1
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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2
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [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: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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3
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [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: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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4
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Wong CX, Buch EF, Beygui R, Lee RJ. Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation. J Clin Med 2024; 13:679. [PMID: 38337373 PMCID: PMC10856493 DOI: 10.3390/jcm13030679] [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: 11/28/2023] [Revised: 12/27/2023] [Accepted: 01/17/2024] [Indexed: 02/12/2024] Open
Abstract
Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment.
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Affiliation(s)
- Christopher X. Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide 5001, Australia
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Eric F. Buch
- Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Ramin Beygui
- Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Randall J. Lee
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, CA 94143, USA
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5
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Shigeta T, Miyazaki S, Inaba O, Inamura Y, Nitta J, Sekiguchi Y, Takahashi A, Hachiya H, Nagata Y, Yamauchi Y, Hayashi T, Iwai S, Mizukami A, Ono Y, Handa K, Suzuki M, Suzuki A, Nakajima J, Hirao K, Okada H, Negishi M, Ikenouchi T, Yamamoto T, Goto K, Nishimura T, Tao S, Takigawa M, Hirakawa A, Goya M, Sasano T. Adjunctive posterior wall isolation for the treatment of persistent and longstanding persistent atrial fibrillation (CORNERSTONE AF) trial: Design and rationale. Clin Cardiol 2024; 47:e24164. [PMID: 37822107 PMCID: PMC10766127 DOI: 10.1002/clc.24164] [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: 07/15/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND A left atrial posterior wall isolation (LAPWI) is one of the atrial fibrillation (AF) ablation strategies. HYPOTHESIS We hypothesized that an additional empirical LAPWI would increase the freedom from recurrent atrial arrhythmias as compared to standard AF ablation in persistent AF patients. METHODS The CORNERSTONE AF study is a prospective, randomized, multicenter study investigating patients with AF persisting for >7 days and <3 years undergoing first-time AF ablation. They will be randomized to pulmonary vein isolation (PVI) or PVI + LAPWI in a 1:1 manner. Although PVI can be performed with either radiofrequency catheters or cryoballoons, only radiofrequency catheters will be permitted to achieve LAPWIs. Additional focal ablation targeting non-pulmonary vein triggers will be allowed. A total of 516 patients will be enrolled in 17 centers between August 2022 and February 2024 based on the calculation with 80% power, considering the assumption that 65% and 75% of the PVI and PVI + LAPWI group patients will be free from atrial arrhythmia recurrence 18-months postprocedure (10% of dropout). The primary endpoint is freedom from documented atrial arrhythmias 18 months postsingle procedures. Clinical follow-up will include 7-day ambulatory electrocardiograms and routine outpatient consultations by electrophysiologists at 1, 3, 6, 9, 12, and 18 months postprocedure. RESULTS As of August 2023, a total of 331 patients (68 ± 9 years, 270 men, 43 longstanding persistent AF) have been enrolled. CONCLUSIONS The CORNERSTONE AF study is a prospective, randomized, multicenter trial designed to evaluate the efficacy and safety of an adjunctive empirical LAPWI following standard AF ablation in persistent AF patients.
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Affiliation(s)
- Takatoshi Shigeta
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Shinsuke Miyazaki
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Osamu Inaba
- Department of CardiologyJapanese Red Cross Saitama HospitalSaitamaJapan
| | - Yukihiro Inamura
- Department of CardiologyJapanese Red Cross Saitama HospitalSaitamaJapan
| | - Junichi Nitta
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Yukio Sekiguchi
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | | | | | - Yasutoshi Nagata
- Department of CardiologyJapanese Red Cross Musashino HospitalTokyoJapan
| | - Yasuteru Yamauchi
- Department of CardiologyJapanese Red Cross Yokohama City Bay HospitalKanagawaJapan
| | - Tatsuya Hayashi
- Division of Cardiovascular Medicine, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Shinsuke Iwai
- Department of CardiologyHiratsuka Kyosai HospitalKanagawaJapan
| | | | - Yuichi Ono
- Department of CardiologyOme Municipal General HospitalTokyoJapan
| | - Keita Handa
- Division of CardiologyKashiwa City HospitalChibaJapan
| | - Makoto Suzuki
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | | | - Jun Nakajima
- Department of CardiologyTokyo Metropolitan Toshima HospitalTokyoJapan
| | - Kenzo Hirao
- Arrhythmia Advanced Therapy CenterAOI Universal HospitalKanagawaJapan
| | - Hiroyuki Okada
- Department of CardiologySoka Municipal HospitalSaitamaJapan
| | - Miho Negishi
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Takashi Ikenouchi
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Tasuku Yamamoto
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Kentaro Goto
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Takuro Nishimura
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Susumu Tao
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Masateru Takigawa
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Masahiko Goya
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
| | - Tetsuo Sasano
- Department of Cardiovascular MedicineTokyo Medical and Dental UniversityTokyoJapan
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6
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Shrestha DB, Pathak BD, Thapa N, Shrestha O, Karki S, Shtembari J, Patel NK, Kapoor K, Kalahasty G, Bodziock G, Whalen P, Pothineni NVK, Narasimhan B, Koneru J, Shantha G. Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01656-z. [PMID: 37773559 DOI: 10.1007/s10840-023-01656-z] [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: 05/27/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF. OBJECTIVE The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation. METHODS Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly. RESULTS Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99). CONCLUSION LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.
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Affiliation(s)
| | - Bishnu Deep Pathak
- Department of Internal Medicine, Jibjibe Primary Health Care Center, Rasuwa, Nepal
| | - Niranjan Thapa
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Oshan Shrestha
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Sagun Karki
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kunal Kapoor
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Gautham Kalahasty
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Bodziock
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Patrick Whalen
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | | | - Bharat Narasimhan
- Department of Cardiology, Debakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | - Jayanthi Koneru
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ghanshyam Shantha
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
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7
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Aryana A, Thiemann AM, Pujara DK, Cossette LL, Allen SL, Vierra EC, Bowers MR, Gandhavadi M, Heath R, Trivedi AD, O'Neill PG, Ellis ER, d'Avila A. Outcomes of adjunct posterior wall isolation in atrial fibrillation patients with cardiac implantable electronic devices. Pacing Clin Electrophysiol 2023. [PMID: 37377391 DOI: 10.1111/pace.14767] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/29/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Although pulmonary vein isolation (PVI) remains the cornerstone of catheter ablation of atrial fibrillation (AF), several studies have illustrated clinical benefits associated with PVI with posterior wall isolation (PWI). METHODS This retrospective study investigated the outcomes of PVI alone versus PVI+PWI performed using the cryoballoon in patients with cardiac implantable electronic devices (CIEDs) and paroxysmal AF (PAF) or persistent AF (PersAF). RESULTS Acute PVI was achieved in all patients using cryoballoon ablation. Compared to PVI alone, PVI+PWI was associated with longer cryoablation, fluoroscopy, and total procedure times. Adjunct radiofrequency was required to complete PWI in 29/77 patients (37.7%). Adverse events were similar with PVI alone versus PVI+PWI. But at 24 ± 7 months of follow-up, not only cryoballoon PVI+PWI was associated with improved freedom from recurrent AF (74.3% vs. 46.0%, P = .007) and all atrial tachyarrhythmias (71.4% vs. 38.1%, P = .001) in patients with PersAF, cryoballoon PVI+PWI also yielded greater freedom from AF (88.1% vs. 63.7%, P = .003) and all atrial tachyarrhythmias (83.3% vs. 60.8%, P = .008) in those with PAF. Additionally, PVI+PWI was associated with higher reductions in atrial tachyarrhythmia burden (97.9% vs. 91.6%, P < .001), need for cardioversion (5.2% vs. 23.6%, P < .001) and repeat catheter ablation (10.4% vs. 26.1%, P = .005), and a longer time-to-arrhythmia recurrence (16 ± 6 months vs. 8 ± 5 months, P < .001) in both PersAF and PAF patients. CONCLUSION In CIED patients with PersAF or PAF, cryoballoon PVI+PWI is associated with a greater freedom from recurrent AF and atrial tachyarrhythmias, as compared to PVI alone during long-term follow-up.
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Affiliation(s)
- Arash Aryana
- Department of Cardiology and Cardiovascular Surgery, Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Anna M Thiemann
- California Northstate University College of Medicine, Elk Grove, California, USA
| | - Deep K Pujara
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Laura L Cossette
- Department of Cardiology and Cardiovascular Surgery, Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Shelley L Allen
- Department of Cardiology and Cardiovascular Surgery, Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Eleanor C Vierra
- Sutter Heart and Vascular Institute, Sacramento, California, USA
| | - Mark R Bowers
- Department of Cardiology and Cardiovascular Surgery, Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | | | - Russell Heath
- University of Colorado Health, Fort Collins, Aurora, Colorado, USA
| | - Amar D Trivedi
- University of Colorado Health, Fort Collins, Aurora, Colorado, USA
| | - Padraig Gearoid O'Neill
- Department of Cardiology and Cardiovascular Surgery, Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Ethan R Ellis
- University of Colorado Health, Fort Collins, Aurora, Colorado, USA
| | - André d'Avila
- The Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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8
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Aryana A, Thiemann AM, Pujara DK, Cossette LL, Allen SL, Bowers MR, Gandhavadi M, Heath R, Trivedi AD, O'Neill PG, Ellis ER, d'Avila A. Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation: IMPPROVE-PAF Trial. JACC Clin Electrophysiol 2023; 9:628-637. [PMID: 37225309 DOI: 10.1016/j.jacep.2023.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Prior studies have demonstrated clinical benefits associated with cryoballoon pulmonary vein isolation (PVI) and concomitant posterior wall isolation (PWI) in patients with persistent atrial fibrillation (AF). However, the role for this approach in patients with paroxysmal atrial fibrillation (PAF) remains unclear. OBJECTIVES This study investigated the acute and long-term outcomes of PVI vs PVI+PWI using cryoballoon in patients with symptomatic PAF. METHODS This retrospective study (NCT05296824) examined the outcomes of cryoballoon PVI (n = 1,342) vs cryoballoon PVI+PWI (n = 442) in patients with symptomatic PAF during long-term follow-up. Using the nearest-neighbor method, a 1:1 matched sample of patients receiving PVI alone and PVI+PWI was created. RESULTS The matched cohort consisted of 320 patients (PVI: n = 160; PVI+PWI: n = 160). PVI+PWI was associated with longer cryoablation (23 ± 10 minutes vs 42 ± 11 minutes; P < 0.001) and procedure times (103 ± 24 minutes vs 127 ± 14 minutes; P < 0.001). In 39 (24.4%) of 160 patients, adjunct radiofrequency ablation was required for PVI+PWI. Adverse event rates were similar (PVI 3.8% vs PVI+PWI 1.9%; P = 0.31). Though there were no differences at 12 months, freedom from all atrial arrhythmias (67.5% vs 45.0%; P < 0.001) and AF (75.6% vs 55.0%; P < 0.001) were significantly greater with PVI+PWI vs PVI alone at 39 ± 9 months of follow-up. PVI+PWI was also associated with reduced long-term need for cardioversion (16.9% vs 27.5%; P = 0.02) and repeat catheter ablation (11.9% vs 26.3%; P = 0.001), and emerged as the only significant predictor of freedom from recurrent AF (HR: 2.79; 95% CI: 1.64-4.74; P < 0.001). CONCLUSIONS Compared with cryoballoon PVI, cryoballoon PVI+PWI appears to be associated with greater freedom from recurrent atrial arrhythmias and AF in patients with PAF during long-term follow-up >3 years.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA.
| | - Anna M Thiemann
- California Northstate University College of Medicine, Elk Grove, California, USA
| | - Deep K Pujara
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Laura L Cossette
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Shelley L Allen
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Mark R Bowers
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | | | - Russell Heath
- University of Colorado Health, Fort Collins, Colorado, USA
| | - Amar D Trivedi
- University of Colorado Health, Fort Collins, Colorado, USA
| | - Padraig Gearoid O'Neill
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Ethan R Ellis
- University of Colorado Health, Fort Collins, Colorado, USA
| | - André d'Avila
- Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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9
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Liu X, Gao X, Chen L, Shen L, Liu M, Xu Y. Clinical Impact of Posterior Wall Isolation in Catheter Ablation for Persistent Atrial Fibrillation: A Systematic Review and Meta-Analysis. Pacing Clin Electrophysiol 2022; 45:1268-1276. [PMID: 36073753 DOI: 10.1111/pace.14591] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 08/22/2022] [Accepted: 09/02/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The clinical outcomes of pulmonary venous isolation alone for persistent atrial fibrillation (PerAF) remain unclear. Adjuvant posterior wall isolation (PWI) has become a potential supplementary strategy for improving the outcome of PerAF ablation. This meta-analysis aimed to evaluate the effect of PWI added to catheter ablation for PerAF. METHODS PubMed, EMBASE, and Cochrane Library databases were searched for studies comparing the outcomes of PerAF ablation with and without PWI. The efficacy outcomes were recurrence of atrial arrhythmia (AA), atrial fibrillation (AF), and atrial tachycardia (AT), and the safety outcome was adverse events. RESULTS In total, 8 studies with 1428 patients were included in the pooled analyses. The results showed that PWI significantly reduced the recurrence of AA (RR = 0.69, 95% CI = 0.55-0.87, p = 0.002, I2 = 63%) and AF (RR = 0.57, 95% CI = 0.40 - 0.80, p = 0.001, I2 = 70%). AT recurrence (RR = 0.92, 95% CI = 0.67 - 1.27, p = 0.63, I2 = 42%) and adverse events (RR = 1.11, 95% CI = 0.67-1.84, p = 0.70, I2 = 0%) were comparable between the two groups. In the sub-analyses, the efficacy of PWI in reducing AA recurrence was consistent in patients who underwent cryoablation or debulking ablation. CONCLUSION PWI effectively decreased AA recurrence after PerAF ablation without increasing the risk of AT or procedure-related complications. However, more randomized studies are needed to confirm these results. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xiaohua Liu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, #261 Huansha Road, Shangcheng District, Hangzhou, Zhejiang Province, China
| | - Xiaofei Gao
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, #261 Huansha Road, Shangcheng District, Hangzhou, Zhejiang Province, China
| | - Lian Chen
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, #261 Huansha Road, Shangcheng District, Hangzhou, Zhejiang Province, China
| | - Lishui Shen
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, #261 Huansha Road, Shangcheng District, Hangzhou, Zhejiang Province, China
| | - Meijun Liu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, #261 Huansha Road, Shangcheng District, Hangzhou, Zhejiang Province, China
| | - Yizhou Xu
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, #261 Huansha Road, Shangcheng District, Hangzhou, Zhejiang Province, China
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10
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Moustafa A, Liu X, Elzanaty A, Meenakshisundaram C, Kancharla K, Kahaly O, Chacko P. Role of adjunctive cryoballoon left atrial posterior wall isolation in non- paroxysmal atrial fibrillation: a meta-analysis. Curr Probl Cardiol 2022; 47:101383. [DOI: 10.1016/j.cpcardiol.2022.101383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022]
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11
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Aryana A, Lafortune P, Di Biase L, Natale A. Cryoballoon Ablation of the Pulmonary Veins, the Posterior Wall, the Left Atrial Appendage, and the Mitral Isthmus Guided by Intracardiac Echocardiography-integrated and Three-dimensional Mapping. J Innov Card Rhythm Manag 2022; 13:4863-4868. [PMID: 35127241 PMCID: PMC8812479 DOI: 10.19102/icrm.2022.130105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/09/2021] [Indexed: 11/06/2022] Open
Abstract
Here, we describe the first reported case of pulmonary vein, posterior wall, and left atrial appendage (LAA) isolation with concomitant ablation of a mitral isthmus flutter using the cryoballoon, guided by intracardiac echocardiography (ICE)-integrated 3-dimensional mapping in a patient with long-standing persistent atrial fibrillation and intolerance to long-term oral anticoagulation, followed by ICE-guided LAA closure using an endocardial occlusion device. This report illustrates the safety and feasibility of this combined approach. Additionally, it advocates for empiric LAA isolation prior to LAA occlusion, as LAA ablation/isolation can prove challenging in those with existing endocardial LAA occlusion devices should they require subsequent ablations to target arrhythmias or triggers arising from this structure.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
| | - Paula Lafortune
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
| | - Luigi Di Biase
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
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12
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Sirico G, Sirico D, Montisci A, Cerrato E, Morosato M, Panigada S, Ottaviano L, De Sanctis V, Mantica M. Contact-Force Guided Posterior Wall Isolation as an Adjunctive Ablation Strategy for Persistent Atrial Fibrillation. J Atr Fibrillation 2021; 14:20200475. [PMID: 34950369 DOI: 10.4022/jafib.20200475] [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: 02/23/2021] [Revised: 03/08/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022]
Abstract
Background The efficacy of posterior wall isolation (PWI) on top of pulmonary vein isolation (PVI) in patients affected by persistent atrial fibrillation (AF) is still controversial and little is known about the impact of contact-force (CF) technology. Objective In this retrospective study, we present our experience with PWI using CF sensing catheters and its efficacy and safety as an adjunctive ablation strategy on top of PVI for management of patients with persistent and longstanding persistent AF. Methods A total of 73 consecutive patients (20.5% female) affected by persistent atrial fibrillation (10.9% long-standing) underwent PWI as an adjunctive therapy to PVI using CF sensing catheters. Outcomes were reported as incidence of atrial arrhythmic recurrences (ARs) lasting >30 seconds at follow up and in addition, in patients provided with insertable cardiac monitors (ICM), as burden of AF or atrial tachycardias (AT) at relevant time points. Results PWI was successfully achieved in 65 (89.0%) patients. Two (2.7%) minor vascular procedural complications were observed. At 1 and 2-year follow-up, ARs free survival was observed in 80.5% and 64.1% of patients, respectively with 75.3% of patients off antiarrhythmic drugs at the last follow-up. Ten patients underwent repeat ablations during the follow-up. At multivariate analysis, early ARs within 3 months after procedure, were associated with a two-fold increased risk of late ARs at follow-up. Among patients provided with ICM, PWI on top of PVI was able to reduce the mean AT/AF burden of more than 50% compared with pre-ablation time, reporting very low levels (≤ 5%) over 2 years. Conclusions In persistent atrial fibrillation, PWI on top of PVI using CF sensing catheters is safe and effective, providing great reduction of burden of ARs. Early ARs are associated with a greater risk of late recurrences.
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Affiliation(s)
- Giusy Sirico
- Department of Cardiac Electrophysiologist and Pacing, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Domenico Sirico
- Pediatric and Congenital Cardiology Unit, Department of Woman and Child's Health, University of Padova, Padova, Italy
| | - Andrea Montisci
- Department of Anesthesia and Intensive Care, Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, Milan, Italy and Chair of Cardiac Surgery, Postgraduate in Cardiac Surgery, University of Milan, Italy.,Department of Anesthesia and Intensive Care, Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, Milan, Italy and Chair of Cardiac Surgery, Postgraduate in Cardiac Surgery, University of Milan, Italy
| | - Enrico Cerrato
- Interventional Unit, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli (Torino), Italy and Chair of Cardiac Surgery, Postgraduate in Cardiac Surgery, University of Milan, Italy
| | - Martina Morosato
- Department of Cardiac Electrophysiologist and Pacing, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Stefania Panigada
- Department of Cardiac Electrophysiologist and Pacing, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Luca Ottaviano
- Department of Cardiac Electrophysiologist and Pacing, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Valerio De Sanctis
- Department of Cardiac Electrophysiologist and Pacing, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Massimo Mantica
- Department of Cardiac Electrophysiologist and Pacing, Istituto Clinico Sant'Ambrogio, Milan, Italy
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13
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Mori S, Bradfield JS, Peacock WJ, Anderson RH, Shivkumar K. Living Anatomy of the Pericardial Space: A Guide for Imaging and Interventions. JACC Clin Electrophysiol 2021; 7:1628-1644. [PMID: 34949433 DOI: 10.1016/j.jacep.2021.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 12/29/2022]
Abstract
The pericardium of the human heart has received increased attention in recent times due to interest in the epicardial approach for cardiac interventions to treat cardiac arrhythmias refractory to conventional endocardial approaches. To support further clinical application of this technique, it is fundamental to appreciate the living anatomy of the pericardial space, as well as its relationships to the surrounding structures. The anatomy of the pericardial space, however, is extremely difficult regions to visualize. This is due to its complex 3-dimensionality, and the "potential" nature of the space, which becomes obvious only when there is collection of pericardial fluid. This potential space, which is bounded by the epicardium and pericardium, can now be visualized by special techniques as we now report, permitting appreciation of its living morphology. Current sources of knowledge are limited to the dissection images, surgical images, and/or illustrations, which are not necessarily precise or sufficient to provide relevant comprehensive anatomical knowledge to those undertaking the epicardial approach. The authors demonstrate, for the first time to their knowledge, the 3-dimensional living anatomy of the pericardial space relative to its surrounding structures. They also provide correlative anatomy of the left sternocostal triangle as a common site for subxiphoid access. The authors anticipate their report serving as a tool for education of imaging and interventional specialists.
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Affiliation(s)
- Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, California, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, California, USA
| | | | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; UCLA Cardiovascular Interventional Programs, Department of Medicine, David Geffen School of Medicine at UCLA & UCLA Health System, Los Angeles, California, USA.
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14
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Hartley A, Shalhoub J, Ng FS, Krahn AD, Laksman Z, Andrade JG, Deyell MW, Kanagaratnam P, Sikkel MB. Size matters in atrial fibrillation: the underestimated importance of reduction of contiguous electrical mass underlying the effectiveness of catheter ablation. Europace 2021; 23:1698-1707. [PMID: 33948648 PMCID: PMC8576280 DOI: 10.1093/europace/euab078] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
Evidence has accumulated over the last century of the importance of a critical electrical mass in sustaining atrial fibrillation (AF). AF ablation certainly reduces electrically contiguous atrial mass, but this is not widely accepted to be an important part of its mechanism of action. In this article, we review data showing that atrial size is correlated in many settings with AF propensity. Larger mammals are more likely to exhibit AF. This is seen both in the natural world and in animal models, where it is much easier to create a goat model than a mouse model of AF, for example. This also extends to humans-athletes, taller people, and obese individuals all have large atria and are more likely to exhibit AF. Within an individual, risk factors such as hypertension, valvular disease and ischaemia can enlarge the atrium and increase the risk of AF. With respect to AF ablation, we explore how variations in ablation strategy and the relative effectiveness of these strategies may suggest that a reduction in electrical atrial mass is an important mechanism of action. We counter this with examples in which there is no doubt that mass reduction is less important than competing theories such as ganglionated plexus ablation. We conclude that, when considering future strategies for the ablative therapy of AF, it is important not to discount the possibility that contiguous electrical mass reduction is the most important mechanism despite the disappointing consequence being that enhancing success rates in AF ablation may involve greater tissue destruction.
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Affiliation(s)
- Adam Hartley
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Joseph Shalhoub
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute,Imperial College London, London, UK
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Zachary Laksman
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Jason G Andrade
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | - Marc W Deyell
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
| | | | - Markus B Sikkel
- Division of Cardiology, University of British Columbia, 740 Hillside Ave, Vancouver, BC V8T 1Z4, Canada
- Division of Medical Sciences, University of Victoria, Victoria, Canada
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15
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Aryana A. Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation. J Innov Card Rhythm Manag 2021; 12:4633-4646. [PMID: 34476116 PMCID: PMC8384303 DOI: 10.19102/icrm.2021.120801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 12/12/2022] Open
Abstract
There is strong evidence in support of pulmonary vein isolation (PVI) with concomitant left atrial (LA) posterior wall (PW) isolation (PWI) for the treatment of patients with persistent atrial fibrillation (persAF). While this may be achieved using surgical and catheter-based strategies, there is growing interest in performing this approach using the cryoballoon. There are several potential advantages to this strategy. First, lesions created using the current-generation cryoballoons are typically large and durable. Second, cryoballoon ablation offers a simple technique to directly ablate and debulk the LAPW. Moreover, some consider cryoenergy a safer modality specifically with regard to collateral structures (ie, the esophagus). Based on the available data, cryoballoon PVI + PWI is associated with greater intraprocedural AF terminations and reductions in long-term AF recurrence (typically by ~20%), as compared to PVI alone in patients with persAF, but with similar rates of adverse events. As such, PVI + PWI has emerged as a significant predictor of freedom from recurrent AF (odds ratio: 3.67, 95% confidence interval: 1.44-9.34; p = 0.006) as well as all atrial arrhythmias (hazard ratio: 2.04, 95% confidence interval: 1.15-3.61; p = 0.015). Adjunct radiofrequency ablation to complete PWI is required in at least one-third of the patients, and this need is highly predicted by the LA size (significantly increased with an LA diameter > 48 mm). LAPW reconnection also seems to be associated with LA dimension, particularly an LA diameter greater than 48 mm (negative predictive value: 89.7%). Nevertheless, based on the analysis of patients who underwent repeat electrophysiology study for arrhythmia recurrences, cryoballoon PVI + PWI yields acceptable long-term durability (> 80%).
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Affiliation(s)
- Arash Aryana
- Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
- Cardiac Catheterization Laboratory, Mercy General Hospital, Sacramento, CA, USA
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Aryana A, Allen SL, Di Biase L, Bowers MR, O'Neill PG, Natale A. Wide-area antral pulmonary vein and posterior wall isolation by way of segmental nonocclusive applications using a novel radiofrequency ablation balloon. HeartRhythm Case Rep 2021; 7:518-521. [PMID: 34434698 PMCID: PMC8377238 DOI: 10.1016/j.hrcr.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California
| | - Shelley L Allen
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California
| | - Luigi Di Biase
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Mark R Bowers
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California
| | - Padraig Gearoid O'Neill
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
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García-Granja PE, Fernández-Palacios G, Sandín-Fuentes M, García-Morán E. Radiofrequency Is Necessary for Left Atrium Posterior Wall Isolation. JACC Clin Electrophysiol 2021; 7:677-678. [PMID: 34016396 DOI: 10.1016/j.jacep.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/11/2021] [Accepted: 03/17/2021] [Indexed: 11/27/2022]
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Aryana A, Su W, Kuniss M, Okishige K, de Asmundis C, Tondo C, Chierchia GB. Segmental nonocclusive cryoballoon ablation of pulmonary veins and extrapulmonary vein structures: Best practices III. Heart Rhythm 2021; 18:1435-1444. [PMID: 33905811 DOI: 10.1016/j.hrthm.2021.04.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 11/19/2022]
Abstract
Although cryoballoon ablation of atrial fibrillation (AF) traditionally has been guided by pulmonary vein (PV) occlusion, there is evidence and growing interest in performing segmental, nonocclusive cryoballoon ablation to target not only large/common PVs but extra-PV structures such as the left atrial (LA) roof and posterior wall in conjunction with PV isolation. A number of studies have demonstrated improved clinical efficacy associated with nonocclusive cryoballoon ablation of the LA roof and posterior wall in addition to PV isolation, particularly in patients with persistent AF. Not only can the cryoballoon be used for targeting extra-PV structures through segmental, nonocclusive ablation, but the large size and durability of cryolesions coupled with the enhanced stability afforded through cryoadhesion render the cryoballoon an effective tool for such an approach. This article reviews the rationale and practical approach to segmental, nonocclusive cryoballoon ablation of large/common PV antra and the LA roof and posterior wall.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California.
| | - Wilber Su
- Banner University Medical Center, Phoenix, Arizona
| | - Malte Kuniss
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | | | - Claudio Tondo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS; Department of Biochemical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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Liang Z, Liu L, Cheng L, Wang Z, Zhang J, Yang W, Wang Y, Wu Y. New method and electrophysiological characteristics of LA posterior wall isolation in persistent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1691-1700. [PMID: 33734464 DOI: 10.1111/pace.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/21/2021] [Accepted: 03/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Left atrial posterior wall isolation (PWI) is commonly used with persistent atrial fibrillation (AF) ablation. However, potentials are often still recorded in the posterior wall after pulmonary vein isolation (PVI), roof linear ablation, and bottom linear ablation in clinical practice. We aimed to explore the methodological approach and electrophysiological characteristics of PWI. METHODS A total of 36 patients who attended our center with long-standing persistent AF were retrospectively analyzed. After routine PVI and roof and bottom linear ablation, complete PWI was confirmed in sinus rhythm by voltage mapping and high-output pacing. Otherwise, activation mapping and voltage mapping were used to guide ablation on the line or inside the posterior wall until bidirectional block was achieved. RESULTS The first-pass success rate of PWI was 39%. In the remaining 61% of patients with posterior wall electrograms, activation mapping in sinus rhythm showed that the earliest activation point was not on the ablation line but in a relatively dispersed focal area, possibly related to epicardial muscular sleeve insertion. Voltage mapping revealed a focal high-voltage area in the posterior wall matching the relatively dispersed earliest activation site, in which an average of five points of ablation achieved complete PWI without serious esophageal injury. The middle zone contained 80% of the additional posterior wall ablation points. CONCLUSIONS PWI was performed safely and effectively with an average of five additional ablation points in the posterior wall in 61% of patients under the guidance of voltage mapping.
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Affiliation(s)
- Zhuo Liang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lifeng Liu
- department of heart center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liting Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zefeng Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junmeng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenxue Yang
- Department of Cardiology, Shijiazhuang Great Wall Hospital of Integrated Traditional Chinese and Western Medicine, Shijiazhuang, China
| | - Yunlong Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongquan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Wang Z, Jia L, Shi T, Liu C. General anesthesia is not superior to sedation in clinical outcome and cost-effectiveness for ablation of persistent atrial fibrillation. Clin Cardiol 2020; 44:218-221. [PMID: 33373042 PMCID: PMC7852177 DOI: 10.1002/clc.23528] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 11/20/2020] [Accepted: 12/01/2020] [Indexed: 11/20/2022] Open
Abstract
Background The strategy of anesthesia used during ablation of atrial fibrillation (AF) remains controversial. This study aimed to compare sedation with general anesthesia (GA) for catheter ablation of AF. Hypothesis The presence of AF is associated with an increased risk of stroke and heart failure and decreased quality of life and survival. Methods We carried out a retrospective single‐centered study with 351 patients undergoing the first ablation procedure for AF under sedation or GA. The main outcome was freedom from recurrence of AF at 1 year. The total time of staying at the ablation laboratory and procedure cost were also calculated. Results Freedom from atrial arrhythmia and ablation time did not differ between AF patients under sedation and GA (77.9% vs 79.9% and 42.27 ± 9.84 minutes vs 41.51 ± 9.27 minutes, respectively), while the total procedure time and cost were lower in patients who underwent sedation than GA (171.39 ± 45.09 minutes vs 202.92 ± 43.85 and 8.00 ± 7.02 CNY vs 8.79 ± 11.63 CNY, respectively). Conclusion GA is not superior to sedation, in terms of ablation time and freedom from atrial arrhythmia at 1 year, whereas patients with GA had more anesthesia time and procedure cost than sedation.
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Affiliation(s)
- Zhengyan Wang
- Cardiology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lihong Jia
- Cardiology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Tieying Shi
- Cardiology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Changli Liu
- Cardiology Department, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Subepicardial and endocardial myocardial layers within the roof of the left atrium. Heart Rhythm 2020; 18:358-359. [PMID: 33212247 DOI: 10.1016/j.hrthm.2020.11.014] [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: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 10/23/2022]
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Pambrun T, Duchateau J, Delgove A, Denis A, Constantin M, Ramirez FD, Chauvel R, Tixier R, Welte N, André C, Nakashima T, Nakatani Y, Kamakura T, Takagi T, Krisai P, Cheniti G, Vlachos K, Bourier F, Takigawa M, Kitamura T, Frontera A, Sacher F, Hocini M, Jaïs P, Haïssaguerre M, Walton RD, Derval N. Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion. Heart Rhythm 2020; 18:349-357. [PMID: 33188900 DOI: 10.1016/j.hrthm.2020.11.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gaps in the roof line have been ascribed to epicardial conduction using the septopulmonary bundle. OBJECTIVES We sought to evaluate the frequency of septopulmonary bundle bypass during roof line ablation, to describe anatomical conditions favoring this epicardial gap, and to propose an alternative strategy when present. METHODS One hundred consecutive patients underwent atrial fibrillation ablation. A de novo roof line was created between the superior pulmonary veins. In cases of residual gaps, a floor line was created between the inferior pulmonary veins. Microtomography imaging and histological analyses of 5 human donor hearts were performed: a specific focus was made on the dome and the posterior wall. RESULTS Residual gaps were more frequent in roof lines than floor lines (33% vs 15%; P = .049). Electrogram morphologies, activation sequences, and pacing maneuvers indicated an epicardial bypass of the roof line in all cases. Conduction block was obtained in 67 roof lines and 28 floor lines, resulting in a 95% success rate of linear block, without "box" isolation. Between the superior pulmonary veins, the atrial myocardium was thicker and consistently displayed adipose tissue separating the septopulmonary bundle from the septoatrial bundle. CONCLUSION Epicardial conduction across the roof line is common and requires careful electrogram analysis to detect. In such cases, a floor line can be an effective alternative strategy, with clear validation criteria. Myocardial thickness and fat interposition may explain difficulties in achieving lesion transmurality during roof line ablation.
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Affiliation(s)
- Thomas Pambrun
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France.
| | - Josselin Duchateau
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Anaïs Delgove
- Bordeaux School of Surgery, CHU Bordeaux, Bordeaux, France
| | - Arnaud Denis
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Marion Constantin
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - F Daniel Ramirez
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Rémi Chauvel
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Romain Tixier
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Nicolas Welte
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Clémentine André
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Takashi Nakashima
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Yosuke Nakatani
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Tsukasa Kamakura
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Takamitsu Takagi
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Philipp Krisai
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Konstantinos Vlachos
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Félix Bourier
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Masateru Takigawa
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Takeshi Kitamura
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Antonio Frontera
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Pierre Jaïs
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Richard D Walton
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Nicolas Derval
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L'Institut de RYthmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
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Aryana A, Allen SL, Pujara DK, Bowers MR, O'Neill PG, Yamauchi Y, Shigeta T, Vierra EC, Okishige K, Natale A. Concomitant Pulmonary Vein and Posterior Wall Isolation Using Cryoballoon With Adjunct Radiofrequency in Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2020; 7:187-196. [PMID: 33602399 DOI: 10.1016/j.jacep.2020.08.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/22/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of this multicenter, randomized, single-blind study was to prospectively evaluate the short-and long-term outcomes of pulmonary vein isolation (PVI) versus PVI with concomitant left atrial posterior wall isolation (PWI) using the cryoballoon in patients with symptomatic persistent/long-standing persistent atrial fibrillation (P/LSP-AF). BACKGROUND Some studies have suggested a clinical benefit associated with PVI+PWI in patients with P/LSP-AF. However, there are limited safety and efficacy data on this approach using cryoballoon ablation. METHODS The immediate and long-term outcomes in patients with P/LSP-AF randomized to PVI (n = 55) versus PVI+PWI (n = 55) using the cryoballoon were prospectively examined. RESULTS Baseline characteristics were similar. PVI was achieved in all patients (21 ± 11 min). PWI was attained using 23 ± 8 min of cryoablation. Adjunct radiofrequency ablation was required in 4 of 110 patients (7.3%) to complete PVI (3 ± 2 min) and in 25 of 55 patients (45.5%) to complete PWI (4 ± 6 min). Although left atrial dwell time (113 ± 31 min vs. 75 ± 32 min; p < 0.001) and total procedure time (168 ± 34 min vs. 127 ± 40 min; p < 0.001) were longer with PVI+PWI, this cohort required fewer intraprocedural cardioversions (89.1% vs. 96.4%; p = 0.04). Adverse events occurred in 5.5% in each group (p = 1.00). However, the incidence of recurrent atrial fibrillation at 12 months was significantly lower with PVI+PWI (25.5% vs. 45.5%; p = 0.028). Additionally, in a multivariate analysis, PVI+PWI emerged as a significant predictor of freedom from recurrent atrial fibrillation (odds ratio: 3.67; 95% confidence interval: 1.44 to 9.34; p = 0.006). CONCLUSIONS In patients with P/LSP-AF, PVI+PWI using the cryoballoon is associated with a significant reduction in atrial fibrillation recurrence, but similar safety, as compared with PVI alone.
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Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA.
| | - Shelley L Allen
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | | | - Mark R Bowers
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Padraig Gearoid O'Neill
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Yasuteru Yamauchi
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Takatoshi Shigeta
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Eleanor C Vierra
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
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Combined epicardial and endocardial ablation for atrial fibrillation: Best practices and guide to hybrid convergent procedures. Heart Rhythm 2020; 18:303-312. [PMID: 33045430 DOI: 10.1016/j.hrthm.2020.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/24/2020] [Accepted: 10/04/2020] [Indexed: 02/07/2023]
Abstract
The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to complete isolation of the pulmonary veins and for additional ablation as needed. Experience gained with the hybrid Convergent procedure during the last decade has led to the development and adoption of strategies to optimize the technique and mitigate risks. Additionally, a surgical and electrophysiology "team" approach including comprehensive training is believed critical to successfully develop the hybrid Convergent program. A recently completed randomized clinical trial indicated that this ablation strategy is superior to an endocardial-only approach for patients with persistent atrial fibrillation. In this review, we propose and describe best practice guidelines for hybrid Convergent ablation on the basis of a combination of published data, author consensus, and expert opinion. A summary of clinical outcomes, emerging evidence, and future perspectives is also given.
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25
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Aryana A, Pujara DK, Allen SL, Baker JH, Espinosa MA, Buch EF, Srivatsa U, Ellis E, Makati K, Kowalski M, Lee S, Tadros T, Baykaner T, Al-Ahmad A, d'Avila A, Di Biase L, Okishige K, Natale A. Left atrial posterior wall isolation in conjunction with pulmonary vein isolation using cryoballoon for treatment of persistent atrial fibrillation (PIVoTAL): study rationale and design. J Interv Card Electrophysiol 2020; 62:187-198. [PMID: 33009645 DOI: 10.1007/s10840-020-00885-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is growing evidence in support of pulmonary vein isolation (PVI) with concomitant posterior wall isolation (PWI) for the treatment of patients with symptomatic persistent atrial fibrillation (persAF). However, there is limited data on the safety and efficacy of this approach using the cryoballoon. OBJECTIVE The aim of this multicenter, investigational device exemption trial (G190171) is to prospectively evaluate the acute and long-term outcomes of PVI versus PVI+PWI using the cryoballoon in patients with symptomatic persAF. METHODS The PIVoTAL is a prospective, randomized controlled study ( ClinicalTrials.gov : NCT04505163) in which patients with symptomatic persAF refractory/intolerant to ≥ 1 class I-IV antiarrhythmic drug, undergoing first-time catheter ablation, will be randomized to PVI (n = 183) versus PVI+PWI (n = 183) using the cryoballoon in a 1:1 fashion. The design will be double-blind until randomization immediately after PVI, beyond which the design will transform into a single-blind. PVI using cryoballoon will be standardized using a pre-specified dosing algorithm. Other empiric ablations aside from documented arrhythmias/arrhythmias spontaneously induced during the procedure will not be permitted. The primary efficacy endpoint is defined as AF recurrence at 12 months, after a single procedure and a 90-day blanking period. Arrhythmia outcomes will be assessed by routine electrocardiograms and 7-14 day ambulatory electrocardiographic monitoring at 3, 6, and 12 months post-ablation. CONCLUSION The PIVoTAL is a prospective, randomized controlled trial designed to evaluate the outcomes of PVI alone versus PVI+PWI using the cryoballoon, in patients with symptomatic persAF. We hypothesize that PVI+PWI will prove to be superior to PVI alone for prevention of AF recurrence.
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Affiliation(s)
- Arash Aryana
- Cardiovascular Services, Mercy General Hospital and Dignity Health Heart and Vascular Institute, 3941 J Street, Suite #350, Sacramento, CA, 95819, USA.
| | | | - Shelley L Allen
- Cardiovascular Services, Mercy General Hospital and Dignity Health Heart and Vascular Institute, 3941 J Street, Suite #350, Sacramento, CA, 95819, USA
| | | | | | - Eric F Buch
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - Uma Srivatsa
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Ethan Ellis
- UCHealth Medical Center, Fort Collins, CO, USA
| | | | | | - Sung Lee
- MedStar Georgetown University Hospital and Medical Center, Washington, DC, USA
| | | | - Tina Baykaner
- Stanford University Medical Center, Stanford, CA, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - André d'Avila
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Luigi Di Biase
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Kaoru Okishige
- Heart Center, Japan Red Cross Yokohama City Bay Hospital, Yokohama, Japan
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
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Long-term durability of posterior wall isolation using the cryoballoon in patients with persistent atrial fibrillation: a multicenter analysis of repeat catheter ablations. J Interv Card Electrophysiol 2020; 62:161-169. [PMID: 33000358 DOI: 10.1007/s10840-020-00887-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE There is a growing interest in performing pulmonary vein isolation (PVI) with concomitant posterior wall isolation (PWI) using the cryoballoon for the treatment of patients with persistent atrial fibrillation (AF). However, there is little known about the long-term durability of PWI using this approach. METHODS In this multicenter study, we retrospectively examined the durability of PVI + PWI using the 28-mm cryoballoon by investigating the outcomes from consecutive patients referred for repeat catheter ablation. RESULTS Altogether, 81/519 patients (15.6%) were referred for repeat catheter ablation. Repeat ablation was associated with a longer AF duration, hypertension, heart failure, multiple cardioversions, and antiarrhythmic therapy as well as larger left atrial (LA) diameters (49 ± 4 mm versus 43 ± 5 mm; P < 0.001) and greater need for "touch-up" (adjunct) radiofrequency ablation (44.4% versus 18.3%; P < 0.001). LA diameter also emerged as a significant predictor for adjunct radiofrequency ablation (P < 0.001). Durable PVI was observed in 66/81 patients (81.5%) and PWI in 67/81 patients (82.7%). Those with incomplete PWI exhibited larger LA diameters, particularly > 48 mm (negative predictive value = 89.7%). Lastly, an atypical LA posterior wall/roof flutter represented the third most common cause of arrhythmia recurrence and essentially every patient with incomplete PWI exhibited such an arrhythmia. CONCLUSION PWI performed using a 28-mm cryoballoon in conjunction with PVI exhibits long-term durability in the vast majority of patients with persistent AF. While LA diameter (particularly > 48 mm) is a significant predictor for the need for adjunct radiofrequency ablation when performing this technique, those with incomplete PWI invariably present with an atypical flutter using this substrate.
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Larson J, Merchant FM, Patel A, Ndubisi NM, Patel AM, DeLurgio DB, Lloyd MS, El‐Chami MF, Leon AR, Hoskins MH, Keeling WB, Halkos ME, Lattouf OM, Westerman S. Outcomes of convergent atrial fibrillation ablation with continuous rhythm monitoring. J Cardiovasc Electrophysiol 2020; 31:1270-1276. [DOI: 10.1111/jce.14454] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/12/2020] [Accepted: 02/21/2020] [Indexed: 01/20/2023]
Affiliation(s)
- John Larson
- Emory University School of Medicine Atlanta Georgia
| | - Faisal M. Merchant
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Akshar Patel
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Nnaemeka M. Ndubisi
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Anshul M. Patel
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - David B. DeLurgio
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Michael S. Lloyd
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Mikhael F. El‐Chami
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Angel R. Leon
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Michael H. Hoskins
- Department of CardiologyNew Mexico Heart Institute Albuquerque New Mexico
| | - W. Brent Keeling
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Michael E. Halkos
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Omar M. Lattouf
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Stacy Westerman
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
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28
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Elbatran AI, Gallagher MM, Li A, Sohal M, Bajpai A, Samir R, Tawfik M, Nabil A, Abou-Elmaaty Nabih M, Saba MM. Isolating the entire pulmonary venous component versus isolating the pulmonary veins for persistent atrial fibrillation: A propensity-matched analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 43:68-77. [PMID: 31808165 DOI: 10.1111/pace.13852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/25/2019] [Accepted: 11/30/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The outcomes of pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) are suboptimal. The entire pulmonary venous component (PV-Comp), consisting of the pulmonary veins, their antra, and the area between the antra, provides triggers and substrate for AF. PV-Comp isolation is an alternative strategy for persistent AF ablation. METHODS Among 328 patients with persistent AF who underwent a first radiofrequency ablation procedure, 200 patients (PVI, n = 100; PV-Comp isolation, n = 100) were selected by propensity score matching. Both groups were followed up for 1 year. RESULTS At 6- and 12-month follow-up, atrial tachyarrhythmia (AF/atrial tachycardia) recurred in 41 and 61 patients in PVI group and 22 (P = .006) and 33 patients (P < .001) in PV-Comp isolation group, respectively. PV-Comp isolation was associated with longer mean time to recurrence (PVI: 8 months, PV-Comp isolation: 10 months, log-rank P < .001) and a lower probability of recurrence (odds ratio [OR] = 0.32; 95% confidence of interval [CI] = 0.18-0.56, P < .001), with no increase in procedural complications (PVI: 5 of 100, PV-Comp isolation: 6 of 100, P = .76). Procedure duration was longer in PV-Comp isolation group (PVI: 186 ± 42 min, PV-Comp isolation: 238 ± 44 min, P < .001), as well as fluoroscopy time (PVI: 22 ± 16 min, PV-Comp isolation: 31 ± 21 min, P = .001). CONCLUSION PV-Comp isolation for persistent AF reduced atrial tachyarrhythmia recurrence up to 1 year compared with PVI alone. While procedure and fluoroscopy time increased, there was no difference in procedural complications.
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Affiliation(s)
- Ahmed I Elbatran
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, London, UK.,Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, London, UK
| | - Anthony Li
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, London, UK
| | - Manav Sohal
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, London, UK
| | - Abhay Bajpai
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, London, UK
| | - Rania Samir
- Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Mazen Tawfik
- Department of Cardiology, Ain Shams University, Cairo, Egypt
| | - Ahmed Nabil
- Department of Cardiology, Ain Shams University, Cairo, Egypt
| | | | - Magdi M Saba
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's University of London, London, UK
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