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Mohanty S, Torlapati PG, Casella M, Della Rocca DG, Schiavone M, Doty B, La Fazia VM, Pahi S, Pierucci N, Valeri Y, Gianni C, Al-Ahmad A, Burkhardt JD, Gallinghouse JG, Di Biase L, Chierchia GB, Nair DG, Dello Russo A, Tondo C, Natale A. Redefining the blanking period following pulsed-field ablation in patients with atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)03117-5. [PMID: 39117003 DOI: 10.1016/j.hrthm.2024.08.011] [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: 06/05/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Recurrence during the 3-month blanking period following radiofrequency ablation of atrial fibrillation (AF) is typically not considered as a predictor for late recurrence. OBJECTIVE We investigated the significance of early recurrence as a risk factor for late recurrence in AF patients receiving pulsed-field ablation (PFA). METHODS Consecutive patients undergoing PFA were prospectively followed-up for 1 year. All patients received isolation of pulmonary veins. Additional ablations were performed per operator's discretion. Following the procedure all remained on their previously ineffective antiarrhythmic drugs (AAD) during the 2-month blanking period after which the AADs were discontinued. Early recurrence was defined as atrial arrhythmia of > 30 second duration during the 3-mo blanking period and any recurrence beyond 3-mo was considered as late recurrence. RESULTS A total of 337 patients undergoing PFA for AF were included. Early recurrence was recorded in 53 (15.7%) patients; 10 in the 1st month, 12 in the 2nd month and 31 in the 3rd month. Of the 10 patients having recurrence during the 1st month, 7 (70%) remained in sinus rhythm after cardioversion whereas 3 (30%) underwent redo because of late-recurrence. At 1 year, all patients with recurrence during the 2nd and 3rd month, experienced late-recurrence of which 10/12 and 27/31 underwent redo and the remaining 6 patients were in sinus on-AAD. CONCLUSION In this consecutive series of AF patients, early-recurrence in the 2nd or 3rd month following the PFA procedure was associated with high risk of late-recurrence. Thus, blanking period could be redefined as 1-month following PFA.
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Affiliation(s)
- Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | | | - Michela Casella
- Department of Electrophysiology, Ospedali Riuniti Hospital, Ancona, Italy
| | | | - Marco Schiavone
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Brandon Doty
- Department of Electrophysiology, St. Bernard's Heart & Vascular Center, Jonesboro, Arkansas
| | | | - Shubham Pahi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Nicola Pierucci
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Yari Valeri
- Department of Electrophysiology, Ospedali Riuniti Hospital, Ancona, Italy
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - John D Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - J G Gallinghouse
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Luigi Di Biase
- Department of Electrophysiology, Albert Einstein College of Medicine at Montefiore Hospital, New York, USA
| | | | - Devi G Nair
- Department of Electrophysiology, St. Bernard's Heart & Vascular Center, Jonesboro, Arkansas
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA; Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy.
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2
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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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3
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Boersma LVA, Natale A, Haines D, DeLurgio D, Sood N, Marchlinski F, Calkins H, Hoyt RH, Sanders P, Irwin J, Packer D, Mittal S, Durrani S, Di Biase L, Sangrigoli R, Tada H, Sasano T, Tomita H, Yamane T, Kuck KH, Wazni O, Tarakji K, Cerkvenik J, van Bragt KA, Abeln BGS, Verma A. Prevalence, timing, and impact of early recurrence of atrial tachyarrhythmias after pulsed field ablation: A secondary analysis of the PULSED AF trial. Heart Rhythm 2024:S1547-5271(24)02810-8. [PMID: 38925335 DOI: 10.1016/j.hrthm.2024.06.036] [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: 04/16/2024] [Revised: 06/06/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Early recurrence of atrial tachyarrhythmias (ERAT) within 3 months of thermal ablation for atrial fibrillation (AF) is common and often considered transient. Pulsed field ablation (PFA) is a nonthermal energy source in which ERAT is not well described. OBJECTIVE The purpose of this study was to analyze ERAT in patients with AF undergoing PFA in the Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF (PULSED AF) trial. METHODS This analysis included 154 (52.4%) paroxysmal AF and 140 (47.6%) persistent AF who had ≥10 rhythm assessments during the 90-day blanking period. ERAT was defined as any instance of ≥30 seconds of AF, atrial flutter, or atrial tachycardia on transtelephonic monitoring (weekly and symptomatic) or ≥10 seconds on electrocardiography (at 3 months), both within 90 days. Late recurrence of atrial tachyarrhythmias (LRAT) was defined as observed atrial tachyarrhythmias between 90 days and 12 months. RESULTS The overall prevalence of ERAT was 27.1% in patients with paroxysmal AF and 31.6% in patients with persistent AF. In patients with ERAT, 73% had ERAT onset within the first month of the procedure. The presence of ERAT was associated with LRAT in patients with paroxysmal AF (hazard ratio 6.4; 95% confidence interval 3.6-11.3) and patients with persistent AF (hazard ratio 3.8; 95% confidence interval 2.2-6.6). Yet, in 29.4% of patients with paroxysmal AF and 34.3% of patients with persistent AF with ERAT, LRAT was not observed. LRAT was positively correlated with the number of ERAT observations. CONCLUSION ERAT after PFA predicted LRAT in patients with paroxysmal and persistent AF. However, the concept of a blanking period after PFA is still valid, as approximately one-third of patients with ERAT did not continue to have LRAT during follow-up and may not need reablation.
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Affiliation(s)
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas; University of Tor Vergata, Rome, Italy; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - David DeLurgio
- Emory Heart & Vascular Center at St. Joseph's, Atlanta, Georgia
| | - Nitesh Sood
- Southcoast Health Center, Fall River, Massachusetts; Brown Alpert School of Medicine, Brown University, Providence, Rhode Island
| | | | | | | | - Prashanthan Sanders
- University of Adelaide, Adelaide, South Australia, Australia; Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James Irwin
- BayCare St. Joseph's Hospital, Tampa, Florida
| | | | - Suneet Mittal
- The Valley Hospital, Ridgewood, New Jersey; The Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Sarfraz Durrani
- MedStar Heart and Vascular Institute, Washington, District of Columbia
| | | | | | | | | | - Hirofumi Tomita
- Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | | | | | | | | | | | | | - Bob G S Abeln
- St. Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Atul Verma
- McGill University Health Centre, Montreal, Quebec, Canada
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4
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [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: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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5
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Vio R, Forlin E, China P. Recurrences after Pulsed Field Ablation of Atrial Fibrillation: Incidence, Mechanisms, Predictors, and Comparison with Thermal Energy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:817. [PMID: 38793000 PMCID: PMC11123187 DOI: 10.3390/medicina60050817] [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: 04/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Pulsed Field Ablation (PFA) is the latest and most intriguing technology for catheter ablation of atrial fibrillation, due to its capability to generate irreversible and cardiomyocytes-selective electroporation of cell membranes by delivering microsecond-lasting high-voltage electrical fields, leading to high expectations. The first trials to assess the clinical success of PFA, reported an arrhythmia-free survival at 1-year of 78.5%, while other trials showed less enthusiastic results: 66.2% in paroxysmal and 55.1% in persistent AF. Nevertheless, real world data are encouraging. The isolation of pulmonary veins with PFA is easily achieved with 100% acute success. Systematic invasive remapping showed a high prevalence of durable pulmonary vein isolation at 75 and 90 days (range 84-96%), which were significatively lower in redo procedures (64.3%). The advent of PFA is prompting a reconsideration of the role of the autonomic nervous system in AF ablation, as PFA-related sparing of the ganglionated plexi could lead to the still undetermined effect on late arrhythmias' recurrences. Moreover, a new concept of a blanking period could be formulated with PFA, according to its different mechanism of myocardial injury, with less inflammation and less chronic fibrosis. Finally, in this review, we also compare PFA with thermal energy.
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Affiliation(s)
- Riccardo Vio
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
| | - Enrico Forlin
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy
| | - Paolo China
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
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6
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De Becker B, El Haddad M, De Smet M, François C, Tavernier R, le Polain de Waroux JB, Duytschaever M, Knecht S. Early atrial fibrillation recurrence post catheter ablation: Analysis from insertable cardiac monitor in the era of optimized radiofrequency ablation. Heart Rhythm 2024; 21:521-529. [PMID: 38246570 DOI: 10.1016/j.hrthm.2024.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND Early recurrence of atrial tachyarrhythmia (ERAT) is associated with ablation-induced proarrhythmogenic inflammation; however, existing studies used intermittent monitoring or nonoptimized radiofrequency (RF) applications (noncontiguous or without ablation index target value). OBJECTIVE The purpose of this study was to investigate the relationship between ERAT and late recurrence based on insertable cardiac monitor (ICM) data. METHODS We compiled data from Close-To-Cure and Close Maze studies, which enrolled patients who underwent RF ablation for paroxysmal or persistent atrial fibrillation (AF). All patients were implanted with an ICM 2-3 months before ablation. RESULTS We studied 165 patients (104 with paroxysmal AF, 61 with persistent AF). Over the 1-year follow-up period, 41 of the patients experienced late recurrence. The risk of late recurrence was higher in patients experiencing ERAT (hazard ratio [HR] 6.2; 95% confidence interval [CI] 3.0-13.0), with negative and positive predictive values of 90.5% and 45.7%, respectively. Median burden of AF during the blanking period was significantly higher in patients with late recurrence (7.9% [0.0%-99.6%]) compared to those without recurrence (0.0% [0.0%-6.0]; P <.001). For each 1% increase in AF burden during the blanking period, late recurrence increased by 4.6% (HR 1.046; 95% CI 1.035-1.059). The best tradeoff for predicting AF from ERAT occurrence was AF burden of 0.6% and last ERAT at 64 days. CONCLUSION In patients ablated for paroxysmal and persistent AF with a durable RF lesion set and implanted with a continuous monitoring device, postablation early AF recurrence and burden significantly predict late recurrence. The post-AF ablation blanking period should be reduced to 2 months.
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Affiliation(s)
| | | | | | - Clara François
- Cardiology Department, AZ Sint Jan Bruges, Bruges, Belgium
| | - René Tavernier
- Cardiology Department, AZ Sint Jan Bruges, Bruges, Belgium
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7
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Musat DL, Milstein NS, Saberito M, Bhatt A, Habibi M, Sichrovsky TC, Preminger MW, Shaw RE, Mittal S. Defining the blanking period, using continuous ECG monitoring, after cryoballoon pulmonary vein isolation. Heart Rhythm 2024; 21:530-537. [PMID: 38350520 DOI: 10.1016/j.hrthm.2024.02.014] [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: 02/04/2024] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. A blanking period (BP) of 3 months is used in clinical trials and practice. However, the optimal BP duration after PVI remains undefined. OBJECTIVE The aim of this study was to objectively define, using continuous monitoring by an implantable loop recorder, the optimal BP duration after cryoballoon PVI. METHODS We enrolled consecutive patients who had cryoballoon PVI and an implantable loop recorder. We determined the time of the last confirmed episode of AF within the blanking period. This was then correlated with AF recurrence in the first year after ablation. RESULTS There were 210 patients (66 ± 9 years; 138 [66%] male; 116 [55%] paroxysmal AF; CHA2DS2-VASc score, 2.5 ± 1.6). We defined 4 distinct groups based on the last AF episode within the BP: no AF days 0-90 (n = 96 [46%]) and last AF 0-30 days (n = 46 [22%]), 31-60 days (n = 18 [9%]), and 61-90 days (n = 50 [24%]). After the 3-month BP, 101 (48%) patients had AF recurrence at 160 ± 86 days. Compared with patients with no AF in the BP, those with recurrent AF and AF burden >0% 30 days after ablation had a significantly greater AF recurrence during long-term follow-up (P = .001). CONCLUSION Our data show that the approximately one-third of patients in whom AF occurs and who have a burden of >0% after the first month that follows PVI are at significantly higher risk of long-term recurrent AF. We therefore suggest that the blanking period be limited to a month after cryoballoon PVI.
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Affiliation(s)
- Dan L Musat
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Nicolle S Milstein
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Matthew Saberito
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Advay Bhatt
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Mohammadali Habibi
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Tina C Sichrovsky
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Mark W Preminger
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Richard E Shaw
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey
| | - Suneet Mittal
- Valley Hospital and the Snyder Center for Comprehensive Atrial Fibrillation, Ridgewood, New Jersey.
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8
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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9
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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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10
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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11
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Wen S, Liao Y, Khurana TS, Bai R. Reconsideration of the definition of blanking period and significance of early recurrences after catheter ablation of atrial fibrillation. Curr Opin Cardiol 2024; 39:15-19. [PMID: 37751368 DOI: 10.1097/hco.0000000000001096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW Early recurrence of atrial tachyarrhythmia (ERAT) during blanking period (BP) is not uncommon after catheter ablation of AF. Current guidelines and consensus statements recommend conservative treatment of ERAT. This review summarized recent studies, underlying mechanism and clinical managements of ERAT, and proposed a reconsideration of the definition and clinical significance of BP. RECENT FINDINGS Recent studies have shown that the entity of ERAT in the very early phase of BP (i.e., first 4 weeks of the 3-month period) is different from those ERATs occurring late which is strongly associated with the late recurrence of atrial tachyarrhythmia. The optimal BP duration suggested by clinical observation ranges from 21 to 58 days. Using antiarrhythmic drugs and early electrical cardioversion are the effective management for ERAT, whereas re-ablation is a reasonable strategy although remains controversial. SUMMARY The definition of BP with a shorter duration, that is, 1 month instead of 3 months post AF ablation, is supported by the observations of latest clinical studies. Recurrent atrial tachyarrhythmia beyond the 1-month time frame is associated with higher risk of late recurrence and may warrant repeat ablation. A revisit to the guideline recommendation on management of ERAT is needed to change clinical practice.
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Affiliation(s)
- Songnan Wen
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale
| | - Yu Liao
- Division of Cardiology, Banner University Medical Center-Phoenix, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Rong Bai
- Division of Cardiology, Banner University Medical Center-Phoenix, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
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12
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Mohanty S, Mansour M, Natale A. Identifying the prognostic significance of early arrhythmia recurrence during the blanking period: a pursuit to rediscover the past. Europace 2023; 25:euad229. [PMID: 37506253 PMCID: PMC10424263 DOI: 10.1093/europace/euad229] [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: 07/14/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023] Open
Affiliation(s)
- Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
| | - Moussa Mansour
- Department of Electrophysiology, Harvard Medical School, 90 Blossom Street, Boston, MA 02114, USA
| | - 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, 3000 N. I-35, Suite 720, San Diego, CA 78705, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, 3000 N. I-35, Suite 720, Cleveland, OH 78705, USA
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13
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Noujaim C, Lim C, Mekhael M, Feng H, Chouman N, Younes H, Assaf A, Shan B, Shamaileh G, Dhore-Patil A, Nelson D, Lanier B, Makan N, Marrouche N, Donnellan E. Identifying the prognostic significance of early arrhythmia recurrence during the blanking period and the optimal blanking period duration: insights from the DECAAF II study. Europace 2023; 25:euad173. [PMID: 37337683 PMCID: PMC10292951 DOI: 10.1093/europace/euad173] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Early atrial arrhythmia recurrence following atrial fibrillation (AF) ablation is common. Current guidelines promulgate a 3-month blanking period. We hypothesize that early atrial arrhythmia recurrence during the blanking period may predict longer-term ablation outcomes. METHODS AND RESULTS A total of 688 patients with persistent AF undergoing catheter ablation were included in the DECAAF II trial database. The primary endpoint of the study was the first confirmed recurrence of atrial arrhythmia. Recurrence was also monitored during the 90-day blanking period. A total of 287 patients experienced recurrent atrial arrhythmia during the blanking period, while 401 remained in sinus rhythm. Rates of longer-term arrhythmia recurrence were substantially higher among those who developed recurrence during the blanking period compared to those who remained in sinus rhythm throughout the blanking period (68% vs. 32%, P < 0.001). The study cohort was divided into three groups according to the timing of arrhythmia recurrence during the blanking period. Of those who had recurrent arrhythmia during the first month of the blanking period (Group 1), 43.9% experienced longer-term recurrence, compared to 61.6% who recurred during the second month of the blanking period (Group 2), and 93.3% of those who had arrhythmia recurrence during the third month (Group 3, P < 0.001). The risk of recurrent arrhythmia was highest in Group 3 (HR = 10.15), followed by Group 2 (HR = 2.35) and Group 1 (HR = 1.5). Receiver operating characteristic analysis was performed to assess the relationship between the timing of arrhythmia recurrence and the primary outcome (AUC = 0.746, P < 0.001). The optimal blanking period duration was identified as 34 days. Atrial fibrillation burden determined by smartphone electrocardiogram technology over the 18 months follow-up period was significantly higher in Group 3 (29%) compared to Groups 1 (6%) and 2 (7%) and in patients who stayed in sinus rhythm during the blanking period (5%) (P < 0.0001). CONCLUSION Early atrial arrhythmia recurrence during the blanking period, particularly during the third month, is significantly associated with later recurrence. Although a blanking period is warranted, it should be abbreviated.
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Affiliation(s)
- Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Chanho Lim
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Han Feng
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Nour Chouman
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Hadi Younes
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Ala Assaf
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Botao Shan
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Ghaith Shamaileh
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Aneesh Dhore-Patil
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Daniel Nelson
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Brennan Lanier
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Noor Makan
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Nassir Marrouche
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
| | - Eoin Donnellan
- Tulane Research Innovation for Arrhythmia Discovery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70130, USA
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14
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Tankut SS, Huang DT, Zareba W, Aktas MK, Rosero SZ, Steinberg J, Henchen J, Kutyifa V, Strawderman RL, Goldenberg I. Insertable cardiac monitor-guided early intervention to reduce atrial fibrillation burden following catheter ablation: Study design and clinical protocol (ICM-REDUCE-AF trial). Ann Noninvasive Electrocardiol 2023; 28:e13043. [PMID: 36718801 PMCID: PMC10023887 DOI: 10.1111/anec.13043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Percutaneous catheter ablation (CA) to achieve pulmonary vein isolation is an effective treatment for drug-refractory paroxysmal and persistent atrial fibrillation (AF). However, recurrence rates after a single AF ablation procedure remain elevated. Conventional management after CA ablation has mostly been based on clinical AF recurrence. However, continuous recordings with insertable cardiac monitors (ICMs) and patient-triggered mobile app transmissions post-CA can now be used to detect early recurrences of subclinical AF (SCAF). We hypothesize that early intervention following CA based on personalized ICM data can prevent the substrate progression that promotes the onset and maintenance of atrial arrhythmias. METHODS This is a randomized, double-blind (to SCAF data), single-tertiary center clinical trial in which 120 patients with drug-refractory paroxysmal or persistent AF are planned to undergo CA with an ICM. Randomization will be to an intervention arm (n = 60) consisting of ICM-guided early intervention based on SCAF and patient-triggered mobile app transmissions versus a control arm (n = 60) consisting of a standard intervention protocol based on clinical AF recurrence validated by the ICM. Primary endpoint is AF burden, which will be assessed from ICMs at 15 months post-AF ablation. Secondary endpoints include healthcare utilization, functional capacity, and quality of life. CONCLUSION We believe that ICM-guided early intervention will provide a novel, personalized approach to post-AF ablation management that will result in a significant reduction in AF burden, healthcare utilization, and improvements in functional capacity and quality of life.
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Affiliation(s)
- Sinan S. Tankut
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - David T. Huang
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Wojciech Zareba
- Clinical Cardiovascular Research CenterUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Mehmet K. Aktas
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Spencer Z. Rosero
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Jonathan Steinberg
- Clinical Cardiovascular Research CenterUniversity of Rochester Medical CenterRochesterNew YorkUSA
- Summit Medical GroupShort HillsNew JerseyUSA
| | - Jennifer Henchen
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Valentina Kutyifa
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Robert L. Strawderman
- Clinical Cardiovascular Research CenterUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research CenterUniversity of Rochester Medical CenterRochesterNew YorkUSA
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15
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Silva MR, Silva GS, Fernandes S, Almeida J, Fonseca P, Oliveira M, Gonçalves H, Saraiva F, Barros AS, Teixeira PG, Lopes RL, Sampaio F, Diaz SO, Primo J, Fontes-Carvalho R. Clinical relevance of the blanking period on late recurrence after catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:24-34. [PMID: 36317466 DOI: 10.1111/jce.15729] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/06/2022] [Accepted: 10/25/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Recurrence of atrial fibrillation (AF) within the blanking period after catheter ablation (CA) is traditionally classified as a transient and benign event. However, recent findings suggest that early recurrence (ER) is associated with late recurrence (LR), challenging the predefined "blanking period". We aimed to determine the clinical and procedural predictors of ER and LR after CA and establish the risk of LR in patients who experience ER. METHODS AND RESULTS Retrospective single-centre study including all patients who underwent a first procedure of AF CA between 2017 and 2019. ER was defined as any recurrence of AF, atrial flutter or atrial tachycardia >30 s within 90 days after CA and LR as any recurrence after 90 days of CA. A total of 399 patients were included, 37% women, median age of 58 years [49-66] and 77% had paroxysmal AF. Median follow-up was 33 months (from 13 to 61). ER after CA was present in 14% of the patients, and LR was reported in 32%. Among patients who experienced ER, 84% also had LR (p < .001). Patients with ER had a higher prevalence of moderate/severe valvular heart disease, persistent AF, previous electrical cardioversion, a larger left atrium, higher coronary artery calcium score, and higher rates of intraprocedural electrical cardioversion and cardiac fibrosis on eletroanatomical mapping compared with patients without ER. After covariate adjustment, ER and female sex were defined as independent predictors of LR (hazard ratio [HR] 4.69; 95% confidence interval [CI], 2.99-7.35; p < .001 and HR 2.73; 95% CI, 1.47-5.10; p = .002, respectively). CONCLUSION The risk of LR after an index procedure of CA was significantly higher in patients with ER (five-fold increased risk). These results support the imperative need to clarify the clinical role of the blanking period.
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Affiliation(s)
- Mariana R Silva
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Gualter S Silva
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Sara Fernandes
- Department of Cardiology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - João Almeida
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Paulo Fonseca
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Marco Oliveira
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Helena Gonçalves
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Francisca Saraiva
- Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - António S Barros
- Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Pedro G Teixeira
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ricardo L Lopes
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Francisco Sampaio
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Sílvia O Diaz
- Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - João Primo
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.,Department of Surgery and Physiology, Cardiovascular Research and Development Centre - UnIC@RISE, Faculty of Medicine of the University of Porto, Porto, Portugal
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Yakimenka A, Labib D, Dykstra S, Mikami Y, Satriano A, Flewitt J, Feuchter P, Rivest S, Howarth AG, Lydell CP, Quinn FR, Wilton SB, White JA. Influence of Sex-Based Differences in Cardiac Phenotype on Atrial Fibrillation Recurrence in Patients Undergoing Pulmonary Vein Isolation. Front Cardiovasc Med 2022; 9:894592. [PMID: 35966521 PMCID: PMC9366168 DOI: 10.3389/fcvm.2022.894592] [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: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPulmonary vein isolation (PVI) is a commonly engaged therapy for symptomatic atrial fibrillation (AF). Prior studies have documented elevated AF recurrence rates among females vs. males. Sex-specific mechanisms underlying this phenomenon are poorly understood. This prospective cohort study aimed to evaluate the sex-based differences in cardiac phenotype and their influence on (AF) recurrence following first-time PVI.MethodsA total of 204 consecutive patients referred for first-time PVI and 101 healthy subjects were prospectively studied by cardiovascular magnetic resonance (CMR) imaging. Multi-chamber volumetric and functional measures were assessed by sex-corrected Z-score analyses vs. healthy subjects. Patients were followed for a median of 2.6 years for the primary outcome of clinical AF recurrence. Multivariable analyses adjusting for age and comorbidities were performed to identify independent predictors of AF recurrence.ResultsAF recurrence following first PVI occurred in 41% of males and 59% of females (p = 0.03). Females were older with higher prevalence of hypertension and thyroid disorders. Z-score-based analyses revealed significantly reduced ventricular volumes, greater left atrial (LA) volumes, and reduced LA contractility in females vs. males. Multivariable analysis revealed each of LA minimum and pre-systolic volumes and booster EF Z-scores to be independently associated with AF recurrence, providing respective hazard ratios of 1.10, 1.19, and 0.89 (p = 0.001, 0.03, and 0.01).ConclusionAmong patients referred for first time PVI, females were older and demonstrated significantly poorer LA contractile health vs. males, the latter independently associated with AF recurrence. Assessment of LA contractile health may therefore be of value to identify female patients at elevated risk of AF recurrence. Factors influencing female patient referral for PVI at more advanced stages of atrial disease warrant focused investigation.
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Affiliation(s)
- Alena Yakimenka
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dina Labib
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt
| | - Steven Dykstra
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Yoko Mikami
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Alessandro Satriano
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Jacqueline Flewitt
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Patricia Feuchter
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Sandra Rivest
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Andrew G. Howarth
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carmen P. Lydell
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - F. Russell Quinn
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen B. Wilton
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - James A. White
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- *Correspondence: James A. White,
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Two-year outcomes of pulmonary vein isolation and cava-tricuspid isthmus radiofrequency ablation vs pharmacological only antiarrhythmic therapy: a single center experience. EUREKA: HEALTH SCIENCES 2022. [DOI: 10.21303/2504-5679.2022.002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The benefit of radiofrequency ablation (RFA) in rhythm control in atrial fibrillation (AF) and flutter patients is uncertain, but risk of death, arrhythmia recurrence and other post ablation complications remains high. Existing data on the impact of pulmonary vein isolation and cava-tricuspid isthmus RFA on long-term prognosis of patients with AF and flutter and its advantage over pharmacological antiarrhythmic therapy (AAT) are insufficient and contradictory.
The aim: we sought to evaluate two-year outcomes of pulmonary vein isolation and cava-tricuspid isthmus RFA vs pharmacological only AAT according to a single center experience.
Material and methods: we enrolled 174 patients after pulmonary vein isolation RFA, cava-tricuspid isthmus RFA and their combination and 122 patient who did not undergo RFA and got pharmacological AAT only.
Results: there was no significant difference in mortality between the RFA and AAT only groups (5.8 % and 9.0 % respectively) with the same structure of causes of death. The Caplan-Meyer curve analysis demonstrated better survivance (p=0.031) after RFA just during first year of observation. RFA effectiveness in arrhythmia relapse prevention was the highest for cava-tricuspid isthmus RFA procedure and worst – in group of combined pulmonary vein isolation and cava-tricuspid isthmus procedures. RFA showed an advantage over AAT in smaller quantities of non-fatal cardiovascular events (p<0.001) and cardiovascular hospitalizations (p=0.0026).
Conclusions: RFA of pulmonary vein isolation and cava-tricuspid isthmus RFA decrease arrhythmia episodes frequency, risk of non-fatal cardiovascular events and cardiovascular hospitalizations. Timely combined PVI and CTI procedure is associated with worsening of all outcomes.
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Vrachatis DA, Papathanasiou KA, Kossyvakis C, Kazantzis D, Giotaki SG, Deftereos G, Sanz-Sánchez J, Raisakis K, Kaoukis A, Avramides D, Lambadiari V, Siasos G, Giannopoulos G, Deftereos S. Early arrhythmia recurrence after cryoballoon ablation in atrial fibrillation: a systematic review and meta-analysis. J Cardiovasc Electrophysiol 2021; 33:527-539. [PMID: 34951496 DOI: 10.1111/jce.15337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early arrhythmia recurrence within the three-month blanking period is a common event that historically has been attributed to reversible phenomena. While its' mechanistic links remain obscure, accumulating evidence support the argument of shortening the blanking period. We aimed to elucidate the association between early and late arrhythmia recurrence after atrial fibrillation cryoablation. METHODS The MEDLINE database, ClinicalTrials.gov, medRxiv and Cochrane Library were searched for studies evaluating early and late arrhythmia recurrence rates in patients undergoing cryoablation for AF. Data were pooled by meta-analysis using a random-effects model. The primary endpoint was late arrhythmia recurrence. RESULTS Early arrhythmia recurrence was found predictive of decreased arrhythmia-free survival after evaluating 3975 patients with paroxysmal or persistent atrial fibrillation who underwent cryoablation (OR: 5.31; 95% CI: 3.75-7.51). This pattern remained unchanged after sub-analyzing atrial fibrillation type (paroxysmal; OR: 7.16; 95% CI: 4.40-11.65 and persistent; OR: 7.63; 95% CI: 3.62-16.07) as well as cryoablation catheter generation (first generation; OR: 5.15, 95% CI: 2.39-11.11 and advanced generation; OR: 5.83, 95% CI: 3.68-9.23). Studies permitting anti-arrhythmic drug utilization during blanking period or examining early recurrence as a secondary outcome were found to be a significant source of statistical heterogeneity. CONCLUSION Our findings suggest that early arrhythmia recurrence is predictive of late outcomes after cryoablation for atrial fibrillation. Identifying which patients deserve earlier re-intervention is an open research avenue. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | | | - Dimitrios Kazantzis
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotiria G Giotaki
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Deftereos
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Greece
| | - Jorge Sanz-Sánchez
- Division of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Centro de Investigacion Biomédica en Red (CIBERCV), Madrid, Spain
| | | | - Andreas Kaoukis
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Greece
| | - Dimitrios Avramides
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Greece
| | - Vaia Lambadiari
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Siasos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Spyridon Deftereos
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
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19
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Davtyan KV, Topchyan AH, Brutyan HA, Kalemberg EN, Kharlap MS, Simonyan GY, Kalemberg AA, Kuznetsova MV. The predictive role of early recurrences of atrial arrhythmias after pulmonary vein cryoballoon ablation. Is blanking period an outdated concept? Insights from 12-month continuous cardiac monitoring. BMC Cardiovasc Disord 2021; 21:483. [PMID: 34620082 PMCID: PMC8499528 DOI: 10.1186/s12872-021-02300-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background Early recurrences of atrial arrhythmias (ERAA) after atrial fibrillation (AF) catheter ablation do not predict procedural failure. A well-demarcated homogeneous lesion delivered by cryoballoon is less arrhythmogenic, and the recommended three-months blanking period may not refer to cryoballoon ablation (CBA). Objective We aimed to evaluate the predictive role of ERAA after second-generation CBA using an implantable loop recorder. Methods This prospective observational study enrolled 100 patients (58 males, median age 58) with paroxysmal/persistent AF undergoing pulmonary vein (PV) CBA using second-generation cryoballoon with simultaneous ECG loop recorder implantation. The duration of follow-up was 12 months, with scheduled visits at 3, 6 and 12 months. Results 99 patients from 100 completed the 12-month follow-up period. ERAA occurred in 31.3 % of patients. 83.9 % of patients with ERAA also developed late recurrences. The 12-month freedom from AF in patients with ERAA was significantly lower than in those without ERAA (p < 0.0001). Non-paroxysmal AF and longer arrhythmia history were associated with increased risk of both early (HR 3.27; 95 % CI 1.32–8.08; p = 0.010 and HR 1.0147; 95 % CI 1.008–1.086; p = 0.015, respectively) and late recurrences (HR 3.89; 95 % CI 1.67–9.04; p = 0.002 and HR 1.0142; 95 % CI 1.007–1.078; p = 0.019, respectively) of AF. ERAA were another predictor for procedural failure (HR 15.2; 95 % CI (6.42–35.99; p = 0.019). Conclusions ERAA occurred in the third of the patients after PV second-generation CBA and are strongly associated with procedural failure. Longer duration of AF history and persistent AF are independent predictors of AF’s early and late recurrence.
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Affiliation(s)
- Karapet V Davtyan
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
| | - Arpi H Topchyan
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990.
| | - Hakob A Brutyan
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
| | - Elena N Kalemberg
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
| | - Maria S Kharlap
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
| | - Georgiy Yu Simonyan
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
| | - Andrey A Kalemberg
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
| | - Maria V Kuznetsova
- National Medical Research Center for Therapy and Preventive Medicine , Petroverigskiy Lane 10-3, Moscow, Russia, 101990
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20
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Zhang Y, Wu F, Gao Y, Wu N, Yang G, Li M, Zhou L, Xu D, Chen M. Bachmann bundle impairment following linear ablation of left anterior wall: impact on left atrial function. Int J Cardiovasc Imaging 2021; 38:41-50. [PMID: 34570357 DOI: 10.1007/s10554-021-02362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
We aimed to evaluate the effect of Bachmann bundle (BB) impairment on electrical and mechanical function of the left atrium (LA), as well as the long-term clinical impact of such impairment. We measured activation time in the five LA walls in 56 patients with atrial fibrillation. LA reservoir, conduit, and contractile function were also evaluated. Patients were divided into two groups based on ablation strategy: the circumferential pulmonary vein isolation (CPVI) group and CPVI with LA anterior wall linear ablation (LAAW) group. Patients in the CPVI + LAAW group were divided into two sub-groups based on ECG differences following ablation: the BB impairment group and intact BB group. LA activation time and function were then compared between the ablation strategy groups and the CPVI + LAAW subgroups. Patients in the CPVI + LAAW group exhibited longer activation times in the anterior and lateral walls of the LA, poorer LA synchrony, and reduced LA contractile and reservoir function when compared with those in the CPVI group. In the BB impairment subgroup, we observed a discrepancy between electrical/mechanical remodeling. Among five walls, activation time was longest in this region. BB impairment was also associated with reduced LA function. Significant changes in LA function and conductibility were observed in patients with anterior wall ablation, especially those with iatrogenic BB impairment.
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Affiliation(s)
- Yanjuan Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China
| | - Fengming Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China
| | - Yu Gao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China.,Department of Cardiology, The Second Peoples's Hospital of Hefei, Anhui, China
| | - Nan Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China
| | - Lei Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China
| | - Di Xu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China.
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 210029, Nanjing, China.
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21
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Early arrhythmia recurrence after catheter ablation for persistent atrial fibrillation: is it predictive for late recurrence? Clin Res Cardiol 2021; 111:85-95. [PMID: 34519875 PMCID: PMC8766394 DOI: 10.1007/s00392-021-01934-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 08/30/2021] [Indexed: 10/29/2022]
Abstract
BACKGROUND Early recurrence of atrial tachyarrhythmia (ERAT) is common after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF), but its clinical significance in patients with persistent AF remains unclear. We sought to determine the predictive value of ERAT for rhythm outcome after RFCA for persistent AF. METHODS The study included 207 consecutive patients (mean age 66.4 ± 10.7 years, male 66.2%) with persistent and long-standing persistent AF undergoing de novo pulmonary vein isolation (± atrial substrate ablation). All patients remained off antiarrhythmic drugs. ERAT was defined as any atrial arrhythmia ≥ 30 s occurring within the first 30 days. Late recurrence (LR) was determined during follow-up visits scheduled 1, 3, 6 and 12 months post-ablation using 7-day Holter ECGs. RESULTS ERAT occurred in 143/207 (69.1%) patients as AF (60%) or atrial tachycardia (40%) and was persistent in 82% of cases. During a median follow-up of 22.2 months, LR occurred significantly more often in patients with ERAT than in patients without ERAT (92.3 vs. 43.8%, P < 0.001). The only independent predictors for LR were ERAT (OR 16.8, 95% CI 6.184-45.797, P < 0.001) and intraprocedural termination to sinus rhythm (OR 0.052, 95% CI 0.003-0.851, P = 0.038). Extending the blanking period from 30 to 90 days did not impact LR rates. CONCLUSION ERAT following ablation of persistent AF is strongly associated with late arrhythmia recurrence, which challenges the assumption that ERAT represents merely a transient phenomenon. While limiting the blanking period to 30 days seems justified, the benefit of early re-ablations remains to be addressed in future studies.
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22
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Steinberg C, Champagne J, Deyell MW, Dubuc M, Leong-Sit P, Calkins H, Sterns L, Badra-Verdu M, Sapp J, Macle L, Khairy P, Andrade JG. Prevalence and outcome of early recurrence of atrial tachyarrhythmias in the Cryoballoon vs Irrigated Radiofrequency Catheter Ablation (CIRCA-DOSE) study. Heart Rhythm 2021; 18:1463-1470. [PMID: 34126269 DOI: 10.1016/j.hrthm.2021.06.1172] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/25/2021] [Accepted: 06/08/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Early recurrence of atrial tachyarrhythmia (ERAT) is common after pulmonary vein isolation (PVI) and has been associated with an increased risk of late atrial fibrillation (AF) recurrence. OBJECTIVE The purpose of this study was to determine the incidence and outcomes of patients experiencing ERAT after PVI using advanced-generation ablation technologies. METHODS This is a prespecified substudy of the CIRCA-DOSE (Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double-Short vs Standard Exposure Duration) trial, a prospective, randomized, multicenter study comparing PVI with contact force-guided radiofrequency ablation to secondary-generation cryoballoon ablation for paroxysmal AF. All study patients received an implantable cardiac monitor to allow continuous rhythm monitoring. ERAT was defined as any recurrent atrial tachyarrhythmia within the first 90 days after AF ablation. RESULTS ERAT occurred in 61% of the 346 patients at a median of 12 days (range 1-90 days) after ablation. ERAF was a significant predictor of late recurrence (60.1% with ER vs 25.9% without ER; P <.001) and symptomatic atrial tachyarrhythmia (31.6% with ERAF vs 6.7% without ERAF; P <.001). Receiver operating curve analyses revealed a strong correlation between ERAT timing and burden and late recurrence. Multivariate analysis identified ER timing (hazard ratio [HR] 2.90; 95% confidence interval [CI] 1.41-5.95; P = .004) and burden (HR 1.05 per 1% ER burden; 95% CI 1.04-1.07; P <.001) as strong independent predictors of late recurrence. Incidence rate, timing, burden, and prognostic significance of ER did not differ between the study groups. CONCLUSION ERAT remains common after PVI despite use of advanced-generation ablation technologies. Early AF recurrence beyond 3 weeks after ablation is associated with increased risk of late recurrence.
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Affiliation(s)
- Christian Steinberg
- Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ-UL), Quebec, Canada
| | - Jean Champagne
- Institut Universitaire de Cardiologie et Pneumologie de Québec (IUCPQ-UL), Quebec, Canada
| | - Marc W Deyell
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada
| | - Marc Dubuc
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | | | - Hugh Calkins
- Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | | | | | - John Sapp
- Queen Elizabeth-II Health Sciences Centre, Dalhousie University, Halifax, Canada
| | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Paul Khairy
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Jason G Andrade
- Heart Rhythm Services, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada; Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada.
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Stabile G, Iacopino S, Verlato R, Arena G, Pieragnoli P, Molon G, Manfrin M, Rovaris G, Curnis A, Bertaglia E, Mantica M, Sciarra L, Landolina M, Tondo C. Predictive role of early recurrence of atrial fibrillation after cryoballoon ablation. Europace 2020; 22:1798-1804. [DOI: 10.1093/europace/euaa239] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
Abstract
Aims
The aims of this study were to determine the rate and the predictors of early recurrences of atrial fibrillation (ERAF) after cryoballoon (CB) ablation and to evaluate whether ERAF correlate with the long-term outcome.
Methods and results
Three thousand, six hundred, and eighty-one consecutive patients (59.9 ± 10.5 years, female 26.5%, and 74.3% paroxysmal AF) were included in the analysis. Atrial fibrillation recurrence, lasting at least 30 s, was collected during and after the 3-month blanking period. Three-hundred and sixteen patients (8.6%) (Group A) had ERAF during the blanking period, and 3365 patients (Group B) had no ERAF. Persistent AF and number of tested anti-arrhythmic drugs ≥2 resulted as significant predictors of ERAF. After a mean follow-up of 16.8 ± 16.4 months, 923/3681 (25%) patients had at least one AF recurrence. The observed freedom from AF recurrence, at 24-month follow-up from procedure, was 25.7% and 64.8% in Groups A and B, respectively (P < 0.001). ERAF, persistent AF, and number of tested anti-arrhythmic drugs ≥2 resulted as significant predictors of AF. In a propensity score matching, the logistic model showed that ERAF 1 month after ablation are the best predictor of long-term AF recurrence (P = 0.042).
Conclusion
In patients undergoing CB ablation for AF, ERAF are rare and are a strong predictor of AF recurrence in the follow-up, above all when occur >30 days after the ablation.
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Affiliation(s)
- Giuseppe Stabile
- Clinica Montevergine, Mercogliano, Avellino, Italy
- Clinica San Michele, via Montella 16, 81024 Maddaloni, Caserta, Italy
- Anthea Hospital, Bari, Italy
| | - Saverio Iacopino
- Maria Cecilia Hospital, GVM Care&Research, Cotignola, Ravenna, Italy
| | - Roberto Verlato
- AULSS 6 Euganea, Ospedale di Cittadella-Camposampiero, Padova, Italy
| | | | | | - Giulio Molon
- IRCCS Sacro Cuore Don Calabria Don Calabria, Negrar, Italy
| | | | | | | | | | | | | | | | - Claudio Tondo
- Heart Rhythm Centre, Centro Cardiologico Monzino IRCCS Milan, Italy
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24
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Choi JH, Hwang KW, Jung SM, Lee SY, Lee SH, Chon MK, Kim JS, Je HG, Park YH, Kim JH, Lee SK, Chun KJ. Incidence and clinical impact of early recurrence of atrial tachyarrhythmia after surgical ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2898-2906. [PMID: 32945008 DOI: 10.1111/jce.14749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/12/2020] [Accepted: 07/20/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atrial tachyarrhythmias (ATAs) are common within the 3-month blanking period after catheter ablation of atrial fibrillation (AF). However, little evidence is available regarding the current guidelines on the blanking period after surgical AF ablation. We investigate the incidence and significance of early recurrence of atrial tachyarrhythmia (ERAT) and evaluate the optimal blanking period after surgical AF ablation. METHODS Data from 259 patients who underwent surgical AF ablation from 2009 to 2016 were collected. ERAT was defined as documented ATA episodes lasting for 30 s. A multivariate Cox proportional hazard model was constructed to evaluate the role of ERAT as a predictor of late recurrences (LR) for AF. RESULTS In total, 127 patients (49.0%) experienced their last episodes of ERAT during the first (n = 65), second (n = 14), or third (n = 48) month of the 3-month blanking period (p < .001). One year freedom from ATAs was 97.8% in patients without ERAT compared with 95.4%, 64.3%, and 8.3% in patients with ERAT in the first, second, and third months after the index procedure, respectively (p < .001). Hazard ratios of LR according to the timing of the last episode of ERAT first, second, and third months after the procedure were 2.84, 16.70, and 119.75, respectively. CONCLUSIONS The ERAT occurred in 49.0% of patients within the first 3 months after surgical ablation. The occurrence of ERAT within 3 months after surgical AF ablation was a significant independent predictor of LR. Hence, the currently accepted 3-month blanking period may be considered for redefining in patients with AF surgical ablation.
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Affiliation(s)
- Jin Hee Choi
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ki Won Hwang
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Soon Myung Jung
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Soo Yong Lee
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Sang Hyun Lee
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Min-Ku Chon
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jeong-Su Kim
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Yong-Hyun Park
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - June Hong Kim
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Sang Kwon Lee
- Department of Cardiovascular and Thoracic Surgery, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Kook Jin Chun
- Division of Cardiology, Pusan National University, School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
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Xia Y, Liu J, Jia Y, Zhang H, Yu M, Li X, Fang P. Redefining the Blanking Period by a Long-Term Follow-Up after Atrial Fibrillation Ablation Using Second-Generation Cryoballoon. Int Heart J 2020; 61:936-943. [PMID: 32879265 DOI: 10.1536/ihj.20-234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
On the basis of radiofrequency ablation of atrial fibrillation (AF), some studies suggested that early recurrences of atrial tachyarrhythmia (ERATs) were associated with late AF recurrence (LAFR), and some also suspected and challenged the current recommended 90 day blanking period. We aim to evaluate the impact of ERAT on long-term success and to determine the optimum blanking period after AF ablation using second-generation cryoballoon (sg-CB). From August 2016 to October 2018, 369 consecutive patients who successfully underwent initial AF ablation using sg-CB at the Fuwai Hospital were finally enrolled. All patients were followed up no less than 12 months. Receiver operating characteristic curve analysis was used to determine the optimum blanking period after AF ablation. There were 62 (16.8%) who experienced ERAT. After a median follow-up of 615 days, 74.5% were free of LAFR after the 90 day blanking period. Incidence of freedom from LAFR during the long-term follow-up was markedly lower in patients with ERAT than in those without ERAT (27.4% versus 84.0%; log-rank P < 0.001). Furthermore, only ERAT (HR 8.579; 95% CI 5.604-13.133; P < 0.001) was significantly associated with an increased risk of LAFR after adjusting for other factors. The optimum cut-off time point for the blanking period was 21.5 days (sensitivity: 71.1%, specificity: 94.1%). In conclusion, ERAT was an independent predictor of LAFR after AF ablation using sg-CB. Based on our findings, blanking period was advised to be shorten to 21.5 days or about 3 weeks instead of 90 days after CB ablation.
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Affiliation(s)
- Yu Xia
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Jun Liu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Yuhe Jia
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Hao Zhang
- Department of Cardiology, Chongqing General Hospital
| | - Miao Yu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Xiaofeng Li
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Pihua Fang
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
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Oka T, Koyama Y, Tanaka K, Hirao Y, Tanaka N, Okada M, Yoshimoto I, Kitagaki R, Okamura A, Iwakura K, Sakata Y, Fujii K, Inoue K. Early recurrence during the blanking period and left atrial reverse remodeling after catheter ablation for non-paroxysmal atrial fibrillation. IJC HEART & VASCULATURE 2020; 30:100588. [PMID: 32743045 PMCID: PMC7385444 DOI: 10.1016/j.ijcha.2020.100588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/20/2020] [Accepted: 07/07/2020] [Indexed: 01/14/2023]
Abstract
Background Early recurrence of atrial tachyarrhythmia (ERAT) during a 90-day blanking period (BP) often occurs after atrial fibrillation (AF) ablation. Left atrial reverse remodeling (LARR), which is the reduction in LA volume (LAV), also occurs during the BP. Both ERAT and LARR are associated with late recurrence (LR, greater than 90 days after ablation). We investigated the association between ERAT and LARR following non-paroxysmal AF (NPAF) ablation. Methods We retrospectively reviewed 330 consecutive patients undergoing initial NPAF ablation (median follow-up: 4.0 years). Based on the timing of the final ERAT, we divided the patients into No-ERAT (N = 154, without ERAT), Early (N = 39, 0–7 days after ablation), Intermediate (N = 67, 8–30), and Late-ERAT (N = 70, 31–90) groups. We assessed the extent of LARR, defined as the percentage of decrease in LAV (%ΔLAV). The %ΔLAV cutoff value was determined by receiver operating characteristic analysis, and incorporated into a multivariate analysis to assess the association between ERAT and LARR. Results Late-ERAT was associated with LR (hazard ratio: 6.31, 95% confidence interval (CI): 4.21–9.47, p = 0.0001). The %ΔLAV in the Late-ERAT group was significantly smaller than the other groups (p < 0.0001). The predictive power of %ΔLAV for LR was slight (AUC, 0.604; best cutoff, 18.8% decrease; p = 0.0011). In the multivariate logistic regression analysis, Late-ERAT was associated with poor LARR (%ΔLAV < 18.8% decrease) (odds ratio, 0.13; 95%CI, 0.06–0.27; p < 0.001), whereas Early- and Intermediate-ERAT did not show any correlation. Conclusions Late-ERAT was strongly associated with poor LARR after NPAF ablation. Both Late-ERAT and poor LARR might reflect a residual arrhythmogenic substrate causing LR.
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Affiliation(s)
- Takafumi Oka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yasushi Koyama
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Koji Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yuko Hirao
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Masato Okada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Issei Yoshimoto
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Ryo Kitagaki
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Atsunori Okamura
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Katsuomi Iwakura
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine Osaka University Graduate School of Medicine, Suita, Japan
| | - Kenshi Fujii
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Koichi Inoue
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
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Yang DY, Cheng ZW, Liu YT, Gao P, Chen TB, Deng H, Cheng KA, Fan JB, Fang Q. Noninvasive electrocardiography monitoring for very early recurrence predicts long-term outcome in patients after atrial fibrillation ablation. Ann Noninvasive Electrocardiol 2020; 25:e12785. [PMID: 32588512 PMCID: PMC7679836 DOI: 10.1111/anec.12785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 05/09/2020] [Accepted: 06/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most common sustained arrhythmia, and catheter ablation has been shown to be a highly effective treatment for patients with symptomatic AF. Very early recurrence (VER) of AF within 7 days after catheter ablation is common, but the clinical significance of VER remains unclear. We have examined the usefulness of the noninvasive electrocardiography monitor for the detection of VER and the relationship between VER and late recurrence (LR). Methods Eighty‐eight patients with paroxysmal or persistent atrial fibrillation were retrospectively included. All patients underwent primary catheter ablation at a large general hospital between March 2016 and August 2018. All patients were followed up in atrial fibrillation clinic at an interval of every 3 months for late recurrence of AF. VER was evaluated by one‐lead continuous noninvasive electrocardiography monitoring device for 7 days after ablation. The association between VER and LR was analyzed by univariate and multivariate Cox regression model. Results Mean age was 62.9 ± 9.7 years, and 39.8% were female. Thirty‐two patients (36.4%) experienced VER. After a mean follow‐up of 539.36 ± 211.66 days, 17 patients (19.3%) experienced LR. Multivariate Cox regression analysis revealed VER was an independent predictor of LR: HR 3.6 (95% CI, 1.2–10.8), p = .020. In addition, diabetes was also associated with LR of atrial fibrillation. Conclusions Noninvasive electrocardiography monitoring was a useful tool for detecting VER and VER after catheter ablation was associated with LR.
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Affiliation(s)
- De-Yan Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhong-Wei Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yong-Tai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Tai-Bo Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hua Deng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kang-An Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jing-Bo Fan
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Olshausen G, Uijl A, Jensen‐Urstad M, Schwieler J, Drca N, Bastani H, Tapanainen J, Saluveer O, Bourke T, Kennebäck G, Insulander P, Deisenhofer I, Braunschweig F. Early recurrences of atrial tachyarrhythmias post pulmonary vein isolation. J Cardiovasc Electrophysiol 2020; 31:674-681. [DOI: 10.1111/jce.14368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Gesa Olshausen
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Alicia Uijl
- Division of Cardiology, Department of MedicineKarolinska InstitutetStockholm Sweden
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht University The Netherlands
- Health Data Research UK London, Institute for Health InformaticsUniversity College London London United Kingdom
| | - Mats Jensen‐Urstad
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Jonas Schwieler
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Nikola Drca
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Hamid Bastani
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Jari Tapanainen
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Ott Saluveer
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Tara Bourke
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Göran Kennebäck
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Per Insulander
- Heart and Vascular DivisionKarolinska University HospitalStockholm Sweden
| | - Isabel Deisenhofer
- Deutsches Herzzentrum München, Klinik für Herz‐ und KreislauferkrankungenTechnische Universität MünchenMunich Germany
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29
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Tokuda M, Yamashita S, Matsuo S, Kato M, Sato H, Oseto H, Okajima E, Ikewaki H, Yokoyama M, Isogai R, Tokutake K, Yokoyama K, Narui R, Tanigawa SI, Yoshimura M, Yamane T. Clinical significance of early recurrence of atrial fibrillation after cryoballoon vs. radiofrequency ablation-A propensity score matched analysis. PLoS One 2019; 14:e0219269. [PMID: 31265482 PMCID: PMC6605651 DOI: 10.1371/journal.pone.0219269] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/19/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives One of the mechanisms of early recurrence of atrial fibrillation (ERAF) after AF ablation is considered to be the inflammatory reaction of the atrial tissue. The aim of this study is to compare the clinical significance of ERAF at each stage for true AF recurrence between cryoballoon (CB) and radiofrequency (RF) ablation. Methods Among 798 paroxysmal AF patients who underwent an initial ablation, 460 patients (CB, n = 230; RF, n = 230) were selected by propensity score matching. Very ERAF (VERAF), ERAF-1M, ERAF-3M and true AF recurrence were defined as AF recurrence at 0–2, 3–30, 31–90 days and more than 90 days after the procedure, respectively. Results The patient characteristics of the two groups were similar. ERAF was observed 21% and 27% in the CB and RF groups, respectively. In both the CB and RF group, VERAF, ERAF-1M and ERAF-3M were more frequently observed in patients with true AF recurrence than in those without. In a multivariable analysis, ERAF-1M and ERAF-3M were found to be independent predictors of true AF recurrence in both the CB (P = 0.04 and P<0.001, respectively) and RF groups (P = 0.02 and P = 0.001, respectively). However, while VERAF was associated with true AF recurrence after RF ablation (P = 0.03), it was not associated with true AF recurrence after CB ablation (P = 0.19). Conclusion The relationship between ERAF and true AF recurrence differed between the RF and CB ablation groups. While VERAF was associated with true AF recurrence after RF ablation, it was not a predictor of true AF recurrence after CB ablation.
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Affiliation(s)
- Michifumi Tokuda
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Seigo Yamashita
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Seiichiro Matsuo
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mika Kato
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hidenori Sato
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirotsuna Oseto
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Eri Okajima
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hidetsugu Ikewaki
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Masaaki Yokoyama
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryota Isogai
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Tokutake
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Yokoyama
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryohsuke Narui
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shin-ichi Tanigawa
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
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30
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Essebag V, Azizi Z, Alipour P, Khaykin Y, Leong‐Sit P, Sarrazin J, Sturmer M, Morillo C, Terricabras M, Amit G, Roux J, Patterson S, Verma A. Comparison of efficacy of phased multipolar versus traditional radiofrequency ablation: A prospective, multicenter study (CAPCOST). PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:942-950. [DOI: 10.1111/pace.13737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/30/2019] [Accepted: 05/30/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Vidal Essebag
- McGill University Health Centre Montreal Quebec Canada
- Hôpital Sacré‐Coeur de Montréal Montreal Quebec Canada
| | - Zahra Azizi
- Southlake Regional Health Centre Newmarket Ontario Canada
- Faculty of HealthYork University Ontario Canada
| | - Pouria Alipour
- Southlake Regional Health Centre Newmarket Ontario Canada
- Faculty of HealthYork University Ontario Canada
| | - Yaariv Khaykin
- Southlake Regional Health Centre Newmarket Ontario Canada
| | | | | | | | - Carlos Morillo
- Libin Cardiovascular Institute of AlbertaUniversity of Calgary Calgary Alberta Canada
| | | | - Guy Amit
- Hamilton Health Sciences Hamilton Ontario Canada
| | - Jean‐Francois Roux
- Centre hospitalier universitaire de Sherbrooke (CHUS) Sherbrooke Quebec Canada
| | | | - Atul Verma
- Southlake Regional Health Centre Newmarket Ontario Canada
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31
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Murase Y, Inden Y, Imai H, Kyo S, Yanagisawa S, Fujii A, Sakamoto Y, Tomomatsu T, Murohara T. Clinical significance of the timing of early recurrence of atrial arrhythmia after pulmonary vein isolation: a two-institution clinical study. Heart Vessels 2018; 34:842-850. [PMID: 30390124 DOI: 10.1007/s00380-018-1295-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/26/2018] [Indexed: 11/28/2022]
Abstract
Early recurrence of atrial arrhythmia (ERAA) after ablation frequently occurs, but there is limited evidence about ERAA-timing. This study aimed to investigate the association between ERAA-timing and late recurrence. We retrospectively investigated 332 patients who underwent PVI for paroxysmal atrial fibrillation at Nagoya University Hospital and Komaki City Hospital. Seventy-six patients (23%) had ERAA. The cutoff value of the first ERAA for late recurrence was set as 3 days, with a specificity of 77% and sensitivity of 43%. On multivariate analysis, first ERAA beyond 3 days (hazard ratio, 2.477; 95% confidence interval, 1.168-5.25; p = 0.018) and large left atrial diameter (LAD) (hazard ratio, 1.101; 95% confidence interval, 1.024-1.184; p = 0.009) were independent predictors for late recurrence. Patients who had first ERAA within 3 days and no ERAA beyond 3 days showed a significantly higher recurrence-free rate than those who had first ERAA beyond 3 days and those who had ERAA both within 3 days and beyond 3 days (89% versus 39%, 44%; p < 0.001). Moreover, the patients with ERAA within 3 days and LAD ≤ 37.7 mm showed a significantly higher recurrence-free rate than those with ERAA beyond 3 days and LAD > 37.7 mm, and as compared with the other patients (100% versus 26% and 60%, respectively; p < 0.001). ERAA beyond 3 days after ablation was a predictor for late recurrence. Among patients with ERAA, those with ERAA within 3 days and smaller LAD showed favorable prognosis after ablation.
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Affiliation(s)
- Yosuke Murase
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Hajime Imai
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Seifuku Kyo
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Satoshi Yanagisawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Aya Fujii
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yusuke Sakamoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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Adjunctive left anterior line ablation induced left atrial dysfunction and dyssynchrony in atrial fibrillation ablation. Heart Vessels 2018; 34:331-342. [PMID: 30088055 DOI: 10.1007/s00380-018-1238-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/03/2018] [Indexed: 10/28/2022]
Abstract
We evaluated the effects of adjunctive left anterior line (LAL) ablation on LA dyssynchrony and function using real-time three-dimensional echocardiography (3DE) in connection with thromboembolic complications and tachyarrhythmia recurrence in patients with persistent atrial fibrillation (AF). We randomly and prospectively assigned consecutive persistent AF patients to the LAL (n = 52, 65 ± 7 years) and control groups (n = 50, 64 ± 10 years). In the LAL group, extensive encircling pulmonary vein isolation (EEPVI), roof line ablation, and LAL ablation regardless of the extent of the low-voltage area (LVA) were performed. The control group underwent EEPVI and roof line ablation. After ablation, 3DE demonstrated LA dyssynchrony in 23 (46%) and 4 patients (8%, P < 0.001) of the LAL and control groups, respectively. Baseline LA LVAs were relatively small in most patients and there were no significant differences in extent of LVA between control and LAL groups or between patients with and without dyssynchrony. During the follow-up periods (771 ± 121 days), patients with LA dyssynchrony in the LAL group did not show significant differences in symptomatic thromboembolic events (0%) and atrial tachyarrhythmia recurrence (39%) from patients without LA dyssynchrony in the LAL (0% and 30%) and control groups (0% and 32%, respectively). LA ejection fraction and active emptying fraction were lower by 9% on average in the LAL group than in the control group (P < 0.0001). Similarly, in the LAL group, LA ejection fraction, active emptying fraction, and expansion index were significantly lower by approximately 7%, 8%, and 15%, respectively, in LA with dyssynchrony than those in LA without dyssynchrony. In conclusion, LA dyssynchrony and LA hypofunction were induced by LAL ablation in patients with persistent AF and relatively mild LVA. LAL ablation with or without LA dyssynchrony is thought not to affect thromboembolic complications or atrial tachyarrhythmia recurrence.
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The relationship of early recurrence of atrial fibrillation and the 3-month integrity of the ablation lesion set. Sci Rep 2018; 8:9875. [PMID: 29959347 PMCID: PMC6026210 DOI: 10.1038/s41598-018-28072-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/07/2018] [Indexed: 01/19/2023] Open
Abstract
Early recurrence of atrial fibrillation (ERAF) after catheter-ablation (CA) can be a transient phenomenon due to inflammation, or a harbinger of late AF recurrence due to CA lesion (re)conduction. We studied the relationship between ERAF and the 3-month CA lesions integrity. Forty one consecutive AF patients who underwent a pulmonary vein isolation (PVI), roof line (RL) and mitral isthmus line (MIL) CA were enrolled. At 3 months all patients underwent invasive assessment of the lesion set integrity irrespective of ERAF. The PVI, RL and MIL ablation was successful in 100.0%, 95.1% and 82.9% patients, respectively. At the 3-month remapping, a gap in PVI-lesion(s), RL or MIL was identified in 61.0%, 31.7% and 36.6% patients, respectively. Patients with (n = 17, 41.5%) compared to those without ERAF (n = 24) had a significantly higher rate of any PV-reconnection (88.2% vs. 41.7%), the right PV(s)-reconnection (82.5% vs. 29.2%) and the RL gap (52.9% vs. 16.7%), as well as a higher number of reconnected right PVI-segments, all p < 0.05. On multivariate analysis, only the number of reconnected right PVI-segments was associated with ERAF (OR 4.26, p = 0.004). The ERAF following PVI + RL + MIL ablation was significantly related to 3-month PV-reconnections and the presence of RL gaps.
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34
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Liang JJ, Dixit S. Early Recurrences During the Blanking Period after Atrial Fibrillation Ablation. J Atr Fibrillation 2018; 10:1726. [PMID: 29988237 DOI: 10.4022/jafib.1726] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 11/10/2022]
Abstract
Early recurrences of atrial arrhythmias (ERAA) after ablation are common and predict late recurrences and ablation failure.However,becausea proportion of patients with ERAA will have no subsequent arrhythmias after the blanking period, consensus guidelines recommend against immediate repeat ablation for ERAA episodes occurring during the first 3 months post-ablation. In this review, we summarize the predictors, significance, and treatment of ERAA after AF ablation.
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Affiliation(s)
- Jackson J Liang
- Division of Cardiology, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sanjay Dixit
- Division of Cardiology, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, PA
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