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Segan L, Chieng D, Crowley R, William J, Sugumar H, Ling LH, Hawson J, Prabhu S, Voskoboinik A, Morton JB, Lee G, Sterns LD, Ginks M, Sanders P, Kalman JM, Kistler PM. Sex-specific outcomes after catheter ablation for persistent AF. Heart Rhythm 2024; 21:762-770. [PMID: 38336190 DOI: 10.1016/j.hrthm.2024.02.008] [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: 12/20/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Sex-specific outcomes after catheter ablation (CA) for atrial fibrillation (AF) have reported conflicting findings. OBJECTIVE We examined the impact of female sex on outcomes in patients with persistent AF (PsAF) from the Catheter Ablation for Persistent Atrial Fibrillation: A Multicentre Randomized Trial of Pulmonary Vein Isolation vs PVI with Posterior Left Atrial Wall Isolation (CAPLA) randomized trial. METHODS A total of 338 patients with PsAF were randomized to pulmonary vein isolation (PVI) or PVI with posterior wall isolation (PWI). The primary outcome was arrhythmia recurrence at 12 months. Clinical and electroanatomical characteristics, arrhythmia recurrence, and quality of life were compared between women and men. RESULTS Seventy-nine women (23.4%; PVI 37; PVI + PWI 42) and 259 men (76.6%; PVI 131; PVI + PWI 128) underwent AF ablation. Women were older {median age 70.4 (interquartile range [IQR] 64.8-74.6) years vs 64.0 (IQR 56.7-69.7) years; P < .001} and had more advanced left atrial electroanatomical remodeling. At 12 months, arrhythmia-free survival was lower in women (44.3% vs 56.8% in men; hazard ratio 1.44; 95% confidence interval 1.02-2.04; log-rank, P = .036). PWI did not improve arrhythmia-free survival at 12 months (hazard ratio 1.02; 95% confidence interval 0.74-1.40; log-rank, P = .711). The median AF burden was 0% in both groups (women: IQR 0.0%-2.2% vs men: IQR 0.0%-2.8%; P = .804). Health care utilization was comparable between women (36.7%) and men (30.1%) (P = .241); however, women were more likely to undergo a repeat procedure (17.7% vs 6.9%; P = .007). Women reported more severe baseline anxiety (average Hospital Anxiety and Depression Scale [HADS] anxiety score 7.5 ± 4.9 vs 6.3 ± 4.3 in men; P = .035) and AF-related symptoms (baseline Atrial Fibrillation Effect on Quality-of-Life Questionnaire [AFEQT] score 46.7 ± 20.7 vs 55.9 ± 23.0 in men; P = .002), with comparable improvements in psychological symptoms (change in HADS anxiety score -3.8 ± 4.6 vs -3.0 ± 4.5; P = .152 (change in HADS depression score -2.9 ± 5.0 vs -2.6 ± 4.0; P = .542) and greater improvement in AFEQT score compared with men at 12 months (change in AFEQT score +45.9 ± 23.1 vs +39.2 ± 24.8; P = .048). CONCLUSION Women undergoing CA for PsAF report more significant symptoms and poorer quality of life at baseline than men. Despite higher arrhythmia recurrence and repeat procedures in women, the AF burden was comparably low, resulting in significant improvements in quality of life and psychological well-being after CA in both sexes.
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Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Rose Crowley
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Jeremy William
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Mulgrave Private Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Joseph B Morton
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Laurence D Sterns
- Royal Jubilee Hospital, Department of Cardiology, Vancouver Island, British Columbia, Canada
| | - Matthew Ginks
- John Radcliffe Hospital, Department of Cardiology, Oxford, United Kingdom
| | - Prashanthan Sanders
- Royal Adelaide Hospital, Department of Cardiology, Adelaide, South Australia, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Department of Cardiology, Melbourne, Victoria, Australia; Melbourne Private Hospital, Department of Cardiology, Melbourne, Victoria, Australia
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Victoria, Australia; The Alfred Hospital, Department of Cardiology, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Monash University, Melbourne Victoria, Australia; Cabrini Hospital, Department of Cardiology, Melbourne, Victoria, Australia; Melbourne Private Hospital, Department of Cardiology, Melbourne, Victoria, Australia.
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Weipert KF, Hutter J, Kuniss M, Kahle P, Yogarajah J, Hain A, Sperzel J, Berkowitsch A, Hamm CW, Neumann T. Pulmonary Vein Isolation Followed by Biatrial Ablation of Rotational Activity in Patients with Persistent Atrial Fibrillation: Results of the Cryo-Vest Study. J Clin Med 2024; 13:1118. [PMID: 38398432 PMCID: PMC10889131 DOI: 10.3390/jcm13041118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Background and Aims: Noninvasive mapping allows the identification of patient-specific atrial rotational activity (RA) that might play a key role in the perpetuation of persistent atrial fibrillation (PsAF). So far, the impact of pulmonary vein isolation by cryoballoon (Cryo-PVI) on RA is unclear. Moreover, the long-term effect of periprocedural termination of AF during the ablation procedure is controversial. Methods: Noninvasive electrocardiographic mapping with a 252-electrode vest was performed in 42 patients with PsAF. After the first analysis, Cryo-PVI was performed. The RA was analyzed again and then targeted by radiofrequency catheter ablation. The primary clinical endpoint was periprocedural termination of AF. The secondary endpoint was freedom from any atrial arrhythmia >30 s during a 12-month follow-up. Results: In 33 patients (79%), right atrial RA was identified leading to biatrial ablation, and nine patients (21%) had left atrial RA only. Twelve patients (28.6%) converted from AF to sinus rhythm (SR) (Group A). Thirteen patients (30.9%) converted to atrial tachycardia (AT) (Group B). In 17 patients (40.5%), AF was not terminated by ablation (Group C). After a mean follow-up time of 13.8 months, 26 patients were free from AF and AT (61.9%). In terms of rhythm, control Group A (75%) and B (83.3%) showed higher success rates than Group C (33.3%) (p < 0.01). Cryo-PVI had no substantial impact on RA. Conclusions: The RA-based ablation approach showed acceptable success rates. Periprocedural termination of AF had a positive predictive impact on the outcome. No difference was observed between conversion to SR or to AT. Cryo-PVI had no impact on RA.
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Affiliation(s)
- Kay Felix Weipert
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Julie Hutter
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Malte Kuniss
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Patrick Kahle
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Joerg Yogarajah
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Andreas Hain
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Johannes Sperzel
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Alexander Berkowitsch
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
- German Center for Cardiovascular Research (DZHK), Rhein-Main Partner Site, 61231 Bad Nauheim, Germany
| | - Thomas Neumann
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany; (J.H.); (M.K.); (P.K.); (J.Y.); (A.H.); (J.S.); (A.B.); (C.W.H.); (T.N.)
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Janosi KF, Debreceni D, Bocz B, Torma D, Keseru M, Simor T, Kupo P. The Influence of Different Multipolar Mapping Catheter Types on Procedural Outcomes in Patients Undergoing Pulmonary Vein Isolation for Atrial Fibrillation. J Clin Med 2024; 13:1029. [PMID: 38398342 PMCID: PMC10889293 DOI: 10.3390/jcm13041029] [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: 12/28/2023] [Revised: 01/27/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), multipolar mapping catheters (MMC) are often used. We aimed to compare the procedural outcomes of two MMCs, specifically a circular-shaped and a five-spline-shaped MMC. (2) Methods: We enrolled 70 consecutive patients in our prospective, observational trial undergoing PVI procedures for paroxysmal AF. The initial 35 patients underwent PVI procedures with circular-shaped MMC guidance (Lasso Group), and the procedures for the latter 35 cases were performed using five-spline-shaped MMC (PentaRay Group). (3) Results: No significant differences were identified between the two groups in total procedure time (80.2 ± 17.7 min vs. 75.7 ± 14.8 min, p = 0.13), time from femoral vein puncture to the initiation of the mapping (31.2 ± 7 min vs. 28.9 ± 6.8, p = 0.80), mapping time (8 (6; 13) min vs. 9 (6.5; 10.5) min, p = 0.73), duration between the first and last ablation (32 (30; 36) min vs. 33 (26; 40) min, p = 0.52), validation time (3 (2; 4) min vs. 3 (1; 5) min, p = 0.46), first pass success rates (89% vs. 91%, p = 0.71), left atrial dwelling time (46 (37; 53) min vs. 45 (36.5; 53) min, p = 0.56), fluoroscopy data (time: 150 ± 71 s vs. 143 ± 56 s, p = 0.14; dose: 6.7 ± 4 mGy vs. 7.4 ± 4.4 mGy, p = 0.90), total ablation time (1187 (1063; 1534) s vs. 1150.5 (1053; 1393.5) s, p = 0.49), the number of ablations (78 (73; 93) vs. 83 (71.3; 92.8), p = 0.60), and total ablation energy (52,300 (47,265; 66,804) J vs. 49,666 (46,395; 56,502) J, p = 0.35). (4) Conclusions: This study finds comparable procedural outcomes bet-ween circular-shaped and five-spline-shaped MMCs for PVI in paroxysmal AF, supporting their interchangeability in clinical practice for anatomical mapping.
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Affiliation(s)
| | | | | | | | | | | | - Peter Kupo
- Heart Institute, Medical School, University of Pecs, 7624 Pecs, Hungary (M.K.)
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Calvert P, Ding WY, Griffin M, Bisson A, Koniari I, Fitzpatrick N, Snowdon R, Modi S, Luther V, Mahida S, Waktare J, Borbas Z, Ashrafi R, Todd D, Gupta D. Silent pulmonary veins at redo ablation for atrial fibrillation: Implications and approaches. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01750-w. [PMID: 38261098 DOI: 10.1007/s10840-024-01750-w] [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: 12/21/2023] [Accepted: 01/14/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Despite promising success rates, redo ablation is sometimes required. At redo, PVs may be found to be isolated (silent) or reconnected. We studied patients with silent vs reconnected PVs at redo and analysed associations with adverse outcomes. METHODS Patients undergoing redo AF ablations between 2013 and 2019 at our institution were included and stratified into silent PVs or reconnected PVs. The primary outcome was a composite of further redo ablation, non-AF ablation, atrioventricular nodal ablation, and death. Secondary outcomes included arrhythmia recurrence. RESULTS A total of 467 patients were included with mean 4.6 ± 1.7 years follow-up, of whom 48 (10.3%) had silent PVs. The silent PV group had had more often undergone >1 prior ablation (45.8% vs 9.8%; p<0.001), had more persistent AF (62.5% vs 41.1%; p=0.005) and had more non-PV ablation performed both at prior ablation procedures and at the analysed redo ablation. The primary outcome occurred more frequently in those with silent PVs (25% vs 13.8%; p=0.053). Arrhythmia recurrence was also more common in the silent PV group (66.7% vs 50.6%; p=0.047). After multivariable adjustment, female sex (aHR 2.35 [95% CI 2.35-3.96]; p=0.001) and ischaemic heart disease (aHR 3.21 [95% CI 1.56-6.62]; p=0.002) were independently associated with the primary outcome, and left atrial enlargement (aHR 1.58 [95% CI 1.20-2.08]; p=0.001) and >1 prior ablation (aHR 1.88 [95% CI 1.30-2.72]; p<0.001) were independently associated with arrhythmia recurrence. Whilst a finding of silent PVs was not itself significant after multivariable adjustment, this provides an easily assessable parameter at clinically indicated redo ablation which informs the clinician of the likelihood of a worse future prognosis. CONCLUSIONS Patients with silent PVs at redo AF ablation have worse clinical outcomes.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Michael Griffin
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Arnaud Bisson
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
- Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France
| | - Ioanna Koniari
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Noel Fitzpatrick
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Richard Snowdon
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Simon Modi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Johan Waktare
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Zoltan Borbas
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Reza Ashrafi
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool, L14 3PE, UK.
- Department of Cardiology, Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool, L14 3PE, UK.
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Segan L, Chieng D, Prabhu S, Hunt A, Watts T, Klys B, Voskoboinik A, Sugumar H, Ling LH, Lee G, Morton J, Pathak RK, Chandh Raja D, Sterns L, Ginks M, Sanders P, Kalman JM, Kistler PM. Posterior Wall Isolation Improves Outcomes for Persistent AF With Rapid Posterior Wall Activity: CAPLA Substudy. JACC Clin Electrophysiol 2023; 9:2536-2546. [PMID: 37702654 DOI: 10.1016/j.jacep.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is less effective in persistent atrial fibrillation (PerAF) than in paroxysmal atrial fibrillation (AF). However, the CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA randomized clinical trial) of PVI vs posterior wall isolation (PWI) did not support empiric PWI in PerAF. We examined pulmonary vein (PV) and posterior wall (PW) electrical characteristics to determine if select patients may benefit from additional PWI. OBJECTIVES This study sought to determine the impact of PV and PW electrical characteristics on AF ablation outcomes in the CAPLA randomized study. METHODS Participants in spontaneous AF at the time of ablation were included from the CAPLA study. The mean, shortest, and longest PV, PW, and left atrial (LA) appendage cycle length measurements were annotated preablation using a multipolar catheter for 100 consecutive cycles. Next, cardioversion was performed with a high-density LA voltage map completed. Cox proportional hazards regression was utilized to determine clinical and electroanatomic predictors of AF recurrence overall and according to ablation strategy. Follow-up included twice daily single-lead electrocardiograms or continuous monitoring for 12 months. RESULTS A total of 151 patients (27% female, age 65 ± 9 years, 18% long-standing PerAF, LA volume index 52 ± 16 mL/m2, median AF duration 5 months [IQR: 2-10 months]) were in AF on the day of procedure and were randomized to PVI alone (50%) or PVI+PWI (50%) according to the CAPLA randomized clinical trial protocol. Baseline clinical, echocardiographic, and electroanatomic parameters were comparable between groups (all P > 0.05) including PV and PW characteristics. After 12 months, freedom from AF off antiarrhythmic drug therapy was 51.7% in PVI and 49.7% in PVI+PWI (log-rank P = 0.564). Rapid PW activity was defined as less than the median of the shortest PW cycle length (140 ms) and rapid PV activity was defined as less than the median of the shortest PV cycle length (126 ms). In those with rapid PW activity, the addition of PWI was associated with greater arrhythmia-free survival (56.4%) vs PVI alone (38.6%) (HR: 0.78; 95% CI: 0.67-0.94; log-rank P = 0.030). Moreover, in those undergoing PVI only, the risk of AF recurrence was higher in those with rapid PW activity (55.3% vs 46.5% in slower PW activity; HR: 1.50, 95%CI 1.11-2.26; log-rank P = 0.036). Rapid PV activity and PV cycle length (individual PVs or average of all 4 PVs) were not associated with outcome (all P > 0.05) regardless of ablation strategy. There was no correlation between PW cycle length and posterior low voltage (r = -0.06, P = 0.496). The addition of PWI did not improve arrhythmia-free survival in subgroups with LA enlargement (LA volume index >34 mL/m2) (HR: 0.69; 95% CI: 0.39-1.25; P = 0.301), posterior low-voltage zone (HR: 1.06; 95% CI: 0.68-1.66; P = 0.807), or long-standing PerAF (HR: 1.10; 95% CI: 0.71-1.72; P = 0.669). CONCLUSIONS Rapid PW activity is associated with an increased risk of AF recurrence post-catheter ablation. The addition of PWI in this subgroup was associated with a significant improvement in freedom from AF compared with PVI alone. The presence of rapid PW activity may identify patients with PerAF likely to benefit from PWI.
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Affiliation(s)
- Louise Segan
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - David Chieng
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Sandeep Prabhu
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | | | - Troy Watts
- Royal Melbourne Hospital, Melbourne, Australia
| | - Brian Klys
- Melbourne Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Geoff Lee
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Joseph Morton
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Rajeev K Pathak
- Canberra Hospital, Canberra, Australia; Australian National University, Canberra, Australia
| | - Deep Chandh Raja
- Canberra Hospital, Canberra, Australia; Australian National University, Canberra, Australia
| | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | - Prashanthan Sanders
- Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Peter M Kistler
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.
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Thind M, Arceluz MR, Lucena-Padros I, Kubala M, Mirwais M, Bode W, Cerantola M, Sugrue A, Van Niekerk C, Vigdor A, Patel NA, AlSalem AB, Zado ES, Kumareswaran R, Lin D, Arkles JS, Garcia FC, Guandalini GS, Markman TM, Riley MP, Deo R, Schaller RD, Nazarian S, Dixit S, Epstein AE, Supple GE, Frankel DS, Tschabrunn CM, Santangeli P, Callans DJ, Hyman MC, Marchlinski FE. Identifying Origin of Nonpulmonary Vein Triggers Using 2 Stationary Linear Decapolar Catheters: A Novel Algorithm. JACC Clin Electrophysiol 2023; 9:2275-2287. [PMID: 37737775 DOI: 10.1016/j.jacep.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/06/2023] [Accepted: 07/15/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Targeting nonpulmonary vein triggers (NPVTs) of atrial fibrillation (AF) after pulmonary vein isolation can be challenging. NPVTs are often single ectopic beats with a surface P-wave obscured by a QRS or T-wave. OBJECTIVES The goal of this study was to construct an algorithm to regionalize the site of origin of NPVTs using only intracardiac bipolar electrograms from 2 linear decapolar catheters positioned in the posterolateral right atrium (along the crista terminalis with the distal bipole pair in the superior vena cava) and in the proximal coronary sinus (CS). METHODS After pulmonary vein isolation in 42 patients with AF, pacing from 15 typical anatomic NPVT sites was conducted. For each pacing site, the electrogram activation sequence was analyzed from the CS catheter (simultaneous/chevron/inverse chevron/distal-proximal/proximal-distal) and activation time (ie, CSCTAT) between the earliest electrograms from the 2 decapolar catheters was measured referencing the earliest CS electrogram; a negative CSCTAT value indicates the crista terminalis catheter electrogram was earlier, and a positive CSCTAT value indicates the CS catheter electrogram was earlier. A regionalization algorithm with high predictive value was defined and tested in a validation cohort with AF NPVTs localized with electroanatomic mapping. RESULTS In the study patient cohort (71% male; 43% with persistent AF, 52% with left atrial dilation), the algorithm grouped with high precision (positive predictive value 81%-99%, specificity 94%-100%, and sensitivity 30%-94%) the 15 distinct pacing sites into 9 clinically useful regions. Algorithm testing in a 98 patient validation cohort showed predictive accuracy of 91%. CONCLUSIONS An algorithm defined by the activation sequence and timing of electrograms from 2 linear multipolar catheters provided accurate regionalization of AF NPVTs to guide focused detailed mapping.
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Affiliation(s)
- Munveer Thind
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martín R Arceluz
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Irene Lucena-Padros
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maciej Kubala
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maiwand Mirwais
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Weeranun Bode
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maxime Cerantola
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan Sugrue
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christoffel Van Niekerk
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aaron Vigdor
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel A Patel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ahmed B AlSalem
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Arkles
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin C Garcia
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rajat Deo
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew E Epstein
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cory M Tschabrunn
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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William J, Chieng D, Sugumar H, Ling LH, Segan L, Crowley R, Al-Kaisey A, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Lee G, McLellan AJ, Wong M, Pathak RK, Sterns L, Ginks M, Reid CM, Sanders P, Kalman JM, Kistler PM. The Role of Posterior Wall Isolation in Catheter Ablation for Persistent Atrial Fibrillation and Systolic Heart Failure: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2023; 8:1077-1082. [PMID: 37755920 PMCID: PMC10534992 DOI: 10.1001/jamacardio.2023.3208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/30/2023] [Indexed: 09/28/2023]
Abstract
Importance Catheter ablation for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) is associated with improved left ventricular ejection fraction (LVEF) and survival compared with medical therapy. Nonrandomized studies have reported improved success with posterior wall isolation (PWI). Objective To determine the impact of pulmonary vein isolation (PVI) with PWI vs PVI alone on outcomes in patients with HFrEF. Design, Setting, and Participants This was an ad hoc secondary analysis of the CAPLA trial, a multicenter, prospective, randomized control trial that involved 11 centers in 3 countries (Australia, Canada, and UK). CAPLA featured 338 patients with persistent AF randomized to either PVI plusPWI or PVI alone. This substudy included patients in the original CAPLA study who had symptomatic HFrEF (LVEF <50% and New York Heart Association class ≥II). Interventions Pulmonary vein isolation with PWI vs PVI alone. Main Outcomes and Measures The primary end point was freedom from any documented atrial arrhythmia greater than 30 seconds, after a single ablation procedure, without the use of antiarrhythmic drug (AAD) therapy at 12 months. Results A total of 98 patients with persistent AF and symptomatic HFrEF were identified (mean [SD] age, 62.1 [9.8] years; 79.5% men; and mean [SD] LVEF at baseline, 34.6% [7.9%]). After 12 months, 58.7% of patients with PVI plus PWI were free from recurrent atrial arrhythmia without the use of AAD therapy vs 61.5% with PVI alone (hazard ratio, 1.02; 95% CI, 0.54-1.91; P = .96). There were no significant differences in freedom from atrial arrhythmia with or without AAD therapy after multiple procedures (PVI plus PWI vs PVI alone, 60.9% vs 65.4%; P = .73) or AF burden (median, 0% in both groups; P = .78). Mean LVEF improved substantially in PVI plus PWI (∆ LVEF, 19.3% [13.0%; P < .01) and PVI alone (18.2% [14.1%; P < .01), with no difference between groups (P = .71). Normalization of LV function occurred in 65.2% of patients in the PVI plus PWI group and 50.0% of patients with PVI alone (P = .13). Conclusions and Relevance The results of this study indicate that addition of PWI to PVI did not improve freedom from arrhythmia recurrence or recovery of LVEF in patients with persistent AF and symptomatic HFrEF. Catheter ablation was associated with significant improvements in systolic function, irrespective of ablation strategy used. These results caution against the routine inclusion of PWI in patients with HFrEF undergoing first-time catheter ablation for persistent AF. Trial Registration http://anzctr.org.au Identifier: ACTRN12616001436460.
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Affiliation(s)
- Jeremy William
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - David Chieng
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Louise Segan
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Rose Crowley
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Geoffrey Wong
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B. Morton
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J. McLellan
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Rajeev K. Pathak
- Canberra Heart Rhythm Centre, Canberra Hospital, Australian Capital Territory, Australia
| | - Laurence Sterns
- Cardiac Electrophysiology Department, Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | - Matthew Ginks
- Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Prashanthan Sanders
- Department of Cardiac Electrophysiology and Pacing, Royal Adelaide Hospital, Adelaide, Australia
| | - Jonathan M. Kalman
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter M. Kistler
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Electrophysiology Research Group, The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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8
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De Lurgio DB. Selection of patients for hybrid ablation procedure. J Cardiovasc Electrophysiol 2023; 34:2179-2187. [PMID: 37003267 DOI: 10.1111/jce.15901] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/07/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
Catheter ablation for treatment of symptomatic non-paroxysmal atrial fibrillation remains challenging. Clinical failure and need for continued medical therapy or repeat ablation is common, especially in more advanced forms of atrial fibrillation. Hybrid ablation has emerged as a more effective and safe therapy than endocardial-only ablation particularly for longstanding persistent atrial fibrillation as demonstrated by the randomized controlled CONVERGE trial. Hybrid ablation requires collaboration of electrophysiologists and cardiac surgeons to develop specific workflows. This review describes the Hybrid Convergent approach in the context of available ablation options and offers guidance for workflow development and patient selection.
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Affiliation(s)
- David B De Lurgio
- Emory St. Joseph's Hospital Suite 300, Emory University, Atlanta, Georgia, USA
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Sau A, Kapadia S, Al-Aidarous S, Howard J, Sohaib A, Sikkel MB, Arnold A, Waks JW, Kramer DB, Peters NS, Ng FS. Temporal Trends and Lesion Sets for Persistent Atrial Fibrillation Ablation: A Meta-Analysis With Trial Sequential Analysis and Meta-Regression. Circ Arrhythm Electrophysiol 2023; 16:e011861. [PMID: 37589197 PMCID: PMC10510845 DOI: 10.1161/circep.123.011861] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Ablation for persistent atrial fibrillation (PsAF) has been performed for over 20 years, although success rates have remained modest. Several adjunctive lesion sets have been studied but none have become standard of practice. We sought to describe how the efficacy of ablation for PsAF has evolved in this time period with a focus on the effect of adjunctive ablation strategies. METHODS Databases were searched for prospective studies of PsAF ablation. We performed meta-regression and trial sequential analysis. RESULTS A total of 99 studies (15 424 patients) were included. Ablation for PsAF achieved the primary outcome (freedom of atrial fibrillation/atrial tachycardia rate at 12 months follow-up) in 48.2% (5% CI, 44.0-52.3). Meta-regression showed freedom from atrial arrhythmia at 12 months has improved over time, while procedure time and fluoroscopy time have significantly reduced. Through the use of cumulative meta-analyses and trial sequential analysis, we show that some ablation strategies may initially seem promising, but after several randomized controlled trials may be found to be ineffective. Trial sequential analysis showed that complex fractionated atrial electrogram ablation is ineffective and further study of this treatment would be futile, while posterior wall isolation currently does not have sufficient evidence for routine use in PsAF ablation. CONCLUSIONS Overall success rates from PsAF ablation and procedure/fluoroscopy times have improved over time. However, no adjunctive lesion set, in addition to pulmonary vein isolation, has been conclusively demonstrated to be beneficial. Through the use of trial sequential analysis, we highlight the importance of adequately powered randomized controlled trials, to avoid reaching premature conclusions, before widespread adoption of novel therapies.
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Affiliation(s)
- Arunashis Sau
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (A. Sau, J.H., A.A., N.S.P., F.S.N.)
| | - Sharan Kapadia
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
| | - Sayed Al-Aidarous
- UCL Institute of Cardiovascular Science, University College London, United Kingdom (S.A.-A.)
| | - James Howard
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
| | - Afzal Sohaib
- The Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom (A. Sohaib)
| | - Markus B. Sikkel
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
- Royal Jubilee Hospital, Victoria, Canada (M.B.S.)
| | - Ahran Arnold
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
| | - Jonathan W. Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.W.W.)
| | - Daniel B. Kramer
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D.B.K.)
| | - Nicholas S. Peters
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (A. Sau, J.H., A.A., N.S.P., F.S.N.)
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, United Kingdom (A. Sau, S.K., J.H., M.B.S., A.A., D.B.K., N.S.P., F.S.N.)
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom (A. Sau, J.H., A.A., N.S.P., F.S.N.)
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10
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Assaf A, Mekhael M, Noujaim C, Chouman N, Younes H, Feng H, ElHajjar A, Shan B, Kistler P, Kreidieh O, Marrouche N, Donnellan E. Effect of fibrosis regionality on atrial fibrillation recurrence: insights from DECAAF II. Europace 2023; 25:euad199. [PMID: 37428891 PMCID: PMC10519620 DOI: 10.1093/europace/euad199] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 06/06/2023] [Indexed: 07/12/2023] Open
Abstract
AIMS The amount of fibrosis in the left atrium (LA) predicts atrial fibrillation (AF) recurrence after catheter ablation (CA). We aim to identify whether regional variations in LA fibrosis affect AF recurrence. METHODS AND RESULTS This post hoc analysis of the DECAAF II trial includes 734 patients with persistent AF undergoing first-time CA who underwent late gadolinium enhancement magnetic resonance imaging (LGE-MRI) within 1 month prior to ablation and were randomized to MRI-guided fibrosis ablation in addition to standard pulmonary vein isolation (PVI) or standard PVI only. The LA wall was divided into seven regions: anterior, posterior, septal, lateral, right pulmonary vein (PV) antrum, left PV antrum, and left atrial appendage (LAA) ostium. Regional fibrosis percentage was defined as a region's fibrosis prior to ablation divided by total LA fibrosis. Regional surface area percentage was defined as an area's surface area divided by the total LA wall surface area before ablation. Patients were followed up for a year with single-lead electrocardiogram (ECG) devices. The left PV had the highest regional fibrosis percentage (29.30 ± 14.04%), followed by the lateral wall (23.23 ± 13.56%), and the posterior wall (19.80 ± 10.85%). The regional fibrosis percentage of the LAA was a significant predictor of AF recurrence post-ablation (odds ratio = 1.017, P = 0.021), and this finding was only preserved in patients receiving MRI-guided fibrosis ablation. Regional surface area percentages did not significantly affect the primary outcome. CONCLUSION We have confirmed that atrial cardiomyopathy and remodelling are not a homogenous process, with variations in different regions of the LA. Atrial fibrosis does not uniformly affect the LA, and the left PV antral region has more fibrosis than the rest of the wall. Furthermore, we identified regional fibrosis of the LAA as a significant predictor of AF recurrence post-ablation in patients receiving MRI-guided fibrosis ablation in addition to standard PVI.
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Affiliation(s)
- Ala Assaf
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Nour Chouman
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Hadi Younes
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Han Feng
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | | | - Botao Shan
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Peter Kistler
- Clinical Electrophysiology Research Laboratory, Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Omar Kreidieh
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Nassir Marrouche
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
| | - Eoin Donnellan
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, 1324 Tulane Avenue, Suite A128, New Orleans, LA 70112, USA
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11
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Almorad A, Del Monte A, Della Rocca DG, Pannone L, Ramak R, Overeinder I, Bala G, Ströker E, Sieira J, Dubois A, Sorgente A, El Haddad M, Iacopino S, Boveda S, de Asmundis C, Chierchia GB. Outcomes of pulmonary vein isolation with radiofrequency balloon vs. cryoballoon ablation: a multi-centric study. Europace 2023; 25:euad252. [PMID: 37671682 PMCID: PMC10481252 DOI: 10.1093/europace/euad252] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/14/2023] [Indexed: 09/07/2023] Open
Abstract
AIMS Cryoballoon (CB) ablation is the mainstay of single-shot pulmonary vein isolation (PVI). A radiofrequency balloon (RFB) catheter has recently emerged as an alternative. However, these two technologies have not been compared. This study aims to evaluate the freedom from atrial tachyarrhythmias (ATas) at 1 year: procedural characteristics, efficacy, and safety of the novel RFB compared with CB for PVI in patients with paroxysmal atrial fibrillation (AF). METHODS AND RESULTS This prospective multi-centre study included consecutive patients with symptomatic drug-resistant paroxysmal AF who underwent PVI with RFB or CB between July 2021 and January 2022 from three European centres. A total of 375 consecutive patients were included, 125 in the RFB group and 250 in the CB. Both groups had comparable clinical characteristics. At 12.33 ± 4.91 months, ATas-free rates were 83.20% and 82.00% in the RFB and CB groups, respectively (P > 0.05). Compared with the CB group, the RFB group showed a shorter procedure time [59.91 (45.80-77.12) vs. 77.0 (35.13-122.71) min (P < 0.001)], dwell time [19.59 (14.41-30.24) vs. 27.03 (17.11-57.21) min (P = 0.04)], time to isolation, and thermal energy delivery in all pulmonary veins (P < 0.001). First-pass isolation was comparable. No major complications occurred in either group, with no stroke, atrio-oesophageal fistula, or permanent phrenic nerve injury. Transient phrenic nerve palsy occurred more frequently with CB than RFB (7.20% vs. 3.20%; P = 0.02). Oesophageal temperature rise occurred in 21 (16.8%) patients in the RFB group, and gastroscopy showed erythema in two of them with complete recovery after 30 days. CONCLUSIONS The RFB appears to have a safety and efficacy profile similar to that of the CB for PVI. Shorter procedural times appear to be driven by shorter left atrial dwell and thermal delivery times.
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Affiliation(s)
- Alexandre Almorad
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alvise Del Monte
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Robbert Ramak
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Ingrid Overeinder
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Gezim Bala
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Erwin Ströker
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Aurélie Dubois
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | | | - Saverio Iacopino
- Arrhythmology Department, Maria Cecilia Hospital SPA, Cotignola, Italy
| | - Serge Boveda
- Département de Rythmologie, Clinique Pasteur, 45 avenue de Lombez, BP 27617, 31076 Toulouse Cedex 3, France
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklaan 101, 1090 Brussels, Belgium
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12
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Persistent atrial fibrillation ablation: the ongoing search for the perfect wave. J Interv Card Electrophysiol 2023; 66:257-259. [PMID: 36322372 DOI: 10.1007/s10840-022-01387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
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Kim D, Pak HN. Reply: The Clinical Outcomes and Success of Posterior Wall Isolation Using a "Box" Approach. JACC Clin Electrophysiol 2023; 9:262-263. [PMID: 36858698 DOI: 10.1016/j.jacep.2022.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 03/03/2023]
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Kistler PM, Chieng D, Sugumar H, Ling LH, Segan L, Azzopardi S, Al-Kaisey A, Parameswaran R, Anderson RD, Hawson J, Prabhu S, Voskoboinik A, Wong G, Morton JB, Pathik B, McLellan AJ, Lee G, Wong M, Finch S, Pathak RK, Raja DC, Sterns L, Ginks M, Reid CM, Sanders P, Kalman JM. Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA Randomized Clinical Trial. JAMA 2023; 329:127-135. [PMID: 36625809 PMCID: PMC9856612 DOI: 10.1001/jama.2022.23722] [Citation(s) in RCA: 106] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison. OBJECTIVE To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation. DESIGN, SETTING, AND PARTICIPANTS Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022. INTERVENTIONS The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone. MAIN OUTCOMES AND MEASURES Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications. RESULTS Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone. CONCLUSIONS AND RELEVANCE In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12616001436460.
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Affiliation(s)
- Peter M. Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Melbourne Private Hospital, Melbourne, Australia
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Ahmed Al-Kaisey
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | | | - Robert D. Anderson
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joshua Hawson
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Mulgrave Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Cabrini Hospital, Melbourne, Australia
| | - Geoffrey Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph B. Morton
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Bhupesh Pathik
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Alex J. McLellan
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- St Vincent’s Private Hospital Fitzroy, Melbourne, Australia
| | - Geoffrey Lee
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Wong
- University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
- Epworth Hospital Richmond, Melbourne, Australia
| | - Sue Finch
- University of Melbourne, Melbourne, Australia
| | - Rajeev K. Pathak
- Canberra Hospital, Australian Capital Territory, Australia
- Australian National University, Australian Capital Territory, Australia
| | - Deep Chandh Raja
- Canberra Hospital, Australian Capital Territory, Australia
- Australian National University, Australian Capital Territory, Australia
| | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | | | | | - Jonathan M. Kalman
- University of Melbourne, Melbourne, Australia
- Monash Health, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne, Australia
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Risk and benefit of extrapulmonary vein ablation in atrial fibrillation. Curr Opin Cardiol 2023; 38:1-5. [PMID: 36598443 DOI: 10.1097/hco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the recent development, benefit, and safety of extrapulmonary vein ablation for atrial fibrillation. RECENT FINDING Studies have shown that extrapulmonary vein ablation can help maintain normal sinus rhythm for patients with persistent atrial fibrillation. As prior strategies targeting anatomical lines and triggers are well utilized, novel techniques for substrate mapping have been rapidly developing. These strategies are well tolerated and could be chosen based on patients' conditions and physicians' experience. SUMMARY Extrapulmonary vein ablation could be safely and effectively performed for patients with atrial fibrillation. It provides further consolidation of normal sinus rhythm.
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Kappel C, Reiss M, Rodrigo M, Ganesan P, Narayan SM, Rappel WJ. Predicting acute termination and non-termination during ablation of human atrial fibrillation using quantitative indices. Front Physiol 2022; 13:939350. [PMID: 36483297 PMCID: PMC9725096 DOI: 10.3389/fphys.2022.939350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 11/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Termination of atrial fibrillation (AF), the most common arrhythmia in the United States, during catheter ablation is an attractive procedural endpoint, which has been associated with improved long-term outcome in some studies. It is not clear, however, whether it is possible to predict termination using clinical data. We developed and applied three quantitative indices in global multielectrode recordings of AF prior to ablation: average dominant frequency (ADF), spectral power index (SPI), and electrogram quality index (EQI). Methods: In N = 42 persistent AF patients (65 ± 9 years, 14% female) we collected unipolar electrograms from 64-pole baskets (Abbott, CA). We studied N = 17 patients in whom AF terminated during ablation ("Term") and N = 25 in whom it did not ("Non-term"). For each index, we determined its ability to predict ablation by computing receiver operating characteristic (ROC) and calculated the area under the curve (AUC). Results: The ADF did not differ for Term and Non-term patients at 5.28 ± 0.82 Hz and 5.51 ± 0.81 Hz, respectively (p = 0.34). Conversely, the SPI for these two groups was. 0.85 (0.80-0.92) and 0.97 (0.93-0.98) and the EQI was 0.61 (0.58-0.64) and 0.56 (0.55-0.59) (p < 0.0001). The AUC for predicting AF termination for the SPI was 0.85 ([0.68, 0.95] 95% CI), and for the EQI, 0.86 ([0.72, 0.95] 95% CI). Conclusion: Both the EQI and the SPI may provide a useful clinical tool to predict procedural ablation outcome in persistent AF patients. Future studies are required to identify which physiological features of AF are revealed by these indices and hence linked to AF termination or non-termination.
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Affiliation(s)
- Cole Kappel
- Department of Physics, UC Irvine, Irvine, CA, United States
| | - Michael Reiss
- Department of Physics, UC San Diego, La Jolla, CA, United States
| | - Miguel Rodrigo
- CoMMLab, Electronic Engineering Department, Universitat de Valencia, Valencia, Spain
| | - Prasanth Ganesan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Sanjiv M. Narayan
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Wouter-Jan Rappel
- Department of Physics, UC San Diego, La Jolla, CA, United States,*Correspondence: Wouter-Jan Rappel,
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Worck R, Sørensen SK, Johannessen A, Ruwald MH, Hansen ML, Haugdal M, Hansen J. Posterior wall isolation in persistent atrial fibrillation. Long-term outcomes of a repeat procedure strategy. J Interv Card Electrophysiol 2022; 66:971-979. [PMID: 36327059 DOI: 10.1007/s10840-022-01402-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Posterior wall isolation (PWI) added to pulmonary vein isolation (PVI) is increasingly used in ablation for persistent atrial fibrillation (PeAF) despite limited evidence of clinical benefit. We investigated the 5-year outcomes of a PVI + PWI ablation strategy with mandatory repeat procedures in PeAF. METHODS Twenty-four patients with PeAF participated in this single-arm prospective study and underwent radiofrequency ablation (RFA) with wide area circumferential ablation (WACA), roof, and inferior lines for PVI + PWI which was reinforced if required during mandated repeat procedures after 6 months. Then, patients were followed for 60 months using continuous heart rhythm monitoring by implanted cardiac monitors (ICM) and atrial fibrillation effect on quality-of-life scoring (AFEQT; range: 20-100 points) for the initial 30 months. RESULTS ICM-verified cumulated AF recurrence was 54% after 30 months but the ensuing AF burden was only median 0‰ [0 to 4.8‰] overall and 1‰ [0 to 8 ‰] among patients with any recurrence. AFEQT scores increased from baseline 60 points [48 to 72] to 93 points [84 to 96] at repeat procedures P < 0.0001 and further to 96 points [93 to 99] P = 0.03 after 30 months. After 60 months, at least one episode of AF had been documented in 63% and two patients (8%) were in permanent AF. CONCLUSION Reinforced PVI + PWI was associated with low long-term AF burden and corresponding improvements in quality-of-life. Reinforced (or durable) PVI + PWI appears to be a promising strategy to treat PeAF. TRIAL REGISTRATION ClinicalTrials.gov. Identifier: NCT05045131.
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Theofilis P, Oikonomou E, Antonopoulos AS, Siasos G, Tsioufis K, Tousoulis D. Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives. Biomedicines 2022; 10:biomedicines10092268. [PMID: 36140368 PMCID: PMC9496262 DOI: 10.3390/biomedicines10092268] [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: 08/11/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.
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Affiliation(s)
- Panagiotis Theofilis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Alexios S. Antonopoulos
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
- Correspondence:
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Calvert P, Gupta D. Left Atrial Posterior Wall Isolation – The Conundrum of Safety versus Efficacy. J Cardiovasc Electrophysiol 2022; 33:1675-1677. [DOI: 10.1111/jce.15557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest HospitalLiverpoolUK
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20
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Voskoboinik A. Posterior Wall Isolation for Atrial Fibrillation: Time to Curb Our Enthusiasm? JACC Clin Electrophysiol 2022; 8:593-594. [PMID: 35589171 DOI: 10.1016/j.jacep.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Aleksandr Voskoboinik
- Alfred Hospital, Prahran, Victoria, Australia; Baker Heart and Diabetes Institute, Prahran, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Western Health, St Albans, Victoria, Australia.
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