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Negishi K, Okumura K, Onishi F, Yoshimura A, Okamatsu H, Tsurugi T, Tanaka Y, Sakai Y, Nakao K, Sakamoto T, Koyama J, Tomita H. Posterior wall thickness of the confluent inferior pulmonary veins measured by left atrial intracardiac echocardiography: implications for catheter ablation. J Interv Card Electrophysiol 2024; 67:193-201. [PMID: 37490133 PMCID: PMC10770267 DOI: 10.1007/s10840-023-01613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/18/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Confluent inferior pulmonary veins (CIPV) is a rare anatomical variant. There is few evidence in the literature regarding anatomic landmarks consideration to guide radiofrequency application in avoiding complications in the esophagus in CIPV cases. METHODS Of 986 consecutive patients undergoing atrial fibrillation (AF) ablation from July 2020 to June 2022, seven (0.7%) had CIPV with a common trunk connecting to the LA diagnosed by 3-dimensional contrast-enhanced computed tomography. Using intracardiac echocardiography (ICE) performed from the left atrium (LA), we measured the posterior wall thickness (PWT) of the CIPV adjacent to the esophagus and compared the measurement with the LA posterior wall thickness (LAPWT) at the left inferior PV level of 25 controls without CIPV. For ablation in CIPV patients, each superior PV was individually isolated, and box isolation of CIPV without ablating the CIPV posterior wall was added (tri-circle ablation technique). RESULTS The CIPV PWT was 0.7 ± 0.1 mm, while non-CIPV LAPWT was 2.0 ± 0.4 mm (P < 0.001). In the CIPV group, upper and lower portions of the CIPV were both apart from the esophagus (mean distances, 6.7 ± 3.4 mm and 7.9 ± 2.7 mm, respectively). Individual superior PV isolation and box CIPV isolation resulted in complete isolation of all PVs, with no complications. All CIPV patients except one remained AF recurrence-free for 376 ± 52 days. CONCLUSIONS Although CIPV frequency is low, CIPV PWT is very thin and special care is needed during ablation. A "tri-circle" ablation strategy avoids ablating in the thinnest portion of the posterior wall. Further studies are warranted to assess the safety.
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Affiliation(s)
- Kodai Negishi
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan.
| | - Fumitaka Onishi
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Akino Yoshimura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Hideharu Okamatsu
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Takuo Tsurugi
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Yasuaki Tanaka
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Yoshiro Sakai
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Junjiro Koyama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, 5-3-1 Chikami Minami-Ku, Kumamoto, 861-4193, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Okamatsu H, Okumura K, Onishi F, Yoshimura A, Negishi K, Tanaka Y, Tsurugi T, Nakao K, Sakamoto T, Koyama J. Predictors of pulmonary vein non-reconnection in the second procedure after ablation index-guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome. J Cardiovasc Electrophysiol 2023; 34:2452-2460. [PMID: 37787003 DOI: 10.1111/jce.16084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/04/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Although first-pass isolation (FPI) of the pulmonary vein (PV) has been suggested as a marker for PV isolation (PVI) durability, it has not been confirmed. Non-PV atrial fibrillation (AF) triggers were the main target in patients without PV reconnection in the second ablation procedure, but the outcome was unclear. We aimed to validate FPI as a marker of PVI durability and evaluate the outcome after the second procedure in patients without PV reconnection by comparing it to those with reconnection. METHODS Among the 2087 patients undergoing the first ablation index-guided radiofrequency AF ablation, 309 with atrial tachyarrhythmias (ATs) recurrence and undergoing the second procedure were studied. Clinical characteristics and outcomes were compared between the patients without PV reconnection (PV non-reconnection group, n = 142) and with reconnection (PV reconnection group, n = 167). RESULTS FPI in both PV sides in the first ablation procedure was significantly more frequent in the PV non-reconnection group (77.5%) than in the PV reconnection group (45.5%) (p < .001). Multivariate logistic regression analysis revealed that FPI (odds ratio, 3.71 [95% confidence interval, 2.23-6.19], p < .001) was the only predictor of PV non-reconnection. Radiofrequency applications for non-PV AF triggers were more frequently performed in the PV non-reconnection group (40.8% vs. 24.6%, respectively, p < .001). Kaplan-Meier analysis revealed that AT recurrence-free rate was significantly lower in the PV non-reconnection group (1-year recurrence-free rate, 62.7% vs. 75.4%, respectively; p = .01 by log-rank test). CONCLUSION FPI was the only independent predictor of PV non-reconnection. Despite aggressive ablation for non-PV triggers, AT recurrence was more frequent in patients with PV non-reconnection.
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Affiliation(s)
- Hideharu Okamatsu
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Fumitaka Onishi
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Akino Yoshimura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kodai Negishi
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Yasuaki Tanaka
- Division of Cardiology, Saiseikai Misumi Hospital, Kumamoto, Japan
| | - Takuo Tsurugi
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Junjiro Koyama
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
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Teres C, Soto-Iglesias D, Penela D, Falasconi G, Viveros D, Meca-Santamaria J, Bellido A, Alderete J, Chauca A, Ordoñez A, Martí-Almor J, Scherer C, Panaro A, Carballo J, Cámara Ó, Ortiz-Pérez JT, Berruezo A. Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial. J Interv Card Electrophysiol 2022; 65:651-661. [PMID: 35861901 DOI: 10.1007/s10840-022-01302-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation. METHODS Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol. RESULTS Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise (> 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p < 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4). CONCLUSION The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).
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Affiliation(s)
- Cheryl Teres
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain.,Lausanne University Hospital, Lausanne, Switzerland
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Diego Penela
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Giulio Falasconi
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Daniel Viveros
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | | | - Aldo Bellido
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Jose Alderete
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Alfredo Chauca
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Augusto Ordoñez
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Julio Martí-Almor
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Claudia Scherer
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Alejandro Panaro
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Julio Carballo
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain
| | - Óscar Cámara
- Department of Information and Communication Technologies, BCN-MedTech, Universitat Pompeu Fabra, PhySense group, Barcelona, Spain
| | | | - Antonio Berruezo
- Heart Institute, Teknon Medical Center, C/Vilana, 12; 08022, Barcelona, Spain.
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