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Natale A, Mohanty S, Sanders P, Anter E, Shah A, Al Mohani G, Haissaguerre M. Catheter ablation for atrial fibrillation: indications and future perspective. Eur Heart J 2024:ehae618. [PMID: 39322413 DOI: 10.1093/eurheartj/ehae618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/12/2024] [Accepted: 08/30/2024] [Indexed: 09/27/2024] Open
Abstract
Recent advances in techniques, technologies and proven superiority over anti-arrhythmic drugs have made catheter ablation the cornerstone of management for atrial fibrillation (AF), which has shown a steady increase in prevalence in the ageing population worldwide. The aim of therapeutic interventions is to achieve stable sinus rhythm that would improve the quality of life and reduce the risk of AF-associated complications. Pulmonary veins (PVs) were first described as the source of initiation of ectopic triggers driving AF, which led to the establishment of PV isolation (PVI) as the most widely practiced procedure to treat AF. Antral PVI is still recognized as the stand-alone ablation strategy for newly diagnosed paroxysmal AF (PAF). However, in non-PAF patients, PVI seems to be inadequate and several adjunctive strategies, including ablation of left atrial posterior wall and non-PV triggers, AF mapping and ablation of rotors and drivers, ethanol infusion of vein of Marshall and renal denervation, etc. have been reported with mixed results. Recent trials have also documented the benefits of early rhythm control in preventing cardiovascular events in addition to slowing the progression of PAF to more persistent forms. Similarly, very late relapse of the arrhythmia after successful PVI has drawn attention to the critical role of non-PV triggers and highlighted their relevance as potential ablation targets during repeat procedures. Ablation technology is also under constant evolution with the introduction of non-thermal energy sources and new tools to create durable lesions. This review summarizes the indications, advancements, and future perspective of AF ablation.
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Affiliation(s)
- Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
- Interventional Electrophysiology, Scripps Clinic, 9898 Genesee Avenue, La Jolla, San Diego, CA 92037, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44109, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
| | | | - Elad Anter
- Shamir Medical Center, Tel Aviv University, Israel
| | - Ashok Shah
- Haut-Lévèque Cardiology Hospital, Bordeaux, France
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Buck B, Houmsse M. Beyond pulmonary vein isolation: approaches to treat patients with persistent atrial fibrillation. Expert Rev Cardiovasc Ther 2024:1-11. [PMID: 39243124 DOI: 10.1080/14779072.2024.2401876] [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: 06/17/2024] [Revised: 08/14/2024] [Accepted: 09/04/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia. Catheter ablation is a successful rhythm control strategy in paroxysmal AF, but it has demonstrated dramatically lower AF-free survival rates in patients with persistent AF. In recent years, myriad novel rhythm control strategies have been developed, each with the promise of improved persistent AF ablation success. AREAS COVERED This review discusses multiple novel techniques and approaches to persistent AF. Authors identified relevant papers by searching PubMed and Google Scholar databases and considered all papers identified, regardless of publication date. It begins by discussing recent advances in electrogram analysis that yielded improved AF-free survival following persistent AF catheter ablation. Next, it discusses several trials revealing the shortcomings of MRI in guiding persistent AF ablation. Finally, it discusses one nascent technique (Vein of Marshall ablation) and technology (AI-assisted electrogram analysis) who have shown promise in improving persistent AF ablation. EXPERT OPINION In the authors' expert opinions, upcoming persistent AF ablations will utilize a stepwise approach of (1) ensuring PV isolation, (2) Vein of Marshall ablation and (3) AI-assisted ablation to optimize future persistent AF ablation outcomes. This approach systematically addresses arrhythmogenic sources beyond the pulmonary veins, the historical treatment target.
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Affiliation(s)
- Benjamin Buck
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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3
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Franco E, Lozano-Granero C, Matía Francés R, Hernández-Madrid A, Sánchez I, Zamorano JL, Moreno J. Subjective identification and ablation of drivers improves rhythm control in patients with persistent atrial fibrillation. The CHAOS-AF study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:723-733. [PMID: 38336154 DOI: 10.1016/j.rec.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal approach for persistent atrial fibrillation (AF) ablation remains unknown. In patients with persistent AF, we compared an ablation strategy based on pulmonary vein isolation (PVI) plus ablation of drivers (PVI+D), with a conventional PVI-only approach performed in a 1:1 propensity score-matched cohort. METHODS Drivers were subjectively identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid), without dedicated software, as fractionated continuous or quasicontinuous electrograms on 1 to 2 adjacent bipoles, which were ablated first; and as sites with spatiotemporal dispersion (the entire cycle length comprised within the mapping catheter) plus noncontinuous fractionation, which were only targeted in patients without fractionated continuous electrograms, or without AF conversion after ablation of fractionated continuous electrograms. Ablation included PVI plus focal or linear ablation targeting drivers. RESULTS A total of 50 patients were included in each group (61±10 years, 25% women). Fractionated continuous electrograms were found and ablated in 21 patients from the PVI+D group (42%), leading to AF conversion in 7 patients. In the remaining 43 patients, 143 sites with spatiotemporal dispersion plus noncontinuous fractionation were targeted. Globally, AF conversion was achieved in 21 patients (42%). The PVI+D group showed lower atrial arrhythmia recurrences at 1 year of follow-up (30.6% vs 48%; P=.048) and at the last follow-up (46% vs 72%; P=.013), and less progression to permanent AF (10% vs 40%; P=.001). CONCLUSIONS Subjective identification and ablation of drivers, added to PVI, increased 1-year freedom from atrial arrhythmia and decreased long-term recurrences and progression to permanent AF.
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Affiliation(s)
- Eduardo Franco
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Cristina Lozano-Granero
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | | | - Inmaculada Sánchez
- Departamento de Cardiología Pediátrica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - José Luis Zamorano
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Javier Moreno
- Departamento de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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4
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Quintanilla JG. "Spatiotemporal Dispersion Reloaded"? "CFAE Resurrections"? A new installment in the saga of subjective identification of atrial fibrillation drivers. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:734-736. [PMID: 38548129 DOI: 10.1016/j.rec.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Jorge G Quintanilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Programa de Nuevos Mecanismos Arritmogénicos, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Unidad de Arritmias, Instituto Cardiovascular, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
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5
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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; 21:e31-e149. [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] [MESH Headings] [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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Rossi P, Cauti FM, Polselli M, Magnocavallo M, Niscola M, Fanti V, Limite LR, Evangelista A, Bellisario A, De Paolis R, Facchetti S, Quaglione R, Piccirillo G, Bianchi S. Ablation of persistent atrial fibrillation based on atrial electrogram duration map: methodology and clinical outcomes from the AEDUM pilot study. J Interv Card Electrophysiol 2024; 67:1365-1376. [PMID: 38206451 PMCID: PMC11379763 DOI: 10.1007/s10840-023-01721-7] [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: 09/12/2023] [Accepted: 12/06/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Catheter ablation of persistent atrial fibrillation (PsAF) represents a challenge for the electrophysiologist and there are still divergences regarding the best ablative approach to adopt. Create a new map of the duration of atrial bipolar electrograms (Atrial Electrogram DUration Map, AEDUM) to recognize a functional substrate during sinus rhythm and guide a patient-tailored ablative strategy for PsAF. METHODS Forty PsAF subjects were assigned in a 1:1 ratio to either for PVI alone (Group B1) or PVI+AEDUM areas ablation (Group B2). A cohort of 15 patients without AF history undergoing left-sided accessory pathway ablation was used as a control group (Group A). In all patients, voltage and AEDUM maps were created during sinus rhythm. The minimum follow-up was 12 months, with rhythm monitoring via 48-h ECG Holter or by implantable cardiac device. RESULTS Electrogram (EGM) duration was higher in Group B than in Group A (49±16.2ms vs 34.2±3.8ms; p-value<0.001). In Group B the mean cumulative AEDUM area was 21.8±8.2cm2; no difference between the two subgroups was observed (22.3±9.1cm2 vs 21.2±7.2cm2; p-value=0.45). The overall bipolar voltage recorded inside the AEDUM areas was lower than in the remaining atrial areas [median: 1.30mV (IQR: 0.71-2.38mV) vs 1.54mV (IQR: 0.79-2.97mV); p-value: <0.001)]. Low voltage areas (<0.5mV) were recorded in three (7.5%) patients in Group B. During the follow-up [median 511 days (376-845days)] patients who underwent PVI-only experienced more AF recurrence than those receiving a tailored approach (65% vs 35%; p-value= 0.04). CONCLUSIONS All PsAF patients exhibited AEDUM areas. An ablation approach targeting these areas resulted in a more effective strategy compared with PVI only.
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Affiliation(s)
- Pietro Rossi
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy.
| | - Filippo Maria Cauti
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Marco Polselli
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Michele Magnocavallo
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Marta Niscola
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | - Veronica Fanti
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | | | - Antonietta Evangelista
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | | | | | | | - Raffaele Quaglione
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Gianfranco Piccirillo
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
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7
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Baqal O, Shafqat A, Kulthamrongsri N, Sanghavi N, Iyengar SK, Vemulapalli HS, El Masry HZ. Ablation Strategies for Persistent Atrial Fibrillation: Beyond the Pulmonary Veins. J Clin Med 2024; 13:5031. [PMID: 39274244 PMCID: PMC11396655 DOI: 10.3390/jcm13175031] [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: 07/24/2024] [Revised: 08/19/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Despite advances in ablative therapies, outcomes remain less favorable for persistent atrial fibrillation often due to presence of non-pulmonary vein triggers and abnormal atrial substrates. This review highlights advances in ablation technologies and notable scientific literature on clinical outcomes associated with pursuing adjunctive ablation targets and substrate modification during persistent atrial fibrillation ablation, while also highlighting notable future directions.
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Affiliation(s)
- Omar Baqal
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | | | - Neysa Sanghavi
- St. George's University School of Medicine, West Indies P.O. Box 7, Grenada
| | - Shruti K Iyengar
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Hema S Vemulapalli
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Hicham Z El Masry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
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Sakata K, Bradley RP, Prakosa A, Yamamoto CAP, Yusuf Ali S, Loeffler S, Kholmovski EG, Kumar Sinha S, Marine JE, Calkins H, Spragg DD, Trayanova NA. Optimizing the Distribution of Ablation Lesions to Prevent Postablation Atrial Tachycardia: A Personalized Digital-Twin Study. JACC Clin Electrophysiol 2024:S2405-500X(24)00651-0. [PMID: 39243255 DOI: 10.1016/j.jacep.2024.07.002] [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: 04/12/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Although targeting atrial fibrillation (AF) drivers and substrates has been used as an effective adjunctive ablation strategy for patients with persistent AF (PsAF), it can result in iatrogenic scar-related atrial tachycardia (iAT) requiring additional ablation. Personalized atrial digital twins (DTs) have been used preprocedurally to devise ablation targeting that eliminate the fibrotic substrate arrhythmogenic propensity and could potentially be used to predict and prevent postablation iAT. OBJECTIVES In this study, the authors sought to explore possible alternative configurations of ablation lesions that could prevent iAT occurrence with the use of biatrial DTs of prospectively enrolled PsAF patients. METHODS Biatrial DTs were generated from late gadolinium enhancement-magnetic resonance images of 37 consecutive PsAF patients, and the fibrotic substrate locations in the DT capable of sustaining reentries were determined. These locations were ablated in DTs by representing a single compound region of ablation with normal power (SSA), and postablation iAT occurrence was determined. At locations of iAT, ablation at the same DT target was repeated, but applying multiple lesions of reduced-strength (MRA) instead of SSA. RESULTS Eighty-three locations in the fibrotic substrates of 28 personalized biatrial DTs were capable of sustaining reentries and were thus targeted for SSA ablation. Of these ablations, 45 resulted in iAT. Repeating the ablation at these targets with MRA instead of SSA resulted in the prevention of iAT occurrence at 15 locations (18% reduction in the rate of iAT occurrence). CONCLUSIONS Personalized atrial DTs enable preprocedure prediction of iAT occurrence after ablation in the fibrotic substrate. It also suggests MRA could be a potential strategy for preventing postablation AT.
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Affiliation(s)
- Kensuke Sakata
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ryan P Bradley
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA; Research Computing, Lehigh University, Bethlehem, Pennsylvania, USA
| | - Adityo Prakosa
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Carolyna A P Yamamoto
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Syed Yusuf Ali
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shane Loeffler
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eugene G Kholmovski
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sunil Kumar Sinha
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph E Marine
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David D Spragg
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.
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9
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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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10
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Zaman JAB, Khan A, Nielsen J, Kristiansen SB, Kronborg MB, Witt CT, Gerdes C, Kristensen J, Jensen HK, Lukac P, Agarwal SC. Repeat ablation of atrial fibrillation using electrogram dispersion to identify additional areas of mechanistic significance. Heart Rhythm O2 2024; 5:543-550. [PMID: 39263613 PMCID: PMC11385402 DOI: 10.1016/j.hroo.2024.07.007] [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] [Indexed: 09/13/2024] Open
Abstract
Background Electrogram dispersion identifies putative atrial fibrillation (AF) drivers in first time ablation procedures, with high acute termination rates and long-term outcomes akin to extensive ablation approaches. Its use in a population that had undergone repeat ablation is unknown, particularly where the pulmonary veins are already isolated. Objective This purpose of this study was to assess electrogram dispersion mapping during repeat ablation procedures for persistent AF. Methods One hundred sixty-seven patients from the United Kingdom and Denmark, all with persistent AF recurrence after prior ablation procedure(s), were mapped using a five splined catheter for electrogram dispersion before ablation. Areas were manually tagged on biatrial electroanatomic maps and ablated once pulmonary vein isolation was confirmed or reisolated if required. All patients had 12-month continuous monitoring, with most of the cohort having follow-up beyond 24 months. Results Of the 167 patients [53 (32%) female; mean age 66 ± 8 years; mean left atrial (LA) diameter 4.8 cm; mean ejection fraction 53%], 108 had pulmonary veins already isolated. Dispersion sites occurred in both atria (3.2 LA, 1.4 right atrium). Acute termination to sinus rhythm occurred in 71 (42%) of the cohort patients, with a further 73 (44%) terminating to atrial tachycardia/flutter. At 12-month follow-up, 95% of patients were free of AF, with 74% overall freedom from all atrial arrhythmias. Heart failure and severely enlarged LA predicted recurrence, and termination to sinus improved freedom from all atrial arrhythmias. Conclusion Dispersion mapping is a promising approach at repeat ablation procedures for persistent AF, with high acute termination rates and good clinical outcomes. Further prospective randomized trials are needed to evaluate this approach in a population that had undergone repeat ablation.
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Affiliation(s)
- Junaid A B Zaman
- Keck School of Medicine, University of Southern California, Los Angeles, California
- Royal Papworth Hospital, Cambridge, United Kingdom
| | - Abdulhaseeb Khan
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jan Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mads B Kronborg
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Lukac
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sharad C Agarwal
- Royal Papworth Hospital, Cambridge, United Kingdom
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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11
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Mizobuchi M, Yamashita T, Sato T, Funatsu A, Kobayashi T, Nakamura S. Selective complex fractionated atrial electrogram ablation based on the number-of-fractionation for persistent atrial fibrillation refractory to pulmonary vein isolation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01889-6. [PMID: 39066980 DOI: 10.1007/s10840-024-01889-6] [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: 04/30/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Previous studies have suggested that the prolonged or highly fractionated electrograms during atrial fibrillation (AF) are closely related to the reentrant driver regions. We hypothesized that exploration and ablation of these critical complex atrial fractionated electrograms (CFAE) may improve the outcome of persistent AF (PeAF) refractory to conventional PVI. METHODS A total of 73 PeAF patients with residual inducibility or failed cardioversions of AF after PVI were enrolled and underwent number-of-fractionation mapping (NFM) by counting the number of fractionations in 2.5 s at each of the points using the CARTO3 (ICL mode) and EnSite (fractionation map) systems. After NFM, selective CFAE ablation (NFM-CA) targeting the sites of the upper 40% of the counted fraction number (NF40) was performed as an additional procedure for refractory PeAF. We investigated the prognosis of these patients within 24 months after the index ablation procedure and the relationship between changes in activation patterns during the ablation procedure and their prognosis. We also performed a propensity score-matched analysis comparing these patients with historical controls (HC) to identify the optimal indications for NFM-CA. RESULTS The AF/AT free survival rate was 79.1% at 12 months and 56.7% at 24 months. Patients with AF termination or AF cycle length prolongation > 21 ms during the procedure had significantly better AF/AT-free survival rates than those without notable activation changes (87.7% vs. 69.0%, logrank p = 0.028). After propensity-matched analysis, AF/AT-free survival showed comparable results between the two groups (1 year; NFM 72.1% vs. HC 77.1%, logrank p = 0.649). CONCLUSIONS NFM-CA is a versatile and less invasive adjunctive procedure for patients with PVI-refractory PeAF who showed a comparable prognosis to patients with PVI-compliant PeAF. In particular, remarkable activation changes during the procedure (AFCL prolongation > 21 ms or acute termination) suggest a favorable prognosis.
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Affiliation(s)
- Masahiro Mizobuchi
- Cardiovascular center, Kyoto-Katsura Hospital, 17 Yamada-Hiraocho, Nishikyo-Ku, Kyoto, 6158256, Japan.
| | - Tomoki Yamashita
- Department of Clinical Engineering, Kyoto-Katsura Hospital, 17 Yamada-Hiraocho, Nishikyo-Ku, Kyoto, 6158256, Japan
| | - Tatsushi Sato
- Cardiovascular center, Kyoto-Katsura Hospital, 17 Yamada-Hiraocho, Nishikyo-Ku, Kyoto, 6158256, Japan
| | - Atsushi Funatsu
- Cardiovascular center, Kyoto-Katsura Hospital, 17 Yamada-Hiraocho, Nishikyo-Ku, Kyoto, 6158256, Japan
| | - Tomoko Kobayashi
- Cardiovascular center, Kyoto-Katsura Hospital, 17 Yamada-Hiraocho, Nishikyo-Ku, Kyoto, 6158256, Japan
| | - Shigeru Nakamura
- Cardiovascular center, Kyoto-Katsura Hospital, 17 Yamada-Hiraocho, Nishikyo-Ku, Kyoto, 6158256, Japan
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12
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Shi L, Qi J, Wang Y, Liao W, Li X, He S, Huang L, Tian Y, Liu X. Ablation of drivers in patients with persistent atrial fibrillation refractory to pulmonary vein antral isolation: Target characteristics and 3-year outcomes. Chin Med J (Engl) 2024; 137:1747-1749. [PMID: 38915226 PMCID: PMC11268809 DOI: 10.1097/cm9.0000000000003194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Indexed: 06/26/2024] Open
Affiliation(s)
- Liang Shi
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Jie Qi
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Yanjiang Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Wenkai Liao
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xuexun Li
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Shunan He
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Lihong Huang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Ying Tian
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Xingpeng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
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13
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Rossi P, Magnocavallo M, Cauti FM, Polselli M, Niscola M, Della Rocca DG, Del Greco A, Iaia L, Quaglione R, Gianfranco P, Bianchi S. Functional substrate analysis in patients with persistent atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01819-6. [PMID: 38811500 DOI: 10.1007/s10840-024-01819-6] [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: 02/28/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES The aim of this study was to describe the correlation between atrial electrogram duration map (AEDUM), spatiotemporal electrogram dispersion (STED) and low voltage areas (LVA) in patients with persistent atrial fibrillation (PsAF). BACKGROUND The degree of left atrial (LA) tissue remodelling and augmented anisotropic conduction is one of the major issues related to PsAF ablation outcome. METHODS This study enrolled consecutive patients with PsAF undergoing pulmonary vein isolation. In all patients, voltage, AEDUM and STED maps were created, and the correlation was reported between these three mapping methods. RESULTS A total of 40 patients with PsAF were enrolled. The mean age was 62.2 ± 7.4 years, and males were 72.5% (n = 29). The overall bipolar voltage of the LA was 3.06 ± 1.87 mV. All patients had at least one AEDUM area (overall AEDUM area: 21.8 ± 8.2 cm2); the mean longest electrogram (EGMs) duration was 90 ± 19 ms. STED areas with < 120 ms was 46.3 ± 20.2 cm2 which covered 45 ± 22% of the LA surface. AEDUM and STED areas were most frequently reported on the roof, the anterior wall and the septum. The extension of the AEDUM areas was significantly smaller than STED areas with CL < 120 ms (21.8 ± 8.2 vs 46.3 ± 20.2; p-value < 0.0001). In 24 patients (60%), AEDUM areas was entirely included in the STED areas with CL < 120 ms. In the three (7.5%) patients with LVA, no correspondence with STED and AEDUM was noted. CONCLUSION AEDUM and STED maps allow to identify areas of conductive dysfunction as a possible atrial substrate even if a normal voltage is detected.
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Affiliation(s)
- Pietro Rossi
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy.
| | | | - Filippo Maria Cauti
- Arrhythmology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Polselli
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Marta Niscola
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard - Heart, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Ambra Del Greco
- Abbott Medical, Via Paracelso 20, 20864, Agrate Brianza, Italy
| | - Luigi Iaia
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy
| | - Raffaele Quaglione
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Piccirillo Gianfranco
- Department of Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Umberto I, Sapienza University of Rome, 00185, Rome, Italy
| | - Stefano Bianchi
- Arrhythmology Unit, Isola Tiberina - Gemelli Isola, Rome, Italy
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14
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Seitz J, Mohr Durdez T, Lotteau S, Bars C, Pisapia A, Gitenay E, Monteau J, Reist M, Serdi M, Dayot A, Bremondy M, Benadel M, Siame S, Appetiti A, Milpied P, Kalifa J. Artificial intelligence-adjudicated spatiotemporal dispersion: A patient-unique fingerprint of persistent atrial fibrillation. Heart Rhythm 2024; 21:540-552. [PMID: 38215808 DOI: 10.1016/j.hrthm.2024.01.007] [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: 07/05/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Spatiotemporal dispersion-guided ablation is a tailored approach for patients in persistent atrial fibrillation (PsAF). The characterization of dispersion extent and distribution and its association with common clinical descriptors of PsAF patients has not been studied. OBJECTIVES Artificial intelligence-adjudicated dispersion extent and distribution (AI-DED) was obtained with a machine/deep learning classifier (VX1 Software, Volta Medical) in PsAF patients undergoing ablation. The purpose of this study was to test the hypothesis that AI-DED is unique to each patient and independent of common procedural and clinical parameters. METHODS In a subanalysis of the Ev-AIFib study (NCT03434964), spatiotemporal dispersion maps were built with VX1 software in 78 consecutive persistent and long-standing PsAF patients. AI-DED was quantified using 2 distinct approaches (visual regional characterization or automated global quantification of AI-DED). RESULTS AI-DED paired-subregion Euclidean distance measurements between 78 patients (average distance 5.07 ± 0.60; min 2.23; max 9.75) demonstrate that AI-DED is a patient-unique characteristic of PsAF. Importantly, both AF type and AF history do not correlate with AI-DED levels (R2 = 0.006, P = .53; and R2 = 0.03, P = .25, respectively). The most extensive AI-DED levels are not associated with poorer procedural (83%, 81%, and 83% of AF termination in low, medium, and high dispersion groups, respectively; P = .954) and long-term (88%, 75%, and 91% of freedom from AF/atrial tachycardia after multiple procedures; P = .517) outcomes. CONCLUSION The atrial distribution and extent of multipolar electrogram spatiotemporal dispersion follow a nonrandom, albeit patient-unique, distribution in PsAF patients. AI-DED may represent a procedure-implementable fingerprint of the PsAF substrate.
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15
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Roney C, Honarbakhsh S. Does spatiotemporal dispersion indicate a patient-unique fingerprint or a generic characteristic of persistent atrial fibrillation? Heart Rhythm 2024; 21:553-554. [PMID: 38307308 DOI: 10.1016/j.hrthm.2024.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/04/2024]
Affiliation(s)
- Caroline Roney
- Queen Mary University of London, London, United Kingdom.
| | - Shohreh Honarbakhsh
- Queen Mary University of London, London, United Kingdom; Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
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16
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Xu C, Zhang F, Chen W, Chen N, Zhang Y, Zhu X, Liu Y, Jiang W, Wu S, Liu X, Qin M. Adjunctive Right Atrial Ablation for Persistent Atrial Fibrillation With Right Atrial Enlargement: A Pilot Study. Can J Cardiol 2024; 40:564-572. [PMID: 37981042 DOI: 10.1016/j.cjca.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/02/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Persistent atrial fibrillation (PerAF) is often associated with right atrial (RA) enlargement. We investigated the efficacy of RA intervention in patients with PerAF and RA enlargement. METHODS Patients with PerAF and RA enlargement were randomised (1:1) to receive adjunctive RA ablation (left atrial [LA] + RA group; n = 60) or to receive LA ablation alone (LA-only group; n = 60). In the LA + RA group, RA ablation was performed if LA ablation failed to terminate AF. The primary end point was freedom from AF/atrial tachycardia (AT) recurrence at 12 months after a single ablation procedure without antiarrhythmic drug therapy. RESULTS In the LA + RA group, 40 patients (67%) required RA ablation. The LA + RA group had a higher rate of acute AF termination than the LA-only group (63.3% vs 36.7%; P = 0.003). At the end of 12-month follow-up, 42 patients (70%) in the LA + RA group were free of AF/AT recurrence, compared with 31 (51.7%) in the LA-only group (log rank P = 0.034; hazard ratio 0.549, 95% confidence interval 0.310-0.974). The rate of freedom from AF recurrence was also higher in the LA + RA group than in the LA-only group (81.7% vs 63.3%; log rank P = 0.019). The 2 groups had similar rates of adverse events (5% vs 3.3%; P = 0.648). CONCLUSIONS Adjunctive RA ablation increased the success rate of a single ablation in patients with PerAF and RA enlargement. CHINESE CLINICAL TRIAL REGISTRATION ChiCTR220056844.
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Affiliation(s)
- Changhao Xu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Zhang
- Department of Cardiology, Jinshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenbo Chen
- Baoshan Branch, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Nannan Chen
- Department of Cardiology, Shanghai Yangpu District Central Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu Zhang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiyao Zhu
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yang Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weifeng Jiang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shaohui Wu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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17
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Veenhuyzen G, Mitchell LB. Selecting Persistent Atrial Fibrillation Patients for Adjunctive Right Atrial Ablation: When You're Right, You're Right. Can J Cardiol 2024; 40:573-575. [PMID: 38145869 DOI: 10.1016/j.cjca.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/17/2023] [Indexed: 12/27/2023] Open
Affiliation(s)
- George Veenhuyzen
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Foothills Hospital, Calgary, Alberta, Canada
| | - L Brent Mitchell
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Alberta Health Services, Foothills Hospital, Calgary, Alberta, Canada.
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18
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Li K, Wu S, Wang X, Han B, Qin M, Hou X, Liu X. A multicenter, cohort study of catheter ablation for persistent atrial fibrillation with/without atrial fibrillation termination (the termination-atrial fibrillation study). Europace 2024; 26:euae085. [PMID: 38573506 PMCID: PMC11022747 DOI: 10.1093/europace/euae085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024] Open
Affiliation(s)
- Kaige Li
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, 241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Shaohui Wu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, 241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Xinhua Wang
- Department of Cardiology, Shanghai Jiaotong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, 241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Xumin Hou
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, 241 West Huaihai Road, Xuhui District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, 241 West Huaihai Road, Xuhui District, Shanghai 200030, China
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19
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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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20
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Riku S, Inden Y, Yanagisawa S, Fujii A, Tomomatsu T, Nakagomi T, Shimojo M, Okajima T, Furui K, Suga K, Suzuki S, Shibata R, Murohara T. Distributions and number of drivers on real-time phase mapping associated with successful atrial fibrillation termination during catheter ablation for non-paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2024; 67:303-317. [PMID: 37354370 DOI: 10.1007/s10840-023-01588-8] [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: 01/15/2023] [Accepted: 05/31/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Real-time phase mapping (ExTRa™) is useful in determining the strategy of catheter ablation for non-paroxysmal atrial fibrillation (AF). This study aimed to investigate the features of drivers of AF associated with its termination during ablation. METHODS Thirty-six patients who underwent catheter ablation for non-paroxysmal AF using online real-time phase mapping (ExTRa™) were enrolled. A significant AF driver was defined as an area with a non-passively activated ratio of ≥ 50% on mapping analysis in the left atrium (LA). All drivers were simultaneously evaluated using a low-voltage area, complex fractionated atrial electrogram (CFAE), and rotational activity by unipolar electrogram analysis. The electrical characteristics of drivers were compared between patients with and without AF termination during the procedure. RESULTS Twelve patients achieved AF termination during the procedure. The total number of drivers detected on the mapping was significantly lower (4.4 ± 1.6 vs. 7.4 ± 3.8, p = 0.007), and the drivers were more concentrated in limited LA regions (2.8 ± 0.9 vs. 3.9 ± 1.4, p = 0.009) in the termination group than in the non-termination group. The presence of drivers 2-6 with limited (≤ 3) LA regions showed a tenfold increase in the likelihood of AF termination, with 83% specificity and 67% sensitivity. Among 231 AF drivers, the drivers related to termination exhibited a greater overlap of CFAE (56.8 ± 34.1% vs. 39.5 ± 30.4%, p = 0.004) than the non-related drivers. The termination group showed a trend toward a lower recurrence rate after ablation (p = 0.163). CONCLUSIONS Rotors responsible for AF maintenance may be characterized in cases with concentrated regions and fewer drivers on mapping.
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Affiliation(s)
- Shuro Riku
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Satoshi Yanagisawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan.
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshifumi Nakagomi
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Masafumi Shimojo
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Takashi Okajima
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Koichi Furui
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Kazumasa Suga
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Susumu Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Rei Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa-Ku, Nagoya, Aichi, 466-8550, Japan
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21
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Bahlke F, Englert F, Popa M, Bourier F, Reents T, Lennerz C, Kraft H, Martinez AT, Kottmaier M, Syväri J, Tydecks M, Telishevska M, Lengauer S, Hessling G, Deisenhofer I, Erhard N. First clinical data on artificial intelligence-guided catheter ablation in long-standing persistent atrial fibrillation. J Cardiovasc Electrophysiol 2024; 35:406-414. [PMID: 38197476 DOI: 10.1111/jce.16184] [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: 09/11/2023] [Revised: 12/20/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Despite advanced ablation strategies and major technological improvements, treatment of persistent atrial fibrillation (AF) remains challenging and the underlying pathophysiology is not fully understood. This study analyzed the multiple procedure outcome and safety of catheter ablation of spatiotemporal dispersions (DISPERS) detected by artificial intelligence (AI)-guided software in patients with long-standing persistent AF. METHODS AND RESULTS The Volta VX1 software was used for 50 consecutive patients undergoing catheter ablation for persistent AF. First, high-density mapping (78% biatrial) with a multipolar mapping catheter was performed. In addition to pulmonary vein isolation (PVI), ablation of DISPERS was performed aiming at homogenizing, dissecting, isolating, or connecting DISPERS areas to nonconducting anatomical structures. Follow-up contained regular visits at our outpatient clinic at 1, 3, 6, and 12 months including 7-day Holter electrocardiograms. Patients were mainly suffering from long-standing persistent AF (mean AF duration 50.30 ± 54.28 months). Following PVI, ablation of left atrial and right atrial DISPERS areas led to AF cycle length prolongation (mean of 162.0 ± 16.6 to 202.2 ± 21.6 ms after) and AF termination to atrial tachycardia (AT) or sinus rhythm (SR) in 12 patients (24%). No stroke or pericardial effusion occurred; major groin complications (pseudoaneurysm n = 1, atrioventricular fistula n = 1) were detected in two patients. After a blanking period of 6 weeks, recurrence of any atrial arrhythmia was documented in 26 patients (52%). The majority of patients presented with organized AT (n = 15) while AF was present in n = 9 patients and AT/AF was observed in n = 2 patients. Twenty-two patients underwent reablation. During a mean follow-up of 363.14 ± 187.42 days and after an average of 1.46 ± 0.68 procedures, 82% of patients remained in stable SR. CONCLUSION DISPERS-guided ablation using machine learning software (the Volta VX1 software) in addition to PVI in long-standing persistent AF ablation resulted in high long-term success rates regarding AF and AT elimination. Most arrhythmia recurrences were reentrant AT. After a total of 1.46 ± 0.68 procedures, freedom from AF/AT was 82%. Despite prolonged procedure times complication rates were low. Randomized studies are necessary to evaluate long-term efficacy of dispersion-guided ablation using AI.
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Affiliation(s)
- Fabian Bahlke
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Florian Englert
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Miruna Popa
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Felix Bourier
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Tilko Reents
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Carsten Lennerz
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Hannah Kraft
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Alex Tunsch Martinez
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Marc Kottmaier
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Jan Syväri
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Madeleine Tydecks
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Marta Telishevska
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Sarah Lengauer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Gabriele Hessling
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Nico Erhard
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
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22
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Sousonis V, Voglimacci-Stephanopoli Q, Zeriouh S, Boveda S, Albenque JP. Pulsed field ablation of spatiotemporal electrogram dispersion following pulmonary vein isolation and left atrial linear lesions for persistent atrial fibrillation: a case report. Eur Heart J Case Rep 2024; 8:ytae085. [PMID: 38405199 PMCID: PMC10894002 DOI: 10.1093/ehjcr/ytae085] [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: 10/09/2023] [Revised: 12/10/2023] [Accepted: 02/07/2024] [Indexed: 02/27/2024]
Abstract
Background Ablation of persistent atrial fibrillation (AF) remains challenging, with atrial substrate modification often being performed as an adjunct to pulmonary vein isolation (PVI). Pulsed field ablation (PFA) is a novel ablation modality that carries a favourable safety profile, which could facilitate complex procedures. Case summary We present the case of a 60-year-old male undergoing catheter ablation for symptomatic persistent AF. The procedure was performed with the Farapulse™ PFA system in a stepwise manner, including PVI and linear lesions for the isolation of the posterior left atrial wall and the ablation of the mitral isthmus. The final step of the procedure included the ablation of areas exhibiting spatiotemporal electrogram dispersion, identified with the help of artificial intelligence-based software (VX1, Volta Medical) in both atria. Sinus rhythm was restored after the abolition of an electrogram dispersion zone in the right atrium. The procedure was carried out without any complications. Discussion Complex ablation procedures for persistent AF can be successfully performed with PFA. In the context of such extensive ablation strategies, PFA is an attractive energy source, given its non-thermal nature that is known to prevent damage to surrounding tissue and result in less chronic fibrosis. However, caution should be exercised to avoid excessive ablation when using the currently available multispline PFA catheter, as it may inadvertently target adjacent areas of healthy myocardium.
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Affiliation(s)
- Vasileios Sousonis
- Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31300 Toulouse, France
| | | | - Sarah Zeriouh
- Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31300 Toulouse, France
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31300 Toulouse, France
| | - Jean Paul Albenque
- Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31300 Toulouse, France
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23
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Schipper JH, Steven D, Lüker J, Wörmann J, van den Bruck JH, Filipovic K, Dittrich S, Scheurlen C, Erlhöfer S, Pavel F, Sultan A. Dipole Density Guided Catheter Ablation versus Conventional Substrate Modification for Repeat Catheter Ablation of Persistent Atrial Fibrillation. J Clin Med 2023; 13:223. [PMID: 38202230 PMCID: PMC10779490 DOI: 10.3390/jcm13010223] [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: 11/08/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS The optimal ablation strategy for recurrent persistent atrial fibrillation (persAF) after initially successful catheter ablation (CA) remains debatable. Dipole density (DD) guided CA using the AcQMap system has been proven to be feasible and effective in patients with persAF. So far, long-term outcome data for DD-guided CA in patients with recurrence of persAF are sparse. This study sought to assess long-term outcome data in patients undergoing a DD-guided CA for recurrence of persAF after previous CA in comparison to conventional repeat CA. METHODS AND RESULTS Patients undergoing DD-guided CA for recurrence of persAF after previous ablation were compared to patients undergoing conventional substrate modification (CSM). A total of 64 patients (32 DD-guided and 32 CSM) were included in this analysis. Procedure duration (DD: 236 ± 61 min; CSM: 198 ± 59 min; p = 0.004) and fluoroscopy time (DD: 36 ± 15 min; CSM: 20 ± 11 min; p = 0.0001) were significantly longer in the DD group. After a long-term median follow-up (FU) of 27 months (interquartile range 12.8-34.3), DD-guided CA was inferior to CSM regarding overall arrhythmia-free survival (DD: 6 patients (19%), CSM: 11 patients (34%); HR 1.47; p = 0.04). Freedom from AF did not differ between both groups (DD: 16 patients (50%); CSM: 18 patients (56%), HR 0.99, p = 0.47). During FU, more patients underwent repeat CA after DD-guided ablation (DD: 16 patients (50%), CSM: 7 patients (22%), p = 0.04). No major complications occurred overall. CONCLUSIONS Dipole density-guided CA is equally safe but associated with longer procedure duration compared to conventional substrate modification for treatment of recurrent persAF after previous CA. Of note, long-term arrhythmia-free survival is significantly worse after DD-guided ablation, and more patients undergo redo procedures.
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Affiliation(s)
- Jan-Hendrik Schipper
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany; (D.S.); (J.L.); (J.W.); (J.-H.v.d.B.); (K.F.); (S.D.); (S.E.); (F.P.); (A.S.)
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24
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Huang W, Luo Y, Sun H, Yang G, Luo D, Xiong S, Long Y, Liu H. Acute and long-term outcomes of pulmonary vein isolation and left atrial substrate modification for non-paroxysmal atrial fibrillation: a non-randomized trial. Cardiovasc Diagn Ther 2023; 13:1056-1067. [PMID: 38162101 PMCID: PMC10753238 DOI: 10.21037/cdt-23-273] [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: 06/26/2023] [Accepted: 10/02/2023] [Indexed: 01/03/2024]
Abstract
Background The long-term success rate of nonparoxysmal atrial fibrillation (AF) treated with pulmonary vein isolation (PVI) alone is not ideal. This may indicate atrial fibrosis as a major cause of recurrence. Therefore, the aim of this study is to investigate the efficacy of left atrial substrate modification (LASM) by targeting low-voltage area. Methods A total of 157 consecutive patients with drug-refractory nonparoxysmal AF who underwent radiofrequency ablation during hospitalization in the Third People's Hospital of Chengdu from April 2017 to August 2021 were prospectively included. Stepwise ablation was performed in two different orders: LASM first (n=53) and PVI first (n=104) group. All patients underwent ablation during AF, and the procedural endpoint was AF termination during ablation. In the LASM first group, LASM was performed first and if AF was terminated, PVI was not performed. Similarly, in the PVI first groups, LASM was performed if AF was not terminated. The primary outcome were AF termination and freedom from AF. The secondary outcome was adverse events. Cox regression analysis was used to define predictors of AF termination, and Kaplan-Meier analysis was used to assess differences between groups in AF freedom. Results The baseline characteristics of the two groups were similar. At a median follow-up of 16 months, the 112 patients (39 in LASM first group and 73 in PVI first group) with AF termination had a higher success rate than the 45 patients who had no AF termination (78.6% vs. 57.8%; P<0.01). The AF termination rate (24/53, 45.3% vs. 12/104, 11.5%; P<0.01) and AF freedom (20/24, 83.3% vs. 7/12, 58.3%; P=0.13) by LASM alone was higher than PVI alone. There were 3 cases of heart failure and 1 case of stroke (4/53) in the LASM first group, and 1 case of pericardial tamponade, 5 cases of heart failure and 1 case of stroke (7/104) in the LASM first group (7.5% vs. 6.7%; P>0.05). Conclusions LASM provides higher immediate success and a slightly better long-term success rate compared to PVI. Patients who terminated AF were more likely to have AF freedom than those who did not. AF termination during procedure may improve symptoms and reduce hospitalization.
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Affiliation(s)
- Wenchao Huang
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yan Luo
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Huaxin Sun
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Guoshu Yang
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Duan Luo
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Shiqiang Xiong
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yu Long
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Hanxiong Liu
- Department of Cardiology, The Third People's Hospital of Chengdu, College of Medicine, Southwest Jiaotong University, Chengdu, China
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25
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Hermans BJ, Bijvoet GP, Holtackers RJ, Mihl C, Luermans JG, Maesen B, Vernooy K, Linz D, Chaldoupi SM, Schotten U. Multi-modal characterization of the left atrium by a fully automated integration of pre-procedural cardiac imaging and electro-anatomical mapping. IJC HEART & VASCULATURE 2023; 49:101276. [PMID: 37854978 PMCID: PMC10579959 DOI: 10.1016/j.ijcha.2023.101276] [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: 07/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023]
Abstract
Background The combination of information obtained from pre-procedural cardiac imaging and electro-anatomical mapping (EAM) can potentially help to locate new ablation targets. In this study we developed and evaluated a fully automated technique to align left atrial (LA) anatomies obtained from CT- and MRI-scans with LA anatomies obtained from EAM. Methods Twenty-one patients scheduled for a pulmonary vein (PV) isolation with a pre-procedural MRI were enrolled. Additionally, a recent computed tomography (CT) scan was available in 12 patients. LA anatomies were segmented from MRI-scans using ADAS-AF (Galgo Medical, Barcelona) and from the CT-scans using Slicer3D. MRI and CT anatomies were aligned with the EAM anatomy using an iterative closest plane-to-plane algorithm. Initially, the algorithm included the PVs, LA appendage and mitral valve anulus as they are the most distinctive landmarks. Subsequently, the algorithm was applied again, excluding these structures, with only three iterative steps to refine the alignment of the true LA surface. The result of the alignments was quantified by the Euclidian distance between the aligned anatomies after excluding PVs, LA appendage and mitral anulus. Results Our algorithm successfully aligned 20/21 MRI anatomies and 11/12 CT anatomies with the corresponding EAM anatomies. The average median residual distances were 1.9 ± 0.6 mm and 2.5 ± 0.8 mm for MRI and CT anatomies respectively. The average LA surface with a residual distance less than 5.00 mm was 89 ± 9% and 89 ± 10% for MRI and CT anatomies respectively. Conclusion An iterative closest plane-to-plane algorithm is a reliable method to automatically align pre-procedural cardiac images with anatomies acquired during ablation procedures.
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Affiliation(s)
- Ben J.M. Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Geertruida P. Bijvoet
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Robert J. Holtackers
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Justin G.L.M. Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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26
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Manongi N, Kim J, Goldbarg S. Dispersion electrogram detection with an artificial intelligence software in redo paroxysmal atrial fibrillation ablation. HeartRhythm Case Rep 2023; 9:948-953. [PMID: 38204832 PMCID: PMC10774588 DOI: 10.1016/j.hrcr.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Ngoda Manongi
- Department of Internal Medicine, NewYork-Presbyterian Queens Hospital, Flushing, New York
| | - Joonhyuk Kim
- Division of Cardiology, NewYork-Presbyterian Queens Hospital, Flushing, New York
| | - Seth Goldbarg
- Division of Cardiology, NewYork-Presbyterian Queens Hospital, Flushing, New York
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27
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Lin CY, Lin YJ, Higa S, Tsai WC, Lo MT, Chiang CH, Chang SL, Lo LW, Hu YF, Chao TF, Chung FP, Liao JN, Chang TY, Lin C, Tuan TC, Kuo L, Wu CI, Liu CM, Liu SH, Kuo MJ, Liao YC, Chuang CM, Chen YY, Hsieh YC, Chen SA. Catheter Ablation With Morphologic Repetitiveness Mapping for Persistent Atrial Fibrillation. JAMA Netw Open 2023; 6:e2344535. [PMID: 37991761 PMCID: PMC10665974 DOI: 10.1001/jamanetworkopen.2023.44535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/09/2023] [Indexed: 11/23/2023] Open
Abstract
Importance Catheter ablation for persistent atrial fibrillation (AF) has shown limited success. Objective To determine whether AF drivers could be accurately identified by periodicity and similarity (PRISM) mapping ablation results for persistent AF when added to pulmonary vein isolation (PVI). Design, Setting, and Participants This prospective randomized clinical trial was performed between June 1, 2019, and December 31, 2020, and included patients with persistent AF enrolled in 3 centers across Asia. Data were analyzed on October 1, 2022. Intervention Patients were assigned to the PRISM-guided approach (group 1) or the conventional approach (group 2) at a 1:1 ratio. Main Outcomes and Measures The primary outcome was freedom from AF or other atrial arrhythmia for longer than 30 seconds at 6 and 12 months. Results A total of 170 patients (mean [SD] age, 62.0 [12.3] years; 136 men [80.0%]) were enrolled (85 patients in group 1 and 85 patients in group 2). More group 1 patients achieved freedom from AF at 12 months compared with group 2 patients (60 [70.6%] vs 40 [47.1%]). Multivariate analysis indicated that the PRISM-guided approach was associated with freedom from the recurrence of atrial arrhythmia (hazard ratio, 0.53 [95% CI, 0.33-0.85]). Conclusions and Relevance The waveform similarity and recurrence pattern derived from high-density mapping might provide an improved guiding approach for ablation of persistent AF. Compared with the conventional procedure, this novel specific substrate ablation strategy reduced the frequency of recurrent AF and increased the likelihood of maintenance of sinus rhythm. Trial Registration ClinicalTrials.gov Identifier: NCT05333952.
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Affiliation(s)
- Chin-Yu Lin
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, Okinawa, Japan
| | - Wen-Chin Tsai
- Division of Cardiology, Tzu-Chi General Hospital, Institute of Medical Sciences, Tzu-Chi University, Hualien, Taiwan
| | - Men-Tzung Lo
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Chia-Hsin Chiang
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Shih-Lin Chang
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Feng Hu
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tze-Fan Chao
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jo-Nan Liao
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ting-Yung Chang
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chen Lin
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, Okinawa, Japan
| | - Ta-Chuan Tuan
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ling Kuo
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-I. Wu
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Min Liu
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shin-Huei Liu
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Jen Kuo
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ying-Chieh Liao
- Division of Cardiovascular Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chieh-Mao Chuang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yun-Yu Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Life Sciences, National Chung Hsing University, Taichung, Taiwan
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Yu-Cheng Hsieh
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shih-Ann Chen
- Medicine and Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, National Chung Hsing University, Taichung, Taiwan
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28
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Garcia AN, Liu B, Nadeem F, Panda N, Kirk M, Tran CT, Wu M. Real-life Clinical Outcomes of Low-voltage Isolation and Spatiotemporal Dispersion Ablation Strategies for Persistent Atrial Fibrillation. J Innov Card Rhythm Manag 2023; 14:5629-5636. [PMID: 37927393 PMCID: PMC10621621 DOI: 10.19102/icrm.2023.14103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 05/12/2023] [Indexed: 11/07/2023] Open
Abstract
Multiple techniques have been developed in addition to pulmonary vein isolation (PVI) to improve the outcomes of catheter ablation in patients with persistent atrial fibrillation (AF). We sought to evaluate the long-term efficacy of alternative techniques used in our laboratory for the treatment of persistent AF, including spatiotemporal dispersion (SD) and low-voltage isolation (LVI). Consecutive patients with persistent AF who underwent catheter ablation with the studied techniques between July 2016 and December 2019 were included in the study. PVI alone was compared with PVI plus SD and PVI plus LVI in terms of long-term freedom from atrial tachycardia (AT) and AF recurrence. Follow-up data were obtained from clinical records and hospital visits, which included a 7-day Holter monitor and electrocardiograms. The study was approved by the institutional review board of Rhode Island Hospital. A total of 382 patients underwent catheter ablation at our institution during the study period. One hundred seventy-two patients had paroxysmal AF and were excluded from the study. The remaining 210 patients had persistent AF and were included in the study. One hundred and three patients underwent PVI alone, while 48 had the addition of LVI and 59 had SD. Additionally, freedom from AT/AF recurrence at 18 months was 68% in the group that underwent LVI, 49% in the SD group, and 40% in the group that underwent PVI alone (log-rank P = .014). Freedom from AF recurrence was 74% in the LVI group, 71% in the SD group, and 43% in the PVI-alone group (log-rank P = .002). On multivariate Cox regression, LVI and left atrial size were found to be independent predictors of recurrence (hazard ratio, 0.39; 95% confidence interval, 0.206-0.760; P = .005 and hazard ratio, 1.4; 95% confidence interval, 1.105-1.923; P = .008, respectively). LVI and SD in addition to PVI were associated with greater freedom from AT/AF recurrence at 18 months compared to PVI alone.
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Affiliation(s)
- Arismendy Nunez Garcia
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute and Brown University, Providence, RI, USA
| | - Brian Liu
- Division of Internal Medicine, Lifespan and Brown University, Providence, RI, USA
| | - Fahd Nadeem
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute and Brown University, Providence, RI, USA
| | - Nikhil Panda
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute and Brown University, Providence, RI, USA
- Division of Cardiology, John Cochran Veteran Affairs Medical Center, St Louis, MO, USA
| | - Malcolm Kirk
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute and Brown University, Providence, RI, USA
| | - Cao Thach Tran
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute and Brown University, Providence, RI, USA
| | - Michael Wu
- Division of Cardiology, Department of Medicine, Lifespan Cardiovascular Institute and Brown University, Providence, RI, USA
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29
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Cunn G, Coleman K, Mountantonakis S. Currently approved imaging modalities of atrial fibrillation drivers: Are they in agreement? HeartRhythm Case Rep 2023; 9:755-758. [PMID: 38047190 PMCID: PMC10691946 DOI: 10.1016/j.hrcr.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Gregory Cunn
- Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart & Lung, New York, New York
| | - Kristie Coleman
- Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart & Lung, New York, New York
| | - Stavros Mountantonakis
- Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart & Lung, New York, New York
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30
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Squara F, Scarlatti D, Bun SS, Moceri P, Ferrari E, Meste O, Zarzoso V. High-density mapping of the average complex interval helps localizing atrial fibrillation drivers and predicts catheter ablation outcomes. Front Cardiovasc Med 2023; 10:1145894. [PMID: 37663412 PMCID: PMC10469913 DOI: 10.3389/fcvm.2023.1145894] [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: 01/16/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
Background Persistent Atrial Fibrillation (PersAF) electrogram-based ablation is complex, and appropriate identification of atrial substrate is critical. Little is known regarding the value of the Average Complex Interval (ACI) feature for PersAF ablation. Objective Using the evolution of AF complexity by sequentially computing AF dominant frequency (DF) along the ablation procedure, we sought to evaluate the value of ACI for discriminating active drivers (AD) from bystander zones (BZ), for predicting AF termination during ablation, and for predicting AF recurrence during follow-up. Methods We included PersAF patients undergoing radiofrequency catheter ablation by pulmonary vein isolation and ablation of atrial substrate identified by Spatiotemporal Dispersion or Complex Fractionated Atrial Electrograms (>70% of recording). Operators were blinded to ACI measurement which was sought for each documented atrial substrate area. AF DF was measured by Independent Component Analysis on 1-minute 12-lead ECGs at baseline and after ablation of each atrial zone. AD were differentiated from BZ either by a significant decrease in DF (>10%), or by AF termination. Arrhythmia recurrence was monitored during follow-up. Results We analyzed 159 atrial areas (129 treated by radiofrequency during AF) in 29 patients. ACI was shorter in AD than BZ (76.4 ± 13.6 vs. 86.6 ± 20.3 ms; p = 0.0055), and mean ACI of all substrate zones was shorter in patients for whom radiofrequency failed to terminate AF [71.3 (67.5-77.8) vs. 82.4 (74.4-98.5) ms; p = 0.0126]. ACI predicted AD [AUC 0.728 (0.629-0.826)]. An ACI < 70 ms was specific for predicting AD (Sp 0.831, Se 0.526), whereas areas with an ACI > 100 ms had almost no chances of being active in AF maintenance. AF recurrence was associated with more ACI zones with identical shortest value [3.5 (3-4) vs. 1 (0-1) zones; p = 0.021]. In multivariate analysis, ACI < 70 ms predicted AD [OR = 4.02 (1.49-10.84), p = 0.006] and mean ACI > 75 ms predicted AF termination [OR = 9.94 (1.14-86.7), p = 0.038]. Conclusion ACI helps in identifying AF drivers, and is correlated with AF termination and AF recurrence during follow-up. It can help in establishing an ablation plan, by prioritizing ablation from the shortest to the longest ACI zone.
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Affiliation(s)
- Fabien Squara
- Cardiology Department, Pasteur Hospital, Université Côte d’Azur, Nice, France
- I3S Laboratory, Université Côte d’Azur, CNRS, Sophia Antipolis, France
| | - Didier Scarlatti
- Cardiology Department, Pasteur Hospital, Université Côte d’Azur, Nice, France
| | - Sok-Sithikun Bun
- Cardiology Department, Pasteur Hospital, Université Côte d’Azur, Nice, France
| | - Pamela Moceri
- Cardiology Department, Pasteur Hospital, Université Côte d’Azur, Nice, France
| | - Emile Ferrari
- Cardiology Department, Pasteur Hospital, Université Côte d’Azur, Nice, France
| | - Olivier Meste
- I3S Laboratory, Université Côte d’Azur, CNRS, Sophia Antipolis, France
| | - Vicente Zarzoso
- I3S Laboratory, Université Côte d’Azur, CNRS, Sophia Antipolis, France
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Nairn D, Eichenlaub M, Müller-Edenborn B, Huang T, Lehrmann H, Nagel C, Azzolin L, Luongo G, Figueras Ventura RM, Rubio Forcada B, Vallès Colomer A, Westermann D, Arentz T, Dössel O, Loewe A, Jadidi A. Differences in atrial substrate localization using late gadolinium enhancement-magnetic resonance imaging, electrogram voltage, and conduction velocity: a cohort study using a consistent anatomical reference frame in patients with persistent atrial fibrillation. Europace 2023; 25:euad278. [PMID: 37713626 PMCID: PMC10533207 DOI: 10.1093/europace/euad278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/10/2023] [Indexed: 09/17/2023] Open
Abstract
AIMS Electro-anatomical voltage, conduction velocity (CV) mapping, and late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) have been correlated with atrial cardiomyopathy (ACM). However, the comparability between these modalities remains unclear. This study aims to (i) compare pathological substrate extent and location between current modalities, (ii) establish spatial histograms in a cohort, (iii) develop a new estimated optimized image intensity threshold (EOIIT) for LGE-MRI identifying patients with ACM, (iv) predict rhythm outcome after pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF). METHODS AND RESULTS Thirty-six ablation-naive persistent AF patients underwent LGE-MRI and high-definition electro-anatomical mapping in sinus rhythm. Late gadolinium enhancement areas were classified using the UTAH, image intensity ratio (IIR >1.20), and new EOIIT method for comparison to low-voltage substrate (LVS) and slow conduction areas <0.2 m/s. Receiver operating characteristic analysis was used to determine LGE thresholds optimally matching LVS. Atrial cardiomyopathy was defined as LVS extent ≥5% of the left atrium (LA) surface at <0.5 mV. The degree and distribution of detected pathological substrate (percentage of individual LA surface are) varied significantly (P < 0.001) across the mapping modalities: 10% (interquartile range 0-14%) of the LA displayed LVS <0.5 mV vs. 7% (0-12%) slow conduction areas <0.2 m/s vs. 15% (8-23%) LGE with the UTAH method vs. 13% (2-23%) using IIR >1.20, with most discrepancies on the posterior LA. Optimized image intensity thresholds and each patient's mean blood pool intensity correlated linearly (R2 = 0.89, P < 0.001). Concordance between LGE-MRI-based and LVS-based ACM diagnosis improved with the novel EOIIT applied at the anterior LA [83% sensitivity, 79% specificity, area under the curve (AUC): 0.89] in comparison to the UTAH method (67% sensitivity, 75% specificity, AUC: 0.81) and IIR >1.20 (75% sensitivity, 62% specificity, AUC: 0.67). CONCLUSION Discordances in detected pathological substrate exist between LVS, CV, and LGE-MRI in the LA, irrespective of the LGE detection method. The new EOIIT method improves concordance of LGE-MRI-based ACM diagnosis with LVS in ablation-naive AF patients but discrepancy remains particularly on the posterior wall. All methods may enable the prediction of rhythm outcomes after PVI in patients with persistent AF.
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Affiliation(s)
- Deborah Nairn
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Martin Eichenlaub
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Björn Müller-Edenborn
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Taiyuan Huang
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Nagel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Luca Azzolin
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Giorgio Luongo
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | | | | | | | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Arentz
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Amir Jadidi
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Arrhythmia Division, Department of Cardiology, Heart Center Lucerne, Lucerne Cantonal Hospital, Lucerne, Switzerland
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32
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Poindron D, Rahim D, Lefoulon A, Amet D, Gedin D, Dhanjal T, Lellouche N, Moini C. Impact of Incidental Left Atrial Isolation During Ablation in Patients With Long-Standing Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1598-1600. [PMID: 37354178 DOI: 10.1016/j.jacep.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
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33
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Jadidi A, Loewe A. Omnipolar Voltage: A Novel Modality for Rhythm-Independent Identification of the Atrial Low-Voltage Substrate During AF? JACC Clin Electrophysiol 2023; 9:1513-1514. [PMID: 37204355 DOI: 10.1016/j.jacep.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Amir Jadidi
- Arrhythmia Division, Department of Cardiology, Heart Center Lucerne, Lucerne Cantonal Hospital, Lucerne, Switzerland; Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
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34
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Hu D, Barajas-Martinez H, Zhang ZH, Duan HY, Zhao QY, Bao MW, Du YM, Burashnikov A, Monasky MM, Pappone C, Huang CX, Antzelevitch C, Jiang H. Advances in basic and translational research in atrial fibrillation. Philos Trans R Soc Lond B Biol Sci 2023; 378:20220174. [PMID: 37122214 PMCID: PMC10150218 DOI: 10.1098/rstb.2022.0174] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/08/2023] [Indexed: 05/02/2023] Open
Abstract
Atrial fibrillation (AF) is a very common cardiac arrhythmia with an estimated prevalence of 33.5 million patients globally. It is associated with an increased risk of death, stroke and peripheral embolism. Although genetic studies have identified a growing number of genes associated with AF, the definitive impact of these genetic findings is yet to be established. Several mechanisms, including electrical, structural and neural remodelling of atrial tissue, have been proposed to contribute to the development of AF. Despite over a century of exploration, the molecular and cellular mechanisms underlying AF have not been fully established. Current antiarrhythmic drugs are associated with a significant rate of adverse events and management of AF using ablation is not optimal, especially in cases of persistent AF. This review discusses recent advances in our understanding and management of AF, including new concepts of epidemiology, genetics and pathophysiological mechanisms. We review the current status of antiarrhythmic drug therapy for AF, new potential agents, as well as mechanism-based AF ablation. This article is part of the theme issue 'The heartbeat: its molecular basis and physiological mechanisms'.
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Affiliation(s)
- Dan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Hector Barajas-Martinez
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Zhong-He Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Hong-Yi Duan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Qing-Yan Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Ming-Wei Bao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Yi-Mei Du
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Alexander Burashnikov
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Michelle M. Monasky
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan 20097, Italy
| | - Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan 20097, Italy
- Vita-Salute San Raffaele University, Milan 20132, Italy
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, Milan 20097, Italy
| | - Cong-Xin Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
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35
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Haines DE, Kong MH, Ruppersberg P, Haeusser P, Avitall B, Szili-Torok T, Verma A. Electrographic flow mapping for atrial fibrillation: theoretical basis and preliminary observations. J Interv Card Electrophysiol 2023; 66:1015-1028. [PMID: 35969338 PMCID: PMC10172240 DOI: 10.1007/s10840-022-01308-8] [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: 06/15/2022] [Accepted: 07/15/2022] [Indexed: 10/15/2022]
Abstract
Ablation strategies remain poorly defined for persistent atrial fibrillation (AF) patients with recurrence despite intact pulmonary vein isolation (PVI). As the ability to perform durable PVI improves, the need for advanced mapping to identify extra-PV sources of AF becomes increasingly evident. Multiple mapping technologies attempt to localize these self-sustained triggers and/or drivers responsible for initiating and/or maintaining AF; however, current approaches suffer from technical limitations. Electrographic flow (EGF) mapping is a novel mapping method based on well-established principles of optical flow and fluid dynamics. It enables the full spatiotemporal reconstruction of organized wavefront propagation within the otherwise chaotic and disorganized electrical conduction of AF. Given the novelty of EGF mapping and relative unfamiliarity of most clinical electrophysiologists with the mathematical principles powering the EGF algorithm, this paper provides an in-depth explanation of the technical/mathematical foundations of EGF mapping and demonstrates clinical applications of EGF mapping data and analyses. Starting with a 64-electrode basket catheter, unipolar EGMs are recorded and processed using an algorithm to visualize the electrographic flow and highlight the location of high prevalence AF "source" activity. The AF sources are agnostic to the specific mechanisms of source signal generation.
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Affiliation(s)
- David E Haines
- Department of Cardiovascular Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3601 West 13 Mile Rd., Royal Oaks, MI, 48973, USA.
| | | | | | | | - Boaz Avitall
- Department of Medicine and Bioengineering, University of Illinois, Chicago, IL, USA
| | - Tamas Szili-Torok
- Department of Cardiology, Electrophysiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Atul Verma
- Southlake Regional Health Centre, Division of Cardiology, University of Toronto, 602-581 Davis Drive, Newmarket, Ontario, L3Y 2P6, Canada.
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36
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Sakata K, Tanaka T, Yamashita S, Kobayashi M, Ito M, Yamashiro K. The spatiotemporal electrogram dispersion ablation targeting rotors is more effective for elderly patients than non-elderly population. J Arrhythm 2023; 39:315-326. [PMID: 37324760 PMCID: PMC10264740 DOI: 10.1002/joa3.12860] [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: 01/27/2023] [Revised: 04/10/2023] [Accepted: 04/16/2023] [Indexed: 06/17/2023] Open
Abstract
Background Modulating atrial fibrillation (AF) drivers has been proposed as one of the effective ablation strategies for non-paroxysmal AF (non-PAF). However, the optimal non-PAF ablation strategy is still under debate because the exact mechanisms of AF persistence including focal activity and/or rotational activity, are not well-understood. Recently, spatiotemporal electrogram dispersion (STED) assumed to indicate rotors in the form of rotational activity is proposed as an effective target for non-PAF ablation. We aimed to clarify the effectiveness of STED ablation for modulating AF drivers. Methods STED ablation plus pulmonary vein isolation was applied in 161 consecutive non-PAF patients not undergoing previous ablation. STED areas within the entire left and right atria were identified and ablated during AF. After the procedures, the STED ablation's acute and long-term outcomes were investigated. Results (1) Despite a more effective acute outcome of the STED ablation for both AF termination and non-inducibility of atrial tachyarrhythmias (ATAs), Kaplan-Meier curves showed that the 24-month freedom ratio from ATAs was 49%, which resulted from the higher recurrence ratio of atrial tachycardia (AT) rather than AF. (2) A multivariate analysis showed that the determinant of ATA recurrences was only a non-elderly age, not long-standing persistent AF, and an enlarged left atrium, which were conventionally considered as key factors. Conclusions STED ablation targeting rotors was effective in elderly non-PAF patients. Therefore, the main mechanism of AF persistency and the component of the fibrillatory conduction might vary between elders and non-elders. However, we should be careful about post-ablation ATs following substrate modification.
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Affiliation(s)
- Kensuke Sakata
- Alliance for Cardiovascular Diagnostic and Treatment InnovationJohns Hopkin UniversityBaltimoreMarylandUSA
| | - Tomomi Tanaka
- Heart Rhythm CenterTakatsuki General HospitalTakatsukiJapan
| | - Soichiro Yamashita
- Department of CardiologyHyogo Prefectural Awaji Medical CenterSumotoJapan
| | - Masanori Kobayashi
- Department of Cardiovascular MedicineMatsumoto Kyoritsu HospitalMatsumotoJapan
| | - Mitsuaki Ito
- Department of Cardiovascular MedicineHyogo Brain and Heart CenterHimejiJapan
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Ganesan P, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Rogers AJ, Clopton P, Wang PJ, Zeemering S, Schotten U, Rappel WJ, Narayan SM. Quantifying a spectrum of clinical response in atrial tachyarrhythmias using spatiotemporal synchronization of electrograms. Europace 2023; 25:euad055. [PMID: 36932716 PMCID: PMC10227659 DOI: 10.1093/europace/euad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/19/2023] Open
Abstract
AIMS There is a clinical spectrum for atrial tachyarrhythmias wherein most patients with atrial tachycardia (AT) and some with atrial fibrillation (AF) respond to ablation, while others do not. It is undefined if this clinical spectrum has pathophysiological signatures. This study aims to test the hypothesis that the size of spatial regions showing repetitive synchronized electrogram (EGM) shapes over time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. METHODS AND RESULTS We studied n = 160 patients (35% women, 65.0 ± 10.4 years) of whom (i) n = 75 had AF terminated by ablation propensity matched to (ii) n = 75 without AF termination and (iii) n = 10 with AT. All patients had mapping by 64-pole baskets to identify areas of repetitive activity (REACT) to correlate unipolar EGMs in shape over time. Synchronized regions (REACT) were largest in AT, smaller in AF termination, and smallest in non-termination cohorts (0.63 ± 0.15, 0.37 ± 0.22, and 0.22 ± 0.18, P < 0.001). Area under the curve for predicting AF termination in hold-out cohorts was 0.72 ± 0.03. Simulations showed that lower REACT represented greater variability in clinical EGM timing and shape. Unsupervised machine learning of REACT and extensive (50) clinical variables yielded four clusters of increasing risk for AF termination (P < 0.01, χ2), which were more predictive than clinical profiles alone (P < 0.001). CONCLUSION The area of synchronized EGMs within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any predetermined mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.
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Affiliation(s)
- Prasanth Ganesan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Brototo Deb
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Ruibin Feng
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
| | - Samuel Ruiperez-Campillo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Albert J Rogers
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul Clopton
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Stef Zeemering
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Wouter-Jan Rappel
- Department of Physics, University of California, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
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Li K, Xu C, Zhu X, Wang X, Ye P, Jiang W, Wu S, Xu K, Li X, Wang Y, Zheng Q, Wang Y, Leng L, Zhang Z, Han B, Zhang Y, Qin M, Liu X. Multi-centre, prospective randomized comparison of three different substrate ablation strategies for persistent atrial fibrillation. Europace 2023; 25:euad090. [PMID: 37050858 PMCID: PMC10228617 DOI: 10.1093/europace/euad090] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/16/2023] [Indexed: 04/14/2023] Open
Abstract
AIMS The optimal strategy for persistent atrial fibrillation (PerAF) is poorly defined. We conducted a multicentre, randomized, prospective trial to compare the outcomes of different ablation strategies for PerAF. METHODS AND RESULTS We enrolled 450 patients and randomly assigned them in a 1:1:1 ratio to undergo pulmonary vein isolation and subsequently undergo the following three different ablation strategies: anatomical guided ablation (ANAT group, n = 150), electrogram guided ablation (EGM group, n = 150), and extensive electro-anatomical guided ablation (EXT group, n = 150). The primary endpoint was freedom from atrial fibrillation (AF) lasting longer than 30 s at 12 months after a single ablation procedure. After 12 months of follow-up, 72% (108) of patients in the EXT group were free from AF recurrence, as compared with the 64% (96) in the EGM group (P = 0.116), and 54% (81) in the ANAT group (P = 0.002). The EXT group showed less AF/atrial tachycardia recurrence than the EGM group (60% vs. 50%, P = 0.064) and the ANAT group (60% vs. 37.3%, P < 0.001). The EXT group showed the highest rate of AF termination (66.7%), followed by 56.7% in the EGM group, and 20.7% in the ANAT group. The AF termination signified less AF recurrence at 12 months compared to patients without AF termination (30.1% vs. 42.7%, P = 0.008). Safety endpoints did not differ significantly between the three groups (P = 0.924). CONCLUSIONS Electro-anatomical guided ablation achieved the most favourable outcomes among the three ablation strategies. The AF termination is a reliable ablation endpoint.
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Affiliation(s)
- Kaige Li
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Changhao Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Xiyao Zhu
- Department of Clinical Integration of Traditional Chinese and Western medicine, First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xinhua Wang
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Ye
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weifeng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Shaohui Wu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Kai Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Xiangting Li
- Department of Cardiology, Affiliated Hospital of Jining Medical University, Jining, China
| | - Ying Wang
- Department of Cardiology, Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Qidong Zheng
- Department of Cardiology, Yuhuan Second People's Hospital, Yuhuan, China
| | - Yanzhe Wang
- Department of Cardiology, Changshu Hospital of Traditional Chinese Medicine, Changshu, China
| | - Lihua Leng
- Department of Cardiology, The PLA Navy Anqing Hospital, Anqing, China
| | - Zengtang Zhang
- Department of Cardiology, Jinan City People’s Hospital, Jinan, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Yu Zhang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Mu Qin
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No.241 West Huaihai Road, Shanghai 200030, China
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Sousonis V, Combes S, Pinon P, Combes N, Cardin C, Zeriouh S, Menè R, Jacob S, Boveda S, Albenque JP. A novel stepwise approach incorporating ethanol infusion in the vein of Marshall for the ablation of persistent atrial fibrillation. Front Cardiovasc Med 2023; 10:1194687. [PMID: 37304968 PMCID: PMC10251404 DOI: 10.3389/fcvm.2023.1194687] [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: 03/27/2023] [Accepted: 04/27/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Apart from pulmonary vein isolation (PVI), several step-by-step procedures that aim to modify left atrial substrate have been proposed for the ablation of persistent atrial fibrillation (AF), yet the optimal strategy remains elusive. There are cumulative data suggesting an incremental benefit of adding vein of Marshall (VOM) ethanol infusion to PVI in patients with persistent AF. We sought to evaluate the feasibility and efficacy of a novel stepwise ablation approach, incorporating a VOM alcoholization step, for persistent AF. Methods In this single-center study, we prospectively enrolled 66 consecutive patients with symptomatic persistent AF and failure of at least one antiarrhythmic drug (ADD). The ablation procedure consisted of (i) PVI, (ii) left atrial segmentation with VOM ethanol infusion and the deployment of linear radiofrequency lesions across the roof and the mitral isthmus and (iii) electrogram-based ablation of dispersion zones. The first two steps were performed in all patients, whereas the third step was carried out only in those still in AF at the end of the second step. Atrial tachycardias during the procedure were mapped and ablated. At the end of the procedure, cavotricuspid isthmus ablation was additionally performed in all patients. The primary endpoint was 12-month freedom from AF and atrial tachycardia after a single procedure and an initial three-month blanking period. Results Total procedure time was 153 ± 38.5 min. Fluoroscopy time was 16 ± 6.5 min and the radiofrequency ablation time was 26.14 ± 0.26 min. The primary endpoint occurred in 54 patients (82%). At 12 months, 65% of patients were off any AAD. In the univariate Cox regression analysis, left ventricular ejection fraction < 40% was the only predictor of arrhythmia recurrence (HR 3.56; 95% CI, 1.04-12.19; p = 0.04). One patient developed a pericardial tamponade and another a minor groin hematoma. Conclusion A novel stepwise approach, including a step of ethanol infusion in the VOM, is feasible, safe and provides a high rate of sinus rhythm maintenance at 12 months in patients with persistent AF.
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Affiliation(s)
| | - Stéphane Combes
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
| | - Pauline Pinon
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
| | - Nicolas Combes
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
| | - Christelle Cardin
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
| | - Sarah Zeriouh
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
| | - Roberto Menè
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
| | - Sophie Jacob
- Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Serge Boveda
- Heart Rhythm Management Department, CliniquePasteur, Toulouse, France
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40
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Higuchi K, Iwai S, Kato N, Muramoto H, Onishi Y, Yokoyama Y, Hirao K, Sasano T. The utility of combining continuous wavelet transform analysis and high-density voltage map in predicting the long-term outcomes after ablation of persistent atrial fibrillation. J Interv Card Electrophysiol 2023; 66:405-416. [PMID: 35948727 DOI: 10.1007/s10840-022-01337-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous wavelet transform (CWT) analysis is a frequency analysis to detect areas of stable high-frequent activity (stable pseudo frequency [sPF]) during atrial fibrillation (AF). As previously reported, patients with the highest sPF area in pulmonary veins (PV) showed better short-term outcomes after PV isolation (PVI). This study sought to evaluate the efficacy of CWT analysis in predicting the long-term (2 years) outcomes after PVI. We also combined the left atrial (LA) voltage map with CWT analysis to further predict the outcome. METHODS Persistent AF patients (n = 109, age 65 ± 10) underwent a CWT analysis at PVs and 8 LA sites during AF for pre-PVI analysis. After PVI during AF, CWT analysis was performed again in the LA as post-PVI analysis and was compared with pre-PVI analysis. A sinus voltage map of LA was created after cardioversion. RESULTS Seventy patients had the highest sPF within PVs (PV-dominant group), while 39 patients had the highest sPF outside PVs (LA-dominant group). The global frequency in the LA showed a significant decrease after PVI only in PV-dominant group (6.55 ± 0.27 to 6.43 ± 0.37, P < 0.01). AF-free survival was better in PV-dominant group than LA-dominant group at 2-year follow-up (87.1% vs. 64.3%, P < 0.002). This trend was recognized throughout all degrees of low voltage area in the LA (LA-LVA), and AF-free survival was well predicted by combining CWT analysis and LA-LVA. CONCLUSIONS By combining CWT analysis and sinus LA-LVA, the long-term AF-free survival after PVI was well stratified and predicted.
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Affiliation(s)
- Koji Higuchi
- Department of Cardiology, Hiratsuka Kyosai Hospital, 9-11 Oiwake Hiratsuka, Kanagawa, Japan.
| | - Shinsuke Iwai
- Department of Cardiology, Hiratsuka Kyosai Hospital, 9-11 Oiwake Hiratsuka, Kanagawa, Japan
| | - Nobutaka Kato
- Department of Cardiology, Hiratsuka Kyosai Hospital, 9-11 Oiwake Hiratsuka, Kanagawa, Japan
| | - Hirotaka Muramoto
- Department of Cardiology, Hiratsuka Kyosai Hospital, 9-11 Oiwake Hiratsuka, Kanagawa, Japan
| | - Yuko Onishi
- Department of Cardiology, Hiratsuka Kyosai Hospital, 9-11 Oiwake Hiratsuka, Kanagawa, Japan
| | - Yasuhiro Yokoyama
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Kenzo Hirao
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
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41
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Ikoma T, Naruse Y, Kaneko Y, Sakakibara T, Narumi T, Sano M, Mogi S, Suwa K, Ohtani H, Saotome M, Urushida T, Maekawa Y. Prevalence and Characteristics of Inspiration-Induced Negative Left Atrial Pressure during Pulmonary Vein Isolation. J Cardiovasc Dev Dis 2023; 10:jcdd10030101. [PMID: 36975865 PMCID: PMC10056480 DOI: 10.3390/jcdd10030101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/30/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023] Open
Abstract
Background: Atrial fibrillation (AF) ablation is performed under deep sedation, which may cause inspiration-induced negative left atrial pressure (INLAP) associated with deep inspiration. INLAP could be the cause of periprocedural complications. Methods: We retrospectively enrolled 381 patients with AF (mean age, 63.9 ± 10.8 years; 76 women; 216 cases of paroxysmal AF) who underwent CA under deep sedation using an adaptive servo ventilator (ASV). Patients whose LAP was not obtained were excluded. INLAP was defined as <0 mmHg of mean LAP during inspiration immediately after the transseptal puncture. The primary and secondary endpoints were the presence of INLAP and the incidence of periprocedural complications. Results: Among 381 patients, INLAP was observed in 133 (34.9%). Patients with INLAP had higher CHA2DS2-Vasc scores (2.3 ± 1.5 vs. 2.1 ± 1.6) and 3% oxygen desaturation indexes (median 18.6 (interquartile range 11.2–31.1) vs. 15.7 (8.1–25.3)), and higher prevalence of diabetes mellitus (23.3 vs. 13.3%) than patients without INLAP. Air embolism occurred in four patients with INLAP (3.0 vs. 0.0%). Conclusion: INLAP is not rare in patients undergoing CA for AF under deep sedation with ASV. Much attention should be paid to the possibility of air embolism in patients with INLAP.
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Xu CH, Xiong F, Jiang WF, Liu X, Liu T, Qin M. Rotor mechanism and its mapping in atrial fibrillation. Europace 2023; 25:783-792. [PMID: 36734272 PMCID: PMC10062333 DOI: 10.1093/europace/euad002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 12/28/2022] [Indexed: 02/04/2023] Open
Abstract
Treatment of atrial fibrillation (AF) remains challenging despite significant progress in understanding its underlying mechanisms. The first detailed, quantitative theory of functional re-entry, the 'leading circle' model, was developed more than 40 years ago. Subsequently, in decades of study, an alternative paradigm based on spiral waves has long been postulated to drive AF. The rotor as a 'spiral wave generator' is a curved 'vortex' formed by spin motion in the two-dimensional plane, identified using advanced mapping methods in experimental and clinical AF. However, it is challenging to achieve complementary results between experimental results and clinical studies due to the limitation in research methods and the complexity of the rotor mechanism. Here, we review knowledge garnered over decades on generation, electrophysiological properties, and three-dimensional (3D) structure diversity of the rotor mechanism and make a comparison among recent clinical approaches to identify rotors. Although initial studies of rotor ablation at many independent centres have achieved promising results, some inconclusive outcomes exist in others. We propose that the clinical rotor identification might be substantially influenced by (i) non-identical surface activation patterns, which resulted from a diverse 3D form of scroll wave, and (ii) inadequate resolution of mapping techniques. With rapidly advancing theoretical and technological developments, future work is required to resolve clinically relevant limitations in current basic and clinical research methodology, translate from one to the other, and resolve available mapping techniques.
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Affiliation(s)
- Chang-Hao Xu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Feng Xiong
- Montreal Heart Institute, Department of Medicine, University of
Montreal, 5000, Bélanger street, Montréal, Québec H1T
1C8, Canada
| | - Wei-Feng Jiang
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Xu Liu
- Department of Cardiology, Shanghai Chest Hospital, School of Medicine,
Shanghai Jiao Tong University, 241 Huaihai West Road, Xuhui
District, Shanghai 200030, China
| | - Tao Liu
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
| | - Mu Qin
- Corresponding authors. Tao Liu, 238 Jiefang Road, Wuchang
District, Wuhan, Hubei 430060, China. Tel: +86 (027) 8804 1911, Fax:+86-(027)-8804-2292.
E-mail address:; Mu Qin, 241 Huaihai
West Road, Xuhui District, Shanghai, 200030, China. Tel: +8621628219902603, Fax:
+862162821105. E-mail address:
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Effect of Left Atrial Pulmonary Vein Angiography on Safety and Efficacy for High-Power, Short-Duration Pulmonary Vein Isolation in Patients with Atrial Fibrillation. J Clin Med 2023; 12:jcm12031094. [PMID: 36769742 PMCID: PMC9917939 DOI: 10.3390/jcm12031094] [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: 01/13/2023] [Revised: 01/25/2023] [Accepted: 01/28/2023] [Indexed: 02/02/2023] Open
Abstract
Imaging of pulmonary vein (PV) anatomy by angiography before pulmonary vein isolation (PVI) for atrial fibrillation (AF) has long been standard practice in many centers. Nowadays, very accurate anatomical maps can be generated by the use of high-resolution mapping catheters, and very effective ablation lesions can be generated by the use of the high-power, short-duration (HPSD) technique. In our center, PV angiography was routinely performed before PVI. However, since there is no clear evidence for this, we refrained from performing PV angiography. This study aimed to investigate whether PV angiography is still necessary when using high-resolution mapping catheters after ablation in the high-power, short-duration (HPSD) technique. A total of 139 consecutive patients with atrial fibrillation (66.25 ± 11.68 years old, 62.39% male) undergoing radiofrequency PVI were included in the study. Ablation was performed with the HPSD technique using a fixed protocol for energy delivery of 50 watts (contact force 3-20 g). We observed no significant effect on the efficacy, efficiency and complications of the ablation procedure if pulmonary vein angiography was omitted before HPSD PVI. Thus, using our protocol, it may be useful that PV angiography is avoided, especially in young patients and those with chronic renal disease.
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Kaneko Y, Naruse Y, Narumi T, Sano M, Maekawa Y. Close Association Between Subjective Assessment of Spatiotemporal Dispersion Electrograms and Objective Fractionation Map. Circ J 2023; 87:578. [PMID: 36642531 DOI: 10.1253/circj.cj-22-0488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Yutaro Kaneko
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Yoshihisa Naruse
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Taro Narumi
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Makoto Sano
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
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Weyand S, Beuter M, Heinzmann D, Seizer P. High-resolution mapping as an alternative for exit block testing in the presence of entrance block after high-power short-duration pulmonary vein isolation. Herzschrittmacherther Elektrophysiol 2022; 33:440-445. [PMID: 36083317 DOI: 10.1007/s00399-022-00895-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND After pulmonary vein isolation (PVI) for atrial fibrillation (AF), it is common as an endpoint to demonstrate an exit block from the pulmonary veins (PVs) in addition to an entrance block into them. By using high-resolution mapping catheters, even very small signals can be detected. OBJECTIVES We investigated whether additional exit block testing is still necessary when using high-resolution mapping catheters after ablation in high-power short-duration (HPSD) techniques. MATERIALS AND METHODS Overall, 114 patients with AF (average age, 65.14 ± 11.3 years; 65.8% male) undergoing radiofrequency PVI were included in the study. Ablation was performed with the HPSD technique using a fixed protocol for energy delivery of 50 W (contact force 3-20 g). Entrance and exit block were tested with a high-resolution mapping catheter. Isolation of the PVs was achieved in all patients. RESULTS Capture of local PV tissue was demonstrated in all patients after PVI and exit block was present in all patients after entrance block was detected using a high-resolution mapping catheter. CONCLUSION Exit block testing in addition to the demonstration of an entrance block as an endpoint of PVI seems to have no additional benefit and might no longer be necessary when a high-resolution mapping catheter is used in HPSD ablation for PVI of AF.
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Affiliation(s)
- Sebastian Weyand
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Im Kälblesrain 1, 73430, Aalen, Germany.
| | - Matthias Beuter
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Im Kälblesrain 1, 73430, Aalen, Germany
| | - David Heinzmann
- Innere Medizin III - Kardiologie und Angiologie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Peter Seizer
- Medizinische Klinik II - Kardiologie und Angiologie, Ostalb-Klinikum Aalen, Im Kälblesrain 1, 73430, Aalen, Germany
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Shi WR, Wu SH, Zou GC, Xu K, Jiang WF, Zhang Y, Qin M, Liu X. A novel approach for quantitative electrogram analysis for driver identification: Implications for ablation in persistent atrial fibrillation. Front Cardiovasc Med 2022; 9:1049854. [DOI: 10.3389/fcvm.2022.1049854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022] Open
Abstract
ObjectiveThis study sought to study the feasibility, efficacy, and safety of using multiscale entropy (MSE) analysis to guide catheter ablation for persistent atrial fibrillation (PsAF) and predict ablation outcomes.MethodsWe prospectively enrolled 108 patients undergoing initial ablation for PsAF. MSE was calculated based on bipolar intracardiac electrograms (iEGMs) to measure the dynamical complexity of biological signals. The iEGMs data were exported after pulmonary vein isolation (PVI), then calculated in a customed platform, and finally re-annotated into the CARTO system. After PVI, regions of the highest mean MSE (mMSE) values were ablated in descending order until AF termination, or three areas had been ablated.ResultsBaseline characteristics were evenly distributed between the AF termination (n = 38, 35.19%) and the non-termination group. The RA-to-LA mean MSE (mMSE) gradient demonstrated a positive gradient in the non-termination group and a negative gradient in the termination group (0.105 ± 0.180 vs. −0.235 ± 0.256, P < 0.001). During a 12-month follow-up, 29 patients (26.9%) had arrhythmia recurrence after single ablation, and 18 of them had AF (62.1%). The termination group had lower rates of arrhythmia recurrence (15.79 vs. 32.86%, Log-Rank P = 0.053) and AF recurrence (10.53 vs. 20%, Log-Rank P = 0.173) after single ablation and a lower rate of arrhythmia recurrence (7.89 vs. 27.14%, Log-Rank P = 0.018) after repeated ablation. Correspondingly, subjects with negative RA-to-LA mMSE gradient had lower incidences of arrhythmia (16.67 vs. 35%, Log-Rank P = 0.028) and AF (16.67 vs. 35%, Log-Rank P = 0.032) recurrence after single ablation and arrhythmia recurrence after repeated ablation (12.5 vs. 26.67%, Log-Rank P = 0.062). Marginal peri-procedural safety outcomes were observed.ConclusionMSE analysis-guided driver ablation in addition to PVI for PsAF could be feasible, efficient, and safe. An RA < LA mMSE gradient before ablation could predict freedom from arrhythmia. The RA-LA MSE gradient could be useful for guiding ablation strategy selection.
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Nishimura A, Harada M, Ashihara T, Nomura Y, Motoike Y, Koshikawa M, Ito T, Watanabe E, Ozaki Y, Izawa H. Effect of pulmonary vein isolation on rotor/multiple wavelet dynamics in persistent atrial fibrillation, association with vagal response and implications for adjunctive ablation. Heart Vessels 2022; 38:699-710. [PMID: 36436027 PMCID: PMC10085924 DOI: 10.1007/s00380-022-02209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
AbstractPersistent atrial fibrillation (PeAF) may develop arrhythmogenic substrates of rotors/multiple wavelets. However, the ways in which pulmonary vein isolation (PVI) affects the dynamics of rotor/multiple wavelets in PeAF patients remain elusive. Real-time phase-mapping (ExTRa mapping, EXT) in the whole left atrium (LA) was performed during PeAF before and after PVI (n = 111). The percentage of time in which rotor/multiple wavelets (phase singularities) was observed during each 5-s phase-mapping recording (non-passive activation ratio, %NP) was measured as an index of its burden. The mapping areas showing %NP ≥ 50% were defined as rotor/multiple-wavelet substrates (RSs). Before PVI, RSs were globally distributed in the LA. After PVI, %NP decreased (< 50%) in many RSs (PVI-modifiable RSs) but remained high (≥ 50%) in some RSs, especially localized in the anterior/septum/inferior regions (PVI-unmodifiable RSs, 2.3 ± 1.0 areas/patient). Before PVI, vagal response (VR) to high-frequency stimulation was observed in 23% of RSs, especially localized in the inferior region. VR disappearance after PVI was more frequently observed in PVI-modifiable RSs (79%) than in PVI-unmodifiable RSs (55%, p < 0.05), suggesting that PVI affects autonomic nerve activities and rotor/multiple wavelet dynamics. PVI-unmodifiable RSs were adjunctively ablated in 104 patients. The 1-year AT/AF-free survival rate was 70% in those with PVI alone (n = 115), and 86% in patients with the adjunctive ablation (log-rank test = 7.65, p < 0.01). PVI suppresses not only ectopic firing but also rotor/multiple wavelets partly via modification of autonomic nerve activities. The adjunctive ablation of PVI-unmodifiable RSs improved the outcome in PeAF patients and might be a novel ablation strategy beyond PVI.
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Affiliation(s)
- Asuka Nishimura
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Masahide Harada
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan.
| | - Takashi Ashihara
- Information Technology and Management Center, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 5202192, Japan
| | - Yoshihiro Nomura
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Yuji Motoike
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Masayuki Koshikawa
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Takehiro Ito
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 4701192, Japan
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Seitz J, Durdez TM, Albenque JP, Pisapia A, Gitenay E, Durand C, Monteau J, Moubarak G, Théodore G, Lepillier A, Zhao A, Bremondy M, Maluski A, Cauchemez B, Combes S, Guyomar Y, Heuls S, Thomas O, Penaranda G, Siame S, Appetiti A, Milpied P, Bars C, Kalifa J. Artificial intelligence software standardizes electrogram-based ablation outcome for persistent atrial fibrillation. J Cardiovasc Electrophysiol 2022; 33:2250-2260. [PMID: 35989543 PMCID: PMC9826214 DOI: 10.1111/jce.15657] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/15/2022] [Accepted: 07/04/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Multiple groups have reported on the usefulness of ablating in atrial regions exhibiting abnormal electrograms during atrial fibrillation (AF). Still, previous studies have suggested that ablation outcomes are highly operator- and center-dependent. This study sought to evaluate a novel machine learning software algorithm named VX1 (Volta Medical), trained to adjudicate multipolar electrogram dispersion. METHODS This study was a prospective, multicentric, nonrandomized study conducted to assess the feasibility of generating VX1 dispersion maps. In 85 patients, 8 centers, and 17 operators, we compared the acute and long-term outcomes after ablation in regions exhibiting dispersion between primary and satellite centers. We also compared outcomes to a control group in which dispersion-guided ablation was performed visually by trained operators. RESULTS The study population included 29% of long-standing persistent AF. AF termination occurred in 92% and 83% of the patients in primary and satellite centers, respectively, p = 0.31. The average rate of freedom from documented AF, with or without antiarrhythmic drugs (AADs), was 86% after a single procedure, and 89% after an average of 1.3 procedures per patient (p = 0.4). The rate of freedom from any documented atrial arrhythmia, with or without AADs, was 54% and 73% after a single or an average of 1.3 procedures per patient, respectively (p < 0.001). No statistically significant differences between outcomes of the primary versus satellite centers were observed for one (p = 0.8) or multiple procedures (p = 0.4), or between outcomes of the entire study population versus the control group (p > 0.2). Interestingly, intraprocedural AF termination and type of recurrent arrhythmia (i.e., AF vs. AT) appear to be predictors of the subsequent clinical course. CONCLUSION VX1, an expertise-based artificial intelligence software solution, allowed for robust center-to-center standardization of acute and long-term ablation outcomes after electrogram-based ablation.
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Huang T, Chen J, Müller-Edenborn B, Mayer L, Eichenlaub M, Moreno Weidmann Z, Allgeier J, Bohnen M, Lehrmann H, Trenk D, Schoechlin S, Westermann D, Arentz T, Jadidi A. Validating left atrial fractionation and low-voltage substrate during atrial fibrillation and sinus rhythm-A high-density mapping study in persistent atrial fibrillation. Front Cardiovasc Med 2022; 9:1000027. [PMID: 36330001 PMCID: PMC9622778 DOI: 10.3389/fcvm.2022.1000027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Low-voltage-substrate (LVS)-guided ablation for persistent atrial fibrillation (AF) has been described either in sinus rhythm (SR) or AF. Prolonged fractionated potentials (PFPs) may represent arrhythmogenic slow conduction substrate and potentially co-localize with LVS. We assess the spatial correlation of PFP identified in AF (PFP-AF) to those mapped in SR (PFP-SR). We further report the relationship between LVS and PFPs when mapped in AF or SR. MATERIALS AND METHODS Thirty-eight patients with ablation naïve persistent AF underwent left atrial (LA) high-density mapping in AF and SR prior to catheter ablation. Areas presenting PFP-AF and PFP-SR were annotated during mapping on the LA geometry. Low-voltage areas (LVA) were quantified using a bipolar threshold of 0.5 mV during both AF and SR mapping. Concordance of fractionated potentials (CFP) (defined as the presence of PFPs in both rhythms within a radius of 6 mm) was quantified. Spatial distribution and correlation of PFP and CFP with LVA were assessed. The predictors for CFP were determined. RESULTS PFPs displayed low voltages both during AF (median 0.30 mV (Q1-Q3: 0.20-0.50 mV) and SR (median 0.35 mV (Q1-Q3: 0.20-0.56 mV). The duration of PFP-SR was measured at 61 ms (Q1-Q3: 51-76 ms). During SR, most PFP-SRs (89.4 and 97.2%) were located within LVA (<0.5 mV and <1.0 mV, respectively). Areas presenting PFP occurred more frequently in AF than in SR (median: 9.5 vs. 8.0, p = 0.005). Both PFP-AF and PFP-SR were predominantly located at anterior LA (>40%), followed by posterior LA (>20%) and septal LA (>15%). The extent of LVA < 0.5 mV was more extensive in AF (median: 25.2% of LA surface, Q1-Q3:16.6-50.5%) than in SR (median: 12.3%, Q1-Q3: 4.7-29.4%, p = 0.001). CFP in both rhythms occurred in 80% of PFP-SR and 59% of PFP-AF (p = 0.008). Notably, CFP was positively correlated to the extent of LVA in SR (p = 0.004), but not with LVA in AF (p = 0.226). Additionally, the extent of LVA < 0.5 mV in SR was the only significant predictor for CFP, with an optimal threshold of 16% predicting high (>80%) fractionation concordance in AF and SR. CONCLUSION Substrate mapping in SR vs. AF reveals smaller areas of low voltage and fewer sites with PFP. PFP-SR are located within low-voltage areas in SR. There is a high degree of spatial agreement (80%) between PFP-AF and PFP-SR in patients with moderate LVA in SR (>16% of LA surface). These findings should be considered when substrate-based ablation strategies are applied in patients with the left atrial low-voltage substrate with recurrent persistent AF.
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Affiliation(s)
- Taiyuan Huang
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Juan Chen
- Department of Cardiology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Björn Müller-Edenborn
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Louisa Mayer
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Martin Eichenlaub
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Zoraida Moreno Weidmann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Sant Pau, Barcelona, Spain
| | - Juergen Allgeier
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marius Bohnen
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Heiko Lehrmann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dietmar Trenk
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Simon Schoechlin
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dirk Westermann
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Arentz
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Amir Jadidi
- Department of Cardiology, Arrhythmia Division, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
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Baptiste F, Kalifa J, Durand C, Gitenay E, Bremondy M, Ayari A, Maillot N, Taormina A, Fofana A, Penaranda G, Siame S, Bars C, Seitz J. Right atrial appendage firing in atrial fibrillation. Front Cardiovasc Med 2022; 9:997998. [DOI: 10.3389/fcvm.2022.997998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe role of atrial fibrillation (AF) drivers located at the left atrium, superior vena cava, crista terminalis and coronary sinus (CS) is well established. While these regions are classically targeted during catheter ablation, the role of right atrial appendage (RAA) drivers has been incompletely investigated.ObjectiveTo determine the prevalence and electrophysiological characteristics of AF driver’s arising from the RAA.Materials and methodsWe conducted a retrospective analysis of clinical and procedural data of 317 consecutive patients who underwent an AF ablation procedure after bi-atrial mapping (multipolar catheter). We selected patients who presented with a per-procedural RAA firing (RAAF). RAAF was defined as the recording of a sustained RAA EGM with a cycle length shorter than 120 ms or 120 < RAAF CL ≤ 130 ms and ratio RAA CL/CS CL ≤ 0.75.ResultsRight atrial/atrium appendage firing was found in 22 patients. The prevalence was estimated at 7% (95% CI, 4–10). These patients were mostly men (72%), median age: 66 yo ± 8 without structural heart disease (77%). RAAFs were predominantly found in paroxysmal AF patients (63%, 32%, and 5% for paroxysmal, short standing and long-standing AF, respectively, p > 0.05). RAAF median cycle length was 117 ms ± 7 while CS cycle length was 180 ms ± 10 (p < 0.01).ConclusionIn 317 consecutive AF ablation patients (22 patients, 7%) the presence of a high-voltage short-cycle-length right atrial appendage driver (RAAF) may conclusively be associated with AF termination. This case series exemplifies the not-so-uncommon role of the RAA in the perpetuation of AF.
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