1
|
Kumar N, Elbanhawy N, Choudhury M, Potluri R, Chalil S, Abozguia K. UBLED AF (Uninterrupted BLackpool EDoxaban vs Warfarin vs Rivaroxaban in Atrial Fibrillation/Flutter ablation) Study. J Atr Fibrillation 2021; 14:20200445. [PMID: 34950367 DOI: 10.4022/jafib.20200445] [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: 02/19/2021] [Revised: 03/05/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022]
Abstract
Aim Catheter ablation in patients with atrial fibrillation (AF)/atrial flutter carries a risk of thromboembolism and major bleeding. In light of recent prospective trial data on the safety and efficacy of uninterrupted edoxaban in patients undergoing AF/flutter ablation, real-world Data was aimed for validation. Methods A total of 228 patients who underwent AF/atrial flutter ablation over 14 months at our centre were retrospectively analyzed. All patients received uninterrupted oral anticoagulation for at least 4 weeks prior to ablation and 3 months post-ablation. Both bleeding and thromboembolic events were assessed at 24 hours comparing patients on warfarin, rivaroxaban and edoxaban. Results Mean age of patients were 68.5 +/- 8 years in the warfarin group ( N =86), 63.4 +/- 10.6 years; in the edoxaban group ( N =63) and 62.3 +/- 11.6 years in the rivaroxaban group ( N =79). CHADSVASc scores were 2.43 +/- 1.34, 1.68 +/- 1.34 and 1.64 +/- 1.38 respectively. The mean left atrial sizes were 42.7 +/- 6.8 mm, 42.0 +/- 6 mm and 41.1 +/- 6.5 mm respectively. The study endpoint was death, acute thromboembolism or major bleeding. There was 1 pericardial effusion (1.2%) in the warfarin group, 1 pericardial effusion and 1 transient ischaemic attack (2.5%) in the rivaroxaban group and 1 pericardial effusion needing drainage (1.6%) in the edoxaban group. There were no significant differences in the study endpoints between groups. Conclusion This real-world study demonstrated no significant difference in safety and efficacy between uninterrupted edoxaban, warfarin and rivaroxaban in patients undergoing AF/flutter ablation.
Collapse
Affiliation(s)
- Narendra Kumar
- Cardiology Department, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool, UK, FY3 8NR
| | - Noha Elbanhawy
- Cardiology Department, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool, UK, FY3 8NR
| | - Moinuddin Choudhury
- Cardiology Department, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool, UK, FY3 8NR
| | - Rahul Potluri
- Department of Cardiology, Bedford Hospital, Bedfordshire Hospitals NHS Foundation trust, Bedford, UK
| | - Shajil Chalil
- Cardiology Department, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool, UK, FY3 8NR
| | - Khalid Abozguia
- Department of Cardiology, Bedford Hospital, Bedfordshire Hospitals NHS Foundation trust, Bedford, UK
| |
Collapse
|
2
|
Palano F, Adduci C, Cosentino P, Silvetti G, Boldini F, Francia P. Assessing Atrial Fibrillation Substrates by P Wave Analysis: A Comprehensive Review. High Blood Press Cardiovasc Prev 2020; 27:341-347. [PMID: 32451990 DOI: 10.1007/s40292-020-00390-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Francesca Palano
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy.
| | - Carmen Adduci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Pietro Cosentino
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Giacomo Silvetti
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Francesca Boldini
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| | - Pietro Francia
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University, Rome, Via di Grottarossa 1035, 00189, Rome, Italy
| |
Collapse
|
3
|
Weiner MM, Baron EL, Joshi K, Villablanca P, Briceno D, Torregrossa G, Evans AS, Augoustides Y, Ramakrishna H. Catheter Versus Surgical Ablation of Atrial Fibrillation: An Analysis of Outcomes. J Cardiothorac Vasc Anesth 2018; 32:2435-2443. [DOI: 10.1053/j.jvca.2018.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 11/11/2022]
|
4
|
Furniss GO, Panagopoulos D, Kanoun S, Davies EJ, Tomlinson DR, Haywood GA. The Effect of Atrial Fibrillation Ablation Techniques on P Wave Duration and P Wave Dispersion. Heart Lung Circ 2018; 28:389-396. [PMID: 29501465 DOI: 10.1016/j.hlc.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/10/2018] [Accepted: 02/04/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND A reduction in surface electrocardiogram (ECG) P wave duration and dispersion is associated with improved outcomes in atrial fibrillation ablation. We investigated the effects of different ablation strategies on P wave duration and dispersion, hypothesising that extensive left atrial (LA) ablation with left atrial posterior wall isolation would give a greater reduction in P wave duration than more limited ablation techniques. METHODS A retrospective analysis of ECGs from patients who have undergone atrial fibrillation (AF) ablation was performed and pre-procedural sinus rhythm ECGs were compared with the post procedure ECGs. Maximal P wave duration was measured in leads I or II, minimum P wave duration in any lead and values were calculated for P wave duration and dispersion. Left atrial dimensions and medications at the time of ECG were documented. Ablation strategies compared were; pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) and the persistent AF (PsAF) ablation strategies of pulmonary vein isolation plus additional linear lesions (Lines), left atrial posterior wall isolation via catheter (PWI) and left atrial posterior wall isolation via staged surgical and catheter ablation (Hybrid). RESULTS Sixty-nine patients' ECGs were analysed: 19 PVI, 21 Lines, 14 PWI, 15 Hybrid. Little correlation was seen between pre-procedure left atrial size and P wave duration (r=0.24) but LA size and P wave duration was larger in PsAF patients. A significant difference was seen in P wave reduction driven by Hybrid AF ablation (p<0.005) and Lines (<0.02). There was no difference amongst P wave dispersion between groups but the largest reduction was seen in the Hybrid ablation group. CONCLUSIONS P wave duration increased with duration of continuous atrial fibrillation. Hybrid AF ablation significantly reduced P wave duration and dispersion compared to other ablation strategies including posterior wall isolation via catheter despite this being the same lesion set.
Collapse
Affiliation(s)
- Guy O Furniss
- Musgrove Park Hospital, Taunton, UK; University of Plymouth, Plymouth, UK; Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK.
| | | | - Sadeek Kanoun
- Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK
| | - Edward J Davies
- Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK
| | | | - Guy A Haywood
- Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK
| |
Collapse
|
5
|
Phan K, Pison L, Wang N, Kanagaratnam A, Yan TD, Maesen B, Maessen JG, Crijns HJ, La Meir M. Effectiveness and safety of simultaneous hybrid thoracoscopic endocardial catheter ablation of atrial fibrillation in obese and non-obese patients. J Thorac Dis 2017; 9:3087-3096. [PMID: 29221283 DOI: 10.21037/jtd.2017.08.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We evaluated the safety and effectiveness of the hybrid thoracoscopic endocardial epicardial ablation technique for the treatment of atrial fibrillation (AF) in obese versus non-obese patients. Methods Between January 2010 and January 2015, a cohort of 61 patients were retrospectively identified to undergo ablation of AF as a stand-alone procedure using a thoracoscopic, hybrid epicardial-endocardial technique. All patients underwent continuous 7-day Holter monitoring at 3, 6 months, 1 year and yearly thereafter. Results A total of 40% of the obese cohort had persistent or long-standing AF, compared to 54.9% of the non-obese cohort. There were no deaths or conversion to cardiopulmonary bypass required. At 3-year follow-up, 60% of the obese group were in sinus rhythm (SR) with no episode of AF, atrial flutter or atrial tachycardia lasting 30 s off anti-arrhythmic drugs. This was compared to 70.6% in the non-obese group, with no significant difference between the groups (P=0.468). For success rates on anti-arrhythmic drugs, this was 80% in the obese group compared to 86% in the non-obese group at 3-year follow-up (P=0.637). No patient died and no thromboembolic/bleeding events or procedure-related complications occurred during the follow-up. Conclusions In a retrospective cohort with approximately half with persistent or long-standing AF, thoracoscopic hybrid epicardial endocardial ablation proved to be equally effective and safe in obese versus non-obese patients. Current preliminary findings require further validation in multi-institutional prospective studies with larger sample sizes.
Collapse
Affiliation(s)
- Kevin Phan
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Collaborative Research (CORE) Group, Macquarie Hospital, Sydney, Australia
| | - Laurent Pison
- Department of Cardiology, Maastricht University, Maastricht, the Netherlands
| | - Nelson Wang
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Aran Kanagaratnam
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Tristan D Yan
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Collaborative Research (CORE) Group, Macquarie Hospital, Sydney, Australia
| | - Bart Maesen
- Department of Cardiology, Maastricht University, Maastricht, the Netherlands
| | - Jos G Maessen
- Department of Cardiology, Maastricht University, Maastricht, the Netherlands
| | - Harry J Crijns
- Department of Cardiology, Maastricht University, Maastricht, the Netherlands
| | - Mark La Meir
- Department of Cardiology, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
6
|
Kumar N. The surgical atrial fibrillation ablation with concomitant coronary artery bypass grafting on the testing grounds of cost and 1-year mortality. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:364. [PMID: 28936458 PMCID: PMC5599278 DOI: 10.21037/atm.2017.06.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 06/21/2017] [Indexed: 08/29/2023]
Affiliation(s)
- Narendra Kumar
- Department of Cardiology, Paras HMRI Hospitals, Patna, India
| |
Collapse
|
7
|
Abstract
PURPOSE Hybrid ablation for AF is performed in a growing number of centers. Due to absence of guidelines, operative approaches and perioperative care differ per center. In this review, an overview of findings from published studies on hybrid ablations is given, and related topics are discussed (e.g., one- and two-stage approaches, lesion sets, and patient management). METHODS A systematic literature search was performed in the PubMed and Embase databases. All identified articles were screened and checked for eligibility by the two authors. RESULTS Twelve studies describing a total of 563 patients were selected. Due to substantial differences in approaches (one-stage, two-stage, sequential), surgical techniques (bilateral or monolateral thoracoscopy, subxiphoideal, transabdominal), energy sources (unipolar, bipolar), lesion sets (applying left or right atrial lesions), periprocedural care and endpoints (monitoring, definition of recurrence), and success rates (sinus rhythm after a mean of 26 months) are difficult to compare and varied from 27 % (without antiarrhythmic drugs, AADs) to 94 % (with AADs). For studies using bipolar devices, success rates with the use of antiarrhythmic drugs were at least 71 %. Major complications such as bleeding, sternotomy, and death occurred in 7 % of the total population (of which ten complications, 16 %, occurred in the concomitant cardiac surgery hybrid group). CONCLUSION The field of AF ablation has dramatically changed over the past years, with one of the most recent developments the hybrid AF ablation. Lack of matching data hinders drawing conclusions and creating guidelines. Early results however are encouraging. More data are awaiting and needed.
Collapse
|
8
|
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in modern clinical practice, with an estimated prevalence of 1.5-2%. The prevalence of AF is expected to double in the next decades, progressing with age and increasingly becoming a global medical challenge. The first-line treatment for AF is often medical treatment with either rate control or anti-arrhythmic agents for rhythm control, in addition to anti-coagulants such as warfarin for stroke prevention in patient at risk. Catheter ablation has emerged as an alternative for AF treatment, which involves myocardial tissue lesions to disrupt the underlying triggers and substrates for AF. Surgical approaches have also been developed for treatment of AF, particularly for patients requiring concomitant cardiac surgery or those refractory to medical and catheter ablation treatments. Since the introduction of the Cox-Maze III, this procedure has evolved into several modern variations, including the use of alternative energy sources (Cox-Maze IV) such as radiofrequency, cryo-energy and microwave, as well as minimally invasive thoracoscopic epicardial approaches. Another recently introduced technique is the hybrid ablation approach, where in a single setting both epicardial thoracoscopic ablation lesions and endocardial catheter ablation lesions are performed by the cardiothoracic surgeon and cardiologist. There remains controversy surrounding the optimal approach for AF ablation, energy sources, and lesion sets employed. The goal of this article is review the history, classifications, pathophysiology and current treatment options for AF.
Collapse
Affiliation(s)
- Joshua Xu
- Sydney Medical School, University of Sydney, Sydney, Australia;; The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Jessica G Y Luc
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia;; The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia;; Faculty of Medicine, University of New South Wales, Sydney, Australia
| |
Collapse
|
9
|
Shrestha S, Chen O, Greene M, John JJ, Greenberg Y, Yang F. Change in P wave morphology after convergent atrial fibrillation ablation. Indian Pacing Electrophysiol J 2016; 16:3-7. [PMID: 27485559 PMCID: PMC4936606 DOI: 10.1016/j.ipej.2016.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Convergent atrial fibrillation ablation involves extensive epicardial as well as endocardial ablation of the left atrium. We examined whether it changes the morphology of the surface P wave. We reviewed electrocardiograms of 29 patients who underwent convergent ablation for atrial fibrillation. In leads V1, II and III, we measured P wave duration, area and amplitude before ablation, and at 1, 3 and 6 months from ablation. After ablation, there were no significant changes in P wave amplitude, area, or duration in leads II and III. There was a significant reduction in the area of the terminal negative deflection of the P wave in V1 from 0.38 mm2 to 0.13 mm2 (p = 0.03). There is also an acute increase in the amplitude and duration of the positive component of the P wave in V1 followed by a reduction in both by 6 months. Before ablation, 62.5% of the patients had biphasic P waves in V1. In 6 months, only 39.2% of them had biphasic P waves. Hybrid ablation causes a reduction of the terminal negative deflection of the P wave in V1 as well as temporal changes in the duration and amplitude of the positive component of the P wave in V1. This likely reflects the reduced electrical contribution of the posterior left atrium after ablation as well as anatomical and autonomic remodeling. Recognition of this altered sinus P wave morphology is useful in the diagnosis of atrial arrhythmias in this patient population.
Collapse
Affiliation(s)
- Suvash Shrestha
- Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY, USA.
| | - On Chen
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA.
| | - Mary Greene
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA.
| | - Jinu Jacob John
- Department of Cardiology, Maimonides Medical Center, Brooklyn, NY, USA; William Beaumont Hospital, Royal Oak, MI, USA.
| | - Yisachar Greenberg
- Department of Cardiac-electrophysiology, Maimonides Medical Center, Brooklyn, NY, USA.
| | - Felix Yang
- Department of Cardiac-electrophysiology, Maimonides Medical Center, Brooklyn, NY, USA.
| |
Collapse
|
10
|
Diverging P waves after convergent procedures: What do they mean? Indian Pacing Electrophysiol J 2016; 16:1-2. [PMID: 27485558 PMCID: PMC4936661 DOI: 10.1016/j.ipej.2016.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
11
|
Abstract
Objective Reconduction across an ablation line is a common reason for arrhythmia recurrence over time. The hybrid procedure combines epicardial ablation of the pulmonary vein (PV) and creation of a box lesion with endocardial touch-ups for any electrical gaps. A high contact force (CF) between the ablation tip and cardiac tissue may increase the risk of thrombus formation, catheter tip charring, steam pop formation, and even cardiac perforation. CF monitoring is a significant new parameter for titration of the CF for creating an adequate lesion. Methods Thirty-eight consecutive patients underwent epicardial ablation using bipolar radiofrequency devices. After checking electrical bidirectional block of the ablation lines, an endocardial CF catheter was used for further ablation (if needed) to complete the isolation of PVs, box lesion, cavotricuspid isthmus (CTI), and complex fractionated atrial electrograms (CFAE). Results Endocardial touch-up was needed for 2 PVs (1.3 %) and 10 (26.3 %) box lesions. It was also used for the CTI line in 7 (18.4 %) patients, atrial tachycardia in 3 (7.9 %) patients, and additional CFAE ablation in 17 (44.7 %) patients. All 5 patients with arrhythmia recurrence had a mean CF < 10 g (p = 0.03). Procedure duration was significantly shorter in the CF group (223 ± 57 vs. 256 ± 60 min, p = 0.03) compared with control group. Conclusion Use of CF catheters is safe, feasible, and complementary to a hybrid procedure setup for atrial fibrillation ablation. Its real-time monitoring may predict future arrhythmia recurrence, and decrease procedure time.
Collapse
|
12
|
Kumar N, Bonizzi P, Mafi Rad M, Lankveld T. Left atrial dyssynchrony time measured by tissue Doppler imaging to predict atrial fibrillation recurrences after pulmonary vein isolation: is this a mirage or the panacea? Anatol J Cardiol 2015; 15:123-4. [PMID: 25625443 PMCID: PMC5336996 DOI: 10.5152/akd.2015.14399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Narendra Kumar
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM); Maastricht-the Netherlands.
| | | | | | | |
Collapse
|