospectively reviewed 77 consecutive PVAC procedures in our centre, from November 2007 to December 2012. RFA was attempted in patients with symptomatic paroxysmal AF (mean age 58.7 ± 9.8 years, 50 men (64.9 %). The ablation strategy consisted of circumferential pulmonary vein isolation (CPVI) with the PVAC system. A questionnaire was used over the follow-up period to assess the efficacy of AF ablation. Success was defined as freedom from AF/atrial flutter or atrial arrhythmia for a period ranging from 3 to 12 months or more.

RESULTS

Seventy-seven patients were included with paroxysmal AF. The mean duration of the procedure was 99.6 ± 26 min and fluoroscopy time 19.4 ± 6.8 min. Time of RFA was 22.4 ± 5.8 min. Acute complication rate was 10.4 % (the most frequent was vascular injury for 6 patients 7.8 %, 1 patient presented sepsis (1.3 %), 1 patient presented transient ischemic stroke). After a single procedure at a mean FU of 55 ± 11 months, 54/77 (70.1 %) patients were free of symptomatic AF.

CONCLUSIONS

These long-term results suggest that PVAC is an efficient system for CPVI of symptomatic paroxysmal AF.

Atrioesophageal fistula formation with cryoballoon ablation is most commonly related to the left inferior pulmonary vein

BACKGROUND

Collateral damage has been reported with use of the cryoballoon for pulmonary vein isolation.

OBJECTIVE

The purpose of this study was to determine the incidence and characteristics associated with atrioesophageal fistula (AEF) after cryoballoon use.

METHODS

Cases of AEF reported with use of the cryoballoon since 2011 were collected from the Manufacturer and User Facility Device Experience (MAUDE) database, publications, and the manufacturer's database. Lowest balloon temperatures were compared with matched control patients undergoing cryoballoon ablation without AEF formation. Location of AEF was compared with AEF associated with radiofrequency ablation.

RESULTS

A total of 11 cases of AEF were identified from a worldwide experience that exceed 120,000 cases. Mean age was 60 (range 31-78 years), and 80% of patients were male. Although mean lowest balloon temperatures were no different between patients with AEF and those with no AEF (-58.5°C ± 7.2°C vs -56°C ± 2.6°C, P = NS), balloon inflation times were longer in patients with AEF (238.8 ± 54.8 seconds vs 178.1 ± 37.5 seconds in the non-AEF group, P ≤.001) All cases of AEF for which location was identified occurred in relation to the left pulmonary veins. The left inferior pulmonary vein (LIPV) was involved in 8 of 10 patients with cryoballoon compared to 0 of 11 patients in the radiofrequency group (P <.05). Mortality for cryoballoon-associated AEF was 64%.

CONCLUSION

AEF after cryoballoon use is rare (<1 in 10,000) and most commonly was identified near the LIPV. Proximity of the esophagus to the LIPV and evidence of esophageal luminal cooling should be considered indications to limit cryoablation at this vein.

Influence of periprocedural anticoagulation strategies on complication rate and hospital stay in patients undergoing catheter ablation for persistent atrial fibrillation

BACKGROUND

The use of non-vitamin K antagonists (NOACs), uninterrupted (uVKA) and interrupted vitamin K antagonists (iVKA) are common periprocedural oral anticoagulation (OAC) strategies for atrial fibrillation (AF) ablation. Comparative data on complication rates resulting from OAC strategies for solely persistent AF (persAF) undergoing ablation are sparse. Thus, we sought to determine the impact of these OAC strategies on complication rates among patients with persAF undergoing catheter ablation.

METHODS

Consecutive patients undergoing persAF ablation were included. Depending on preprocedural OAC, three groups were defined: (1) NOACs (paused 48 h preablation), (2) uVKA, and (3) iVKA with heparin bridging. A combined complication endpoint (CCE) composed of bleeding and thromboembolic events was analyzed.

RESULTS

Between 2011 and 2014, 1440 persAF ablation procedures were performed in 1092 patients. NOACs were given in 441 procedures (31 %; rivaroxaban 57 %, dabigatran 33 %, and apixaban 10 %), uVKA in 488 (34 %), and iVKA in 511 (35 %). Adjusted CCE rates were 5.5 % [95 % confidence interval (CI) (3.1-7.8)] in group 1 (NOACs), 7.5 % [95 % CI (5.0-10.1)] in group 2 (uVKA), and 9.9 % [95 % CI (6.6-13.2)] in group 3. Compared to group 1, the combined complication risk was almost twice as high in group 3 [odd's ratio (OR) 1.9, 95 % CI (1.0-3.7), p = 0.049)]. The major complication rate was low (0.9 %). Bleeding complications, driven by minor groin complications, are more frequent than thromboembolic events (n = 112 vs. 1, p < 0.0001).

CONCLUSIONS

Patients undergoing persAF ablation with iVKA anticoagulation have an increased risk of complications compared to NOACs. Major complications, such as thromboembolic events, are generally rare and are exceeded by minor bleedings.

Concomitant cryoballoon ablation and percutaneous closure of left atrial appendage in patients with atrial fibrillation

AIMS

Pulmonary veins (PVs) isolation is the cornerstone of atrial fibrillation (AF) ablation and can be achieved either by conventional radiofrequency ablation or by cryoenergy. Left atrial appendage (LAA) closure has been proposed as alternative treatment to vitamin K antagonists (VKA). We aimed to evaluate the feasibility of combining cryoballoon (CB) ablation and LAA occlusion in patients with AF and a high thromboembolic risk or contraindication to antithrombotic therapy.

METHODS AND RESULTS

Thirty-five patients (28 males, 74 ± 2 years) underwent CB ablation. Left atrial appendage occlusion was carried out by using two occluder devices (Amplatz Cardiac Plug, ACP, St. Jude Medical, MN, USA, in 25 patients; Watchman, Boston Scientific, MA, USA, in 10 patients). Thirty patients (86%) had previous stroke/TIA episodes, 6 patients (17%) had major bleeding while on VKA therapy, and 7 patients (20%) had inherited bleeding disorders. Over the follow-up (24 ± 12 months), atrial arrhythmias recurred in 10 (28%) patients. Thirty patients (86%) had complete sealing; 5 patients (14%) showed a residual flow (<5 mm) at first transoesophageal echocardiography (TEE) check, while at 1-year TEE residual flow was detected in 3 patients. In 13 patients (37%), VKA therapy was immediately discontinued. Six patients (17%) received novel oral anticoagulants treatment and then discontinued 3 months thereafter. No device-related complications or clinical thromboembolic events occurred.

CONCLUSION

Combined CB ablation and LAA closure using different devices appears to be feasible in patients with non-valvular AF associated with high risk of stroke or contraindication to antithrombotic treatment.

Periprocedural Management of Novel Oral Anticoagulants During Atrial Fibrillation Ablation: Controversies and Review of the Current Evidence

Oral anticoagulation (OAC) has been the cornerstone for the prevention of thromboembolic complications in patients with atrial fibrillation (AF) at significant risk of stroke. Catheter ablation is an established efficacious technique for the treatment of AF. Ameliorating the risk of stroke or transient ischaemic attack (TIA) in patients with AF undergoing ablation requires meticulous planning of pharmacotherapy. The advent of non-vitamin K oral anticoagulants (NOACs) has broadened the therapeutic scope, representing a viable alternative to traditional vitamin K antagonists (VKA) in non-valvular AF. Potential advantages of NOACs include greater pharmacokinetic predictability, at least comparable efficacy as compared to VKA and a superior haemorrhagic complication profile. However, robust evidence for the safety and efficacy of periprocedural NOAC use for AF ablation remains uncertain with a non-uniform clinical approach between and within institutions. The following review will summarise the current and emerging evidence on periprocedural management of NOACs in patients undergoing catheter ablation of AF. An overview of NOAC pharmacology will provide a foundation for the review of reversal agents in the context of catheter ablation of AF. The purpose of the review is to outline key studies and identify key areas for further critical research with the ultimate aim of developing evidence-based guidelines for optimal care.

Early release of high-sensitive cardiac troponin during complex catheter ablation for ventricular tachycardia and atrial fibrillation

BACKGROUND

Radiofrequency ablation results in intentional cardiac injury. We aimed to assess the kinetics of cardiac injury as measured by cardiac troponin release following ventricular ablation and atrial ablation.

METHODS

Patients undergoing ablation for ventricular tachycardia (VT) with structural heart disease (19 patients) or atrial fibrillation (AF, 24 patients) were prospectively enrolled. High-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI) were measured before ablation as well as 30 min, 60 min, 90 min, 120 min, 4 h, 8 h, and 24 h after applying the first ablation lesion.

RESULTS

Median ablation time, power used, and energy delivered were 28 min, 39 W, and 69,713 J in VT ablations and 55 min, 29 W, and 95,425 J in AF ablations, respectively. Release of hs-cTnT occurred promptly with both, but reached greater levels earlier for ventricular compared to atrial ablation (hs-cTnT after 30 min 191 vs. 31 ng/l, after 1 h 467 vs. 80 ng/l; hs-cTnI after 30 min 132 vs. 30 ng/l, after 1 h 331 vs. 76 ng/l; p < 0.001 for all comparisons). After 24 h, levels were similar (hs-cTnT 1325 vs. 1303 ng/l, p = 0.92; hs-cTnI 2165 vs. 1996 ng/l, p = 0.55). Levels of hs-cTnT after 24 h correlated well with the energy delivered in AF ablations (r = 0.81 and r = 0.75, p < 0.001), but not in VT ablations (r = 0.35 and r = 0.44, p = ns).

CONCLUSIONS

Evidence of cardiac injury as indicated by the release of hs-cTnT and hs-cTnI occurs early with atrial and ventricular ablation. Higher early levels are observed in ventricular ablations, but levels are similar after 24 h. The extent of total troponin release seems to correlate well with the amount of energy delivered in AF ablations, but not in VT ablations.

Measurement of diffuse ventricular fibrosis with myocardial T1 in patients with atrial fibrillation

Background

Atrial fibrillation (AF) is associated with cardiac fibrosis, which can now be measured noninvasively using T1-mapping with cardiac magnetic resonance imaging (CMRI). This study aimed to assess the impact of AF on ventricular T1 at the time of CMRI.

Methods

Subjects with AF scheduled for AF ablation underwent CMRI with standard electrocardiography gating and breath-hold protocols on a 1.5 T scanner with post-contrast ventricular T1 recorded from 6 regions of interest at the mid-ventricle. Baseline demographic, clinical, and imaging characteristics were examined using univariate and multivariable linear regression modeling for an association with myocardial T1.

Results

One hundred fifty-seven patients were studied (32% women; median age, 61 years [interquartile range {IQR}, 55–67], 50% persistent AF [episodes>7 days or requiring electrical or pharmacologic cardioversion], 30% in AF at the time of the CMRI). The median global T1 was 404 ms (IQR, 381–428). AF at the time of CMRI was associated with a 4.4% shorter T1 (p=0.000) compared to sinus rhythm when adjusted for age, sex, persistent AF, body mass index, congestive heart failure, and renal dysfunction (estimated glomerular filtration rate<60). A post-hoc multivariate model adjusted for heart rate suggested that heart rate elevation (p=0.009) contributes to the reduction in T1 observed in patients with AF at the time of CMRI. No association between ventricular T1 and AF recurrence after ablation was demonstrated.

Conclusion

AF at the time of CMRI was associated with lower post-contrast ventricular T1 compared with sinus rhythm. This effect was at least partly due to elevated heart rate. T1 was not associated with the recurrence of AF after ablation.

Are implantable cardiac monitors the 'gold standard' for atrial fibrillation detection? A prospective randomized trial comparing atrial fibrillation monitoring using implantable cardiac monitors and DDDRP permanent pacemakers in post atrial fibrillation ablation patients

AIMS

Implantable devices are widely accepted, but not proven, to be the most reliable monitoring method to assess atrial fibrillation (AF) therapies. We compared REVEAL(®)XT implantable cardiac monitors (ICMs) and permanent pacemakers (PPMs).

METHODS AND RESULTS

Fifty patients with paroxysmal AF were randomized to ICM or PPM implant 6 weeks prior to pulmonary vein isolation. Permanent pacemakers were programmed to monitoring only (ODO). Device downloads were performed at 0, 3, 6, 9, and 12 months. All patients underwent 7-day external loop recorder. Device ECGs and EGMs were compared for AF burden. A total of 20 744 and 11 238 arrhythmia episodes were identified in the ICM and PPM groups, respectively. Correct identification of AF was significantly better in the PPM group (97 vs. 55% P < 0.001). In the ICM group, 26% of ECGs were un-interpretable. Sensitivity and specificity for each episode of AF was significantly better in the PPM group (100 vs. 79% and 98 vs. 66%, respectively, P < 0.001). The positive predictive value for the detection of any AF was significantly better in the PPM than the ICM (100 vs. 58%, P = 0.03). The negative predictive value for the absence of all AF was not significantly different between the PPM and ICM (100% vs. 92%, P = 0.76).

CONCLUSION

Permanent pacemakers Holters are the most accurate method of evaluating arrhythmia burden and the therapeutic efficacy of novel AF therapies. ICM has a high degree of artefact, which reduces its specifity and sensitivity. Despite the deficiencies of ICM monitoring the negative predictive value of the ICM is satisfactory if zero AF burden is the aim of therapy.

Contact force threshold for permanent lesion formation in atrial fibrillation ablation: A cardiac magnetic resonance-based study to detect ablation gaps

BACKGROUND

Catheter contact force (CF) has a strong correlation with lesion formation during radiofrequency ablation. Delayed-enhancement cardiac magnetic resonance (DE-CMR) provides lesion information in patients with prior atrial fibrillation (AF) ablation.

OBJECTIVE

The aim of this study was to determine the CF threshold to create permanent lesions detected by DE-CMR.

METHODS

A total of 36 patients referred for AF ablation were included. A CF catheter was used during the ablation procedure, and DE-CMR was performed 3 months after the ablation procedure. Eighteen pulmonary vein (PV) segments were defined, and 3-dimensional (3D) reconstructions of the left atrium (LA) derived from the DE-CMR images were obtained. One observer evaluated the presence of any discontinuity of previous ablation lesions (gap) in the 3D reconstructions of the LA, and another observer (blinded to the gap findings) determined the minimum CF value in each PV segment.

RESULTS

The PV segments where a gap was observed had a lower maximal CF value than did the segments without gap in the 3D LA reconstructions (6.7 ± 4.4 g vs 12.2 ± 4.7 g; P < .001). In receiver operating characteristic analysis, a CF threshold of >8 g provided 73% sensitivity and 81% specificity in the prediction of a complete PV lesion (positive predictive value [PPV] 84%). A CF threshold of >12 g had a specificity of 94% and increased the PPV to 91% in creating a complete lesion in the LA wall (area under the curve 0.834).

CONCLUSION

A CF threshold of >12 g H5H20 predicts a complete lesion with high specificity and PPV when a dragging ablation strategy is used in AF ablation.