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Thamthanaruk A, Nokkhuntong V, Pajareya P, Siranart N, Simadibrata DM, Techasatian W, Chokesuwattanaskul R, Jongnarangsin K, Chung EHJ. Comparing Low-to-Zero Fluoroscopic Navigation Systems for AVNRT Catheter Ablation: A Network Meta-Analysis. Pacing Clin Electrophysiol 2024. [PMID: 39437197 DOI: 10.1111/pace.15096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 09/17/2024] [Accepted: 10/05/2024] [Indexed: 10/25/2024]
Abstract
BACKGROUND Low-to-zero fluoroscopic navigation systems lower radiation exposure which improves health outcomes. Conventional x-ray fluoroscopy (CF) has long been the standard to guide to catheter location for cardiac ablation. With advancements in technology, alternative safety navigation systems have been developed. Three primary modalities commonly utilized are three-dimensional electroanatomic mapping (3D-EAM), magnetic navigation system (MNS), and intracardiac echocardiography (ICE), all of which can reduce radiation exposure during the procedure. OBJECTIVE We aim to compare the efficacy and safety among ICE, EAM, MNS, and CF in ablation of atrioventricular nodal reentrant tachycardia (AVNRT). METHODS This is a meta-analysis consisting of observational studies and randomized controlled trials, which evaluated the performance of navigation systems of catheter ablation in AVNRT patients. Primary endpoint was to access the AVNRT recurrence after the procedure during follow-up periods. Secondary endpoints were technical success, fluoroscopic time, fluoroscopic dose area product, radiofrequency ablation time, and adverse events. Random-effect model was applied for pooled estimated effects of included studies. RESULTS A total of 21 studies (21 CF, 2 ICE, 9 EAM, 11 MNS) including 1716 patients who underwent catheter ablation for AVNRT treatment were analyzed. Of these, 16 were observational studies and 5 were randomized controlled trials. PRIMARY OUTCOME Point estimation of AVNRT recurrence showed ICE exhibited a pooled odds ratio (ORs) of 1.06 (95% confidence interval [CI]: 0.064-17.322), MNS with ORs of 0.51 (95% CI: 0.214-1.219], and EAM with ORs of 0.394 (95% CI: 0.119-1.305) when compared to CF. SECONDARY OUTCOMES EAM had significant higher technical success with ORs of 2.781 (95% CI: 1.317-5.872) when compared to CF. Regarding fluoroscopy time, EAM showed the lowest time with mean differences (MD) of -10.348 min (95% CI: -13.385 to -7.3101) and P-score of 0.998. It was followed by MNS with MD of -3.712 min (95% CI: -7.128 to -0.295) and P-score of 0.586, ICE with MD of -1.150 min (95% CI: -6.963 to 4.662) with a P-score of 0.294 compared to CF, which has a P-score of 0.122. There were insignificant adverse events across the procedures. CONCLUSION AVNRT ablation navigated by low-to-zero fluoroscopic navigation systems achieves higher efficacy and comparable safety to conventional fluoroscopywhile also reducing risk of radiation exposure time.
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Affiliation(s)
- Akaravit Thamthanaruk
- Center of Excellence in Arrhythmia Research, Cardiac Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Division of Cardiovascular Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vanit Nokkhuntong
- Center of Excellence in Arrhythmia Research, Cardiac Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Division of Cardiovascular Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Patavee Pajareya
- Center of Excellence in Arrhythmia Research, Cardiac Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Division of Cardiovascular Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Noppachai Siranart
- Center of Excellence in Arrhythmia Research, Cardiac Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Division of Cardiovascular Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Martin Simadibrata
- Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Witina Techasatian
- Division of Cardiovascular Medicine, Louisiana State University, Shreveport, Louisiana, USA
| | - Ronpichai Chokesuwattanaskul
- Center of Excellence in Arrhythmia Research, Cardiac Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Division of Cardiovascular Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Krit Jongnarangsin
- Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Eugene Ho-Joon Chung
- Department of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Bocz B, Debreceni D, Janosi KF, Turcsan M, Simor T, Kupo P. Electroanatomical Mapping System-Guided vs. Intracardiac Echocardiography-Guided Slow Pathway Ablation: A Randomized, Single-Center Trial. J Clin Med 2023; 12:5577. [PMID: 37685645 PMCID: PMC10488800 DOI: 10.3390/jcm12175577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/22/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Radiofrequency (RF) catheter ablation is an effective treatment option for targeting the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT). Previous data suggested that using intracardiac echocardiography (ICE) guidance could improve procedural outcomes when compared to using fluoroscopy alone. In this prospective study, we aimed to compare the effectiveness of an electroanatomical mapping system (EAMS)-guided approach with an ICE-guided approach for SP ablation. Eighty patients undergoing SP ablation for AVNRT were randomly assigned to either the ICE-guided or EAMS-guided group. If the procedural endpoint was not achieved after 8 RF applications; patients were allowed to crossover to the ICE-guided group. The ICE-guided approach reduced the total procedure time (61.0 (56.0; 66.8) min vs. 71.5 (61.0; 80.8) min, p < 0.01). However, the total fluoroscopy time was shorter (0 (0-0) s vs. 83.5 (58.5-133.25) s, p < 0.001) and the radiation dose was lower (0 (0-0) mGy vs. 3.3 (2.0-4.7) mGy, p < 0.001) with EAMS-guidance. The ICE-guided group had a lower number of RF applications (4 (3-5) vs. 5 (3.0-7.8), p = 0.03) and total ablation time (98.5 (66.8-186) s vs. 136.5 (100.5-215.8) s, p = 0.02). Nine out of 40 patients (22.5%) in the EAMS-guided group crossed over to the ICE-guided group, and they were successfully treated with similar RF applications in terms of number, time, and energy compared to the ICE-guided group. There were no recurrences during the follow-up period. In conclusion, the utilization of ICE guidance during SP ablation has demonstrated notable reductions in procedural time and RF delivery when compared to procedures guided by EAMS. In challenging cases, an early switch to ICE-guided ablation may be the optimal choice for achieving successful treatment.
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Affiliation(s)
| | | | | | | | | | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, Ifjusag Utja 13, H-7624 Pécs, Hungary; (B.B.); (D.D.); (K.-F.J.); (M.T.); (T.S.)
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Randomized trial of intracardiac echocardiography-guided slow pathway ablation. J Interv Card Electrophysiol 2022; 63:709-714. [PMID: 35044581 DOI: 10.1007/s10840-022-01126-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Radiofrequency (RF) catheter ablation of the slow pathway (SP) in atrioventricular nodal reentry tachycardia (AVNRT) is highly effective; however, it may require prolonged fluoroscopy and RF time. We postulated that visualization of the SP region with intracardiac echocardiography (ICE) could decrease ablation time, minimize radiation exposure, and facilitate SP ablation compared to the standard, fluoroscopy-guided approach. METHODS In our study, we randomized 91 patients undergoing electrophysiologic study and SP ablation for AVNRT into 2 groups: fluoroscopy-only (n = 48) or ICE-guided (n = 43) group. Crossover to ICE-guidance was allowed after 8 unsuccessful RF applications. RESULTS Mapping plus ablation time (mean ± standard deviation: 18.8 ± 16.1 min vs 11.6 ± 15.0 min, p = 0.031), fluoroscopy time (median [interquartile range]: 4.9 [2.93-8.13] min vs. 1.8 [1.2-2.8] min, p < 0.001), and total ablation time (144 [104-196] s vs. 81 [60-159] s, p = 0.001) were significantly shorter in the ICE group. ICE-guidance was associated with reduced radiation exposure (13.2 [8.2-13.4] mGy vs. 3.7 [1.5-5.8] mGy, p < 0.001). The sum of delivered RF energy (3866 [2786-5656] Ws vs. 2283 [1694-4284] Ws, p = 0.002) and number of RF applications (8 [4.25-12.75] vs. 4 [2-7], p = 0.001) were also lower with ICE-guidance. Twelve (25%) patients crossed over to the ICE-guided group. All were treated successfully thereafter with similar number, time, and cumulative energy of RF applications compared to the ICE group. No recurrence occurred during the follow-up. CONCLUSIONS ICE-guidance during SP ablation significantly reduces mapping and ablation time, radiation exposure, and RF delivery in comparison to fluoroscopy-only procedures. Moreover, early switching to ICE-guided ablation seems to be an optimal choice in challenging cases.
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Hong KL, Verma A, Lee T, Jiang Y, Skobic D, Huang G, Park J, Terricabras M, Malaweera A, Sanhueza E, Korogyi A, Lashevsky I, Crystal E, Glover BM. Age-Related Changes in the Anatomy of the Triangle of Koch: Implications for Catheter Ablation of Atrioventricular Nodal Re-entry Tachycardia. CJC Open 2021; 3:924-928. [PMID: 34401699 PMCID: PMC8348584 DOI: 10.1016/j.cjco.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/09/2021] [Indexed: 11/18/2022] Open
Abstract
Background Atrioventricular nodal re-entrant tachycardia is the most common type of paroxysmal supraventricular tachycardia. We sought to assess whether important anatomic factors, such as the location of the slow pathway, proximity to the bundle of His, and coronary sinus ostium dimensions, varied with patient age, and whether these factors had an impact on procedural duration, acute success, and complications. Methods Baseline demographic and procedural data were collected, and the maps were analyzed. Linear regression models were performed to evaluate the associations between age and these anatomic variations. Associations were also assessed, with age categorized as being ≥ 60 years or < 60 years. Results The slow pathway was more commonly located in a superior location relative to the coronary sinus ostium in older patients. The location of the slow pathway moved in a superior direction by 1 mm for every increase in 2 years from the mean estimate of age. Additionally the slow pathway tended to be closer to the coronary sinus ostium in older patients, and the diameter of the ostium was larger in older patients. This resulted in longer procedure time, longer ablation times, and a greater need for long sheaths for stability. Conclusions The location of the slow pathway becomes more superior and closer to the coronary sinus ostium with increasing age. Additionally, the coronary sinus diameter increases with age. These factors result in longer ablation and procedural times in older patients.
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Affiliation(s)
- Kathryn L. Hong
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Atul Verma
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
- Southlake Hospital, Toronto, Ontario, Canada
| | - Thea Lee
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yidi Jiang
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Grace Huang
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joy Park
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Maria Terricabras
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anura Malaweera
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eduardo Sanhueza
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adam Korogyi
- Abbott Laboratories, Mississauga, Ontario, Canada
| | - Ilan Lashevsky
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eugene Crystal
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benedict M. Glover
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Benedict M. Glover, Associate Professor, Division of Cardiology, Schulich Heart Centre, University of Toronto, Toronto, Ontario, Canada. Tel.: +1-416-786-5988; fax: +1-416-480-6913.
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Chaumont C, Mirolo A, Savouré A, Godin B, Auquier N, Viart G, Hatrel A, Gillibert A, Eltchaninoff H, Anselme F. Very long‐term outcomes after catheter ablation of atrioventricular nodal reentrant tachycardia: How does cryoenergy differ from radiofrequency? J Cardiovasc Electrophysiol 2020; 31:3215-3222. [DOI: 10.1111/jce.14784] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Corentin Chaumont
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Adrian Mirolo
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Arnaud Savouré
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Bénédicte Godin
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Nathanaël Auquier
- Department of Cardiology Groupe Hospitalier du Havre Le Havre France
| | - Guillaume Viart
- Department of Cardiology Rouen University Hospital Rouen France
| | - Amandine Hatrel
- Department of Cardiology Rouen University Hospital Rouen France
- Department of Cardiology Elbeuf Hospital Elbeuf France
| | - André Gillibert
- Department of Biostatistics Rouen University Hospital Rouen France
| | - Hélène Eltchaninoff
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
| | - Frédéric Anselme
- Department of Cardiology Rouen University Hospital Rouen France
- UNIROUEN, INSERM U1096 FHU REMOD‐VHF Rouen France
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6
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Wang Y, Liu L, Lakin R, Polidovitch N, Liu G, Yang H, Yu M, Yan M, Zhao D, Backx PH, Sun H, He Y, Yang P. Revisiting right anterior oblique projections for the triangle of Koch: implications from computed tomography. BMC Cardiovasc Disord 2020; 20:383. [PMID: 32838758 PMCID: PMC7446209 DOI: 10.1186/s12872-020-01632-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/20/2020] [Indexed: 11/22/2022] Open
Abstract
Background Variability in the anatomy and orientation of the triangle of Koch (TK) complicates ablation procedures involving the atrioventricular (AV) node. We used CT angiography (CTA) to assess the anatomical TK orientation, the CS ostium direction, and the relationship between the two, and we validated an individualized CS-guided projection during ablation procedures. Methods In 104 patients without structural heart disease undergoing computed tomography (CT) angiography, TK orientations were determined in relation to the coronary sinus ostium (CSo) as well as two standard right anterior oblique (RAO) projection angles (30o and 45o) commonly used in ablation procedures. Results A CS-guided RAO projection (RAOCS) was shown to best track the orientation of the TK compared to RAO30° and 45°, with TK orientation strongly correlating with the CSo direction (r = 0.86, P < 0.001). In addition, the mean relative difference between the angle of the CSo and TK orientation was 5.54 ± 0.48°, consistent with a reduction in the degree of image shortening compared to traditional RAOs. Moreover, in vivo validation following ablation revealed that using a CS-guided projection limited the degree of on-screen image shortening compared to both the RAO30° and 45° in 25 patients with catheter ablation procedures. Conclusion In hearts with a normal structure, the CSo direction offers a reliable predictor of the TK orientation which can be used to guide the projection of the TK during ablation procedures.
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Affiliation(s)
- Yanjing Wang
- Radiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai street, Changchun, Jilin Province, 130033, China
| | - Lin Liu
- Radiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai street, Changchun, Jilin Province, 130033, China
| | - Robert Lakin
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Nazari Polidovitch
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Guohui Liu
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Hongliang Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Ming Yu
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Mingzhou Yan
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Dong Zhao
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
| | - Peter H Backx
- Department of Biology, York University, 4700 Keele Street, Toronto, ON, Canada
| | - Huan Sun
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China.
| | - Yuquan He
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China. .,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China.
| | - Ping Yang
- Cardiology Department, China-Japan Union Hospital of Jilin University, 126 Xiantai Street, Changchun, Jilin Province, 130033, China.,Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin Province, 130033, China.,Jilin Provincial Cardiovascular Research Institute, Changchun, 130033, China
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Young M, Niu J. Using coronary sinus ostium as the reference for the slow pathway ablation of atrioventricular nodal reentrant tachycardia in children. J Arrhythm 2020; 36:712-719. [PMID: 32782644 PMCID: PMC7411203 DOI: 10.1002/joa3.12379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/13/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful slow pathway (SP) ablation sites for atrioventricular nodal reentrant tachycardia (AVNRT) are usually located inside the Koch's triangle (KT). This study aimed to determine the ablation site of SP using the coronary sinus (CS) ostium (CSO) as the reference and to evaluate the efficacy of the CSO-guided SP ablation. METHODS A regional geometry around the KT was constructed by 3D mapping in 52 consecutive patients under age 18 with AVNRT. SP cryoablation was performed. If initial cryoablation was unsuccessful or cryoablation was deemed not suitable, then radiofrequency (RF) ablation was performed. The successful ablation site direction relative to the CSO was expressed as o'clock with the CSO viewed as a clock. RESULTS Cryoablation was used as the primary energy source in 40 patients. Of which, 32 were successful and eight required additional RF ablation. Direct RF ablation was performed in 11 patients. Using the CSO as reference, the successful site with cryoablation was at its 2.2 ± 0.6 o'clock; the RF ablation success site was at CSO 2.7 ± 0.5 o'clock (P = .006). During a median follow-up of 12 month, there was 98% success of SP ablation in these patients, with one patient with RF ablation had a tachycardia recurrence. CONCLUSIONS Using CSO as reference, the cryoablation site at its 2:00 o'clock and RF ablation at its 3:00 o'clock are highly efficacious for SP ablation with good short-term outcomes, and may be a useful tool in guiding the ablation target for AVNRT.
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Affiliation(s)
- Ming‐Lon Young
- Heart InstituteJoe DiMaggio Children’s Hospital, Memorial Healthcare SystemHollywoodFLUSA
| | - Jianli Niu
- Office of Human ResearchMemorial Healthcare SystemHollywoodFLUSA
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Iizuka T, Nakajima T, Tamura S, Hasegawa H, Kobari T, Nakahara S, Kurabayashi M, Kaneko Y. Simple differential entrainment screens ablation strategy for slow-fast atrioventricular nodal reentrant tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:671-679. [PMID: 32469105 DOI: 10.1111/pace.13946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/13/2020] [Accepted: 05/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ablation of slow-fast atrioventricular nodal reentrant tachycardia (S/F-AVNRT) is occasionally refractory. We hypothesized that the site of ablation for curing S/F-AVNRT can be screened by simple differential atrial entrainment pacing (EP) from the high right atrium (HRA) and proximal coronary sinus (prox-CS). METHODS We enrolled 43 patients with S/F-AVNRT who underwent successful differential atrial EP followed by successful ablation of slow pathway (SP) using step-wise approach, and compared the atrio-His (A-H) interval at the recording of His bundle immediately after EP from the HRA [A-H(HRA)], with the interval between atrial deflection at the prox-CS and His bundle electrogram after EP at an identical cycle length from the prox-CS [A-H (prox-CS)]. RESULTS A typical A-H(CS) shorter than A-H(HRA), consistent with typical SP conduction, was observed in 39 patients (91%), and an atypical A-H(HRA) shorter than A-H(CS) was observed in 4 patients (9%). Successful ablation was obtained at the posteroseptum/midseptum in 32/7 patients with typical responses but only at the midseptum in all 4 patients with atypical responses (P = .0027). The atypical responses predicted a necessity for ablation at the midseptum, with positive and negative predictive values of 100% and 82%, respectively. The mechanism of an atypical response remains unclear but may involve an anatomical variation of Koch's triangle and/or the participation of a variant of the SP, including the superior SP, over which retrograde conduction was observed more frequently in patients with atypical responses (P = .0013). CONCLUSIONS Differential atrial EP predicts the ablation site for successfully curing S/F-AVNRT.
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Affiliation(s)
- Takashi Iizuka
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tadashi Nakajima
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shuntaro Tamura
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroshi Hasegawa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takashi Kobari
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Shiro Nakahara
- Department of Cardiology, Dokkyo Medical University Saitama Hospital, Koshigaya, Saitama, Japan
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yoshiaki Kaneko
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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9
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The low specificity of low voltage bridges associating atrioventricular nodal reentry in pediatric patients. J Interv Card Electrophysiol 2018; 54:277-281. [PMID: 30032471 DOI: 10.1007/s10840-018-0382-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/15/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Patients with atrioventricular nodal reentry tachycardia (AVNRT) often are managed successfully by ablation of the slow pathway with success rates reported as high as 99%. Low voltage bridges (LVBs) have been demonstrated to be helpful in guiding AVNRT ablation. Patients may present to the electrophysiology lab without evidence of inducible arrhythmia. In these scenarios, the demonstration of LVBs may be diagnostic and guide catheter ablation treatment. The purpose of our study was to prospectively investigate the specificity of LVBs as a diagnostic marker of AVNRT. METHODS Patients aged < 19 years with narrow complex tachycardia prospectively underwent electrophysiology study with intention to perform catheter ablation. In each patient, the primary objective was the collection of right atrial voltage data that was then used to identify LVBs. RESULTS Twenty-four patients were included after exclusion criteria were applied. Final diagnosis was 11 AVNRT and 13 non-AVNRT (nAVNRT). LVBs were identified in 11/11 AVNRT patients and 9/13 non-AVNRT patients (p = 0.09). CONCLUSIONS LVBs are not specific to patients with AVNRT and cannot solely be used for diagnosis. However, in patients with documented AVNRT, the LVB can be used to identify the location of the slow pathway.
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Fragakis N, Krexi L, Kyriakou P, Sotiriadou M, Lazaridis C, Karamanolis A, Dalampyras P, Tsakiroglou S, Skeberis V, Tsalikakis D, Vassilikos V. Electrophysiological markers predicting impeding AV-block during ablation of atrioventricular nodal reentry tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:7-13. [DOI: 10.1111/pace.13245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Nikolaos Fragakis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Lydia Krexi
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiota Kyriakou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Melani Sotiriadou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Charalambos Lazaridis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Athanasios Karamanolis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Panagiotis Dalampyras
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Stelios Tsakiroglou
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Vassilios Skeberis
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Dimitrios Tsalikakis
- Department of Informatics and Telecommunications; University of Western Macedonia; Macedonia Greece
| | - Vassilios Vassilikos
- Third Department of Cardiology; Hippokration Hospital; Medical School; Aristotle University of Thessaloniki; Thessaloniki Greece
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11
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Kiuchi K, Fukuzawa K, Shumpei M, Nishii T. The inferior displacement of the His bundle and fast pathway in a patient with common type atrioventricular nodal tachycardia: Three-dimensional computed tomography analysis. J Arrhythm 2017; 33:147-149. [PMID: 28416984 PMCID: PMC5388057 DOI: 10.1016/j.joa.2016.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 07/13/2016] [Accepted: 07/25/2016] [Indexed: 11/29/2022] Open
Abstract
A 66-year-old woman with palpitations was referred to our center for catheter ablation due to drug-refractory, common type atrioventricular nodal tachycardia (AVNRT). A selective slow pathway ablation was attempted. A fast junctional rhythm with transient ventriculoatrial block followed by transient prolongation of the A–H interval occurred immediately after the radiofrequency (RF) application at the coronary sinus ostium (CSOS) level. To assess the location of the fast pathway and His bundle, we sought to visualize the anatomy of the triangle of Koch (TOK) by three-dimensional computed tomography (CT).
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Affiliation(s)
- Kunihiko Kiuchi
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
- Corresponding author. Fax: +81 78 382 5859.
| | - Koji Fukuzawa
- Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
| | - Mori Shumpei
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
| | - Tatsuya Nishii
- Department of Radiology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-chou chuou-ku, Kobe, Hyogo, Japan
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12
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Bhaskaran A, Albarri M, Ross N, Al Raisi S, Samanta R, Roode L, Nadri F, Ng J, Thomas S, Thiagalingam A, Kovoor P. Slow Pathway Radiofrequency Ablation Using Magnetic Navigation: A Description of Technique and Retrospective Case Analysis. Heart Lung Circ 2017; 26:1297-1302. [PMID: 28318819 DOI: 10.1016/j.hlc.2017.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 12/18/2016] [Accepted: 01/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Magnetic Navigation System (MNS) catheter was shown to be stable in the presence of significant cardiac wall motion and delivered more effective lesions compared to manual control. This stability could potentially make AV junctional re-entrant tachycardia (AVNRT) ablation safer. The aim of this study is to describe the method of mapping and ablation of AVNRT with MNS and 3-D electro-anatomical mapping system (CARTO, Biosense Webster, Diamond bar, CA, USA) anatomical mapping, with a view to improve the safety of ablation. METHODS The method of precise mapping and ablation with MNS is described. Consecutive AVNRT cases (n=30) from 2012 January to 2015 November, in which magnetic navigation was used, are analysed. RESULTS Ablation was successful in 27 (90%) out of 30 patients. In three cases, ablation was abandoned due to the proximity of the three-dimensional His image to the potential ablation site. No complications, including AV nodal injury, occurred. The distance from the nearest His position to successful ablation site in both LAO and RAO projections of CARTO images was 26.4±8.8 and 27±7.7mm respectively. Only in two (9%) patients, ablation needed to be extended superior to the plane of coronary sinus ostium, towards the His bundle region, to achieve slow pathway modification. CONCLUSION AVNRT ablation with MNS allows for accurate mapping of the AV node and stable ablation at a safe distance, which could help avoid AV nodal injury. We recommend this modality for younger patients with AVNRT.
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Affiliation(s)
- Abhishek Bhaskaran
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Maha Albarri
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Neil Ross
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia
| | - Sara Al Raisi
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Rahul Samanta
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | | | - Fazlur Nadri
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jeanette Ng
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Stuart Thomas
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Aravinda Thiagalingam
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Pramesh Kovoor
- Cardiology Department, Westmead Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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13
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Klimek-Piotrowska W, Holda MK, Koziej M, Salapa K, Piatek K, Holda J. Geometry of Koch's triangle. Europace 2017; 19:452-457. [PMID: 27247009 DOI: 10.1093/europace/euw022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/20/2016] [Indexed: 11/12/2022] Open
Abstract
Aims The first aim of this study was to determine the size of the Koch's triangle. The second one was to investigate relation between its dimensions and other individual-specific and heart-specific parameters as well as to create universal formula to estimate triangle dimensions based on these parameters. Methods and results This study is a prospective one, presenting 120 randomly selected autopsied hearts dissected from adult humans (Caucasian) of both sexes (31.7% females), with mean age of 49.3 ± 17.4 years. The length of triangle sides and angles were measured and the triangle area was calculated as well. Sixteen additional heart parameters were measured in order to analyse potential relationship between the dimensions of Koch's triangle and other dimensions of the heart, using linear regression analysis. The mean (±SD) length of the anterior edge was approximated to 18.0 ± 3.8 mm, the posterior edge to 20.3 ± 4.3 mm, and the basal edge to 18.5 ± 4.0 mm. The average values of the apex angle, the Eustachian angle, and the septal leaflet angle were 58.0 ± 14.4°, 53.8 ± 10.6°, and 67.6 ± 14.4°, respectively. The mean value of the Koch's triangle area was 151.5 ± 55.8 mm2. The 95th percentile of triangle's height (the distance from the apex to the coronary sinus) was 21.8 mm. Conclusion Mean values and proportions of triangle's sides and angles were presented. Koch's triangle showed considerable individual variations in size. The dimensions of the triangle were strongly independent from individual-specific and heart-specific morphometric parameters; however, the maximum triangle's height can be estimated as 22 mm.
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Affiliation(s)
| | - Mateusz K Holda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Kinga Salapa
- Department of Bioinformatics and Telemedicine, Jagiellonian University Medical College, Cracow, Poland
| | - Katarzyna Piatek
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
| | - Jakub Holda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034 Cracow, Poland
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14
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Shanubhogue S, Mohamed T, Shankar N. Morphometry of the triangle of Koch and position of the coronary sinus opening in cadaveric fetal hearts. Indian Heart J 2017; 69:125-128. [PMID: 28228296 PMCID: PMC5319009 DOI: 10.1016/j.ihj.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 06/09/2016] [Accepted: 07/02/2016] [Indexed: 11/25/2022] Open
Abstract
AIMS The aim of the present study was to determine the variations in the position of the coronary sinus (CS) ostium in normal cadaveric fetal (28 weeks or more) hearts and to assess the impact that these variations had on the dimensions of the triangle of Koch (TK). METHODS This cross-sectional analytical study was conducted on 28 fetal hearts. The dimensions and area of the TK were calculated by two methods, M1 (anatomical) and M2 (clinical). The position of the CS was defined with respect to the tendon of Todaro. Differences between M1 and M2 were estimated using the paired T test. Pearson's correlation coefficient and the adjusted correlation coefficient were used to estimate the strength of association between measurements made by the methods. RESULTS Ten (35.7%) cadavers were male and 18 (64.3%) female. The mean gestational age was 32.4±3.3 weeks. Using M1, the mean dimensions of the triangle in millimeters (mm) were 9.2±2.2, 6.6±1.8, and 6±2.4 respectively for a, b and c. Similarly, the dimensions using M2 were 7±2.1, 4.7±1.5, and 4.8±2.2. The area in mm2 was 20.4±10.4 and 11.7±6.7 using M1 and M2 respectively. All measurements were significantly greater with M1. All correlation coefficients were high and significant. The CS ostium and tendon of Todaro maintained a relatively constant positional relationship. CONCLUSIONS Significantly higher values were noted in the dimensions of TK using M1. High significant positive correlations were observed in measurements made by the two methods. The CS ostium was relatively constantly placed within the TK.
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Affiliation(s)
| | - Thuslima Mohamed
- Department of Anatomy, St. John's Medical College, Bangalore, Karnataka, India
| | - Nachiket Shankar
- Department of Anatomy, St. John's Medical College, Bangalore, Karnataka, India.
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Alihanoglu YI, Yildiz BS, Kilic DI, Evrengul H, Kose S. Clinical and electrophysiological characteristics of typical atrioventricular nodal reentrant tachycardia in the elderly - changing of slow pathway location with aging. Circ J 2015; 79:1031-6. [PMID: 25739340 DOI: 10.1253/circj.cj-14-1320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively evaluate the clinical and electrophysiological characteristics of elderly patients with typical atrioventricular nodal reentrant tachycardia (AVNRT), and to assess the acute safety and efficacy of slow-pathway radiofrequency (RF) ablation in this specific group of patients. METHODS AND RESULTS The present study retrospectively included a total of 1,290 patients receiving successful slow-pathway RF ablation for typical slow-fast AVNRT. Patients were divided into 2 groups: group I included 1,148 patients aged <65 years and group II included 142 patients aged >65 years. The required total procedure duration and total fluoroscopy exposure time were significantly higher in group II vs. group I (P=0.005 and P=0.0001, respectively). The number of RF pulses needed for a successful procedural end-point was significantly higher in group II than in group I (4.4 vs. 7.2, P=0.005). While the ratio of the anterior location near to the His-bundle region was significantly higher in group II, the ratio of posterior and midseptal locations were significantly higher in group I (P=0.0001). The overall procedure success rates were similar. There was no significant difference between the 2 groups in respect of the complications rates. CONCLUSIONS This experience demonstrates that RF catheter ablation, targeting the slow pathway, could be considered as first-line therapy for typical AVNRT patients older than 65 years as well as younger patients, as it is very safe and effective in the acute period of treatment.
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SUZUKI ATSUSHI, YOSHIDA AKIHIRO, TAKEI ASUMI, FUKUZAWA KOJI, KIUCHI KUNIHIKO, TANAKA SATOKO, ITOH MITSUAKI, IMAMURA KIMITAKE, FUJIWARA RYUDO, NAKANISHI TOMOYUKI, YAMASHITA SOICHIRO, MATSUMOTO AKINORI, KONISHI HIROKI, ICHIBORI HIROTOSHI, HIRATA KENICHI. Visualization of the Antegrade Fast and Slow Pathway Inputs in Patients with Slow-Fast Atrioventricular Nodal Reentrant Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:874-83. [DOI: 10.1111/pace.12363] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 12/30/2013] [Accepted: 01/01/2014] [Indexed: 11/28/2022]
Affiliation(s)
- ATSUSHI SUZUKI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - AKIHIRO YOSHIDA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
- Section of Arrhythmia; Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Chuo-ku Kobe Japan
| | - ASUMI TAKEI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - KOJI FUKUZAWA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
- Section of Arrhythmia; Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Chuo-ku Kobe Japan
| | - KUNIHIKO KIUCHI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - SATOKO TANAKA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - MITSUAKI ITOH
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - KIMITAKE IMAMURA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - RYUDO FUJIWARA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - TOMOYUKI NAKANISHI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - SOICHIRO YAMASHITA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - AKINORI MATSUMOTO
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - HIROKI KONISHI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - HIROTOSHI ICHIBORI
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
| | - KEN-ICHI HIRATA
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine
- Section of Arrhythmia; Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Chuo-ku Kobe Japan
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