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Lankaputhra M, Voskoboinik A. Congenital Long QT Syndrome: A Clinician's Guide. Intern Med J 2021; 51:1999-2011. [PMID: 34151491 DOI: 10.1111/imj.15437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022]
Abstract
Congenital long QT syndrome (LQTS) is a familial cardiac ion channelopathy first described over sixty years ago. It is characterised by prolonged ventricular repolarization (long QT on ECG), ventricular arrhythmias and associated syncope or sudden cardiac death. As the most closely studied cardiac channelopathy, over the decades we have gained a deep appreciation of the complex genetic model of LQTS. Variability in genetic expression and incomplete penetrance leads to a heterogenous phenotype that can be challenging to clinically classify. In recent times, progress has been made in diagnostic method, risk stratification and treatment options. This review has been written as a guide for the general cardiologist to understand the basic pathophysiology, diagnosis, and management priorities for the most encountered LQTS subtypes: LQT1, LQT2 and LQT3. This article is protected by copyright. All rights reserved.
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Chen YC, Voskoboinik A, Gerche AL, Marwick TH, McMullen JR. Prevention of Pathological Atrial Remodeling and Atrial Fibrillation: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:2846-2864. [PMID: 34082914 DOI: 10.1016/j.jacc.2021.04.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 12/29/2022]
Abstract
Atrial enlargement in response to pathological stimuli (e.g., hypertension, mitral valve disease) and physiological stimuli (exercise, pregnancy) can be comparable in magnitude, but the diseased enlarged atria is associated with complications such as atrial fibrillation (AF), whereas physiological atrial enlargement is not. Pathological atrial enlargement and AF is also observed in a small percentage of athletes undergoing extreme/intense endurance sport and pregnant women with preeclampsia. Differences between physiological and pathological atrial enlargement and underlying mechanisms are poorly understood. This review describes human and animal studies characterizing atrial enlargement under physiological and pathological conditions and highlights key knowledge gaps and clinical challenges, including: 1) the limited ability of atria to reverse remodel; and 2) distinguishing physiological and pathological enlargement via imaging/biomarkers. Finally, this review discusses how targeting distinct molecular mechanisms underlying physiological and pathological atrial enlargement could provide new therapeutic and diagnostic strategies for preventing or reversing atrial enlargement and AF.
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Im SI, Voskoboinik A, Lee A, Higuchi S, Moss JD, Hsia H, Tseng ZH, Lee R, Marcus GM, Vedantham V, Scheinman M, Lee B, Park KM, Gerstenfeld EP. Predictors of long-term success after catheter ablation of premature ventricular complexes. J Cardiovasc Electrophysiol 2021; 32:2254-2261. [PMID: 34041816 DOI: 10.1111/jce.15114] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/23/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Some patients have late recurrence after acutely successful radiofrequency catheter ablation (RFCA) of premature ventricular complexes (PVCs). The aim of this study was to evaluate predictors of long-term success following acutely successful PVC RFCA. METHODS We identified consecutive patients at our institution with frequent PVCs undergoing RFCA and reviewed procedural data and medical records. Acute success was defined as elimination of targeted PVCs for at least 30-min after RFCA. Long-term success was defined as absence of targeted PVCs during all follow-up visits and PVC-burden <5% on follow-up monitoring. RESULTS Among 241 patients (mean age 57 ± 15 years, 58% male), 161 (66.8%) had long-term success with median follow-up of 17.7 (IQR, 12.2-29.8) months. Unadjusted predictors of late PVC recurrence were increasing age, diabetes mellitus and alcohol use, while female-sex, shorter ablation-time, right ventricular PVC-origin, single PVC morphology, and earliest bipolar activation ≥24 ms pre-QRS were predictors of long-term success. In multivariate-analysis, female-sex, single-PVC morphology and earliest-onset of PVC ≥ 24 ms pre-QRS were independent predictors for long-term success. The positive-predictive value of earliest-bipolar onset of PVC ≥ 24 ms pre-QRS for long-term success was 0.77 (p < .001). Negative-predictive value of PVC < 15 ms pre-QRS for long-term success was 0.86 (p = .003), suggesting that RFCA when the bipolar electrogram preceded QRS by <15 ms was unlikely to result in long-term success. CONCLUSIONS Female-sex, single-PVC morphology, and earliest-onset of bipolar electrogram ≥24 ms pre-QRS were multivariable predictors of long-term success in patients with PVCs undergoing RFCA. RFCA at sites with local onset <15 ms pre-QRS are unlikely to be successful.
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Voskoboinik A, Moss JD. Marshalling the Tools for Successful Endocardial Atrial Ablation. JACC Clin Electrophysiol 2021; 7:305-307. [PMID: 33736750 DOI: 10.1016/j.jacep.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022]
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Sugumar H, Chieng D, Prabhu S, Voskoboinik A, Anderson RD, Al-Kaisey A, Lee G, McLellan AJ, Morton JB, Taylor AJ, Ling LH, Kalman JM, Kistler PM. A prospective evaluation of the impact of individual RF applications for slow pathway ablation for AVNRT: Markers of acute success. J Cardiovasc Electrophysiol 2021; 32:1886-1893. [PMID: 33855753 DOI: 10.1111/jce.15045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/25/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Catheter ablation is highly effective for atrioventricular nodal re-entrant tachycardia (AVNRT). Generally junctional rhythm (JR) is an accepted requirement for successful ablation however there is a lack of detailed prospective studies to determine the characteristics of JR and the impact on slow pathway conduction. METHODS Multicentre prospective observational study evaluating the impact of individual radiofrequency (RF) applications in typical AVNRT (slow/fast). Characteristics of JR during ablation were documented and detailed testing was performed after every RF application to determine outcome. Procedural success was defined as ≤1 AV nodal echo. RESULTS Sixty-seven patients were included (mean age 53 ± 18years, 57% female and a history of SVT 2.9 ± 4.7 years). RF (50w, 60°) ablation for AVNRT was applied in 301 locations with JR in 178 (59%). Successful slow pathway modification was achieved in 66 (99%) patients with slow pathway block in 30 (46%). Success was associated with JR in all patients. Success was achieved in six patients with RF < 10 s. There was no significant difference in the CL of JR during RF between effective (587 ± 150 ms) versus ineffective (611 ± 193 ms, p = .4) applications. Inadvertent junctional beat-atrial (JA) block with immediate termination of RF was observed in 19 (28%) patients with AVNRT no longer inducible in 14 (74%). Freedom from SVT was achieved in 66 (99%) patients at a mean follow up of 15 ± 6 months. CONCLUSION In this prospective study, JR was required during RF for acute success in AVNRT. Cycle length of JR during RF was not predictive of success. Although unintended JA block during faster JR was associated with slow pathway block, this is a precursor to fast pathway block and should not be intentionally targeted.
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Sugumar H, Nanayakkara S, Vizi D, Wright L, Chieng D, Leet A, Mariani JA, Voskoboinik A, Prabhu S, Taylor AJ, Kalman JM, Kistler PM, Kaye DM, Ling LH. A prospective STudy using invAsive haemodynamic measurements foLLowing catheter ablation for AF and early HFpEF: STALL AF-HFpEF. Eur J Heart Fail 2021; 23:785-796. [PMID: 33565197 DOI: 10.1002/ejhf.2122] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS The impact of atrial fibrillation (AF) ablation in early heart failure with preserved ejection fraction (HFpEF) is unknown. Our aim was to determine the impact of AF ablation on symptoms and exercise haemodynamic parameters of early HFpEF. METHODS AND RESULTS Symptomatic AF patients referred for index AF ablation with ejection fraction ≥50% underwent baseline quality of life questionnaires, echocardiography, cardiac magnetic resonance imaging, exercise right heart catheterisation (exRHC), and brain natriuretic peptide (BNP) testing. HFpEF was defined by resting pulmonary capillary wedge pressure (PCWP) ≥15 mmHg or peak exercise PCWP ≥25 mmHg. Patients with HFpEF were offered AF ablation and follow-up exRHC ≥6 months post-ablation. Of 54 patients undergoing baseline evaluation, 35 (65%) had HFpEF identified by exRHC. HFpEF patients were older (64 ± 10 vs. 54 ± 13 years, P < 0.01), and more frequently female (54% vs. 16%, P < 0.01), hypertensive (63% vs. 16%, P < 0.001), and suffering persistent AF (66% vs. 11%, P < 0.001), compared to those without HFpEF. Twenty HFpEF patients underwent AF ablation and follow-up exRHC 12 ± 6 months post-ablation. Nine (45%) patients no longer fulfilled exRHC criteria for HFpEF at follow-up. Patients remaining arrhythmia free (n = 9, 45%) showed significant improvements in peak exercise PCWP (29 ± 4 to 23 ± 2 mmHg, P < 0.01) and Minnesota Living with Heart Failure (MLHF) score (55 ± 30 to 22 ± 30, P < 0.01) while the remainder did not (PCWP 31 ± 5 to 30.0 ± 4 mmHg, P = NS; MLHF score 55 ± 23 to 25 ± 20, P = NS). CONCLUSION Heart failure with preserved ejection fraction frequently coexists in patients with symptomatic AF and preserved ejection fraction. Restoration and maintenance of sinus rhythm in patients with comorbid AF and HFpEF improves haemodynamic parameters, BNP and symptoms associated with HFpEF.
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Voskoboinik A, McDonald C, Chieng D, O'Brien J, Gutman S, Ngu P, Sugumar H, Wong G, Kalman JM, Taylor AJ, Kistler PM. Acute electrical, autonomic and structural effects of binge drinking: Insights into the 'holiday heart syndrome'. Int J Cardiol 2021; 331:100-105. [PMID: 33548379 DOI: 10.1016/j.ijcard.2021.01.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Binge drinking is a common atrial fibrillation (AF) trigger, however the mechanisms are poorly understood. OBJECTIVE To investigate the effects of alcohol intoxication and hangover with rhythm monitoring and cardiac MRI. METHODS Patients underwent serial cardiac MRI pre- and post-binge with continuous Holter monitoring. Time periods analyzed: baseline (24 h pre-binge), consumption, hangover (0- 24 h post-consumption) and post-hangover (24-48 h post-consumption). RESULTS 50 patients (age 49 ± 15 years, 40% paroxysmal AF) completed the study (intake 8.4 ± 3.1 standard drinks). Mean heart rate increased from 72 ± 10 to 80 ± 13 beats per minute (bpm) during consumption (p < 0.001). The hangover period was characterised by higher daily atrial ectopic count (50, IQR 10-132 vs baseline 43, IQR 10-113; p = 0.04) and reduced heart rate variability (SDNN 55 ms, IQR 40-65 versus 62 ms, IQR 51-66; p = 0.007). There was evidence of heightened parasympathetic activity post-hangover with heart rate slowing (mean HR 54 ± 6 bpm; p = 0.03) and increased activity in the High frequency band when separating the complex heart rate variability waveform into its component rhythms (291 ms2, 97-538 versus baseline 237 ms2, IQR 104-332; p = 0.04). Three patients developed AF 11, 29 and 34 h post-binge. Cardiac MRI (2.7 ± 0.7 days post-binge) demonstrated a decrease in left atrial (LA) emptying fraction (57.9 ± 8.5 to 53.5 ± 6.7%; p = 0.003) but no change in LA volume, left ventricular ejection fraction or markers of ventricular inflammation. CONCLUSION Binge drinking is associated with sympathetic activation followed by a 'rebound' parasympathetic response and atrial mechanical dysfunction which may explain the propensity and temporal association between binge drinking and AF.
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Lankaputhra M, Voskoboinik A. Radiation exposure in cardiac electrophysiology: How low can we go? Int J Cardiol 2021; 331:120-121. [PMID: 33516846 DOI: 10.1016/j.ijcard.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
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84
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Xiao X, Joseph S, Mariani J, Kalman J, Kistler P, Voskoboinik A. Predictors of Subsequent Pacemaker Requirement in Patients with Loop Recorders Inserted for Syncope. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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85
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Koh Y, Kwok C, Voskoboinik A, Wong M. Selective Serotonin/Noradrenaline Inhibitors and Atrial Fibrillation on Cardiac Devices: The SAF-Device Study. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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86
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Block T, Paratz E, La Gerche A, Stub D, Strathmore N, Mond H, Kistler P, Kalman J, Burke M, Voskoboinik A. Unearthing the Evidence: Post-Mortem Interrogation of Cardiac Implantable Electronic Devices. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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87
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Kistler P, Chieng D, Tonchev I, Sugumar H, McLellan A, Prabhu S, Voskoboinik A, Schwartz L, Parameswaran R, Anderson R, Al-Kaisey A, Ling L, Lee G, Kalman J. P-wave Morphology in Focal Atrial Tachycardia: An Updated 2021 Algorithm to Predict Site of Origin. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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88
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Shirwaiker A, William J, Mariani J, Kistler P, Patel H, Voskoboinik A. Long-term Implications of Pacemaker Insertion in Younger Adults: A Single Centre Experience. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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89
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Chieng D, Sugumar H, Kaye D, Azzopardi S, Vizi D, Rossi E, Voskoboinik A, Prabhu S, Ling L, Lee G, Kalman J, Kistler P. Prone and Supine 12 Lead Electrocardiography Comparisons: Utility of the Prone ECG for the Detection of Cardiac Conditions in Patients Requiring Prone Ventilation with COVID-19. Heart Lung Circ 2021. [PMCID: PMC8324102 DOI: 10.1016/j.hlc.2021.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sugumar H, Prabhu S, Costello B, Chieng D, Azzopardi S, Voskoboinik A, Parameswaran R, Wong GR, Anderson R, Al-Kaisey AM, Ling LH, Kotschet E, Taylor AJ, Kalman JM, Kistler PM. Catheter Ablation Versus Medication in Atrial Fibrillation and Systolic Dysfunction. JACC Clin Electrophysiol 2020; 6:1721-1731. [DOI: 10.1016/j.jacep.2020.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/27/2020] [Accepted: 08/13/2020] [Indexed: 11/25/2022]
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Voskoboinik A, Gerstenfeld EP, Moss JD, Hsia H, Goldberger J, Nazer B, Dewland T, Singh D, Badhwar N, Tchou PJ, Meriwether JN, Sauer W, Danon A, Belhassen B, Scheinman MM. Complex Re-Entrant Arrhythmias Involving the His-Purkinje System: A Structured Approach to Diagnosis and Management. JACC Clin Electrophysiol 2020; 6:1488-1498. [PMID: 33213808 DOI: 10.1016/j.jacep.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/16/2020] [Accepted: 06/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to characterize the presentations, electrophysiological features and diagnostic maneuvers for a series of unique arrhythmias involving the HPS. BACKGROUND By virtue of its unique anatomy and ion channel composition, the His-Purkinje system (HPS) is prone to a variety of arrhythmic perturbations. METHODS The authors present a collaborative multicenter case series of 6 patients with HPS-related arrhythmias. All patients underwent electrophysiological studies using standard multipolar catheters. RESULTS In 3 patients, both typical and reverse bundle branch re-entry were seen, with 1 patient demonstrating "figure of 8" re-entry likely involving the septal fascicle. One patient presented with systolic dysfunction associated with a high premature ventricular complex burden, with the mechanism being bundle-to-bundle re-entrant beats masquerading as dual response to a single sinus impulse. Two patients were diagnosed with interfascicular re-entry. Diagnosis was aided by careful assessment of HV interval in sinus rhythm and ventricular tachycardia, multipolar catheters to assess the activation sequence of the His-right bundle branch, and fascicles and entrainment of different components of the HPS. Cure of the arrhythmia was achieved by ablation of the right bundle branch block in 3 patients, the left septal fascicle in 2 patients, and the left posterior fascicle in 1 patient. CONCLUSIONS Proper diagnosis of re-entrant arrhythmias involving the HPS may prove challenging. We emphasize a structured approach for diagnosis and effective therapy.
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Oesterle A, Lee AC, Voskoboinik A, Moss JD, Vedantham V, Walters TE, Lee BK, Tseng ZH, Gerstenfeld EP, Scheinman MM. Electrophysiologic approach to diagnosis and ablation of patients with permanent junctional reciprocating tachycardia associated with complex anatomy and/or physiology. J Cardiovasc Electrophysiol 2020; 31:3232-3242. [PMID: 33107135 DOI: 10.1111/jce.14788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Permanent junctional reciprocating tachycardia (PJRT) is a rare supraventricular tachycardia (SVT), typically involving a single decremental posteroseptal accessory pathway (AP). METHODS Four patients with long RP SVT underwent electrophysiology (EP) study and ablation. The cases were reviewed. RESULTS Case 1 recurred despite 3 prior ablations at the site of earliest retrograde atrial activation during orthodromic reciprocating tachycardia (ORT). Mapping during a repeat EP study demonstrated a prepotential in the coronary sinus (CS). Ablation over the earliest atrial activation in the CS resulted in dissociation of the potential from the atrium during sinus rhythm. The potential was traced back to the CS os and ablated. Case 2 underwent successful ablation at 6 o'clock on the mitral annulus (MA). ORT recurred and successful ablation was performed at 1 o'clock on the MA. Case 3 had tachycardia with variation in both V-A and A-H intervals which precluded the use of usual maneuvers so we used simultaneous atrial and ventricular pacing and introduced a premature atrial contraction with a closely coupled premature ventricular contraction. Case 4 had had two prior atrial fibrillation ablations with continued SVT over a decremental atrioventricular bypass tract that was successfully ablated at 5 o'clock on the tricuspid annulus. A second SVT consistent with a concealed nodoventricular pathway was successfully ablated at the right inferior extension of the AV nodal slow pathway. CONCLUSION We describe challenging cases of PJRT by virtue of complex anatomy, diagnostic features, and multiple arrhythmia mechanisms.
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Wong GR, Nalliah CJ, Lee G, Voskoboinik A, Prabhu S, Parameswaran R, Sugumar H, Anderson RD, Ling LH, McLellan A, Johnson R, Sanders P, Kistler PM, Fatkin D, Kalman JM. Genetic Susceptibility to Atrial Fibrillation Is Associated With Atrial Electrical Remodeling and Adverse Post-Ablation Outcome. JACC Clin Electrophysiol 2020; 6:1509-1521. [PMID: 33213811 DOI: 10.1016/j.jacep.2020.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES This study sought to assess the atrial electrophysiological properties and post-ablation outcomes in patients with atrial fibrillation (AF) with and without the rs2200733 single nucleotide variant. BACKGROUND The phenotype associated with chromosome 4q25 of the AF-susceptibility locus remains unknown. METHODS In this study, 102 consecutive patients (ages 61 ± 9 years, 64% male) with paroxysmal or persistent AF were prospectively recruited prior to ablation. Patients were genotyped for rs2200733 and high-density left atrial (LA) electroanatomic maps were created using a multipolar catheter during distal coronary sinus (CS) pacing at 600 ms. Voltage, conduction velocity (CV), CV heterogeneity, and fractionated signals of 6 LA segments were determined. Arrhythmia recurrence was assessed by continuous device (51%) and Holter monitoring. RESULTS Overall, 41 patients (40%) were single nucleotide variant carriers (38 heterozygous, 3 homozygous). A mean of 2,239 ± 852 points per patient were collected. Carriers had relatively increased CV heterogeneity (45.7 ± 7.5% vs. 35.9 ± 2.3%; p < 0.001), complex signals (9.4 ± 2.9% vs 6.0 ± 1.2%; p = 0.008), regional LA slowing, or conduction block (31.7 ± 8.2% vs. 17.9 ± 1.9%; p = 0.013) particularly in the posterior and lateral walls. There were no differences in CV, voltage, atrial refractoriness, or sinus node function. At follow-up (median: 27 months; range 19 to 31 months), carriers had lower arrhythmia-free survival (51% vs. 80%; p = 0.003). On multivariable analysis, carrier status was independently associated with CV heterogeneity (p = 0.001), complex signals (p = 0.002), and arrhythmia recurrence (p = 0.019). CONCLUSIONS These data provide the first evidence that the rs2200733-tagged haplotype alters LA electrical remodeling and is a determinant of long-term outcome following AF ablation. The molecular mechanisms underpinning these changes warrant further investigation.
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Gutman SJ, Costello BT, Papapostolou S, Voskoboinik A, Iles L, Ja J, Hare JL, Ellims A, Kistler PM, Marwick TH, Taylor AJ. Reduction in mortality from implantable cardioverter-defibrillators in non-ischaemic cardiomyopathy patients is dependent on the presence of left ventricular scar. Eur Heart J 2020; 40:542-550. [PMID: 30107489 DOI: 10.1093/eurheartj/ehy437] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 07/06/2018] [Indexed: 12/17/2022] Open
Abstract
Aims In patients with non-ischaemic cardiomyopathy (NICM), the mortality benefit of a primary prevention implantable cardioverter-defibrillator (ICD) has been challenged. Left ventricular (LV) scar identified by cardiac magnetic resonance (CMR) imaging is associated with a high risk of malignant arrhythmia in NICM. We aimed to determine the impact of LV scar on the mortality benefit from a primary prevention ICD in NICM. Methods and results We recruited 452 consecutive heart failure patients [New York Heart Association (NYHA) Class II/III] with NICM and LV ejection fraction ≤35% from a state-wide CMR service. All patients fulfilled European Society of Cardiology guidelines for primary prevention ICD implantation; however, the decision to implant was at the treating physician's discretion. Baseline clinical and CMR data were recorded prospectively and heart failure mortality risk (MAGGIC score) was calculated. The primary study outcome measurement was all-cause mortality based on presence or absence of ICD, stratified by LV scar. Median follow-up was 37.9 months and there was no difference in MAGGIC score between those who did and did not receive a primary prevention ICD (19.30 ± 5.46 vs. 18.90 ± 5.67, P = 0.50). In patients without LV scar, ICD implantation was not associated with improved mortality [hazard ratio (HR) = 1.22, 95% confidence interval (CI): 0.53-2.78, P = 0.64]. In patients with LV scar, ICD implantation was independently associated with reduced mortality (HR = 0.45, 95% CI: 0.26-0.77, P = 0.003). Conclusions In patients with NICM, primary prevention ICD implantation is only associated with reduced mortality in patients with LV scar. This may enable more effective selection of NICM patients for ICD implantation compared with current guidelines.
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Parameswaran R, Kalman JM, Royse A, Goldblatt J, Larobina M, Watts T, Walters TE, Nalliah CJ, Wong G, Al-Kaisey A, Douglas Anderson R, Voskoboinik A, Sugumar H, Chieng D, Sanders P, Kistler PM, Gerstenfeld EP, Lee G. Endocardial-Epicardial Phase Mapping of Prolonged Persistent Atrial Fibrillation Recordings. Circ Arrhythm Electrophysiol 2020; 13:e008512. [DOI: 10.1161/circep.120.008512] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Endocardial-epicardial dissociation and focal breakthroughs in humans with atrial fibrillation (AF) have been recently demonstrated using activation mapping of short 10-second AF segments. In the current study, we used simultaneous endo-epi phase mapping to characterize endo-epi activation patterns on long segments of human persistent AF.
Methods:
Simultaneous intraoperative mapping of endo- and epicardial lateral right atrium wall was performed in patients with persistent AF using 2 high-density grid catheters (16 electrodes, 3 mm spacing). Filtered unipolar and bipolar electrograms of continuous 2-minute AF recordings and electrodes locations were exported for phase analyses. We defined endocardial-epicardial dissociation as phase difference of ≥20 ms between paired endo-epi electrodes. Wavefronts were classified as rotations, single wavefronts, focal waves, or disorganized activity as per standard criteria. Endo-Epi wavefront patterns were simultaneously compared on dynamic phase maps. Complex fractionated electrograms were defined as bipolar electrograms with ≥5 directional changes occupying at least 70% of sample duration.
Results:
Fourteen patients with persistent AF undergoing cardiac surgery were included. Endocardial-epicardial dissociation was seen in 50.3% of phase maps with significant temporal heterogeneity. Disorganized activity (Endo: 41.3% versus Epi: 46.8%,
P
=0.0194) and single wavefronts (Endo: 31.3% versus Epi: 28.1%,
P
=0.129) were the dominant patterns. Transient rotations (Endo: 22% versus Epi: 19.2%,
P
=0.169; mean duration: 590±140 ms) and nonsustained focal waves (Endo: 1.2% versus Epi: 1.6%,
P
=0.669) were also observed. Apparent transmural migration of rotational activations (n=6) from the epi- to the endocardium was seen in 2 patients. Electrogram fractionation was significantly higher in the epicardium than endocardium (61.2% versus 51.6%,
P
<0.0001).
Conclusions:
Simultaneous endo-epi phase mapping of prolonged human persistent AF recordings shows significant Endocardial-epicardial dissociation marked temporal heterogeneity, discordant and transitioning wavefronts patterns and complex fractionations. No sustained focal activity was observed. Such complex 3-dimensional interactions provide insight into why endocardial mapping alone may not fully characterize the AF mechanism and why endocardial ablation may not be sufficient.
Graphic Abstract:
A
graphic abstract
is available for this article.
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Voskoboinik A, Hadjis A, Alhede C, Im SI, Park H, Moss J, Marcus GM, Hsia H, Lee B, Tseng Z, Lee R, Scheinman M, Vedantham V, Vittinghoff E, Park KM, Gerstenfeld EP. Predictors of adverse outcome in patients with frequent premature ventricular complexes: The ABC-VT risk score. Heart Rhythm 2020; 17:1066-1074. [DOI: 10.1016/j.hrthm.2020.02.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 02/14/2020] [Indexed: 12/21/2022]
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Costello BT, Voskoboinik A, Qadri AM, Rudman M, Thompson MC, Touma F, La Gerche A, Hare JL, Papapostolou S, Kalman JM, Kistler PM, Taylor AJ. Measuring atrial stasis during sinus rhythm in patients with paroxysmal atrial fibrillation using 4 Dimensional flow imaging: 4D flow imaging of atrial stasis. Int J Cardiol 2020; 315:45-50. [PMID: 32439367 DOI: 10.1016/j.ijcard.2020.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/14/2020] [Accepted: 05/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Paroxysmal atrial fibrillation (PAF) is associated with cardioembolic risk, however events may occur during sinus rhythm (SR). 4D-flow cardiac magnetic resonance (CMR) imaging allows visualisation of left atrial blood flow, to determine the residence time distribution (RTD), an assessment of atrial transit time. OBJECTIVE To determine if atrial transit time is prolonged in PAF patients during SR, consistent with underlying atrial stasis. METHOD 91 participants with PAF and 18 healthy volunteers underwent 4D flow analysis in SR. Velocity fields were produced RTDs, calculated by seeding virtual 'particles' at the right upper pulmonary vein and counting them exiting the mitral valve. An exponential decay curve quantified residence time of particles in the left atrium, and atrial stasis was expressed as the derived constant (RTDTC) based on heartbeats. The RTDTC was evaluated within the PAF group, and compared to healthy volunteers. RESULTS Patients with PAF (n = 91) had higher RTDTC compared with gender-matched controls (n = 18) consistent with greater atrial stasis (1.68 ± 0.46 beats vs 1.51 ± 0.20 beats; p = .005). PAF patients with greater thromboembolic risk had greater atrial stasis (median RTDTC of 1.72 beats in CHA₂DS₂-VASc≥2 vs 1.52 beats in CHA₂DS₂-VASc<2; p = .03), only female gender and left ventricular ejection fraction contributed significantly to the atrial RTDTC (p = .006 and p = .023 respectively). CONCLUSIONS Atrial stasis quantified by 4D flow is greater in PAF, correlating with higher CHA₂DS₂-VASc scores. Female gender and systolic dysfunction are associated with atrial stasis. RTD offers an insight into atrial flow that may be developed to provide a personalised assessment of thromboembolic risk.
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Voskoboinik A, Butcher E, Sandhu A, Nguyen DT, Tzou W, Della Rocca DG, Natale A, Zado ES, Marchlinski FE, Aguilar M, Sauer W, Tedrow UB, Gerstenfeld EP. Direct Thrombin Inhibitors as an Alternative to Heparin During Catheter Ablation: A Multicenter Experience. JACC Clin Electrophysiol 2020; 6:484-490. [PMID: 32276868 DOI: 10.1016/j.jacep.2019.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/22/2019] [Accepted: 12/03/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The goal of this study was to report a multicenter series of left-sided catheter ablations performed by using intravenous direct thrombin inhibitors (DTIs) as an alternative to heparin. BACKGROUND Amidst a looming worldwide shortage of heparin, there are insufficient data to guide nonheparin-based peri-procedural anticoagulation in patients undergoing catheter ablation. METHODS This study reviewed all catheter ablations at 6 institutions between 2006 and 2019 to assess the safety and efficacy of DTIs for left-sided radiofrequency catheter ablation of atrial fibrillation and ventricular tachycardia. RESULTS In total, 53 patients (age 63.0 ± 9.3 years, 68% male, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score 2.8 ± 1.6, left ventricular ejection fraction 46 ± 15%) underwent ablation with DTIs (75% bivalirudin, 25% argatroban) due to heparin contraindication(s) (72% heparin-induced thrombocytopenia, 21% heparin allergy, 4% protamine reaction, and 4% religious reasons). The patient's usual oral anticoagulant was continued without interruption in 69%. Procedures were performed for atrial fibrillation (64%) or ventricular tachycardia/premature ventricular contractions (36%). Transseptal puncture was undertaken in 81%, and a contact force-sensing catheter was used in 70%. Vascular ultrasound was used in 71%, and femoral arterial access was gained in 36%. A bolus followed by infusion was used in all but 4 cases, and activated clotting time was monitored peri-procedurally in 72%, with 32% receiving additional boluses. Procedure duration was 216 ± 116 min, and ablation time was 51 ± 22 min. No major bleeding or embolic complications were observed. Four patients had minor self-limiting bleeding complications, including a small pericardial effusion (<1 cm), a small groin hematoma, and hematuria. CONCLUSIONS In this multicenter series, intravenous DTIs were safely used as an alternative to heparin for left-sided catheter ablation.
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Voskoboinik A, Hsia H, Moss J, Vedantham V, Tanel RE, Patel A, Wojciak J, Downs N, Scheinman MM. The many faces of early repolarization syndrome: A single-center case series. Heart Rhythm 2020; 17:273-281. [DOI: 10.1016/j.hrthm.2019.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Indexed: 01/23/2023]
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Voskoboinik A, Kalman JM, De Silva A, Nicholls T, Costello B, Nanayakkara S, Prabhu S, Stub D, Azzopardi S, Vizi D, Wong G, Nalliah C, Sugumar H, Wong M, Kotschet E, Kaye D, Taylor AJ, Kistler PM. Alcohol Abstinence in Drinkers with Atrial Fibrillation. N Engl J Med 2020; 382:20-28. [PMID: 31893513 DOI: 10.1056/nejmoa1817591] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Excessive alcohol consumption is associated with incident atrial fibrillation and adverse atrial remodeling; however, the effect of abstinence from alcohol on secondary prevention of atrial fibrillation is unclear. METHODS We conducted a multicenter, prospective, open-label, randomized, controlled trial at six hospitals in Australia. Adults who consumed 10 or more standard drinks (with 1 standard drink containing approximately 12 g of pure alcohol) per week and who had paroxysmal or persistent atrial fibrillation in sinus rhythm at baseline were randomly assigned in a 1:1 ratio to either abstain from alcohol or continue their usual alcohol consumption. The two primary end points were freedom from recurrence of atrial fibrillation (after a 2-week "blanking period") and total atrial fibrillation burden (proportion of time in atrial fibrillation) during 6 months of follow-up. RESULTS Of 140 patients who underwent randomization (85% men; mean [±SD] age, 62±9 years), 70 were assigned to the abstinence group and 70 to the control group. Patients in the abstinence group reduced their alcohol intake from 16.8±7.7 to 2.1±3.7 standard drinks per week (a reduction of 87.5%), and patients in the control group reduced their alcohol intake from 16.4±6.9 to 13.2±6.5 drinks per week (a reduction of 19.5%). After a 2-week blanking period, atrial fibrillation recurred in 37 of 70 patients (53%) in the abstinence group and in 51 of 70 patients (73%) in the control group. The abstinence group had a longer period before recurrence of atrial fibrillation than the control group (hazard ratio, 0.55; 95% confidence interval, 0.36 to 0.84; P = 0.005). The atrial fibrillation burden over 6 months of follow-up was significantly lower in the abstinence group than in the control group (median percentage of time in atrial fibrillation, 0.5% [interquartile range, 0.0 to 3.0] vs. 1.2% [interquartile range, 0.0 to 10.3]; P = 0.01). CONCLUSIONS Abstinence from alcohol reduced arrhythmia recurrences in regular drinkers with atrial fibrillation. (Funded by the Government of Victoria Operational Infrastructure Support Program and others; Australian New Zealand Clinical Trials Registry number, ACTRN12616000256471.).
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