High-density mapping and ablation of concealed low-voltage activity within pulmonary vein antra results in improved freedom from atrial fibrillation compared to pulmonary vein isolation alone

Cryoablation Utilizing the KODEX-EPD Mapping System Versus Conventional Cryoballoon Ablation in the Management of Patients With Atrial Fibrillation: A Literature Review and Meta-Analysis

Atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia globally. AF is associated with different consequences, such as peripheral vascular embolism, stroke, dementia, heart failure, and death. Catheter ablation (CA) has become a reliable therapeutic option for symptomatic AF. Utilizing mapping systems in conducting cryoablation is supposed to improve pulmonary vein isolation (PVI) durability and overall treatment success rate. We performed a review of relevant articles. We formulated a search strategy as follows: (atrial fibrillation AND ("cryoballoon ablation" OR cryoablation) AND (KODEX-EPD AND KODEX OR mapping). Data were collected from Web of Science, PubMed, Cochrane Library, and SCOPUS databases. We assessed the efficacy, procedural characteristics, and safety of cryoablation using the KODEX-EPD mapping system versus conventional cryoablation. We demonstrated the superiority of cryoablation guided by the KODEX-EPD system as it was associated with a significantly lower recurrence rate after the procedure (RR = 0.61, P = 0.03). Furthermore, it allowed a significant reduction in the volume of contrast medium used during the procedure (MD = -20.46, P = 0.04) when compared to the conventional cryoablation. We found no significant difference between both procedures in terms of successful cryoballoon-based PVI (P = 1.00), procedural duration (P = 0.95), procedural complications (P = 0.607), fluoroscopic time (P = 0.36), and fluoroscopic dose (P = 0.16). The use of the novel KODEX-EPD mapping system in the cryoablation procedure was associated with a significant reduction of the volume of contrast medium use and the recurrence rate compared with the conventional cryoablation while preserving similar efficacy, safety profile, and procedure time.

One-year outcomes of wide antral cryoballoon ablation guided by high-density mapping vs. conventional cryoballoon ablation for atrial fibrillation: a propensity score-matched study

Background

Pulmonary vein isolation with wide antral ablation leads to better clinical outcomes for the treatment of atrial fibrillation, but the isolation lesion is invisible in conventional cryoballoon ablation. In this study, we aim to investigate the efficacy of the wide pulmonary vein isolation technique that includes the intervenous carina region, guided by high-density mapping, compared with pulmonary vein isolation alone without the mapping system.

Methods

We conducted a propensity score-matched comparison of 74 patients who underwent a wide cryoballoon ablation guided by high-density mapping (mapping group) and 74 controls who underwent conventional cryoballoon ablation in the same period (no-mapping group). The primary outcome was a clinical recurrence of documented atrial arrhythmias for >30 s during the 1-year follow-up.

Results

Of 74 patients in the mapping group, residual local potential in the pulmonary vein antrum was found in 30 (40.5%) patients, and additional cryothermal applications were performed to achieve a wide pulmonary vein isolation. Compared with the no-mapping group, the use of the mapping system in the mapping group was associated with a longer fluoroscopic time (26.97 ± 8.07 min vs. 23.76 ± 8.36 min, P = 0.023) and greater fluoroscopic exposure [339 (IQR181-586) mGy vs. 224 (IQR133-409) mGy, P = 0.012]. However, no significant differences between the two groups were found in terms of procedural duration and left atrial dwell time (104.10 ± 18.76 min vs. 102.45 ± 21.01 min, P = 0.619; 83.52 ± 17.01 min vs. 79.59 ± 17.96 min, P = 0.177). The rate of 12-month freedom from clinical atrial arrhythmia recurrence was 85.1% in the mapping group and 70.3% in the no-mapping group (log-rank P = 0.029).

Conclusion

Voltage and pulmonary vein potential mapping after cryoballoon pulmonary vein isolation can identify residual potential in the pulmonary vein antrum, and additional cryoablation guided by mapping leads to improved freedom from atrial arrhythmias compared with conventional pulmonary vein isolation without the mapping system.

Clinical Trial Registration Number

ChiCTR2200064383.

Detection of a unidirectional epicardial connection between the right-sided pulmonary venous carina and the right atrium by pacing from a high-density mapping catheter

We report a case of recurring, persistent atrial fibrillation (AF) in a patient with a unidirectional epicardial connection (EC) between the right-sided pulmonary venous (PV) carina and the right atrium detected using a high-density mapping catheter with a steerable introducer support, but not a conventional circular mapping catheter. This unidirectional EC could be steadily abolished by a radiofrequency delivery. Finally, we were able to successfully achieve complete PV antrum isolation. Thereafter, he has remained well without any AF.

Epicardial Connections After a Conventional Pulmonary Vein Antrum Isolation in Patients With Atrial Fibrillation

BACKGROUND

The existence of epicardial connection(s) (ECs) between the pulmonary veins (PVs) and atrium may hinder establishing a complete PV antrum isolation (AI) (PVAI) in patients with atrial fibrillation (AF). Thus, the purpose of this study was to determine the prevalence and location of ECs inside the conventional PVAI lines.Methods and Results: Three-hundred consecutive patients with non-valvular AF were evaluated. This study revealed that: (1) the prevalence of patients with ECs and the number of ECs per patient between the PVs and atrium became significantly greater, respectively, in accordance with the progression of paroxysmal to long-lasting AF and left atrial enlargement; (2) some ECs were located at sites far distal to the PVAI lines; (3) 25% of ECs could be detected only by high-density mapping catheters, but not by conventional circular mapping catheters; (4) a B-type natriuretic peptide (BNP) level of 176.6pg/mL and left atrial volume (LAV) of 129.0 mL may be important predictors of the presence of ECs; and (5) the rate of conduction of ECs from the right PVs was dominantly to the atrium and His-bundle, and that from the left PVs to the coronary sinus was most dominant.

CONCLUSIONS

The PVAI may not be completed by using only a conventional PVAI method, and additional EC ablation inside the PVAI lines detected using high-density mapping may be able to achieve a more complete PVAI.

Targeted ablation of residual pulmonary vein potentials in atrial fibrillation ablation through ultra-high-density mapping: insights from the CHARISMA registry

INTRODUCTION

Low-voltage activity beyond pulmonary veins (PVs) may contribute to the failure of ablation of atrial fibrillation (AF) in the long term. We aimed to assess the presence of gaps (PVG) and residual potential (RAP) within the antral scar by means of an ultra-high density mapping (UHDM) system.

METHODS

We studied consecutive patients from the CHARISMA registry who were undergoing AF ablation and had complete characterization of residual PV antral activity. The Lumipoint^TM (Boston Scientific) map-analysis tool was used sequentially on each PV component. The ablation endpoint was PV isolation (PVI) and electrical quiescence in the antral region.

RESULTS

Fifty-eight cases of AF ablation were analyzed. A total of 86 PVGs in 34 (58.6%) patients and 44 RAPs in 34 patients (58.6%) were found. In 16 (27.6%) cases, we found at least one RAP in patients with complete absence of PV conduction. RAPs showed a lower mean voltage than PVG (0.3±0.2mV vs 0.7±0.5mV, p<0.0001), whereas the mean number of EGM peaks was higher (8.4±1.4 vs 3.2±1.5, p<0.0001). The percentage of patients in whom RAPs were detected through Lumipoint^TM was higher than through propagation map analysis (58.6% vs 36.2%, p=0.025). Acute procedural success was 100%, with all PVs successfully isolated and RAPs completely abolished in all study patients. During a mean follow-up of 453±133 days, 6 patients (10.3%) suffered an AF/AT recurrence.

CONCLUSION

Local vulnerabilities in antral lesion sets were easily discernible by means of the UHDM system in both de novo and redo patients when no PV conduction was present.

CLINICAL TRIAL REGISTRATION

Catheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice (CHARISMA). URL: http://clinicaltrials.gov/Identifier: NCT03793998 This article is protected by copyright. All rights reserved.

Improved procedural workflow for catheter ablation of paroxysmal AF with high-density mapping system and advanced technology: Rationale and study design of a multicenter international study

BACKGROUND

The antral region of pulmonary veins (PV)s seems to play a key role in a strategy aimed at preventing atrial fibrillation (AF) recurrence. Particularly, low-voltage activity in tissue such as the PV antra and residual potential within the antral scar likely represent vulnerabilities in antral lesion sets, and ablation of these targets seems to improve freedom from AF. The aim of this study is to validate a structured application of an approach that includes the complete abolition of any antral potential achieving electrical quiescence in antral regions.

METHODS

The improveD procEdural workfLow for cathETEr ablation of paroxysmal AF with high density mapping system and advanced technology (DELETE AF) study is a prospective, single-arm, international post-market cohort study designed to demonstrate a low rate of clinical atrial arrhythmias recurrence with an improved procedural workflow for catheter ablation of paroxysmal AF, using the most advanced point-by-point RF ablation technology in a multicenter setting. About 300 consecutive patients with standard indications for AF ablation will be enrolled in this study. Post-ablation, all patients will be monitored with ambulatory event monitoring, starting within 30 days post-ablation to proactively detect and manage any recurrences within the 90-day blanking period, as well as Holter monitoring at 3, 6, 9, and 12 months post-ablation. Healthcare resource utilization, clinical data, complications, patients' medical complaints related to the ablation procedure and patient's reported outcome measures will be prospectively traced and evaluated.

DISCUSSION

The DELETE AF trial will provide additional knowledge on long-term outcome following a structured ablation workflow, with high density mapping, advanced algorithms and local impedance technology, in an international multicentric fashion. DELETE AF is registered at ClinicalTrials.gov (NCT05005143).

Impact of nocturnal hypoxemia on the recurrence of atrial tachyarrhythmia after catheter ablation of atrial fibrillation

Factors causing atrial tachyarrhythmia recurrence after catheter ablation (CA) of atrial fibrillation (AF) remain undetermined. This study aimed to investigate the effect of nocturnal hypoxemia on the recurrence of atrial tachyarrhythmia after CA of AF. Among 594 patients with AF who underwent an ambulatory sleep study at the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (2014-2019), 365 underwent CA of AF; 290 patients who underwent CA were followed up for > 3 months. Multivariate Cox regression analysis was used to calculate hazard ratios (HRs) using clinical variables, to identify the independent predictors of atrial tachyarrhythmia recurrence after the final CA. Atrial tachyarrhythmia recurred in 45 of 290 (15.5%) patients during the median follow-up period of 479 days (interquartile range 225-1002). On the performing multivariate analysis of the data of patients who did not receive continuous positive airway pressure (CPAP), severe nocturnal hypoxemia [defined as the percentage of sleep time spent with SaO₂ of < 90% (T90) over 20%] [HR 8.53, 95% confidence interval (CI) 1.872-38.814; P < 0.01] and an 1 mL/m² increase in the left atrial volume index (HR 1.02, 95% CI 1.004-1.044; P = 0.02) were found to be independently associated with the recurrence of atrial tachyarrhythmia. In addition, the rates of freedom from atrial tachyarrhythmia after the final AF ablation with CPAP were significantly lower in the group with more severe nocturnal hypoxemia (Log-rank P = 0.03). In conclusion, it is necessary to consider both, AHI and nocturnal hypoxia while performing an ambulatory sleep apnea study. CA may be less effective in patients with more severe nocturnal hypoxia, despite the administration of CPAP.

Catheter ablation vs. thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: CASA-AF randomized controlled trial

AIMS

Long-standing persistent atrial fibrillation (LSPAF) is challenging to treat with suboptimal catheter ablation (CA) outcomes. Thoracoscopic surgical ablation (SA) has shown promising efficacy in atrial fibrillation (AF). This multicentre randomized controlled trial tested whether SA was superior to CA as the first interventional strategy in de novo LSPAF.

METHODS AND RESULTS

We randomized 120 LSPAF patients to SA or CA. All patients underwent predetermined lesion sets and implantable loop recorder insertion. Primary outcome was single procedure freedom from AF/atrial tachycardia (AT) ≥30 s without anti-arrhythmic drugs at 12 months. Secondary outcomes included clinical success (≥75% reduction in AF/AT burden); procedure-related serious adverse events; changes in patients' symptoms and quality-of-life scores; and cost-effectiveness. At 12 months, freedom from AF/AT was recorded in 26% (14/54) of patients in SA vs. 28% (17/60) in the CA group [OR 1.128, 95% CI (0.46-2.83), P = 0.83]. Reduction in AF/AT burden ≥75% was recorded in 67% (36/54) vs. 77% (46/60) [OR 1.13, 95% CI (0.67-4.08), P = 0.3] in SA and CA groups, respectively. Procedure-related serious adverse events within 30 days of intervention were reported in 15% (8/55) of patients in SA vs. 10% (6/60) in CA, P = 0.46. One death was reported after SA. Improvements in AF symptoms were greater following CA. Over 12 months, SA was more expensive and provided fewer quality-adjusted life-years (QALYs) compared with CA (0.78 vs. 0.85, P = 0.02).

CONCLUSION

Single procedure thoracoscopic SA is not superior to CA in treating LSPAF. Catheter ablation provided greater improvements in symptoms and accrued significantly more QALYs during follow-up than SA.

CLINICAL TRIAL REGISTRATION

ISRCTN18250790 and ClinicalTrials.gov: NCT02755688.

Pulmonary vein isolation in atrial fibrillation patients guided by a novel local impedance algorithm: 1-year outcome from the CHARISMA study

BACKGROUND

Highly localized impedance (LI) measurements during atrial fibrillation (AF) ablation have recently emerged as a viable real-time indicator of tissue characteristics and durability of the lesions created. We report the outcomes of acute and long-term clinical evaluation of the new DirectSense algorithm in AF ablation.

METHODS

Consecutive patients undergoing AF ablation were included in the CHARISMA registry. RF delivery was guided by the DirectSense algorithm, which records the magnitude and time-course of the impedance drop. The ablation endpoint was pulmonary vein isolation (PVI), as assessed by the entrance and exit block.

RESULTS

3556 point-by-point first-pass RF applications of >10 s duration were analyzed in 153 patients (mean age=59 ± 10 years, 70% men, 61% paroxysmal AF, 39% persistent AF). The mean baseline LI was 105 ± 15 Ω before ablation and 92 ± 12 Ω after ablation (p < .0001). Both absolute drops in LI and the time to LI drop (LI drop/τ) were greater at successful ablation sites (n = 3122, 88%) than at ineffective ablation sites (n = 434, 12%) (14 ± 8 Ω vs 6 ± 4 Ω, p < .0001 for LI; 0.73 [0.41-1.25] Ω/s vs. 0.35[0.22-0.59 Ω/s, p < .0001 for LI drop/τ). No major complications occurred during or after the procedures. All PVs had been successfully isolated. During a mean follow-up of 366 ± 130 days, 18 patients (11.8%) suffered an AF/atrial tachycardia recurrence after the 90-day blanking period.

CONCLUSION

The magnitude and time-course of the LI drop during RF delivery were associated with effective lesion formation. This ablation strategy for PVI guided by LI technology proved safe and effective and resulted in a very low rate of AF recurrence over 1-year follow-up.

Novel approaches to mechanism-based atrial fibrillation ablation

Modern cardiac electrophysiology has reported significant advances in the understanding of mechanisms underlying complex wave propagation patterns during atrial fibrillation (AF), although disagreements remain. One school of thought adheres to the long-held postulate that AF is the result of randomly propagating wavelets that wonder throughout the atria. Another school supports the notion that AF is deterministic in that it depends on a small number of high-frequency rotors generating three-dimensional scroll waves that propagate throughout the atria. The spiralling waves are thought to interact with anatomic and functional obstacles, leading to fragmentation and new wavelet formation associated with the irregular activation patterns documented on AF tracings. The deterministic hypothesis is consistent with demonstrable hierarchical gradients of activation frequency and AF termination on ablation at specific (non-random) atrial regions. During the last decade, data from realistic animal models and pilot clinical series have triggered a new era of novel methodologies to identify and ablate AF drivers outside the pulmonary veins. New generation electroanatomical mapping systems and multielectrode mapping catheters, complimented by powerful mathematical analyses, have generated the necessary platforms and tools for moving these approaches into clinical procedures. Recent clinical data using such platforms have provided encouraging evidence supporting the feasibility of targeting and effectively ablating driver regions in addition to pulmonary vein isolation in persistent AF. Here, we review state-of-the-art technologies and provide a comprehensive historical perspective, characterization, classification, and expected outcomes of current mechanism-based methods for AF ablation. We discuss also the challenges and expected future directions that scientists and clinicians will face in their efforts to understand AF dynamics and successfully implement any novel method into regular clinical practice.

Anatomical targets and expected outcomes of catheter-based ablation of atrial fibrillation in 2020

Anatomical-based approaches, targeting either pulmonary vein isolation (PVI) or additional extra PV regions, represent the most commonly used ablation treatments in symptomatic patients with atrial fibrillation (AF) recurrences despite antiarrhythmic drug therapy. PVI remains the main anatomical target during catheter-based AF ablation, with the aid of new technological advances as contact force monitoring to increase safety and effective radiofrequency (RF) lesions. Nowadays, cryoballoon ablation has also achieved the same level of scientific evidence in patients with paroxysmal AF undergoing PVI. In parallel, electrical isolation of extra PV targets has progressively increased, which is associated with a steady increase in complex cases undergoing ablation. Several atrial regions as the left atrial posterior wall, the vein of Marshall, the left atrial appendage, or the coronary sinus have been described in different series as locations potentially involved in AF initiation and maintenance. Targeting these regions may be challenging using conventional point-by-point RF delivery, which has opened new opportunities for coadjuvant alternatives as balloon ablation or selective ethanol injection. Although more extensive ablation may increase intraprocedural AF termination and freedom from arrhythmias during the follow-up, some of the targets to achieve such outcomes are not exempt of potential severe complications. Here, we review and discuss current anatomical approaches and the main ablation technologies to target atrial regions associated with AF initiation and maintenance.

Successful Catheter Ablation of Two Macro-reentrant Atrial Tachycardias in a Patient with Congenitally Corrected Transposition of the Great Arteries: A Case Report

Adults with congenital heart disease represent a complex and growing patient population. By virtue of their variant anatomy and the complex surgical repair often required in infancy, these patients are at risk of developing unique atrial and ventricular arrhythmias throughout their lifetimes. Electrophysiologists involved in the care of these patients should have a detailed understanding of their underlying anatomy and any prior surgical procedures to guide procedural planning and should have knowledge of the range of possible arrhythmia mechanisms that may differ from patients without structural heart disease. Despite this complexity, standard mapping techniques and electrophysiologic maneuvers may still be used to elucidate arrhythmia mechanisms, map tachycardia circuits, and guide catheter ablation. We report a case of two different macroreentrant right atrial tachycardias that were successfully ablated in a patient with congenitally-corrected transposition of the great arteries.

The Rapid Prediction of Focal Wavefront Origins: Integration With a 3-Dimensional Mapping System

OBJECTIVES

This study assessed the accuracy of an algorithm that predicts the origin of focal arrhythmias using a limited number of data points.

BACKGROUND

Despite advances in technology, ablations can be time-consuming, and activation mapping continues to have inherent limitations. The authors developed an algorithm that can predict the origin of a focal wavefront using the location and activation timing information in 2 pairs of sampled points. This algorithm was incorporated into an electroanatomic mapping (EAM) system to assess its accuracy in a 3-dimensional clinical environment.

METHODS

EAM data from patients who underwent successful ablation of a focal wavefront using the CARTO3 system were loaded onto an offline version of the software modified to contain the algorithm. Prediction curves were retrospectively generated. Predictive accuracy, defined as the distance between true and predicted origin wavefront origins, was measured.

RESULTS

Seventeen wavefronts in as many patients (2 with atrial tachycardia, 3 with orthodromic re-entrant tachycardia, 8 with premature ventricular complex and/or ventricular tachycardia, 4 with focal pulmonary vein isolation breakthroughs) were studied. Thirty-three origin predictions were attempted (1.9 ± 0.4 per patient) using 132 points. Predictions were successfully calculated in 31 of 33 (93.9%) attempts and were accurate to within 5.7 ± 6.9 mm. Individual prediction curves were accurate to within 3.0 ± 4.7 mm.

CONCLUSIONS

Focal wavefront origins may be accurately predicted in 3 dimensions using a novel algorithm incorporated into an EAM system.

The feasibility and effectiveness of a streamlined single-catheter approach for radiofrequency atrial fibrillation ablation

BACKGROUND

Catheter ablation for atrial fibrillation (AF) traditionally requires the use of circular mapping catheter (CMC) for pulmonary vein isolation (PVI). This study aimed to assess the feasibility and effectiveness of a CMC-free approach for AF ablation performed by a contiguous optimized (CLOSE) ablation protocol.

METHODS

A CLOSE-guided and CMC-free PVI protocol with a single transseptal puncture was attempted in 67 patients with AF. Left atrial (LA) CARTO voltage mapping was performed with the ablation catheter pre- and postablation to demonstrate entry block into the pulmonary veins, and pacing maneuvers were used to confirm exit block.

RESULTS

The CMC-free approach was successful in achieving PVI in 66 (98.5%) cases, with procedure time of 148 ± 32 minutes, ablation time of 27.5 ± 5.7 minutes, and fluoroscopy time of 7.8 ± 1.0 minutes. First-pass PVI was seen in 58(86.5%) patients, and pacing maneuvers successfully identified the residual gap in eight of the other nine cases. No complication was observed. At 12 months follow-up, 60 (89.6%) patients remained free from AF. The CMC-free approach resulted in a cost saving of £47,190.

CONCLUSION

A CMC-free CLOSE-guided PVI approach is feasible, safe, and cost-saving, and is associated with excellent clinical outcomes at 1 year.

A novel local impedance algorithm to guide effective pulmonary vein isolation in atrial fibrillation patients: Preliminary experience across different ablation sites from the CHARISMA pilot study

INTRODUCTION

Recently, a novel technology able to measure local impedance (LI) and tissue characteristics has been made available for clinical use. This analysis explores the relationships among LI and generator impedance (GI) parameters in atrial fibrillation (AF) patients. Characterization of LI among different ablation spots and procedural success were also evaluated.

METHODS AND RESULTS

Consecutive patients undergoing AF ablation from the CHARISMA registry at five Italian centers were included. A novel radiofrequency (RF) ablation catheter with a dedicated algorithm (DIRECTSENSE™) was used to measure LI and to guide ablation. The ablation endpoint was pulmonary vein (PV) isolation. We analyzed 2219 ablation spots created around PVs in 46 patients for AF ablation. The mean baseline tissue impedance was 105.8 ± 14 Ω for LI versus 91.8 ± 10 Ω for GI (p < .0001). Baseline impedance was homogenous across the PV sites and proved higher in high-voltage areas than in intermediate- and low-voltage areas and the blood pool (p < .001). Both LI and GI displayed a significant drop after RF delivery, and absolute LI drop values were significantly larger than GI drop values (14 ± 8 vs. 3.7 ± 5 Ω, p < .0001). Every 5-point increment in LI drop was associated with successful ablation (odds ratio = 3.05, 95% confidence interval: 2.3-4.1, p < .0001). Conversely, GI drops were not significantly different comparing successful versus unsuccessful sites (3.7 ± 5 vs. 2.8 ± 4 Ω, p = .1099). No steam pops or major complications occurred during or after the procedures. By the end of the procedures, all PVs had been successfully isolated in all patients.

CONCLUSIONS

The magnitude of the LI drop was more closely associated with effective lesion formation than the GI drop.

Basket catheter-guided ultra-high-density mapping of cardiac arrhythmias: a systematic review and meta-analysis

Aim: Ultra-high-density mapping (HDM) is increasingly used for guidance of catheter ablation in cardiac arrhythmias. While initial results are promising, a systematic evaluation of long-term outcome has not been performed so far. Methods: A systematic review and meta-analysis was conducted on studies investigating long-term outcome after Rhythmia HDM-guided atrial fibrillation (AF) or atrial tachycardia catheter ablation. Results: Beyond multiple studies providing novel insights into arrhythmia mechanisms, follow-up data from 17 studies analyzing Rhythmia HDM-guided ablation (1768 patients, 49% with previous ablation) were investigated. Cumulative acute success was 100/90.2%, while 12 months long-term pooled success displayed at 71.6/71.2% (AF/atrial tachycardia). Prospective data are limited, showing similar outcome between HDM-guided and conventional AF ablation. Conclusion: Acute results of HDM-guided catheter ablation are promising, while long-term success is challenged by complex arrhythmogenic substrates. Prospective randomized trials investigating different HDM-guided ablation strategies are warranted and underway.

How, When, and Why: High-Density Mapping of Atrial Fibrillation

High-density (HD) mapping presents opportunities to enhance delineation of atrial fibrillation (AF) substrate, improve efficiency of the mapping procedure without sacrificing safety, and afford new mechanistic insights regarding AF. Innovations in hardware, software algorithms, and development of novel multielectrode catheters have allowed HD mapping to be feasible and reliable. Patients to particularly benefit from this technology are those with paroxysmal AF in setting of preexisting atrial scar, persistent AF, and AF in the setting of complex congenital heart disease. The future will bring refinements in automated HD mapping including evolution of noncontact methodologies and artificial intelligence to supplant current techniques.

Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature

BACKGROUND AND AIM OF STUDY

The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA).

METHODS

A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method.

RESULTS

Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%.

CONCLUSION

CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.

Successful case of complex atrial flutter occurring in a patient with congenitally corrected transposition of the great arteries, aberrant left atrial appendage, and situs inversus

Background

Congenitally corrected transposition of great arteries (ccTGA) is a rare congenital cardiac defect with atrioventricular and ventriculoarterial discordance which leads to heart failure and limits patients’ lifespan. The extremely aberrant cardiac structure makes electrophysiological procedure and radiofrequency ablation very difficult to be performed in such patients. Until now, there were only sporadical cases that have reported the successful ablation of atrial flutter in ccTGA patients.

Case presentation

We report a case of a 36-year-old male who was diagnosed with dextrocardia, atrial septal defect and congenitally corrected transposition of great arteries (ccTGA) at a young age and received atrial septal defect repair and morphological tricuspid valve plasty in 2014. As for reasons of heart failure and atrial flutter, he frequently suffered from progressively worsening dyspnea and recurrent episodes of palpitations. Cardiac anatomic imaging reconstruction before electrophysiological test revealed an unusually huge left atrial appendage in this patient. After high-density mapping of both right atrium and left atrium, activation mapping showed reentry circuit loops were located in left atrium. Successful ablation strategy was performed under the guidance of high-density mapping and entrainment.

Conclusion

This is a clinical case showing high-density mapping and successful ablation of a complex dual-loop atrial flutter in a patient with ccTGA and aberrant left atrial appendage. The successful procedure corroborates clinical utility of high-density mapping approach in the treatment of the patients with complex congenital heart disease accompanied by rapid arrhythmia, can be simpler, safer and more effective.

Impact of mapping points in high-density mapping of the left atrium

PURPOSE

Currently, high-density mapping techniques are being discussed for more precise voltage mapping, lesion validation after pulmonary vein isolation (PVI) and superior left atrial tachycardia (LAT) mapping. However, the quality of high-density maps varies according to different mapping systems, multipolar catheter (MPC) types and numbers of mapping points. The aim of this study was to evaluate the impact of different numbers of mapping points in high-density mapping on validity.

METHODS

From February 2016 to August 2018, 154 patients with previous PVI ablation and recurrent atrial fibrillation (AF) or left atrial tachycardia (LAT) were mapped by Orion™ multipolar catheter and Rhythmia HDx™ mapping system at our centre. Of those, 90 maps from 25 patients [11 male patients/14 female patients; age 76 ± 12 years] with 8000 to 16,000 mapping points in the primary map were collected. All maps were evaluated offline by two independent and blinded electrophysiologists regarding the following issues: (1) Is PVI observable in all veins? (2) Does voltage map cover the whole left atrium? (3) Does activation map display one or more isthmuses? The 90 maps consist of 30 maps with deactivated 24 of 64 electrodes of MPC with < 1000 mapping points (A), 30 maps with deactivated 16 of 64 electrodes of MPC and 2000 to 6000 mapping points (B) and 30 primary maps with 8000 to 16,000 mapping points (C).

RESULTS

For (A), only in one map (3.3%), for (B) in 20 maps (66.7%, p < 0.05) and for (C) in 24 maps (80%) both investigators agreed with evaluable PVI in all veins. Investigators were able to assess whether the voltage map covered the whole left atrium and the same low voltage areas in (A) in 0 maps, in (B) in 16 maps (53%, p < 0.05) and in (C) in 23 maps (77%, p < 0.05). Also, investigators were able to locate the same critical isthmuses in the activation maps in (A) in 0 maps, in (B) in 2 maps (7%) and in (C) in 20 maps (67%, p < 0.05).

CONCLUSIONS

In order to achieve comparable high-density maps which are verified by independent investigators, a minimum of 2000 to 6000 mapping points are required in the majority of voltage maps to evaluate PVI and low voltage areas. To define the critical isthmuses in activations maps, 8000 mapping points or more might be necessary. High-density maps with more than 8000 points increase the interrater reliability.

Advanced mapping strategies for ablation therapy in adults with congenital heart disease

Background

Ultra-high density mapping (HDM) is a promising tool in the treatment of patients with complex arrhythmias. In adults with congenital heart disease (CHD), rhythm disorders are among the most common complications but catheter ablation can be challenging due to heterogenous anatomy and complex arrhythmogenic substrates. Here, we describe our initial experience using HDM in conjunction with novel automated annotation algorithms in patients with moderate to great CHD complexity.

Methods

We studied a series of consecutive adult patients with moderate to great CHD complexity and an indication for catheter ablation due to symptomatic arrhythmia. HDM was conducted using the Rhythmia™ mapping system and a 64-electrode mini-basket catheter for identification of anatomy, voltage, activation pattern and critical areas of arrhythmia for ablation guidance. To investigate novel advanced mapping strategies, postprocedural signal processing using the Lumipoint™ software was applied.

Results

In 19 patients (53±3 years; 53% male), 21 consecutive ablation procedures were conducted. Procedures included ablation of atrial fibrillation (n=7; 33%), atrial tachycardia (n=11; 52%), atrioventricular accessory pathway (n=1; 5%), the atrioventricular node (n=1; 5%) and ventricular arrhythmias (n=4; 19%). A total of 23 supraventricular and 8 ventricular arrhythmias were studied with the generation of 56 complete high density maps (atrial n=43; ventricular n=11, coronary sinus n=2) and an average of 12,043±1,679 mapping points. Multiple arrhythmias were observed in n=7 procedures (33% of procedures; range of arrhythmias detected 2-4). A total range of 1-4 critical areas were defined per procedure and treated within a radiofrequency application time of 16 (interquartile range 12-45) minutes. Postprocedural signal processing using Lumipoint™ allowed rapid annotation of fractionated signals within specific windows of interest. This supported identification of a practical critical isthmus in 20 out of 27 completed atrial and ventricular tachycardia activation maps.

Conclusions

Our findings suggest that HDM in conjunction with novel automated annotation algorithms provides detailed insights into arrhythmia mechanisms and might facilitate tailored catheter ablation in patients with moderate to great CHD complexity.

Comparison of ablation outcomes of the second ablation procedure for recurrent atrial fibrillation using an ultra-high-resolution mapping system and conventional mappings system

Background

The utility of an ultra‐high‐resolution electroanatomical mapping system (UHR‐EAM, Rhythmia) for repeat atrial fibrillation (AF) ablation has not been evaluated.

Hypothesis

A second AF ablation procedure performed using UHR‐EAM may demonstrate different outcomes compared with that using a conventional electroanatomical mapping system (C‐EAM, CARTO3).

Method

This observational study enrolled consecutive patients who underwent a second AF ablation procedure using UHR‐EAM (n = 103) and C‐EAM (n = 153). The second ablation procedure included re‐isolation of reconnected pulmonary veins (PVs) and elimination of clinical or induced non‐PV AF triggers and atrial tachycardia (AT). Other empirical ablations were additionally conducted at the discretion of the operators.

Results

Re‐isolation of PVs was achieved in 196 patients who had ≥1 left atrial‐PV reconnection. The elimination rate of AT was higher in the UHR‐EAM group than the C‐EAM group (87% vs 65%, P = .040), while that of non‐PV AF triggers was similar (63% vs 63%, P = 1.00). The UHR‐EAM demonstrated shorter radiofrequency application time (21.8 ± 16.8 vs 28.0 ± 21.3 minutes, P = .017), but longer fluoroscopic time (26.2 ± 12.6 vs 21.4 ± 9.3 minutes, P = .0001). No severe complication developed. The total 1‐year AF/AT‐free survival rates were similar between the two groups (off AADs, 59.2% vs 56.2%, P = .62; on AADs, 65.0% vs 69.3%, P = .49).

Conclusion

The efficacy and safety outcomes of repeat AF ablation using UHR‐EAM was comparable to those using C‐EAM.

Comparison between novel and standard high-density 3D electro-anatomical mapping systems for ablation of atrial tachycardia

Ultra-high-density mapping allows very accurate characterization of circuits/mechanisms in atrial tachycardia (AT). Whether these advantages will translate into a better procedural or long-term clinical outcome is unknown. Sixty consecutive AT ablation procedures using ultra-high-density mapping (Rhythmia™, group 1) were retrospectively compared to 60 consecutive procedures using standard high-density mapping (Carto/NavX™, group 2) (total 209 AT, 79% left AT). A higher number of maps were performed in group 1 (4.8 ± 2.5 vs 3.2 ± 1.7, p = 0.0001) with similar acquisition duration (12 ± 5 vs 13 ± 6 min per map, p = ns), although with a greater number of activation points (10,543 ± 5854 vs 689 ± 1827 per map, p < 0.0001). AT location remained undetermined in 5 AT in group 1 vs 10 (p = 0.1). Mechanism remained undetermined in 5 AT from group 1 vs 11 (p = 0.06). Acute complete success was achieved in 77%, in both groups. At 1-year follow-up, AT recurred in 37% in group 1 vs 50% in group 2 (p = 0.046). There are less long-term recurrences after AT ablation using ultra-high-density mapping system compared to standard high-density 3D mapping, possibly because of a better comprehensive approach of AT mechanisms.

Mapping of atrial fibrillation: strategies to understand an enigmatic arrhythmia

The three-dimensional (3D) mapping of cardiac arrhythmias has evolved in recent years to an important and extremely useful tool, providing important insights into arrhythmia mechanisms and thus improving ablation success rates, especially in complex arrhythmias. In atrial fibrillation (AF), the most common but also one of the most complex cardiac arrhythmias, progress in mapping technology has been focusing on several aspects according to the type of AF.In paroxysmal AF, important progress in the exact anatomic reconstruction of the main ablation target, i.e., the pulmonary veins (PV), has been achieved. Perhaps even more importantly, new insights into conduction patterns, such as deceleration at the PV ostia, spiral conduction more distally into the PV, and PV cross-talk have been detected and enable faster and more sustainable PV isolation.In persistent AF, the basic understanding of ongoing AF is perhaps the electrophysiological challenge of the 21st century. Since AF is instable in its course, mapping tools that assess statistically returning patterns or deal with so-called AF "rotors" or "drivers" have been developed, offering unique insights into possible AF mechanisms. Refined high-density bi-atrial voltage maps make it possible to further characterize the arrhythmogenic substrate and scar zones, while new and innovative mapping algorithms enable automated, fast, and reliable annotation of up to thousands of electrograms.This improved understanding of AF mechanisms has led to the development of promising new ablation strategies, some of which are already in use in clinical routine.