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; 67:921-1072. [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] [MESH Headings] [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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Kistler PM, Sanders P, Amarena JV, Bain CR, Chia KM, Choo WK, Eslick AT, Hall T, Hopper IK, Kotschet E, Lim HS, Ling LH, Mahajan R, Marasco SF, McGuire MA, McLellan AJ, Pathak RK, Phillips KP, Prabhu S, Stiles MK, Sy RW, Thomas SP, Toy T, Watts TW, Weerasooriya R, Wilsmore BR, Wilson L, Kalman JM. 2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation. Heart Lung Circ 2024; 33:828-881. [PMID: 38702234 DOI: 10.1016/j.hlc.2023.12.024] [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: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 05/06/2024]
Abstract
Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.
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Affiliation(s)
- Peter M Kistler
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia.
| | - Prash Sanders
- University of Adelaide, Adelaide, SA, Australia; Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Chris R Bain
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Karin M Chia
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Wai-Kah Choo
- Gold Coast University Hospital, Gold Coast, Qld, Australia; Royal Darwin Hospital, Darwin, NT, Australia
| | - Adam T Eslick
- University of Sydney, Sydney, NSW, Australia; The Canberra Hospital, Canberra, ACT, Australia
| | | | - Ingrid K Hopper
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Emily Kotschet
- Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia
| | - Han S Lim
- University of Melbourne, Melbourne, Vic, Australia; Austin Health, Melbourne, Vic, Australia; Northern Health, Melbourne, Vic, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia
| | - Rajiv Mahajan
- University of Adelaide, Adelaide, SA, Australia; Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Silvana F Marasco
- The Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | | | - Alex J McLellan
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia; St Vincent's Hospital, Melbourne, Vic, Australia
| | - Rajeev K Pathak
- Australian National University and Canberra Heart Rhythm, Canberra, ACT, Australia
| | - Karen P Phillips
- Brisbane AF Clinic, Greenslopes Private Hospital, Brisbane, Qld, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Vic, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Vic, Australia; University of Melbourne, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Martin K Stiles
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Raymond W Sy
- Royal Prince Alfred Hospital, Sydney, NSW, Australia; Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Stuart P Thomas
- University of Sydney, Sydney, NSW, Australia; Westmead Hospital, Sydney, NSW, Australia
| | - Tracey Toy
- The Alfred Hospital, Melbourne, Vic, Australia
| | - Troy W Watts
- Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Rukshen Weerasooriya
- Hollywood Private Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, Vic, Australia; Royal Melbourne Hospital, Melbourne, Vic, Australia
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3
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van Waaij K, Keçe F, de Riva M, Alizadeh Dehnavi R, Wijnmaalen AP, Piers SRD, Mertens BJ, Zeppenfeld K, Trines SA. Validation of a prediction model for early reconnection after cryoballoon ablation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01811-0. [PMID: 38743141 DOI: 10.1007/s10840-024-01811-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND We previously developed an early reconnection/dormant conduction (ERC) prediction model for cryoballoon ablation to avoid a 30-min waiting period with adenosine infusion. We now aimed to validate this model based on time to isolation, number of unsuccessful cryo-applications, and nadir balloon temperature. METHODS Consecutive atrial fibrillation patients who underwent their first cryoballoon ablation in 2018-2019 at the Leiden University Medical Center were included. Model performance at the previous and at a new optimal cutoff value was determined. RESULTS A total of 201 patients were included (85.57% paroxysmal AF, 139 male, median age 61 years (IQR 53-69)). ERC was found in 35 of 201 included patients (17.41%) and in 41 of 774 veins (5.30%). In the present study population, the previous cutoff value of - 6.7 provided a sensitivity of 37.84% (previously 70%) and a specificity of 89.07% (previously 86%). Shifting the cutoff value to - 7.2 in both study populations resulted in a sensitivity of 72.50% and 72.97% and a specificity of 78.22% and 78.63% in data from the previous and present study respectively. Negative predictive values were 96.55% and 98.11%. Applying the model on the 101 patients of the present study with all necessary data for all veins resulted in 43 out of 101 patients (43%) not requiring a 30-min waiting period with adenosine testing. Two patients (2%) with ERC would have been missed when applying the model. CONCLUSIONS The previously established ERC prediction model performs well, recommending its use for centers routinely using adenosine testing following PVI.
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Affiliation(s)
- Kevin van Waaij
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fehmi Keçe
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Electrophysiology, Heart Center, University of Cologne, Cologne, Germany
| | - Marta de Riva
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Reza Alizadeh Dehnavi
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Sebastiaan R D Piers
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Bart J Mertens
- Bioinformatics Center of Expertise, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Heart Lung Center, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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4
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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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5
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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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6
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Babak A, Kauffman CB, Lynady C, McClellan R, Venkatachalam K, Kusumoto F. Pulmonary vein capture is a predictor for long-term success of stand-alone pulmonary vein isolation with cryoballoon ablation in patients with persistent atrial fibrillation. Front Cardiovasc Med 2024; 10:1150378. [PMID: 38410505 PMCID: PMC10895012 DOI: 10.3389/fcvm.2023.1150378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 11/29/2023] [Indexed: 02/28/2024] Open
Abstract
Background The mechanisms of AF development and progression are still not completely understood. Despite the relative efficacy of ablation, the risk of AF recurrence is substantial, particularly in patients with persistent AF (perAF). At present we do not have any reliable intra-procedural electrophysiologic predictors of long-term success of AF ablation other than pulmonary vein isolation. We evaluated selected intraprocedural pulmonary vein characteristics that may be helpful in future guidance of persistent AF ablation. Methods 390 consecutive procedures using cryoballoon for initial AF ablation were divided by clinical presentation (paroxysmal or persistent AF), and by pulmonary vein (PV) response to pacing after completion of ablation (discrete electrogram elicited with pacing-"PV capture" or not-"Control"). Patients were followed (median 20 months) for recurrent atrial arrhythmias as the primary end point of the study. Results PV capture was identified in 20.3% and 17.1% and patients with paroxysmal and persistent AF respectively (ns). In patients with persistent AF presence of PV capture was associated with significantly better outcomes compared to patients without PV capture (p < 0.001). In the group "persistent AF and PV capture", an initial strategy of PV isolation and reisolation of the PVs (without additional lesions) for patients with recurrent atrial arrhythmias resulted in 20/23 (87%) patients in sinus rhythm off antiarrhythmic medications at study completion. In patients with paroxysmal AF, PV capture was not associated with outcome benefits. Specific electrophysiologic characteristics of PV (PV capture cycle length: PVCCL) did not have an impact on AF recurrence, although 25% shortening of PVCCL was observed after 60 s periods of pacing at short cycle lengths. No background demographic patient characteristic differences were identified between patients with vs. without PV capture. Conclusion The presence of PV capture was associated with better outcomes in patients with persistent AF. PV capture may identify those patients with persistent AF in whom cryoballoon PV isolation alone is sufficient as an initial ablation procedure and as the primary ablation strategy for recurrent AF.
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Affiliation(s)
- Alexey Babak
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
- School of Medicine, Emory University, Atlanta, GA, United States
| | | | - Cynthia Lynady
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Reginald McClellan
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Kalpathi Venkatachalam
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
| | - Fred Kusumoto
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, United States
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7
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Tzeis S, Brusich S, Manola Š, Kojić D, Pernat A, Asvestas D, Xenos T, Bastiančić AL, Tomović M, Rauber M, Vardas P, Pavlović N. Ablation of residual potentials along the circumferential line reduces acute pulmonary vein reconnection. Hellenic J Cardiol 2023; 72:1-8. [PMID: 36907510 DOI: 10.1016/j.hjc.2023.03.001] [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: 12/08/2022] [Revised: 02/18/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023] Open
Abstract
INTRODUCTION Acute pulmonary vein (PV) reconnection is frequently encountered in patients undergoing PV isolation (PVI) procedure for the treatment of atrial fibrillation. In this study, we investigated whether the identification and ablation of residual potentials (RPs), after the initial achievement of PVI, reduces acute PV reconnection rate. METHODS Following PVI in 160 patients, mapping along the ablation line was performed to identify RPs, defined as bipolar amplitude ≥0.2 mV or 0.1-0.19 mV combined with a negative component of the unipolar electrogram. Ipsilateral PV sets with RPs were randomized to either no further ablation (Group B) or to additional ablation of the identified RPs (Group C). The primary study endpoint was spontaneous or adenosine-mediated acute PV reconnection after a 30-min waiting period and was also evaluated in ipsilateral PV sets without RPs (Group A). RESULTS After isolation of 287 PV pairs, 135 had no RPs (Group A), whereas the remaining PV pairs were randomized to either Group B (n = 75) or Group C (n = 77). Ablation of RPs resulted in a reduction of spontaneous or adenosine-mediated PV reconnection rate (16.9% in Group C vs 48.0% in Group B; p < 0.001). Group A was associated with a significantly lower percentage of acute PV reconnection as compared to Group B (5.9% vs 48.0%; p < 0.001) and Group C (5.9% vs 16.9%; p = 0.016). CONCLUSION After PVI achievement, the absence of RPs along the circumferential line is associated with a low likelihood of acute PV reconnection rate. Ablation of RPs significantly reduces spontaneous or adenosine-mediated acute PV reconnection rate.
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Affiliation(s)
- Stylianos Tzeis
- Cardiology Department, Mitera Hospital, Hygeia Group, Athens, Greece.
| | - Sandro Brusich
- Clinic for Cardiovascular Diseases, University Hospital Centre Rijeka, Rijeka, Croatia
| | - Šime Manola
- Department of Cardiovascular Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Dejan Kojić
- Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Andrej Pernat
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Theodoros Xenos
- Biosense Webster, Johnson & Johnson MedTech Greece, Athens, Greece
| | - Ana Lanča Bastiančić
- Clinic for Cardiovascular Diseases, University Hospital Centre Rijeka, Rijeka, Croatia
| | | | - Martin Rauber
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Panos Vardas
- Cardiology Department, Mitera Hospital, Hygeia Group, Athens, Greece
| | - Nikola Pavlović
- Department of Cardiovascular Medicine, University Hospital Dubrava, Zagreb, Croatia
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8
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Nair GM, Birnie DH, Nery PB, Redpath CJ, Sarrazin JF, Roux JF, Parkash R, Bernier M, Sterns LD, Sapp J, Novak P, Veenhuyzen G, Morillo CA, Singh SM, Sadek MM, Golian M, Klein A, Sturmer M, Chauhan VS, Angaran P, Green MS, Bernick J, Wells GA, Essebag V. Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation Recurrence: The AWARE Randomized Clinical Trial. JAMA Cardiol 2023; 8:475-483. [PMID: 36947030 PMCID: PMC10034661 DOI: 10.1001/jamacardio.2023.0212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/24/2023] [Indexed: 03/23/2023]
Abstract
Importance Recurrent atrial fibrillation (AF) commonly occurs after catheter ablation and is associated with patient morbidity and health care costs. Objective To evaluate the superiority of an augmented double wide-area circumferential ablation (WACA) compared with a standard single WACA in preventing recurrent atrial arrhythmias (AA) (atrial tachycardia, atrial flutter, or atrial fibrillation [AF]) in patients with paroxysmal AF. Design, Setting, and Participants This was a pragmatic, multicenter, prospective, randomized, open, blinded end point superiority clinical trial conducted at 10 university-affiliated centers in Canada. The trial enrolled patients 18 years and older with symptomatic paroxysmal AF from March 2015 to May 2017. Analysis took place between January and April 2022. Analyses were intention to treat. Interventions Patients were randomized (1:1) to receive radiofrequency catheter ablation for pulmonary vein isolation with either a standard single WACA or an augmented double WACA. Main Outcomes and Measures The primary outcome was AA recurrence between 91 and 365 days postablation. Patients underwent 42 days of ambulatory electrocardiography monitoring after ablation. Secondary outcomes included need for repeated catheter ablation and procedural and safety variables. Results Of 398 patients, 195 were randomized to the single WACA (control) arm (mean [SD] age, 60.6 [9.3] years; 65 [33.3%] female) and 203 to the double WACA (experimental) arm (mean [SD] age, 61.5 [9.3] years; 66 [32.5%] female). Overall, 52 patients (26.7%) in the single WACA arm and 50 patients (24.6%) in the double WACA arm had recurrent AA at 1 year (relative risk, 0.92; 95% CI, 0.66-1.29; P = .64). Twenty patients (10.3%) in the single WACA arm and 15 patients (7.4%) in the double WACA arm underwent repeated catheter ablation (relative risk, 0.72; 95% CI, 0.38-1.36). Adjudicated serious adverse events occurred in 13 patients (6.7%) in the single WACA arm and 14 patients (6.9%) in the double WACA arm. Conclusions and Relevance In this randomized clinical trial of patients with paroxysmal AF, additional ablation by performing a double ablation lesion set did not result in improved freedom from recurrent AA compared with a standard single ablation set. Trial Registration ClinicalTrials.gov Identifier: NCT02150902.
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Affiliation(s)
- Girish M. Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H. Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pablo B. Nery
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | | | - Ratika Parkash
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Martin Bernier
- McGill University Health Center, Montreal, Québec, Canada
| | | | - John Sapp
- Queen Elizabeth II Health Sciences, Halifax, Nova Scotia, Canada
| | - Paul Novak
- Victoria Cardiac Arrhythmia Trials, Victoria, British Columbia, Canada
| | - George Veenhuyzen
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Carlos A. Morillo
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Mehrdad Golian
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marcio Sturmer
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vijay S. Chauhan
- University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Martin S. Green
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jordan Bernick
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A. Wells
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Québec, Canada
- Hôpital Sacré-Cœur de Montréal, Montréal, Québec, Canada
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9
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Keçe F, de Riva M, Alizadeh Dehnavi R, Wijnmaalen AP, Mertens BJ, Schalij MJ, Zeppenfeld K, Trines SA. Predicting early reconnection after cryoballoon ablation with procedural and biophysical parameters. Heart Rhythm O2 2021; 2:290-297. [PMID: 34337580 PMCID: PMC8322820 DOI: 10.1016/j.hroo.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Predicting early reconnection/dormant conduction (ERC) immediately after pulmonary vein isolation (PVI) can avoid a waiting period with adenosine testing. OBJECTIVE To identify procedural and biophysical parameters predicting ERC. METHODS Consecutive atrial fibrillation (AF) patients undergoing a first cryoballoon ablation (Arctic Front Advance) between 2014 and 2017 were included. ERC was defined as manifest or dormant pulmonary vein (PV) reconnection with adenosine 30 minutes after PVI. Time to isolation (TTI), balloon temperatures (BT), and thawing times were evaluated as potential predictors for ERC. Based on a multivariable model, cut-off-values were defined and a formula was constructed to be used in clinical practice. RESULTS A total of 136 patients (60 ± 10 years, 96 male, 95% paroxysmal AF) were included. ERC was found in 40 (29%) patients (ERC group) and in 53 of 575 (9%) veins. Procedural and total ablation time and the number of unsuccessful freezes were significantly longer/higher in the ERC group compared to the non-ERC group (150 ± 40 vs 125 ± 34 minutes; 24 ± 5 vs 17 ± 4 minutes, and 38% vs 24%, respectively (P = .028). Multivariable analysis showed that a higher nadir balloon temperature (hazard ratio [HR] 1.17 [1.09-1.23, P < .001), a higher number of unsuccessful freezes (HR 1.69 [1.15-2.49], P = .008) and a longer TTI (HR 1.02 [1.01-1.03], P < .001) were independently associated with ERC, leading to the following formula: 0.02 × TTI + 0.5 × number of unsuccessful freezes + 0.2 × nadir BT with a cut-off value of ≤-6.7 to refrain from a waiting period with adenosine testing. CONCLUSION Three easily available parameters were associated with ERC. Using these parameters during ablation can help to avoid a 30-minute waiting period and adenosine testing.
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Affiliation(s)
- Fehmi Keçe
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Marta de Riva
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Reza Alizadeh Dehnavi
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Adrianus P. Wijnmaalen
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J. Mertens
- Bioinformatics Center of Expertise, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J. Schalij
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Serge A. Trines
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Leiden, The Netherlands
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10
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Sharif ZI, Heist EK. Optimizing Durability in Radiofrequency Ablation of Atrial Fibrillation. J Innov Card Rhythm Manag 2021; 12:4507-4518. [PMID: 34035983 PMCID: PMC8139307 DOI: 10.19102/icrm.2021.120505] [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: 10/19/2020] [Accepted: 11/27/2020] [Indexed: 11/06/2022] Open
Abstract
Radiofrequency ablation (RFA) remains a highly effective therapy in the management of paroxysmal atrial fibrillation (PAF) and is an important therapeutic option in the management of persistent atrial fibrillation (PeAF) when clinically indicated. Lesion size is influenced by many parameters, which include those related to energy application (RFA power, temperature, and time), delivery mechanism (electrode size, orientation, and contact force), and the environment (blood flow and local tissue contact, stability, and local impedance). Successful durable RFA is dependent on achieving lesions that are reliably transmural and contiguous, whilst also avoiding injury to the surrounding structures. This review focuses on the variables that can be adjusted in connection with RFA to achieve long-lasting lesions that enable patients to derive the maximum sustained benefit from pulmonary vein isolation and additional lesion sets if utilized.
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Affiliation(s)
- Zain I Sharif
- Clinical Cardiac Electrophysiology Department, Massachusetts General Hospital, Boston, MA, USA
| | - E Kevin Heist
- Clinical Cardiac Electrophysiology Department, Massachusetts General Hospital, Boston, MA, USA
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11
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Garg L, Pothineni NVK, Daw JM, Hyman MC, Arkles J, Tschabrunn CM, Santangeli P, Marchlinski FE. Impact of Left Atrial Bipolar Electrogram Voltage on First Pass Pulmonary Vein Isolation During Radiofrequency Catheter Ablation. Front Physiol 2021; 11:594654. [PMID: 33384608 PMCID: PMC7769759 DOI: 10.3389/fphys.2020.594654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background First pass pulmonary vein isolation (PVI) is associated with durable isolation and reduced recurrence of atrial fibrillation (AF). Objective We sought to investigate the relationship between left atrial electrogram voltage using multielectrode fast automated mapping (ME-FAM) and first pass isolation with radiofrequency ablation. Methods We included consecutive patients (pts) undergoing first time ablation for paroxysmal AF (pAF), and compared the voltage characteristics between patients with and without first pass isolation. Left atrium (LA) adjacent to PVs was divided into 6 regions, and mean voltages obtained with ME-FAM (Pentaray, Biosense Webster) in each region and compared. LA electrograms with marked low voltage (<0.5 mV) were identified and the voltage characteristics at the site of difficult isolation was compared to the voltage in adjacent region. Results Twenty consecutive patients (10 with first pass and 10 without) with a mean age of 63.3 ± 6.2 years, 65% males, were studied. Difficult isolation occurred on the right PVs in eight pts and left PVs in three pts. The mean voltage in pts without first pass isolation was lower in all 6 regions; posterior wall (1.93 ± 1.46 versus 2.99 ± 2.19; p < 0.001), roof (1.83 ± 2.29 versus 2.47 ± 1.99; p < 0.001), LA-LPV posterior (1.85 ± 3.09 versus 2.99 ± 2.19, p < 0.001), LA-LPV ridge (1.42 ± 1.04 versus 1.91 ± 1.61; p < 0.001), LA-RPV posterior (1.51 ± 1.11 versus 2.30 ± 1.77, p < 0.001) and LA-RPV septum (1.55 ± 1.23 versus 2.31 ± 1.40, p < 0.001). Patients without first pass isolation also had a larger percentage of signal with an amplitude of <0.5 mV for each of the six regions (12.8% versus 7.5%). In addition, the mean voltage at the site of difficult isolation was lower at 8 out of 11 sites compared to mean voltage for remaining electrograms in that region. Conclusion In patients undergoing PVI for paroxysmal AF, failure in first pass isolation was associated with lower global LA voltage, more marked low amplitude signal (<0.5 mV) and lower local signal voltage at the site with difficult isolation. The results suggest that a greater degree of global and segmental fibrosis may play a role in ease of PV isolation with radiofrequency energy.
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Affiliation(s)
- Lohit Garg
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Naga Venkata K Pothineni
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - J Michael Daw
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew C Hyman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Cory M Tschabrunn
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
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12
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Hansen BJ, Zhao J, Helfrich KM, Li N, Iancau A, Zolotarev AM, Zakharkin SO, Kalyanasundaram A, Subr M, Dastagir N, Sharma R, Artiga EJ, Salgia N, Houmsse MM, Kahaly O, Janssen PML, Mohler PJ, Mokadam NA, Whitson BA, Afzal MR, Simonetti OP, Hummel JD, Fedorov VV. Unmasking Arrhythmogenic Hubs of Reentry Driving Persistent Atrial Fibrillation for Patient-Specific Treatment. J Am Heart Assoc 2020; 9:e017789. [PMID: 33006292 PMCID: PMC7792422 DOI: 10.1161/jaha.120.017789] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Atrial fibrillation (AF) driver mechanisms are obscured to clinical multielectrode mapping approaches that provide partial, surface‐only visualization of unstable 3‐dimensional atrial conduction. We hypothesized that transient modulation of refractoriness by pharmacologic challenge during multielectrode mapping improves visualization of hidden paths of reentrant AF drivers for targeted ablation. Methods and Results Pharmacologic challenge with adenosine was tested in ex vivo human hearts with a history of AF and cardiac diseases by multielectrode and high‐resolution subsurface near‐infrared optical mapping, integrated with 3‐dimensional structural imaging and heart‐specific computational simulations. Adenosine challenge was also studied on acutely terminated AF drivers in 10 patients with persistent AF. Ex vivo, adenosine stabilized reentrant driver paths within arrhythmogenic fibrotic hubs and improved visualization of reentrant paths, previously seen as focal or unstable breakthrough activation pattern, for targeted AF ablation. Computational simulations suggested that shortening of atrial refractoriness by adenosine may (1) improve driver stability by annihilating spatially unstable functional blocks and tightening reentrant circuits around fibrotic substrates, thus unmasking the common reentrant path; and (2) destabilize already stable reentrant drivers along fibrotic substrates by accelerating competing fibrillatory wavelets or secondary drivers. In patients with persistent AF, adenosine challenge unmasked hidden common reentry paths (9/15 AF drivers, 41±26% to 68±25% visualization), but worsened visualization of previously visible reentry paths (6/15, 74±14% to 34±12%). AF driver ablation led to acute termination of AF. Conclusions Our ex vivo to in vivo human translational study suggests that transiently altering atrial refractoriness can stabilize reentrant paths and unmask arrhythmogenic hubs to guide targeted AF driver ablation treatment.
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Affiliation(s)
- Brian J Hansen
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | | | - Katelynn M Helfrich
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Ning Li
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Alexander Iancau
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Alexander M Zolotarev
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Skolkovo Institute of Science and Technology Moscow Russia
| | - Stanislav O Zakharkin
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Anuradha Kalyanasundaram
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Megan Subr
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | | | | | - Esthela J Artiga
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Nicholas Salgia
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Mustafa M Houmsse
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH
| | - Omar Kahaly
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH
| | - Paul M L Janssen
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Peter J Mohler
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
| | - Nahush A Mokadam
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Division of Cardiac Surgery The Ohio State University Wexner Medical Center Columbus OH
| | - Bryan A Whitson
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Division of Cardiac Surgery The Ohio State University Wexner Medical Center Columbus OH
| | - Muhammad R Afzal
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH
| | - Orlando P Simonetti
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Biomedical Engineering The Ohio State University Wexner Medical Center Columbus OH
| | - John D Hummel
- Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH.,Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH
| | - Vadim V Fedorov
- Department of Physiology & Cell Biology and Frick Center for Heart Failure and Arrhythmia The Ohio State University Wexner Medical Center Columbus OH.,Davis Heart & Lung Research InstituteThe Ohio State University Wexner Medical Center Columbus OH
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