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Calvert P, Lip GYH, Gupta D. Radiofrequency catheter ablation of atrial fibrillation: A review of techniques. Trends Cardiovasc Med 2023; 33:405-415. [PMID: 35421538 DOI: 10.1016/j.tcm.2022.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/21/2022] [Accepted: 04/04/2022] [Indexed: 11/24/2022]
Abstract
Ablation of atrial fibrillation is a key area of current research. A multitude of techniques have been tested, some of which are poorly evidenced and not recommended in routine clinical practice whilst others are more promising. Additionally, a plethora of issues exist when researching ablation techniques, from control arm ablation strategy to the relevance of outcome measures. In this review article, we discuss these issues in the context of the current evidence base.
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Affiliation(s)
- Peter Calvert
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Gregory Y H Lip
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Clinical Medicine, Aalborg University, Denmark
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK.
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Left atrial epicardial adipose tissue is closely associated with left atrial appendage flow velocity in patients with nonvalvular atrial fibrillation. Sci Rep 2022; 12:10742. [PMID: 35750694 PMCID: PMC9232655 DOI: 10.1038/s41598-022-13988-3] [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: 02/16/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
Epicardial adipose tissue (EAT) can play an important role in the occurrence and development of atrial fibrillation and stroke. In this study, we explored the relationship between left atrial epicardial adipose tissue (LA-EAT) and left atrial appendage flow velocity (LAA-FV) in patients with nonvalvular atrial fibrillation (NV-AF). A total of 145 patients with NV-AF who underwent their first radiofrequency ablation were enrolled. They underwent left aortopulmonary vein computed tomography angiography (CTA) and transesophageal echocardiography (TEE) before AF ablation. Left atrial (LA) electroanatomical mapping was performed intraoperatively to assess left atrial voltage. Univariate regression analysis showed that LAA-FV was lower in patients with a low voltage zone (LAA-FV; 35.02 ± 10.78 cm/s vs. 50.60 ± 12.17 cm/s, P < 0.001). A multiple linear regression model showed that the left atrial low voltage zone (β = − 0.311 P < 0.001), LA-EAT volume (β = − 0.256 P < 0.001), left atrial appendage shape (β = − 0.216 P = 0.041), LAVI (β = − 0.153 P = 0.041), and type of atrial fibrillation (paroxysmal vs. persistence) (β = − 0.146 P < 0.048) were independent predictors of LAA-FV. In NV-AF patients, the increase in LA-EAT volume is related to the decrease in LAA-FV.
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Ding X, Li M, Chen H, Yang G, Zhang F, Ju W, Gu K, Li J, Chen M. Low-Voltage Area at the Anterior Wall of the Left Atrium Is Associated With Thromboembolism in Atrial Fibrillation Patients With a Low CHA2DS2-VA Score. Front Cardiovasc Med 2022; 9:869862. [PMID: 35770214 PMCID: PMC9234162 DOI: 10.3389/fcvm.2022.869862] [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: 02/05/2022] [Accepted: 05/09/2022] [Indexed: 11/21/2022] Open
Abstract
Background Non-valvular atrial fibrillation (NVAF) in patients at low risk of thromboembolism (TE) does not mean “no risk.” We sought to assess the risk factors associated with TE in clinically low-risk AF patients with a non-gender CHA2DS2-VASc score (CHA2DS2-VA score) of 0 or 1. Methods In this single-center cross-sectional study, NVAF patients with a CHA2D-VA score of 0 or 1 who underwent index high-density bipolar voltage mapping of the left atrium (LA) and AF ablation were consecutively enrolled from 2017 to 2020. The population was divided into patients with and without TE history before voltage mapping. AF patients with CHA2DS2-VA score of 0 to 1 before TE (TE group) were analyzed and compared with clinically low-risk AF patients without TE history (non-TE group). The association among LA low voltage area (LVA), other clinical factors and TE history was analyzed with logistic regression. Results In the TE group, LVA was more prevalent [15/25 (60%) vs. 105/359 (29.2%), p = 0.003] and more preferentially located at the anterior wall [8/15 (53%) vs. 24/105 (23%), p = 0.025]. Among patients with LVA, the activation time from the sinus node to the left atrial appendage was significantly longer in the TE group (77.09 ± 21.09 vs. 57.59 ± 15.19 ms, p < 0.001). Multivariate analysis demonstrated that LVA at the anterior wall of the LA [OR: 4.17 (95% CI: 1.51 to 11.51); p = 0.006] and being female [OR: 3.40 (95% CI: 1.36 to 8.51); p = 0.009] were associated with TE history. Conclusions LVA at the anterior wall of the LA is associated with TE history in NVAF patients with a low CHA2DS2-VA score.
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Affiliation(s)
- Xiangwei Ding
- School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Cardiology, Taizhou People's Hospital, Taizhou, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianqing Li
- School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Jianqing Li
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Minglong Chen
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Kiedrowicz RM, Wielusinski M, Wojtarowicz A, Kazmierczak J. Left and right atrial appendage functional features as predictors for voltage-defined left atrial remodelling in patients with long-standing persistent atrial fibrillation. Heart Vessels 2021; 36:853-862. [PMID: 33386923 PMCID: PMC8093174 DOI: 10.1007/s00380-020-01752-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/04/2020] [Indexed: 12/03/2022]
Abstract
It was hypothesised that left atrial (LA) fibrosis identified by the presence of low-voltage areas (LVA) may influence the mechanical and electrical function of the left (LAA) and right (RAA) atrial appendage among the long-standing persistent atrial fibrillation (LSPAF) population. 140 consecutive patients underwent voltage mapping of LA with a multielectrode catheter following pulmonary vein isolation and restoration of sinus rhythm with cardioversion. Echocardiography determined LAA peak outflow and inflow velocities and intracardiac catheter-based mean LAA and RAA AF cycle length (AFCL) were obtained during AF before ablation. The impact of flow velocities and AFCL on the prevalence and location of LVA was further evaluated. LVA were detected in 54% of the patients. 14% of the patients presented severe global LVA burden > 20% of the total LA surface area. 29% of the patients presented a disseminated pattern of remodelling as 3 out of 5 LA segments were affected. LAA AFCL, RAA AFCL, LAA flow velocities did not predict the absolute presence of LVA. However LAA AFCL > 155 ms predicted disseminated LVA pattern and LAA AFCL > 165 ms severe LVA incidence. LAA AFCL > 155 ms was predictive for existence of LVA within antero-septal LA segments whilst LAA emptying velocity ≤ 0.2 m/s within lateral wall. Moreover RAA AFCL > 165 ms was strongly related to the presence of LAA AFCL > 15 ms and > 165 ms. LAA and RAA functional assessment was predictive of the presence of advanced stages of voltage-defined LA fibrosis and its regional distribution among LSPAF population.
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Affiliation(s)
- Radoslaw Marek Kiedrowicz
- Cardiology Department, Pomeranian Medical University, Powstancow Wlkp. 72, 70-111, Szczecin, Poland.
| | - Maciej Wielusinski
- Cardiology Department, Pomeranian Medical University, Powstancow Wlkp. 72, 70-111, Szczecin, Poland
| | - Andrzej Wojtarowicz
- Cardiology Department, Pomeranian Medical University, Powstancow Wlkp. 72, 70-111, Szczecin, Poland
| | - Jaroslaw Kazmierczak
- Cardiology Department, Pomeranian Medical University, Powstancow Wlkp. 72, 70-111, Szczecin, Poland
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Hayashida S, Nagashima K, Kurokawa S, Arai M, Watanabe R, Wakamatsu Y, Otsuka N, Yagyu S, Iso K, Okumura Y. Formation of low-voltage zones on the anterior left atrial wall due to mechanical compression by the ascending aorta. J Cardiovasc Electrophysiol 2021; 32:2275-2284. [PMID: 33969564 DOI: 10.1111/jce.15076] [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: 01/23/2021] [Revised: 04/09/2021] [Accepted: 04/27/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although low-voltage zones (LVZs) in the left atrium (LA) are considered arrhythmogenic substrates in some patients with atrial fibrillation (AF), the pathophysiologic factors responsible for LVZ formations remain unclear. OBJECTIVE To elucidate the anatomical relationship between the LA and ascending aorta responsible for anterior LA wall remodeling. METHODS We assessed the relationship between existence of LVZs on the anterior LA wall and the three-dimensional computed tomography image measurements in 102 patients who underwent AF ablation. RESULTS Twenty-nine patients (28%) had LVZs grearer than 1.0 cm2 on the LA wall in the LA-ascending aorta contact area (LVZ group); no LVZs were seen in the other 73 patients (no-LVZ group). The LVZ group (vs. no-LVZ group) had a smaller aorta-LA angle (21.0 ± 7.7° vs. 24.9 ± 7.1°, p = .015), greater aorta-left-ventricle (LV) angle (131.3 ± 8.8° vs. 126.0 ± 7.9°; p = .005), greater diameter of the noncoronary cusp (NCC; 20.4 ± 2.2 vs. 19.3 ± 2.5 mm; p = .036), thinner LA wall-thickness adjacent to the NCC (2.3 ± 0.7 vs. 2.8 ± 0.8 mm; p = .006), and greater cardiothoracic ratio (percentage of the area in the thoracic area, 40.1 ± 7.1% vs. 35.4 ± 5.7%, p < .001). The aorta-LA angle correlated positively with the patients' body mass index (BMI), and the aorta-LV angle correlated negatively with the body weight and BMI. CONCLUSION Deviation of the ascending aorta's course and distention of the NCC appear to be related to the development of LA anterior wall LVZs in the LA-ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with the limited thoracic space may contribute to the development of LVZs associated with AF.
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Affiliation(s)
- Satoshi Hayashida
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Cardiology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Arai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ryuta Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Naoto Otsuka
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Seina Yagyu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuki Iso
- Department of Cardiology, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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Quah JX, Dharmaprani D, Tiver K, Lahiri A, Hecker T, Perry R, Selvanayagam JB, Joseph MX, McGavigan A, Ganesan A. Atrial fibrosis and substrate based characterization in atrial fibrillation: Time to move forwards. J Cardiovasc Electrophysiol 2021; 32:1147-1160. [PMID: 33682258 DOI: 10.1111/jce.14987] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia in clinical practice. However, current therapeutic interventions for atrial fibrillation have limited clinical efficacy as a consequence of major knowledge gaps in the mechanisms sustaining atrial fibrillation. From a mechanistic perspective, there is increasing evidence that atrial fibrosis plays a central role in the maintenance and perpetuation of atrial fibrillation. Electrophysiologically, atrial fibrosis results in alterations in conduction velocity, cellular refractoriness, and produces conduction block promoting meandering, unstable wavelets and micro-reentrant circuits. Clinically, atrial fibrosis has also linked to poor clinical outcomes including AF-related thromboembolic complications and arrhythmia recurrences post catheter ablation. In this article, we review the pathophysiology behind the formation of fibrosis as AF progresses, the role of fibrosis in arrhythmogenesis, surrogate markers for detection of fibrosis using cardiac magnetic resonance imaging, echocardiography and electroanatomic mapping, along with their respective limitations. We then proceed to review the current evidence behind therapeutic interventions targeting atrial fibrosis, including drugs and substrate-based catheter ablation therapies followed by the potential future use of electro phenotyping for AF characterization to overcome the limitations of contemporary substrate-based methodologies.
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Affiliation(s)
- Jing X Quah
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia.,College of Science and Engineering, Flinders University of South Australia, Adelaide, Australia
| | - Kathryn Tiver
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Anandaroop Lahiri
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Teresa Hecker
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Rebecca Perry
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia.,UniSA Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | | | - Majo X Joseph
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | | | - Anand Ganesan
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia.,Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
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