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Dong Y, Zhao D, Chen X, Shi L, Chen Q, Zhang H, Yu Y, Ullah I, Kojodjojo P, Zhang F. Role of electroanatomical mapping-guided superior vena cava isolation in paroxysmal atrial fibrillation patients without provoked superior vena cava triggers: a randomized controlled study. Europace 2024; 26:euae039. [PMID: 38306471 PMCID: PMC10906951 DOI: 10.1093/europace/euae039] [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: 09/28/2023] [Accepted: 11/27/2023] [Indexed: 02/04/2024] Open
Abstract
AIMS Data about whether empirical superior vena cava (SVC) isolation (SVCI) improves the success rate of paroxysmal atrial fibrillation (PAF) are conflicting. This study sought to first investigate the characteristics of SVC-triggered atrial fibrillation and secondly investigate the impact of electroanatomical mapping-guided SVCI, in addition to circumferential pulmonary vein isolation (CPVI), on the outcome of PAF ablation in the absence of provoked SVC triggers. METHODS AND RESULTS A total of 130 patients undergoing PAF ablation underwent electrophysiological studies before ablation. In patients for whom SVC triggers were identified, SVCI was performed in addition to CPVI. Patients without provoked SVC triggers were randomized in a 1:1 ratio to CPVI plus SVCI or CPVI only. The primary endpoint was freedom from any documented atrial tachyarrhythmias lasting over 30 s after a 3-month blanking period without anti-arrhythmic drugs at 12 months after ablation. Superior vena cava triggers were identified in 30 (23.1%) patients with PAF. At 12 months, 93.3% of those with provoked SVC triggers who underwent CPVI plus SVCI were free from atrial tachyarrhythmias. In patients without provoked SVC triggers, SVCI, in addition to CPVI, did not increase freedom from atrial tachyarrhythmias (87.9 vs. 79.6%, log-rank P = 0.28). CONCLUSION Electroanatomical mapping-guided SVCI, in addition to CPVI, did not increase the success rate of PAF ablation in patients who had no identifiable SVC triggers. REGISTRATION ChineseClinicalTrials.gov: ChiCTR2000034532.
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Affiliation(s)
- Yan Dong
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Dongsheng Zhao
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Xinguang Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Linshen Shi
- Department of Cardiology, The Second Affiliated Hospital of Nantong University, Nantong, China
| | - Qiushi Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Haiyan Zhang
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Yu
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Inam Ullah
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Pipin Kojodjojo
- Asian Heart and Vascular Centre, National University of Singapore, Singapore, Singapore
| | - Fengxiang Zhang
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
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Fujisawa T, Nagai T, Kawakami H, Yamaguchi O. Atrial fibrillation arising from a silent superior vena cava. HeartRhythm Case Rep 2022; 9:156-159. [PMID: 36970386 PMCID: PMC10030296 DOI: 10.1016/j.hrcr.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Clinical Significance of Adenosine-Induced Atrial Fibrillation after Complete Pulmonary Vein Isolation. J Clin Med 2022; 11:jcm11195679. [PMID: 36233544 PMCID: PMC9570534 DOI: 10.3390/jcm11195679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Adenosine can cause dormant electrical conduction between the pulmonary vein and left atrium after pulmonary vein isolation (PVI). Adenosine can also induce atrial fibrillation (AF) during catheter ablation. However, the clinical outcomes and effects of additional ablation for the trigger sites of adenosine-induced AF (AIAF) are unknown. This study therefore aimed to evaluate the clinical significance of AIAF. Methods: Between January 2010 and September 2019, we analyzed 616 consecutive patients with paroxysmal AF (PAF) who underwent radiofrequency catheter ablation (RFCA), including wide-area circumferential pulmonary vein isolation (PVI) and post-PVI adenosine testing. Results: Among 616 patients, 134 (21.7%) and 34 (5.5%) showed dormant conduction and AIAF, respectively. Eight patients (1.3%) had both dormant conduction and AIAF. The AF recurrence rate was not significantly different between patients with and without AIAF (16.7% vs. 18.6%, log-rank p = 0.827) during a mean follow-up period of 17.9 ± 18 months. Additional RFCA for the trigger site was attempted in 10 patients with AIAF; however, the recurrence rate of atrial arrhythmias was also not different between the groups with and without additional ablation (20% vs. 16.7%, log-rank p = 0.704). Conclusions: AIAF after PVI was not clinically associated with recurrence during long-term follow-up. Ablation of the trigger site in AIAF did not improve the clinical outcomes.
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Ishimura M, Yamamoto M, Himi T, Kobayashi Y. Long-term outcome of adenosine-induced atrial fibrillation after atrial fibrillation ablation: A propensity score matching analysis. Pacing Clin Electrophysiol 2022; 45:1172-1179. [PMID: 35766984 DOI: 10.1111/pace.14557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/30/2022] [Accepted: 06/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nonpulmonary vein (non-PV) foci, in addition to pulmonary vein (PV), are considered important in initiating atrial fibrillation (AF). OBJECTIVE This study investigates the adenosine triphosphate (ATP) as a method for inducing non-PV ectopy. METHODS The study cohort consisted of 1388 patients with AF (728 with paroxysmal AF, 650 with nonparoxysmal AF) who underwent catheter ablation. To confirm dormant PV conductions and non-PV foci, 20 or 40 mg ATP was administered intravenously at the end of the procedure. RESULTS The ATP test induced AF in 36 of 1388 (2.6%) patients, in whom two (6%) had ectopy arising from the both atria, 15 (42%) from the right atrium (RA), and five (14%) from left atrium (LA). Because of a lack of reproducibility, the accurate location of non-PV foci was unidentified in the remaining 11 (31%) patients. Additional radiofrequency ablation to non-PV foci induced ATP administration was not performed in 34 patients. Among all 1388 patients, 64 were assigned to the ATP-AF(+) and ATP-AF(-) groups using a propensity score matching analysis (32 patients in each group). During the follow-up period, recurrent AF was observed in 9 of 32 (28%) patients in the ATP-AF(+) group and in 10 of 32 (31%) patients in the ATP-AF(-) group (log-rank p = .84, hazard ratio 0.91 [95% confidence interval 0.36-2.27]). In the univariate analysis, AF induction by ATP test was not predictive of AF recurrence (p = .78). CONCLUSION ATP-induced AF was not associated with AF recurrence in the distant period.
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Affiliation(s)
| | - Masashi Yamamoto
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Toshiharu Himi
- Department of Cardiology, Kimitsu Central Hospital, Kisarazu, Japan
| | - Yoshio Kobayashi
- Department of Cardiology, Chiba University Hospital, Chiba, Japan
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Sakamoto K, Mukai Y, Kawai S, Nagaoka K, Inoue S, Takase S, Yakabe D, Ikeda S, Mannoji H, Nagayama T, Chishaki A, Tsutsui H. Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation. PLoS One 2022; 17:e0264894. [PMID: 35468171 PMCID: PMC9037930 DOI: 10.1371/journal.pone.0264894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background Pulmonary vein isolation (PVI) is an established ablation procedure for atrial fibrillation (AF), however, PVI alone is insufficient to suppress AF recurrence. Non-pulmonary vein (non-PV) trigger ablation is one of the promising strategies beyond PVI and has been shown to be effective in refractory/persistent AF cases. To make non-PV trigger ablation more standardized, it is essential to develop a simple method to localize the origin of non-PV triggers. Methods We retrospectively analyzed 37 non-PV triggers in 751 ablation sessions for symptomatic AF from January 2017 to December 2020. Regarding non-PV triggers, intra-atrial activation interval from the earliest in right atrium (RA) to proximal coronary sinus (CS) (RA-CSp) and that from the earliest in RA to distal CS (RA-CSd) obtained by a basically-positioned duodecapolar RA-CS catheter were compared among 3 originating non-PV areas [RA, atrial septum (SEP) and left atrium (LA)]. Results RA-CSp of RA non-PV trigger (56.4 ± 23.4 ms) was significantly longer than that of SEP non-PV (14.8 ± 25.6 ms, p = 0.019) and LA non-PV (-24.9 ± 27.9 ms, p = 0.0004). RA-CSd of RA non-PV (75.9 ± 32.1 ms) was significantly longer than that of SEP non-PV (34.2 ± 32.6 ms, p = 0.040) and LA non-PV (-13.3 ± 41.2 ms, p = 0.0008). RA-CSp and RA-CSd of SEP non-PV were significantly longer than those of LA non-PV (p = 0.022 and p = 0.016, respectively). Sensitivity and specificity of an algorithm to differentiate the area of non-PV trigger using RA-CSp (cut-off value: 50 ms) and RA-CSd (cut-off value: 0 ms) were 88% and 97% for RA non-PV, 81% and 73% for SEP non-PV, 65% and 95% for LA non-PV, respectively. Conclusions The analysis of intra-atrial activation sequences was useful to differentiate non-PV trigger areas. A simple algorithm to localize the area of non-PV trigger would be helpful to identify non-PV trigger sites in AF ablation.
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Affiliation(s)
- Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yasushi Mukai
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
- Department of Cardiovascular Medicine, Japanese Red Cross Fukuoka Hospital, Okusu, Minami-ku, Fukuoka, Japan
- * E-mail:
| | - Shunsuke Kawai
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
- Department of Cardiovascular Medicine, Japanese Red Cross Fukuoka Hospital, Okusu, Minami-ku, Fukuoka, Japan
| | - Kazuhiro Nagaoka
- Department of Cardiology, St. Mary’s Hospital, Tsubuku-honmachi, Kurume, Fukuoka, Japan
| | - Shujiro Inoue
- Department of Cardiology, Aso Iizuka Hospital, Yoshio-machi, Iizuka, Fukuoka, Japan
| | - Susumu Takase
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Daisuke Yakabe
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
- Department of Cardiology, Kyushu Medical Center, Jigyohama, Chuo-ku, Fukuoka, Japan
| | - Shota Ikeda
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Hiroshi Mannoji
- Department of Cardiology, Hamanomachi Hospital, Nagahama, Chuo-ku, Fukuoka, Japan
| | - Tomomi Nagayama
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Akiko Chishaki
- Division of Cardiology, Fukuoka Dental College Hospital, Tamura, Sawara-ku, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
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Cryoballoon atrial fibrillation ablation experience in Japan. Curr Opin Cardiol 2022; 37:68-73. [PMID: 34857716 DOI: 10.1097/hco.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In Japan, cryoballoon ablation has been widely accepted and more than 70 000 patients have undergone pulmonary vein isolation using this novel technology since the introduction. This review focused on the current status of cryoballoon ablation in Japan and clarified the characteristics as compared to Europe and the United States. RECENT FINDINGS The number of atrial fibrillation patients undergoing cryoballon ablation has rapidly increased over the last 6 years. Most of the Japanese physicians consider the indication of cryoballoon ablation based on the anatomy of the pulmonary veins and left atrium evaluated on preprocedural computed tomography, and often perform adjunctive radiofrequency ablation after the pulmonary vein isolation. The reported overall efficacy and safety were similar to that in Europe and the United States; however, there are some distinctive complications of the cryoballoon procedure in Japan, such as air embolisms, gastric hypomotility and coronary artery spasms. SUMMARY Currently, the cryoballoon pulmonary vein isolation is widely accepted in Japan owing to the low incidence of lethal complications, shorter procedure time and acceptable single procedure atrial fibrillation freedom.
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Nishida T, Takitsume A, Sugiura J, Keshi A, Kanaoka K, Hirai K, Yano H, Hashimoto Y, Ueda T, Nakagawa H, Onoue K, Soeda T, Watanabe M, Kawakami R, Saito Y. Catheter ablation of ganglionated plexi in patients with adenosine triphosphate-induced atrial fibrillation after pulmonary vein isolation. Heart Vessels 2021; 37:854-866. [PMID: 34741632 DOI: 10.1007/s00380-021-01979-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/22/2021] [Indexed: 11/24/2022]
Abstract
Intravenous ATP may induce atrial fibrillation (AF). ATP shares similar receptor-effector coupling systems with acetylcholine. However, the association between an ATP injection and the hyperactivity of the intrinsic cardiac autonomic nervous system, known as ganglionated plexi (GPs), is not well understood. We describe a series of patients with non-pulmonary vein (PV) trigger sites provoked by an ATP injection, and assess the feasibility of a ganglionated plexus (GP) ablation. We retrospectively analyzed 547 patients (69% male; mean age 67.4 ± 10.4 years; 38.5% non-paroxysmal AF) who underwent a total of 604 ablation procedures. Intravenous ATP was administered with an isoproterenol infusion during sinus rhythm after a pulmonary vein isolation in 21.3%, Box isolation in 78.6%, and SVC isolation in 52.0% of the procedures, respectively. We reviewed the incidence, the distribution of the foci, and the ablation outcomes in patients with ATP-induced AF. A total of seven patients (1.3%) had ATP-induced AF. Foci were identified in the coronary sinus (CS) in six patients, right atrial posterior wall (RAPW) adjacent to the interatrial groove in two, mitral annulus in two, ligament of Marshall in one, right septum below the foramen ovale in one and left atrial posterior wall in one, respectively. Among these trigger foci, we confirmed the vagal response by high-frequency stimulation in the CS and RAPW in six and two patients, respectively. After a median RF time of 2.9 min (range 2.5-11.3) targeting these foci, in five of six patients who received a repeat ATP injection, the AF became non-inducible. ATP-provoked trigger foci were distributed among certain sites that overlapped with the distribution of the GPs. The GP ablation was effective for this rare, but challenging situation.
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Affiliation(s)
- Taku Nishida
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan.
| | - Akihiro Takitsume
- Department of Cardiology, Nara Prefecture General Medical Center, Kashihara, Japan
| | - Junichi Sugiura
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Ayaka Keshi
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Koshiro Kanaoka
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kaeko Hirai
- Department of Cardiology, Nara Prefecture Seiwa Medical Center, Kashihara, Japan
| | - Hiroki Yano
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yukihiro Hashimoto
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Tomoya Ueda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Nakagawa
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Tsunenari Soeda
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Rika Kawakami
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
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Omuro T, Yoshiga Y, Ueyama T, Shimizu A, Ono M, Fukuda M, Kato T, Ishiguchi H, Fujii S, Hisaoka M, Kobayashi S, Yano M. An impact of superior vena cava isolation in non-paroxysmal atrial fibrillation patients with low voltage areas. J Arrhythm 2021; 37:965-974. [PMID: 34386123 PMCID: PMC8339082 DOI: 10.1002/joa3.12552] [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: 03/09/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This study aimed to investigate the correlation between left atrial low-voltage areas (LVAs) and an arrhythmogenic superior vena cava (SVC) and the impact on the efficacy of an empiric SVC isolation (SVCI) along with a pulmonary vein isolation (PVI) of non-paroxysmal atrial fibrillation (non-PAF) with or without LVAs. METHODS We retrospectively enrolled 153 consecutive patients with non-PAF who underwent a PVI alone (n = 51) or empiric PVI plus an SVCI (n = 102). Left atrial voltage maps were constructed during sinus rhythm to identify the LVAs (<0.5 mV). An arrhythmogenic SVC was defined as firing from the SVC and an SVC associated with the maintenance of AF-like rapid SVC activity. RESULTS An arrhythmogenic SVC and LVAs were identified in 28% and 65% of patients with a PVI alone and 36% and 73% of patients with a PVI plus SVCI, respectively (P = .275 and P = .353). In the multivariate analysis a female gender, higher pulmonary artery systolic pressure (PAPs), and arrhythmogenic SVC were associated with the presence of LVAs. In the PVI plus SVCI strategy, there was no significant difference in the atrial tachyarrhythmia/AF-free survival between the patients with and without LVAs after initial and multiple sessions (50% vs. 61%; P = .386, 73% vs. 79%; P = .530), however, differences were observed in the PVI alone group (27% vs. 61%; P = .018, 49% vs. 78%; P = .046). CONCLUSIONS The presence of LVAs was associated with an arrhythmogenic SVC. An SVCI may have the potential to compensate for an impaired outcome after a PVI in non-PAF patients with LVAs.
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Affiliation(s)
- Takuya Omuro
- Faculty of Health SciencesYamaguchi University Graduate School of MedicineUbeJapan
| | - Yasuhiro Yoshiga
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Takeshi Ueyama
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Akihiko Shimizu
- Faculty of Health SciencesYamaguchi University Graduate School of MedicineUbeJapan
| | - Makoto Ono
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Masakazu Fukuda
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Takayoshi Kato
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Hironori Ishiguchi
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Shohei Fujii
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Masahiro Hisaoka
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Shigeki Kobayashi
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Masafumi Yano
- Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
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Miyazaki S, Hasegawa K, Mukai M, Aoyama D, Nodera M, Yamaguchi J, Shiomi Y, Tama N, Ikeda H, Ishida K, Uzui H, Tada H. Superior vena cava isolation using a novel ablation catheter incorporating local impedance monitoring. J Interv Card Electrophysiol 2021; 64:291-300. [PMID: 33755817 DOI: 10.1007/s10840-021-00980-6] [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: 02/04/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND A novel technology able to measure the local impedance (LI) during radiofrequency ablation has become available for clinical use. We investigated the change in the LI characteristics during superior vena cava isolations (SVCIs) using a novel catheter equipped with mini-electrodes. METHODS Twenty paroxysmal atrial fibrillation patients (68 ± 9 years; 14 males) underwent an SVCI by targeting breakthroughs. Subsequently, dormant conduction provoked by adenosine triphosphate (ATP) was evaluated. RESULTS Electrical SVCIs were successfully achieved in all with 7.2 ± 3.0 radiofrequency applications (RFA) without any complications. The procedure and fluoroscopic times were 13.1 ± 8.1 and 2.8 ± 2.3 min. No ablation was required at the anteroseptal SVC in 19 (95.0%) patients. The baseline LI and generator impedance (GI) were 125 ± 23 and 105 ± 14Ω. LI drops during RFA were significantly greater than GI drops (17 ± 12 vs. 4 ± 4Ω, p < 0.001). The correlation between the LI drops and GI drops was relatively high (R = 0.69, p < 0.001). LI drops were highest at the septal SVC and lowest at the lateral followed by antero-lateral SVC. The baseline electrogram amplitude between the mini-electrodes and tip-ring electrodes was 1.2 ± 1.4 and 0.8 ± 0.6 mV. The mini-electrode amplitude is more sharply attenuated with a greater magnitude than the tip-ring amplitude (p < 0.001). ATP-provoked dormant conduction was exposed in 10/17 (58.8%) patients and antero-lateral SVC gap locations in 7. Antero-lateral SVC LI drops were similar between patients with and without dormancy. CONCLUSIONS The LI drop magnitude during RFA significantly differed among the SVC segments. Antero-lateral SVC ATP-provoked dormant conduction was often exposed, and additional applications are recommended following the isolation for a robust SVCI.
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Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.
| | - Kanae Hasegawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Moe Mukai
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Daisetsu Aoyama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Minoru Nodera
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Junya Yamaguchi
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Yuichiro Shiomi
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Naoto Tama
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hiroyuki Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kentaro Ishida
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Shimo-aiduki, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
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Nyuta E, Takemoto M, Sakai T, Mito T, Masumoto A, Todoroki W, Yagyu K, Ueno J, Antoku Y, Koga T, Ueno T, Tsuchihashi T. Importance of the length of the myocardial sleeve in the superior vena cava in patients with atrial fibrillation. J Arrhythm 2021; 37:43-51. [PMID: 33664885 PMCID: PMC7896468 DOI: 10.1002/joa3.12494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/03/2020] [Accepted: 12/17/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Pulmonary vein (PV) antrum isolation (PVAI) has proven to be a useful strategy for radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) worldwide. However, non-PV foci, especially from the superior vena cava (SVC), play an important role in initiating and maintaining AF. METHODS In all, 427 consecutive patients with non-valvular AF who were admitted to our hospitals to undergo RFCA of AF using an EnSite™ system were evaluated. The length from the top of the sinus node to the top of the myocardial sleeve of SVC (L-SVC), longer and shorter diameter of SVC of 1 cm above of junction of right atrium and SVC, and local activation time (LAT) of SVC were measured. Then, the SVC firing was evaluated by an intravenous administration of isoproterenol and adenosine triphosphate. RESULTS L-SVC, longer and shorter diameter of SVC, and LAT of SVC were significantly longer in the SVC firing group than non-SVC firing group (P < .05). Moreover, in accordance with the L-SVC, the frequency of the SVC firing significantly increased (P < .001). A univariate analysis and multivariate statistical analysis revealed that L-SVC longer than 37.0 mm (odds ratio 6.39) and longer diameter of SVC (odds ratio 6.78) were independent risk factors for SVC firing in patients with AF who underwent RFCA of AF. CONCLUSIONS In view of these findings, L-SVC longer than 37.0 mm longer diameter SVC longer than 17.0 mm may be one of the important predictors of SVC firing in patients with AF.
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Affiliation(s)
- Eiji Nyuta
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Masao Takemoto
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
- CardiologyMunakata Suikokai General HospitalFukutsuJapan
| | - Togo Sakai
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Takahiro Mito
- CardiologyMunakata Suikokai General HospitalFukutsuJapan
- CardiologyHakujuji HospitalFukuokaJapan
| | | | - Wataru Todoroki
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Keishiro Yagyu
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Jiro Ueno
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
| | - Yoshibumi Antoku
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
- CardiologyMunakata Suikokai General HospitalFukutsuJapan
| | - Tokushi Koga
- Cardiovascular CenterSteel Memorial Yawata HospitalKitakyusyuJapan
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11
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Sakamoto Y, Osanai H, Hiramatsu S, Matsumoto H, Tagahara K, Hosono H, Miyamoto S, Uno H, Kurokawa H, Kondo S, Tokuda K, Kanbara T, Nakashima Y, Asano H, Ajioka M. Efficacy of isoproterenol in the evaluation of dormant conduction and arrhythmogenic foci identification in atrial fibrillation ablation. BMC Cardiovasc Disord 2020; 20:397. [PMID: 32867695 PMCID: PMC7461289 DOI: 10.1186/s12872-020-01685-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/25/2020] [Indexed: 11/10/2022] Open
Abstract
Background Catheter ablation for atrial fibrillation (AF) is an established therapy. However, postoperative recurrence is a serious issue caused by the reconduction of the isolated pulmonary veins (PV) and the onset of non-PV foci. The objectives of this study were to elucidate dormant conduction, confirm PV arrhythmia substrate, induce non-PV foci after PV isolation, and assess the acute efficacy of high dose isoproterenol (ISP) when administered in addition to adenosine. Methods The study consisted of 100 patients with drug-refractory AF (paroxysmal and persistent) who underwent ablation therapy (either radio-frequency or cryoballoon ablation) as the first-line of therapy at our hospital. All patients first underwent PV isolation (PVI) and were administered adenosine followed by ISP (6 μg × 5 min). The effects were observed, and the therapeutic strategy was evaluated. Results Persistent dormant conduction due to ISP administration was observed in 13 patients. In over half of the patients, arrhythmia substrates were identified in the PV. Ten patients presented with persistent PV firing. The ablation of non-PV foci was additionally performed in 23 patients. Conclusions We found that dormant conduction, as a result of ISP administration, is persistent and ISP is useful when performing an ablation. In addition, ISP administration is useful for the identification of PV arrhythmia substrates and induction of non-PV foci. However, the effectiveness of ISP may be partially due to the complementary effect of adenosine, and, therefore, a combination of the two drugs seems preferable.
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Affiliation(s)
- Yusuke Sakamoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan.
| | - Hiroyuki Osanai
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shotaro Hiramatsu
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hikari Matsumoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Kensuke Tagahara
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hirotaka Hosono
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shun Miyamoto
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hiroto Uno
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hideki Kurokawa
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Shun Kondo
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Kotaro Tokuda
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Takahiro Kanbara
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Yoshihito Nakashima
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Hiroshi Asano
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
| | - Masayoshi Ajioka
- Department of Cardiology, Tosei General Hospital, 160 Nishi-Oiwake-cho, Seto-city, Aichi, 489-8642, Japan
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12
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Miyazaki S, Horie T, Hachiya H, Hasegawa K, Kajiyama T, Watanabe T, Nakamura H, Ishikawa E, Mukai M, Aoyama D, Nodera M, Kaseno K, Iesaka Y, Tada H. The mechanisms of recurrent atrial arrhythmias after second-generation cryoballoon ablation. Am Heart J 2020; 221:29-38. [PMID: 31901798 DOI: 10.1016/j.ahj.2019.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 12/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with paroxysmal atrial fibrillation (PAF), 10%-15% of patients require repeat procedures after second-generation cryoballoon pulmonary vein isolation (CB-PVI). We sought to explore the mechanisms of recurrences after cryoballoon ablation. METHODS The data of 122 PAF patients who underwent second procedures for recurrent arrhythmias 7.0 (4.0-12.0) months after the CB-PVI were analyzed. During second procedures, non-PV AF foci were explored with isoproterenol, adenosine, and repetitive cardioversions. RESULTS In total, 378/487 (77.6%) PVs remained isolated, and reconnections were not observed in any PVs in 59 (48.4%) patients. PV reconnections were associated with recurrences in 38 (31.1%) patients, of whom 33 (86.8%) had reconnections of at least 1 upper PV. In 6 (4.9%) patients, non-PV AF foci were identified in the upper PV antra where cryoballoons cannot isolate but within the circumferential radiofrequency PVI line. Non-PV AF foci were identified in the superior vena cava, right atrial body, left atrial body, and atrial septum in 28 (23.0%), 18 (14.7%), 4 (3.3%), and 5 (4.1%) patients, respectively. Twelve (9.8%) patients had multiple non-PV AF foci. Four (3.3%), 3 (2.4%), and 8 (6.5%) patients underwent second procedures for atrioventricular nodal reentrant tachycardia, atrial flutter, and atrial tachycardias. During 16.0 (8.0-24.0) months of follow-up, freedom from any atrial arrhythmia at 1 year and 2 years after the second procedure was 79.2% and 60.6%. Nineteen (15.5%) patients had antiarrhythmic drug therapy at the last follow-up. CONCLUSIONS Our study suggested that improvement in the upper PV PVI durability, eliminating arrhythmogenic superior vena cavae and coexisting atrial arrhythmias, and bonus cryoballoon applications at PV antra might improve the single procedure outcome in cryoballoon ablation.
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Affiliation(s)
- Shinsuke Miyazaki
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan.
| | - Tomoki Horie
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Kanae Hasegawa
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Takatsugu Kajiyama
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Tomonori Watanabe
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroaki Nakamura
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Eri Ishikawa
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Moe Mukai
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Daisetsu Aoyama
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Minoru Nodera
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Kenichi Kaseno
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
| | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroshi Tada
- Department of Cardiovascular medicine, Fukui University, Fukui, Japan
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13
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Johner N, Namdar M, Shah DC. Individualised Approaches for Catheter Ablation of AF: Patient Selection and Procedural Endpoints. Arrhythm Electrophysiol Rev 2019; 8:184-190. [PMID: 31463056 PMCID: PMC6702473 DOI: 10.15420/aer.2019.33.2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Pulmonary vein isolation (PVI) is the cornerstone of AF ablation, but studies have reported improved efficacy with high rates of repeat procedures. Because of the large interindividual variability in the underlying electrical and anatomical substrate, achieving optimal outcomes requires an individualised approach. This includes optimal candidate selection as well as defined ablation strategies with objective procedure endpoints beyond PVI. Candidate selection is traditionally based on coarse and sometimes arbitrary clinical stratification such as AF type, but finer predictors of treatment efficacy including biomarkers, advanced imaging and electrocardiographic parameters have shown promise. Numerous ancillary ablation strategies beyond PVI have been investigated, but the absence of a clear mechanistic and evidence-based endpoint, unlike in other arrhythmias, has remained a universal limitation. Potential endpoints include functional ones such as AF termination or non-inducibility and substrate-based endpoints such as isolation of low-voltage areas. This review summarises the relevant literature and proposes guidance for clinical practice and future research.
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Affiliation(s)
- Nicolas Johner
- Cardiology Division, University Hospital of Geneva Geneva, Switzerland
| | - Mehdi Namdar
- Cardiology Division, University Hospital of Geneva Geneva, Switzerland
| | - Dipen C Shah
- Cardiology Division, University Hospital of Geneva Geneva, Switzerland
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14
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Higa S, Lo LW, Chen SA. Catheter Ablation of Paroxysmal Atrial Fibrillation Originating from Non-pulmonary Vein Areas. Arrhythm Electrophysiol Rev 2018; 7:273-281. [PMID: 30588316 DOI: 10.15420/aer.2018.50.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 11/16/2018] [Indexed: 02/04/2023] Open
Abstract
Pulmonary veins (PVs) are a major source of ectopic beats that initiate AF. PV isolation from the left atrium is an effective therapy for the majority of paroxysmal AF. However, investigators have reported that ectopy originating from non-PV areas can also initiate AF. Patients with recurrent AF after persistent PV isolation highlight the need to identify non-PV ectopy. Furthermore, adding non-PV ablation after multiple AF ablation procedures leads to lower AF recurrence and a higher AF cure rate. These findings suggest that non-PV ectopy is important in both the initiation and recurrence of AF. This article summarises current knowledge about the electrophysiological characteristics of non-PV AF, suitable mapping and ablation strategies, and the safety and efficacy of catheter ablation of AF initiated by ectopic foci originating from non-PV areas.
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Affiliation(s)
- Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital Okinawa, Japan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital Taipei, Taiwan.,Institute of Clinical Medicine, Department of Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital Taipei, Taiwan.,Institute of Clinical Medicine, Department of Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
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15
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Enriquez A, Liang JJ, Santangeli P, Marchlinski FE, Riley MP. Focal Atrial Fibrillation from the Superior Vena Cava. J Atr Fibrillation 2017; 9:1593. [PMID: 29250296 DOI: 10.4022/jafib.1593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 03/22/2017] [Accepted: 04/25/2017] [Indexed: 11/10/2022]
Abstract
We report the case of a 66 year-old male who underwent catheter ablation for drug-refractory paroxysmal atrial fibrillation (AF) at our institution. Radiofrequency catheter ablation was performed using a three-dimensional electroanatomical mapping system. During ablation of the pulmonary veins (PV), right atrial ectopics were noted to repeatedly trigger AF and atrial tachycardia (AT). After PV isolation, mapping of the right atrium revealed that the superior vena cava (SVC) was in AF, while both atria were in an organized AT. Segmental ablation was performed around the SVC ostium, resulting in vein isolation and immediate restoration of sinus rhythm, while the SVC remained in AF. This case highlights the importance of the SVC in some AF patients as a potential source for non-PV triggers. SVC isolation can be safely achieved in most cases to improve outcomes.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson J Liang
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Riley
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Kumar S, Michaud GF. Catheter Ablation for Paroxysmal Atrial Fibrillation: Time to Focus More on Trigger Ablation? Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004129. [PMID: 27162036 DOI: 10.1161/circep.116.004129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Saurabh Kumar
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Gregory F Michaud
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA.
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