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Jeong JH, Lee HS, Choi YY, Kim YG, Choi JI, Kim YH, Lim HE, Oh IY, Cha MJ, Lee SR, Kim JY, Kwon CH, Lee SH, Park J, Kim KH, Yang PS, Kim JH, Shim J. Association of typical atrial flutter and cavotricuspid isthmus ablation on clinical recurrence after cryoballoon ablation for atrial fibrillation. Front Cardiovasc Med 2023; 10:1303635. [PMID: 38162135 PMCID: PMC10755020 DOI: 10.3389/fcvm.2023.1303635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Typical atrial flutter commonly occurs in patients with atrial fibrillation (AF). Limited information exists regarding the effects of concurrent atrial flutter on the long-term outcomes of rhythm control. This study investigated the association between concurrent typical atrial flutter and cavotricuspid isthmus (CTI) ablation and the recurrence of atrial arrhythmia. The data were obtained from a multicenter registry of cryoballoon ablation for AF (n = 2,689). Patients who were screened for typical atrial flutter were included in the analysis (n = 1,907). All the patients with typical atrial flutter underwent CTI ablation. The primary endpoint was the late recurrence of atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia. Among the 1,907 patients, typical atrial flutter was detected in 493 patients (25.9%). Patients with concurrent atrial flutter had a lower incidence of persistent AF and a smaller size of the left atrium. Patients with atrial flutter had a significantly lower recurrence rate of atrial arrhythmia (19.7% vs. 29.9%, p < 0.001). In patients with atrial flutter, the recurrence rate of atrial tachycardia or atrial flutter was more frequent (7.3% vs. 4.7%, p = 0.028), but the recurrence rate of AF was significantly lower (17.0% vs. 29.4%, p < 0.001). Atrial flutter has been identified as an independent predictor of the primary endpoint (adjusted hazard ratio, 0.704; 95% confidence interval, 0.548-0.906; p = 0.006). Typical atrial flutter in patients with AF may serve as a positive marker of the recurrence of atrial arrhythmia, and performing CTI ablation in this population is associated with a reduced likelihood of AF recurrence. Performing routine screening and ablation procedures for coexisting atrial flutter may improve the clinical outcomes of AF.
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Affiliation(s)
- Joo Hee Jeong
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hyoung Seok Lee
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yun Young Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Yun Gi Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
| | - Hong Euy Lim
- Division of Cardiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea
| | - Il-Young Oh
- Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Myung-Jin Cha
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ju Youn Kim
- Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chang Hee Kwon
- Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sung Ho Lee
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Junbeom Park
- Department of Cardiology, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ki-Hun Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Jun-Hyung Kim
- Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Anam Hospital, Seoul, Republic of Korea
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4693] [Impact Index Per Article: 586.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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3
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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4
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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García Seara J, Raposeiras Roubin S, Gude Sampedro F, Balboa Barreiro V, Martínez Sande JL, Rodríguez Mañero M, González Juanatey JR. Failure of hybrid therapy for the prevention of long-term recurrence of atrial fibrillation. Int J Cardiol 2014; 176:74-9. [DOI: 10.1016/j.ijcard.2014.06.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/30/2014] [Accepted: 06/24/2014] [Indexed: 10/25/2022]
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Govindan M, Savelieva I, Catanchin A, Camm AJ. Atrial fibrillation-the final frontier. J Cardiovasc Pharmacol Ther 2010; 15:36S-50S. [PMID: 20940451 DOI: 10.1177/1074248410371947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and represents a significant health care issue. The diagnosis and management of AF uses a significant proportion of the health care budget and is responsible for substantial morbidity and mortality. Restoration and maintenance of sinus rhythm is still an important treatment option for symptomatic AF. Anti-arrhythmic drugs (AADs) have had inconsistent results for the prevention of recurrent AF and have been hampered by significant adverse effects. Catheter ablation has rapidly evolved and is fast becoming an alternative for AF prevention. Although multiple treatment options exist, no single modality is effective for all patients. This review outlines best current practice for AF prevention and future perspectives, focusing on new and promising developments in antiarrhythmic drug therapy, strategies for ablation therapy, and forms of hybrid therapy that may offer improved outcomes in selected patients.
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Affiliation(s)
- Malini Govindan
- Division of Cardiac & Vascular Sciences, St George's University of London, London, UK
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7
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Govindan M, Catanchin A, Camm AJ. The place of hybrid therapies with drugs to supplement nonpharmacological therapies in atrial fibrillation. J Cardiovasc Pharmacol 2008; 52:210-21. [PMID: 18806601 DOI: 10.1097/fjc.0b013e3181799677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, and its prevalence continues to rise as the aged population increases. Comparative studies of rhythm control and rate control have been equivocal; however, the benefits of rhythm control may have been offset by the limitations of antiarrhythmic drugs. More recently, nonpharmacological therapies have emerged that provide hope of more effective rhythm control. Catheter ablation techniques have gained favour with high success rates in specialized centers, although these techniques are not without complications and require considerable expertise. Pacing therapies designed to reduce harmful right ventricular pacing and increase physiological pacing have shown benefit in AF patients with bradycardia. Despite this progress, no single modality confers benefit for all patients. Strategies to combine these treatment modalities in a hybrid approach has shown increasing promise for subgroups of AF patients.
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Affiliation(s)
- Malini Govindan
- Division of Cardiac and Vascular Sciences, St Georges Hospital University of London, London, UK.
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8
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Silberbauer J, Sulke N. The role of pacing in rhythm control and management of atrial fibrillation. J Interv Card Electrophysiol 2007; 18:159-86. [PMID: 17473977 DOI: 10.1007/s10840-007-9087-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2006] [Accepted: 02/01/2007] [Indexed: 11/28/2022]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is increasing in prevalence with an ageing population. As the arrhythmia is often asymptomatic the true prevalence is likely even higher. Largely because of stroke this arrhythmia places a huge financial burden on the health economy. Despite this, large studies assessing rate versus rhythm control have been equivocal. Because of the ineffectiveness of pharmacological therapy much research effort has been undertaken in device and ablative approaches to rhythm management. Although catheter ablation has gained favour because of the high success rates the technique requires considerable expertise and still has a significant complication profile maintaining interest in pacing therapies for atrial fibrillation. Dual chamber versus single-chamber ventricular pacing has been shown to significantly reduce the incidence of atrial fibrillation. Research is currently underway to see if minimising the deleterious effects of right ventricular apical pacing could further increase the benefits of atrioventricular synchronous pacing. Several studies show some (albeit variable) reduction in AF burden with anti-AF algorithms in the setting of bradycardia. Antitachycardia pacing, on the other hand, has not been shown to treat AF in a randomised trial despite the successful termination of co-existent atrial tachycardias. There is increasing evidence that alternative atrial pacing sites may treat AF by improving atrial function. Furthermore, these strategies coupled with other therapies in a 'hybrid approach' have also showed promising results.
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Affiliation(s)
- John Silberbauer
- Eastbourne General Hospital East Sussex Hospitals NHS Trust, Eastbourne, BN21 2UD, UK
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Saksena S, Skadsberg ND, Rao HB, Filipecki A. Biatrial and Three-Dimensional Mapping of Spontaneous Atrial Arrhythmias in Patients with Refractory Atrial Fibrillation. J Cardiovasc Electrophysiol 2005; 16:494-504. [PMID: 15877620 DOI: 10.1111/j.1540-8167.2005.40531.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION While atrial fibrillation (AF) initiation in the pulmonary veins has been well-studied, simultaneous biatrial and three-dimensional noncontact mapping (NCM) has not been performed. We hypothesized that these two techniques would provide novel information on triggers, initiation, and evolution of spontaneous AF and permit study of different AF populations. METHODS AND RESULTS The origin of atrial premature beats (APBs), onset of spontaneous AF and its evolution were analyzed in 50 patients with AF in the presence or absence of structural heart disease (SHD) and in different AF presentations (group A: Persistent, group B: Paroxysmal). In 45 patients, spontaneous APBs in the right atrium (RA; n = 60) and left atrium (LA; n = 25) with similar regional distributions regardless of heart disease status were demonstrated. In total, 22 patients (44%) had > or =2 disparate regional origins. Biatrial regional foci were seen with equal frequency in patients with SHD (31%), without SHD (40%), in group A (32%), and in group B (36%). Biatrial mapping and NCM showed organized monomorphic atrial tachyarrhythmias arising in the RA (17), septum (17), or LA (21) and were classified as atrial flutter (RA = 34, LA = 8), macro-reentrant atrial tachycardia (RA = 1, LA = 3) or focal atrial tachycardia (RA = 2, LA = 7). Their regional distribution was more extensive in patients with SHD and persistent AF compared with patients without SHD or paroxysmal AF. Simultaneous biatrial tachycardias were observed only in group A patients and those with SHD. CONCLUSIONS Simultaneous biatrial and NCM permits successful AF mapping in different AF populations and demonstrates a biatrial spectrum of spontaneous triggers and tachycardias. Organized monomorphic tachycardias with multiple unilateral or biatrial locations are commonly observed in human AF. Patients with heart disease or persistent AF have a more extensive distribution as well as simultaneous coexistence of multiple tachycardias during AF.
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Affiliation(s)
- Sanjeev Saksena
- Electrophysiology Research Foundation, Warren, New Jersey, USA
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Scharf C, Veerareddy S, Ozaydin M, Chugh A, Hall B, Cheung P, Good E, Pelosi F, Morady F, Oral H. Clinical significance of inducible atrial flutter during pulmonary vein isolation in patients with atrial fibrillation. J Am Coll Cardiol 2004; 43:2057-62. [PMID: 15172412 DOI: 10.1016/j.jacc.2003.11.063] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2003] [Revised: 10/22/2003] [Accepted: 11/13/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study was designed to determine the prevalence and clinical significance of atrial flutter (AFL) that occurs during catheter ablation for atrial fibrillation (AF). BACKGROUND Atrial flutter frequently occurs in patients with AF. METHODS Pulmonary vein isolation was performed in 133 consecutive patients (age 52 +/- 11 years) for paroxysmal (n = 112) or persistent (n = 21) AF. A clinical episode of AFL was documented in 40 of the 133 patients (30%). During the ablation procedure, AFL occurred in 86 patients (65%), either spontaneously (n = 36) or by rapid atrial pacing (n = 50), with AFL being typical in the majority (80%). Cavo-tricuspid isthmus ablation was performed in 28 of the 133 patients. RESULTS Among the 105 patients who did not undergo isthmus ablation, 25 patients (24%) were documented to have symptomatic AFL during a mean follow-up of 609 +/- 252 days. Among the clinical variables of age, gender, history of clinical AFL, ejection fraction, left atrial diameter, duration of AF, and occurrence of AFL during ablation, only a history of clinical AFL (p = 0.05) and occurrence of typical AFL during the ablation (p = 0.01) were independent predictors of symptomatic AFL during follow-up. The incidence of symptomatic AFL during follow-up was similar among patients who did and did not have long-term freedom from recurrent AF. CONCLUSIONS In patients with AF who have either a history of AFL or an episode of typical AFL during an electrophysiologic study, symptomatic AFL is common after pulmonary vein isolation. Therefore, cavo-tricuspid isthmus ablation is appropriate during pulmonary vein isolation if AFL has been observed clinically or in the electrophysiology laboratory.
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Affiliation(s)
- Christoph Scharf
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
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Hsieh MH, Tai CT, Chan P, Chen SA. Spontaneous transition from atrial fibrillation to typical atrial flutter during catheter ablation of the pulmonary vein. J Interv Card Electrophysiol 2004; 10:289-91. [PMID: 15133369 DOI: 10.1023/b:jice.0000026926.90896.57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A 71-year-old male patient was admitted for catheter ablation of the pulmonary veins to treat paroxysmal atrial fibrillation. Atrial fibrillation originating from the left superior pulmonary vein was induced after a pause of atrial pacing under isoproterenol infusion and became sustained. Spontaneous transition from atrial fibrillation to typical atrial flutter was noted after complete isolation of the pulmonary vein focus from the left atrium. Subsequently linear ablation of the cavotricuspid isthmus was created with completely bi-directional isthmus conduction block. We hypothesized that ectopic pulmonary vein focus played an important role in the spontaneous conversion of atrial fibrillation to typical atrial flutter, and complete isolation of the pulmonary vein could stop the spontaneous transition between the two atrial tachyarrhythmias.
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Affiliation(s)
- Ming-Hsiung Hsieh
- Division of Cardiovascular Medicine, Department of Medicine, Taipei Medical University, School of Medicine and Taipei Wan-Fang Hospital, Taiwan.
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Madan N, Saksena S. Long-term rhythm control of drug-refractory atrial fibrillation with "hybrid therapy" incorporating dual-site right atrial pacing, antiarrhythmic drugs, and right atrial ablation. Am J Cardiol 2004; 93:569-75. [PMID: 14996581 DOI: 10.1016/j.amjcard.2003.11.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Revised: 11/04/2003] [Accepted: 11/04/2003] [Indexed: 11/22/2022]
Abstract
We evaluated the long-term efficacy, safety, and applicability of a "hybrid" therapy strategy for rhythm control in atrial fibrillation (AF), incorporating dual-site right atrial pacing, antiarrhythmic drugs, and right atrial ablation. One hundred thirteen patients (paroxysmal AF [n = 70], persistent/permanent AF [n = 43]) with refractory symptomatic AF were treated with this strategy and followed for 1 to 81 months (mean 30 +/- 23). All-cause mortality, AF recurrences, and progression to permanent AF were monitored and recorded by implanted device data logs. There was no procedural mortality. Rhythm control was achieved in 90% of all patients at 3 and 5 years, with comparable efficacy in subpopulations with paroxysmal (98%), persistent, or permanent AF (87%, p >2). Overall survival was 84% at 3 years and 80% at 5 years, and was higher in patients with paroxysmal AF than in patients with persistent or permanent AF (86% vs 67% at 4 years, p <0.001). Patients with persistent or permanent AF had a greater need for cardioversion (p <0.004) and right atrial ablation (p <0.04) than patients with paroxysmal AF to achieve comparable rhythm control. A hybrid therapy strategy can provide safe and effective long-term rhythm control in patients with drug-refractory AF, and can be implemented in subpopulations presenting with paroxysmal, persistent, or permanent AF.
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Affiliation(s)
- Nandini Madan
- Arrhythmia and Pacemaker Service, Cardiovascular Institute, Atlantic Health System, Passaic, New Jersey, USA
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13
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Abstract
Rhythm control methods have not shown superior outcomes to rate control strategies in atrial fibrillation. Newer approaches to rhythm control employ "hybrid" therapies combining pharmacologic and non pharmacologic interventions. Pathophysiologic insights into mechanisms of atrial fibrillation (AF) suggest that arrhythmogenesis is due to interactions of multiple triggering rhythms and a complex electrophysiologic substrate resulting in the emergence of multiple tachyarrhythmias, often in disparate locations that may coexist in time. Thus, an "hybrid" therapy prescription is more likely to address several of the etiologic factors culminating in clinical AF. Results of pilot clinical studies of hybrid therapy are encouraging and involve drugs, devices and ablation techniques in varying permutations. Hybrid therapy algorithms using right heart procedures can improve efficacy with potentially lower risk. Considerations in implementation of these algorithms include staged or simultaneous interventions and a right versus left heart strategy. The parallel with the current coronary disease management paradigm is obvious and relevant.
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Affiliation(s)
- Sanjeev Saksena
- Arrhythmia and Pacemaker Service, Cardiovascular Institute, Atlantic Health System, Passaic, NJ, USA.
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Camm AJ, Savelieva I. Rationale and patient selection for "hybrid" drug and device therapy in atrial and ventricular arrhythmias. J Interv Card Electrophysiol 2003; 9:207-14. [PMID: 14574033 DOI: 10.1023/a:1026288508343] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Three quite different forms of direct antiarrhythmic therapy are available for the treatment of cardiac arrhythmias: antiarrhythmic drugs, cardiac ablation and implantable devices (pacemakers and defibrillators). None of these therapies is fully effective and consequently they are increasingly combined. This combination therapy is often described as "hybrid" a term that implies fundamental different qualities of treatment which together provide some form of synergism. The mechanisms for the initiation and perpetuation of most cardiac arrhythmias are complex and multiple. It is therefore not surprising that single therapies are not completely effective. Theoretically the use of multiple different therapies allows more specific mechanisms of arrhythmia to be directly addressed. However, this is largely a theoretical concept that has only been strictly evaluated in a small number of studies. Studies of multiple therapies are difficult to perform unless the combination therapy is regarded as a strategy which can be compared to baseline, conventional treatment or one or more single constituent therapies from the combination. Despite the lack of formal studies there is a very substantial clinical experience which testifies to the value of hybrid therapy for the management of both atrial fibrillation and ventricular tachycardia/fibrillation.
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Affiliation(s)
- A John Camm
- Department of Cardiological Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.
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Padeletti L, Botto G, Spampinato A, Michelucci A, Colella A, Porciani MC, Pieragnoli P, Ciapetti C, Musilli N, Sagone A, Martelli M, Raneri R, Grammatico A. Prevention of paroxysmal atrial fibrillation in patients with sinus bradycardia: role of right atrial linear ablation and pacing site. J Cardiovasc Electrophysiol 2003; 14:733-8. [PMID: 12930254 DOI: 10.1046/j.1540-8167.2003.02588.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Right atrial linear lesions (RALL), either alone or in combination with antiarrhythmic drug therapy, may modify the substrate for maintenance of atrial fibrillation (AF). The aim of this prospective randomized study was to determine whether RALL provides additional benefit to right atrial appendage pacing (RAAP) and/or interatrial septum pacing (IASP) and drug therapy in patients with symptomatic paroxysmal AF and sinus bradycardia requiring permanent atrial pacing. METHODS AND RESULTS Sixty-four patients (33 men and 31 women, mean age 73 +/- 10 years) completed the 6-month follow-up. Patients were randomized to either RALL (n = 33) or non-right atrial linear lesions (NRALL), and then to either IASP (n = 32) or RAAP (n = 32). Fifteen RALL patients were paced at the IAS and 18 at the RAA. Seventeen NRALL patients were paced at the IAS and 14 at the RAA. No statistical difference was observed with regard to the mean atrial tachyarrhythmia (AT) burden between NRALL (84 +/- 169 min/day) and RALL patients (202 +/- 219 min/day). Mean AT burden was significantly lower in the IASP group (70 +/- 150 min/day) than in RAAP group (219 +/- 317 min/day; P < 0.016). In the RALL group, the mean AT burden was 99 +/- 180 min/day in the IASP patients and 288 +/- 372 min/day in the RAAP patients (P < 0.046). In the NRALL group, no statistical difference in the mean AT burden was observed between IASP patients (46 +/- 117 min/day) and RAAP patients (130 +/- 211 min/day). CONCLUSION The results of the present study indicate that RALL did not provide any additional therapeutic benefit to combined antiarrhythmic drug therapy and septal or nonseptal atrial pacing in patients with sinus bradycardia and paroxysmal AF.
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Affiliation(s)
- Luigi Padeletti
- Institute of Internal Medicine and Cardiology, University of Florence, Viale Morgagni 85, 50134 Florence, Italy.
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Saksena S. Classifications and practice guidelines in atrial fibrillation: a changing landscape. J Interv Card Electrophysiol 2003; 8:5-8. [PMID: 12652171 DOI: 10.1023/a:1022384924732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Sanjeev Saksena
- Cardiovascular Institute, Atlantic Health System (East), Passaic, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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