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Compagnucci P, Dello Russo A, Bergonti M, Anselmino M, Zucchelli G, Gasperetti A, Cipolletta L, Volpato G, Ascione C, Ferraris F, Valeri Y, Bongiorni MG, Natale A, Tondo C, De Ferrari GM, Casella M. Ablation Index Predicts Successful Ablation of Focal Atrial Tachycardia: Results of a Multicenter Study. J Clin Med 2022; 11:jcm11071802. [PMID: 35407408 PMCID: PMC8999753 DOI: 10.3390/jcm11071802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 02/05/2023] Open
Abstract
A radiofrequency energy lesion transmurality marker incorporating power, contact force, and time (Ablation Index, AI) was shown to be associated with outcomes of catheter ablation (CA) of multiple arrhythmias, but was never systematically assessed in the CA of focal atrial tachycardias (AT). We aimed to evaluate the role of AI as a predictor of outcomes in focal AT CA, and therefore, retrospectively included 45 consecutive patients undergoing CA for focal AT in four referral electrophysiology laboratories. Clinical and procedural information were collected. For each patient, maximum and mean (by averaging maximum AI values for each radiofrequency ablation lesion) AI were measured. The primary outcome was focal AT-free survival, and was systematically assessed with periodical Holter monitors or cardiac implantable electronic devices. CA was acutely effective in each case; however, 20% (n = 9) of the study population experienced a focal AT recurrence over a median follow-up of 288 days. Both maximum and mean AI values were significantly higher among patients without AT recurrences (maximum AI = 568 ± 91, mean AI = 426 ± 105) than in patients with AT relapses (maximum AI = 447 ± 142, mean AI = 352 ± 76, p = 0.036, and p = 0.028, respectively). The optimal cutoffs associated with freedom from recurrences were 461 for maximum AI (sensitivity, 0.89; specificity, 0.56) and 301 for mean AI (sensitivity, 0.97; specificity, 0.44). In a time-to-event analysis, maximum AI was significantly associated with survival free from AT recurrence (p = 0.001), whereas mean AI was not (p = 0.08). In summary, maximum AI is the best procedural parameter associated with the outcomes of CA for focal AT, and may help standardize the procedural approach.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
- Correspondence:
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Marco Bergonti
- Operation Unit of Arrhythmology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 20138 Milan, Italy; (M.B.); (C.A.); (C.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Matteo Anselmino
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (M.A.); (F.F.); (G.M.D.F.)
| | - Giulio Zucchelli
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy; (G.Z.); (M.G.B.)
| | - Alessio Gasperetti
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Ciro Ascione
- Operation Unit of Arrhythmology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 20138 Milan, Italy; (M.B.); (C.A.); (C.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Federico Ferraris
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (M.A.); (F.F.); (G.M.D.F.)
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Maria Grazia Bongiorni
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy; (G.Z.); (M.G.B.)
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX 78705, USA;
| | - Claudio Tondo
- Operation Unit of Arrhythmology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 20138 Milan, Italy; (M.B.); (C.A.); (C.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (M.A.); (F.F.); (G.M.D.F.)
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, 60126 Ancona, Italy
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Manolis AS, Manolis TA, Manolis AA, Melita H. Atrial fibrillation-induced tachycardiomyopathy and heart failure: an underappreciated and elusive condition. Heart Fail Rev 2022; 27:2119-2135. [PMID: 35318562 DOI: 10.1007/s10741-022-10221-1] [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] [Accepted: 02/02/2022] [Indexed: 11/04/2022]
Abstract
Many patients with persistent, chronic, or frequently recurring paroxysmal atrial fibrillation (AF) may develop a tachycardiomyopathy (TCM) with left ventricular (LV) dysfunction and heart failure (HF), which is reversible upon restoration and maintenance of sinus rhythm, when feasible, or via better and tighter ventricular rate (VR) control. Mechanisms involved in producing this leading cause of TCM (AF-TCM) include loss of atrial contraction, irregular heart rate, fast VR, neurohumoral activation, and structural myocardial changes. The most important of all mechanisms relates to optimal VR control, which seems to be an elusive target. Uncontrolled AF may also worsen preexisting LV dysfunction and exacerbate HF symptoms. Data, albeit less robust, also point to deleterious effects of slow VRs on LV function. Thus, a J-shaped relationship between VR and clinical outcome has been suggested, with the optimal VR control hovering at ~ 65 bpm, ranging between 60 and 80 bpm; VRs above and below this range may confer higher morbidity and mortality rates. A convergence of recent guidelines is noted towards a stricter rather than a more lenient VR control with target heart rate < 80 bpm at rest and < 110 bpm during moderate exercise which seems to prevent TCM or improve LV function and exercise capacity and relieve TCM-related symptoms and signs. Of course, restoring and maintaining sinus rhythm is always a most desirable target, when feasible, either with drugs or more likely with ablation. All these issues are herein reviewed, current guidelines are discussed and relevant data are tabulated and pictorially illustrated.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece.
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Kellnar A, Fichtner S, Mehr M, Czermak T, Sinner MF, Lackermair K, Estner HL. Single-center experience of ultra-high-density mapping guided catheter ablation of focal atrial tachycardia. Clin Cardiol 2022; 45:291-298. [PMID: 35019172 PMCID: PMC8922533 DOI: 10.1002/clc.23774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Catheter ablation is the treatment of choice for recurrent focal atrial tachycardia (FAT) as medical therapy is limited. Routinely, a three‐dimensional mapping system is used. Whether or not optimized signal detection does improve ablation success rates has not yet been investigated. This retrospective cohort study compared ablation procedures using an ultra‐high‐density mapping system (UHDM, Rhythmia, Boston Scientific) with improved signal detection and automatic annotation with procedures using a conventional electroanatomic mapping system (CEAM, Biosense Webster, CARTO). Methods All patients undergoing ablation for FAT using UHDM or CEAM from April 2015 to August 2018 were included. Endpoints comprised procedural parameters, acute success as well as freedom from arrhythmia 12 months after ablation. Results A total of 70 patients underwent ablation (48 with UHDM, 22 with CEAM). No significant differences were noted for parameters like procedural and radiation duration, area dose, and RF applications. Acute success was significantly higher in the UHDM cohort (89.6% vs. 68.2%, p = .03). Nevertheless, arrhythmia freedom 12 months after ablation was almost identical (56.8% vs. 60%, p = .87), as more patients with acute success of ablation presented with a relapse during follow‐up (35.0 vs. 7.7%, p = .05). Conclusion Acute success rate of FAT ablation might be improved by UHDM, without an adverse effect on procedural parameters. Nevertheless, further research is needed to understand the underlying mechanism for increased recurrence rates after acute successful ablation.
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Affiliation(s)
- Antonia Kellnar
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Stephanie Fichtner
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Michael Mehr
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Thomas Czermak
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Moritz F Sinner
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany.,German Cardiovascular Research Centre (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Korbinian Lackermair
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Heidi L Estner
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
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Transcatheter ablation using near-zero fluoroscopy in children with focal atrial tachycardia: a single-centre experience. Cardiol Young 2020; 30:1266-1272. [PMID: 32684196 DOI: 10.1017/s1047951120001973] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Focal atrial tachycardia accounts for up to 10-15% of supraventricular tachycardiasubstrates in patients < 30 years. In this study, we aimed to demonstrate the outcome of transcatheter ablation procedures performed through three-dimensional electroanatomic mapping systems using minimal fluoroscopy in a paediatric cohort with focal atrial tachycardia. METHODS Forty-nine consecutive patients with focal atrial tachycardia who underwent an electrophysiologic study and a transcatheter ablation procedure in our hospital from September 2014 to February 2020 were included into the study. RESULTS The mean weight of the patients was 48.63 ± 15.4 kg, and the mean age was 14.56 ± 3.5 (5.5-18.4) years. The tachycardia was defined as incessant in 26 patients. Thirteen patients had left ventricular systolic dysfunction with a mean left ventricular ejection fraction of 38.47 ± 12.4% on echocardiography. The mean procedure time was 148.7 ± 94.5 minutes. Transseptal puncture and thus fluoroscopy were required in nine patients. The mean fluoroscopy time was 4.51 ± 5.9 minutes. No fluoroscopy was needed in ablations performed in the right atrium. The acute success rate of the ablation procedures was 97.9%. The mean follow-up period was 50.71 ± 23.5 months. Recurrence was noted in two patients (4.2%). CONCLUSION The outcomes of three-dimensional electroanatomic mapping-guided transcatheter ablation procedures are promising with high acute success, low recurrence and complication rates in children with focal atrial tachycardia. The use of fluoroscopy can be significantly decreased with three-dimensional mapping systems in this group of patients.
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[Catheter ablation of supraventricular tachycardia]. Herzschrittmacherther Elektrophysiol 2019; 30:336-342. [PMID: 31713026 DOI: 10.1007/s00399-019-00654-x] [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: 09/13/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
Supraventricular tachycardias (SVT) are common, with atrioventricular nodal reentry tachycardias (AVNRT) being the most common paroxysmal supraventricular tachycardia. The pathophysiological understanding and the catheter ablation of SVTs have developed steadily in recent years. For example, dividing AVNRT into "typical" and "atypical" depending on the HA-, VA-interval and AH/HA ratio is recommended. Because of higher rates of recurrences after cryoablation, radiofrequency ablation has prevailed in AVNRT. The current ESC guidelines for SVTs recommend the ablation of accessory pathways in asymptomatic high-risk patients and it is now a Class I recommendation. There is no recommendation for the access in left-sided accessory pathways. However, a transseptal compared to transaortic approach seems more promising in acute success. The use of a three-dimensional (3D) mapping system leads to a reduction of the fluoroscopy times and procedure duration. Ablation of focal atrial tachycardia remains challenging despite the use of 3D electroanatomical mapping systems. However, new technologies such as high-density (HD) multipoint mapping systems can be helpful. HD mapping systems also allow a better understanding of left and right atrial macroreentry tachycardia after previous ablation or cardiac surgery and in primary nature. However, in all technological advances, a proficient understanding of the basic techniques in electrophysiology, such as entrainment mapping, is mandatory.
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Markowitz SM, Thomas G, Liu CF, Cheung JW, Ip JE, Lerman BB. Atrial Tachycardias and Atypical Atrial Flutters: Mechanisms and Approaches to Ablation. Arrhythm Electrophysiol Rev 2019; 8:131-137. [PMID: 31114688 PMCID: PMC6528065 DOI: 10.15420/aer.2019.17.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Atrial tachycardias (ATs) may be classified into three broad categories: focal ATs, macroreentry and localised reentry – also known as ‘microreentry’. Features that distinguish these AT mechanisms include electrogram characteristics, responses to entrainment and pharmacological sensitivities. Focal ATs may occur in structurally normal hearts but can also occur in patients with structural heart disease. These typically arise from preferential sites such as the valve annuli, crista terminalis and pulmonary veins. Macro-reentrant ATs occur in the setting of atrial fibrosis, often after prior catheter ablation or post atriotomy, but also de novo in patients with atrial myopathy. High-resolution mapping techniques have defined details of macro-reentrant circuits, including zones of conduction block, scar and slow conduction. Localised reentry occurs in the setting of diseased atrial myocardium that supports very slow conduction. A characteristic feature of localised reentry is highly fractionated, low-amplitude electrograms that encompass most of the tachycardia cycle length over a small diameter. Advances in understanding the mechanisms of ATs and their signature electrogram characteristics have improved the efficacy and efficiency of catheter ablation.
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Affiliation(s)
- Steven M Markowitz
- Department of Medicine, Division of Cardiology, Weill Cornell Medical Center New York, US
| | - George Thomas
- Department of Medicine, Division of Cardiology, Weill Cornell Medical Center New York, US
| | - Christopher F Liu
- Department of Medicine, Division of Cardiology, Weill Cornell Medical Center New York, US
| | - Jim W Cheung
- Department of Medicine, Division of Cardiology, Weill Cornell Medical Center New York, US
| | - James E Ip
- Department of Medicine, Division of Cardiology, Weill Cornell Medical Center New York, US
| | - Bruce B Lerman
- Department of Medicine, Division of Cardiology, Weill Cornell Medical Center New York, US
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