1
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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2
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Bianchini L, Schiavone M, Vettor G, Gasperetti A, Penza E, Ballotta A, Pirola S, Brambillasca C, Zito E, De Lio F, Ventrella N, Tundo F, Moltrasio M, Fassini G, Polvani G, Tondo C. Hybrid-Convergent Procedure or Pulsed Field Ablation in Long-Standing Persistent Atrial Fibrillation. JACC Clin Electrophysiol 2024; 10:1700-1710. [PMID: 39084744 DOI: 10.1016/j.jacep.2024.05.029] [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: 03/26/2024] [Revised: 05/14/2024] [Accepted: 05/25/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Hybrid-convergent radiofrequency (RF) ablation targeting pulmonary veins (PVs) and left atrial posterior wall (LAPW) has shown better arrhythmic outcomes than an endocardial-only RF strategy, despite higher rates of complications. Comparisons with extensive pulsed field ablation (PFA) are currently lacking. OBJECTIVES This study aimed to compare the efficacy and safety of the hybrid-convergent RF vs PFA of PVs and LAPW in long-standing persistent atrial fibrillation (LSPAF). METHODS Ninety-three consecutive LSPAF patients, treated with 2-step hybrid-convergent RF ablation (hybrid group, n = 49) or with PFA of PVs and LAPW (PFA group, n = 44) were enrolled. Primary efficacy endpoint was defined as any atrial tachyarrhythmias (ATA) recurrence after the 3-month blanking period, over a follow-up time of 12 months. Periprocedural adverse events and late complications during follow-up were deemed primary safety outcomes. RESULTS The hybrid and PFA groups had similar baseline characteristics; mean age was hybrid 63.8 ± 10.6 years vs PFA 66.0 ± 7.4 years; P = 0.105. PV and LAPW ablation were acutely successful in all patients. Step 1 hybrid-epicardial procedures were longer than PFA (166 [Q1-Q3: 140-205] minutes vs 107.5 [Q1-Q3: 82.5-12] minutes; P < 0.01). At 12-month follow-up, there was no difference in ATA recurrences between groups (hybrid 36.7% vs PFA 40.9%; P = 0.680; log-rank at survival analysis P = 0.539). After adjusting for confounders, a larger left atrial volume and recurrences during the blanking-period were predictors of ATA recurrences after ablation, regardless of procedural technique employed. PFA showed a better safety profile with a lower rate of major periprocedural complications compared with hybrid ablation (12% vs 0%; P = 0.028). CONCLUSIONS Hybrid-convergent and PFA share comparable arrhythmic outcomes in LSPAF, but hybrid-convergent ablation carries higher periprocedural risks.
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Affiliation(s)
- Lorenzo Bianchini
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Marco Schiavone
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy; Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Giulia Vettor
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Alessio Gasperetti
- Division of Cardiology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eleonora Penza
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Andrea Ballotta
- Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Anaesthesia and Intensive Care Unit, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Sergio Pirola
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Claudio Brambillasca
- Department of Cardiac Anesthesia and Intensive Care Unit, Cardiac Anaesthesia and Intensive Care Unit, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | | | - Francesca De Lio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | | | - Fabrizio Tundo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Massimo Moltrasio
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Gaetano Fassini
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy
| | - Gianluca Polvani
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino, IRCSS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCSS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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3
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Galuszka OM, Baldinger SH, Servatius H, Seiler J, Madaffari A, Kozhuharov N, Thalmann G, Kueffer T, Muehl A, Maurhofer J, Haeberlin A, Noti F, Tanner H, Reichlin T, Roten L. Durability of CLOSE-Guided Pulmonary Vein Isolation in Persistent Atrial Fibrillation: A Prospective Remapping Study. JACC Clin Electrophysiol 2024; 10:1090-1100. [PMID: 38639700 DOI: 10.1016/j.jacep.2024.02.026] [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: 10/25/2023] [Revised: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Recurrence of paroxysmal atrial fibrillation (AF) following pulmonary vein isolation (PVI) is presumably caused by pulmonary vein (PV) reconnections. However, there is little data available on the durability of PVI and incidence of arrhythmia recurrence in patients with persistent AF. OBJECTIVES The purpose of this study was to evaluate the lesion durability by means of an a priori planned remapping procedure in patients with persistent AF undergoing CLOSE-guided PVI. METHODS In a prospective study, we included patients with symptomatic, persistent AF undergoing CLOSE-guided radiofrequency ablation. Irrespective of AF recurrence, a redo procedure was mandated 6 months following the index procedure to evaluate PV reconnections. The outcome of AF ablation was based on clinical recurrence and 7-day Holter electrocardiogram 3 and 6 months after the index procedure and 3, 6, and 12 months after the redo procedure. RESULTS Of 30 patients included, 26 (81% men; median age 68 years) underwent the planned remapping study a median of 6 months after the index procedure, whereas 4 patients without recurrence refused a repeat procedure. In total, 78 of 102 (76%) PVs showed durable isolation and 15 patients (58%) presented complete isolation of all PVs. Beyond the blanking period, 6 of 26 patients (23%) had arrhythmia recurrence before the redo procedure. Recurrence had occurred in 33% of patients with complete isolation of all veins and in 9% of patients with PV reconnections (P = 0.197). After re-PVI in patients with PV reconnections and additional ablation in patients with recurrence but durable PVI, 17 of 26 patients (65%) were free of arrhythmia after 12 months. CONCLUSIONS In patients with persistent AF, CLOSE-guided PVI resulted in durable rate of PVI on a per-vein and per-patient level of 76% and 58%, respectively. Arrhythmia recurrence was numerically higher in patients with durable PVI compared with patients without.
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Affiliation(s)
- Oskar M Galuszka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Samuel H Baldinger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Helge Servatius
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Madaffari
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikola Kozhuharov
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gregor Thalmann
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Kueffer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Aline Muehl
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jens Maurhofer
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Fabian Noti
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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4
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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5
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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6
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Moser F, Rillig A, Metzner A. Empiric isolation of the superior vena cava in atrial fibrillation patients: old concept, new insights? Europace 2024; 26:euae041. [PMID: 38306483 PMCID: PMC10906950 DOI: 10.1093/europace/euae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024] Open
Affiliation(s)
- Fabian Moser
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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7
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Dong Y, Zhao D, Chen X, Shi L, Chen Q, Zhang H, Yu Y, Ullah I, Kojodjojo P, Zhang F. Role of electroanatomical mapping-guided superior vena cava isolation in paroxysmal atrial fibrillation patients without provoked superior vena cava triggers: a randomized controlled study. Europace 2024; 26:euae039. [PMID: 38306471 PMCID: PMC10906951 DOI: 10.1093/europace/euae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/27/2023] [Indexed: 02/04/2024] Open
Abstract
AIMS Data about whether empirical superior vena cava (SVC) isolation (SVCI) improves the success rate of paroxysmal atrial fibrillation (PAF) are conflicting. This study sought to first investigate the characteristics of SVC-triggered atrial fibrillation and secondly investigate the impact of electroanatomical mapping-guided SVCI, in addition to circumferential pulmonary vein isolation (CPVI), on the outcome of PAF ablation in the absence of provoked SVC triggers. METHODS AND RESULTS A total of 130 patients undergoing PAF ablation underwent electrophysiological studies before ablation. In patients for whom SVC triggers were identified, SVCI was performed in addition to CPVI. Patients without provoked SVC triggers were randomized in a 1:1 ratio to CPVI plus SVCI or CPVI only. The primary endpoint was freedom from any documented atrial tachyarrhythmias lasting over 30 s after a 3-month blanking period without anti-arrhythmic drugs at 12 months after ablation. Superior vena cava triggers were identified in 30 (23.1%) patients with PAF. At 12 months, 93.3% of those with provoked SVC triggers who underwent CPVI plus SVCI were free from atrial tachyarrhythmias. In patients without provoked SVC triggers, SVCI, in addition to CPVI, did not increase freedom from atrial tachyarrhythmias (87.9 vs. 79.6%, log-rank P = 0.28). CONCLUSION Electroanatomical mapping-guided SVCI, in addition to CPVI, did not increase the success rate of PAF ablation in patients who had no identifiable SVC triggers. REGISTRATION ChineseClinicalTrials.gov: ChiCTR2000034532.
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Affiliation(s)
- Yan Dong
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Dongsheng Zhao
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Xinguang Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Linshen Shi
- Department of Cardiology, The Second Affiliated Hospital of Nantong University, Nantong, China
| | - Qiushi Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Haiyan Zhang
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Yu
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Inam Ullah
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
| | - Pipin Kojodjojo
- Asian Heart and Vascular Centre, National University of Singapore, Singapore, Singapore
| | - Fengxiang Zhang
- Section of Pacing and Electrophysiology, Division of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing 210029, China
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8
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Müller J, Nentwich K, Berkovitz A, Sonne K, Kozlova O, Barth S, Deacanu A, Waechter C, Halbfass P, Lehrmann H, Deneke T. Recurrent Atrial Fibrillation Ablation after Initial Successful Pulmonary Vein Isolation. J Clin Med 2023; 12:7177. [PMID: 38002789 PMCID: PMC10672075 DOI: 10.3390/jcm12227177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is an effective treatment option for patients with symptomatic atrial fibrillation (AF). However, the electrical recovery of pulmonary veins (PVs) is the main trigger for AF recurrences. This study investigates the characteristics of patients admitted for redo AF ablation, the PV reconnection rates depending on previous ablation modalities and the impact of different ablation strategies for redo procedures. METHODS Consecutive patients undergoing first redo AF ablation were included. Patients were grouped according to the electrical recovery of at least one PV. The impacts of the technique for first AF ablation on PV reconnection rates and patients with and without PV reconnection were compared. Different ablation strategies for redo procedures were compared and its recurrence rates after a mean follow-up of 25 ± 20 months were investigated. RESULTS A total of 389 patients (68 ± 10 years; 57% male; 39% paroxysmal AF) underwent a first redo. The median time between the first and redo procedure was 40 ± 39 months. Radiofrequency was used in 278 patients, cryoballoon was used in 85 patients and surgical AF ablation was performed on 26 patients. In total, 325 patients (84%) had at least one PV reconnected, and the mean number of reconnected PVs was 2.0 ± 1.3, with significant differences between ablation approaches (p for all = 0.002); this was mainly due to differences in the left inferior PV and right superior PV reconnections. The presence of PV reconnection during redo was not associated with better long-term success compared to completely isolated PVs (67% vs. 67%; log-rank p = 0.997). Overall, the different ablation strategies for redos were comparable regarding AF recurrences during follow-up (p = 0.079), with the ablation approach having no impact in the case of left atrial low voltage or without. CONCLUSIONS PV reconnections after initial successful PVI are common among all techniques of AF ablation. Long-term rhythm control off antiarrhythmic drugs was possible in 2/3 of all patients after the redo procedure; however, different ablation strategies with extra-PV trigger ablation did not improve long-term success. Patients with recurrent AF after PVI constitute a challenging group of patients.
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Affiliation(s)
- Julian Müller
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, 79085 Freiburg im Breisgau, Germany;
| | - Karin Nentwich
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Artur Berkovitz
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Kai Sonne
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Olena Kozlova
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Sebastian Barth
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Alexandru Deacanu
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
| | - Christian Waechter
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Philipp Halbfass
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
- Department of Cardiology and Angiology, Philipps-University Marburg, 35037 Marburg, Germany;
| | - Heiko Lehrmann
- Department of Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, 79085 Freiburg im Breisgau, Germany;
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Centre Bad Neustadt, 97616 Bad Neustadt a. d. Saale, Germany (O.K.); (P.H.)
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9
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Shrestha DB, Pathak BD, Thapa N, Shrestha O, Karki S, Shtembari J, Patel NK, Kapoor K, Kalahasty G, Bodziock G, Whalen P, Pothineni NVK, Narasimhan B, Koneru J, Shantha G. Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01656-z. [PMID: 37773559 DOI: 10.1007/s10840-023-01656-z] [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: 05/27/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF. OBJECTIVE The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation. METHODS Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly. RESULTS Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99). CONCLUSION LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.
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Affiliation(s)
| | - Bishnu Deep Pathak
- Department of Internal Medicine, Jibjibe Primary Health Care Center, Rasuwa, Nepal
| | - Niranjan Thapa
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Oshan Shrestha
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Sagun Karki
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL, USA
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Kunal Kapoor
- Department of Internal Medicine, Division of Cardiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Gautham Kalahasty
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - George Bodziock
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Patrick Whalen
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | | | - Bharat Narasimhan
- Department of Cardiology, Debakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | - Jayanthi Koneru
- Department of Internal Medicine, Division of Electrophysiology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Ghanshyam Shantha
- Department of Cardiology, Division of Electrophysiology, Wake Forest University School of Medicine, Winston Salem, NC, USA
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10
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Hsu JC, Darden D, Du C, Marine JE, Nichols S, Marcus GM, Natale A, Noseworthy PA, Selzman KA, Varosy P, Masoudi F, Freeman J, Curtis J, Akar J, Kowey PR. Initial Findings From the National Cardiovascular Data Registry of Atrial Fibrillation Ablation Procedures. J Am Coll Cardiol 2023; 81:867-878. [PMID: 36858707 DOI: 10.1016/j.jacc.2022.11.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND The National Cardiovascular Data Registry (NCDR) AFib Ablation Registry was created to assess real-world prevalence, demographic characteristics, procedural management, and outcomes of patients undergoing atrial fibrillation (AF) ablation procedures. OBJECTIVES The goal of this study was to characterize the patient, hospital, and physician characteristics and in-hospital outcomes related to AF ablation in the first 5 years of the registry. METHODS This paper describes the AFib Ablation Registry structure and governance, outcome assessment processes, data quality, and data collection processes. The characteristics of the patient population, hospitals, and in-hospital outcomes are also described. RESULTS A total of 76,219 patients were included in the registry between January 2016 and December 2020 (mean age 65.5 ± 10.3 years, 65.2% male, 55.8% paroxysmal AF, mean CHA2DS2-VASc score 2.7 ± 1.6) treated by 708 physicians in 162 hospitals. Successful isolation of all pulmonary veins was achieved in 92.4% of patients. The prevalence of any complication during procedural admission was 2.50% and major complication was 0.9%, including significant bradycardia in 0.47%, heart failure in 0.47%, and pericardial effusion requiring intervention in 0.44%. Hospitalization >1 day occurred in 11.8% of patients, and in-hospital death was rare (n = 41 [0.05%]). CONCLUSIONS The NCDR AFib Ablation Registry is the largest multicenter, prospective cohort study of patients undergoing catheter ablation worldwide. Results in the first 5 years showed that successful pulmonary vein isolation is achieved in the majority of patients, with a low rate of complications. Future studies from the registry will assess practice trends, evaluate treatment patterns associated with different patient outcomes, and support development of evidence-based guidelines.
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Affiliation(s)
- Jonathan C Hsu
- University of California-San Diego, La Jolla, California, USA.
| | - Douglas Darden
- Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA
| | - Chengan Du
- Yale University, New Haven, Connecticut, USA
| | - Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Gregory M Marcus
- University of California-San Francisco, San Francisco, California, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | | | | | | | | | | | - Joseph Akar
- Yale University, New Haven, Connecticut, USA
| | - Peter R Kowey
- Lankenau Heart Institute Center, Wynnewood, Pennsylvania, USA
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11
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Chakraborty P, Po SS. The role of autonomic denervation in the success of atrial fibrillation ablation: Can pulsed-field ablation provide the answer? Heart Rhythm 2023; 20:341-342. [PMID: 36503178 DOI: 10.1016/j.hrthm.2022.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Praloy Chakraborty
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Sunny S Po
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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12
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Jin S, Lin W, Fang X, Liao H, Zhan X, Fu L, Jiang J, Ye X, Liu H, Chen Y, Pu S, Wu S, Deng H, Xue Y. High-Power, Short-Duration Ablation under the Guidance of Relatively Low Ablation Index Values for Paroxysmal Atrial Fibrillation: Long-Term Outcomes and Characteristics of Recurrent Atrial Arrhythmias. J Clin Med 2023; 12:jcm12030971. [PMID: 36769620 PMCID: PMC9917927 DOI: 10.3390/jcm12030971] [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: 12/02/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the difference in effectiveness and safety of high-power, short-duration (HPSD) radiofrequency catheter ablation (RFA) guided by relatively low ablation index (AI) values and conventional RFA in paroxysmal atrial fibrillation (PAF) patients. METHODS The HPSD RFA strategy (40-50 W, AI 350-400 for anterior, 320-350 for posterior wall; n = 547) was compared with the conventional RFA strategy (25-40 W, without AI; n = 396) in PAF patients who underwent their first ablation. Propensity-score matching analyses were used to compare the outcomes of the two groups while controlling for confounders. RESULTS After using propensity-score matching analysis, the HPSD group showed a higher early recurrence rate (22.727% vs. 13.636%, p = 0.003), similar late recurrence rate, and comparable safety (p = 0.604) compared with the conventional group. For late recurrent atrial arrhythmia types, the rate of regular atrial tachycardia was significantly higher in the HPSD group (p = 0.013). Additionally, the rate of chronic pulmonary vein reconnection and non-pulmonary vein triggers during repeat procedures was similar in both groups. CONCLUSIONS For PAF patients, compared with the conventional RFA strategy, the HPSD RFA strategy at relatively low AI settings had a higher early recurrence rate, similar long-term success rate, and comparable safety.
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Affiliation(s)
- Shuyu Jin
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Weidong Lin
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xianhong Fang
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hongtao Liao
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xianzhang Zhan
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Lu Fu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Junrong Jiang
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xingdong Ye
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huiyi Liu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Yanlin Chen
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Sijia Pu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Shulin Wu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hai Deng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (H.D.); (Y.X.)
| | - Yumei Xue
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (H.D.); (Y.X.)
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13
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Sandhu A, Holman B, Lammers S, Cerbin L, Barrett C, Sabzwari R, Garg L, Zipse MM, Tumolo AZ, Aleong RG, Von Alvensleben J, Rosenberg M, West JJ, Varosy P, Nguyen DT, Sauer WH, Tzou WS. Evaluating temperature gradients across the posterior left atrium with radiofrequency ablation. J Cardiovasc Electrophysiol 2023; 34:880-887. [PMID: 36682068 DOI: 10.1111/jce.15826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Esophageal injury is a well-known complication associated with catheter ablation. Though novel methods to mitigate esophageal injury have been developed, few studies have evaluated temperature gradients with catheter ablation across the posterior wall of the left atrium, interstitium, and esophagus. METHODS To investigate temperature gradients across the tissue, we developed a porcine heart-esophageal model to perform ex vivo catheter ablation on the posterior wall of the left atrium (LA), with juxtaposed interstitial tissue and esophagus. Circulating saline (5 L/min) was used to mimic blood flow along the LA and alteration of ionic content to modulate impedance. Thermistors along the region of interest were used to analyze temperature gradients. Varying time and power, radiofrequency (RF) ablation lesions were applied with an externally irrigated ablation catheter. Ablation strategies were divided into standard approaches (SAs, 10-15 g, 25-35 W, 30 s) or high-power short duration (HPSD, 10-15 g, 40-50 W, 10 s). Temperature gradients, time to the maximum measured temperature, and the relationship between measured temperature as a function of distance from the site of ablation was analyzed. RESULTS In total, five experiments were conducted each utilizing new porcine posterior LA wall-esophageal specimens for RF ablation (n = 60 lesions each for SA and HPSD). For both SA and HPSD, maximum temperature rise from baseline was markedly higher at the anterior wall (AW) of the esophagus compared to the esophageal lumen (SA: 4.29°C vs. 0.41°C, p < .0001 and HPSD: 3.13°C vs. 0.28°C, p < .0001). Across ablation strategies, the average temperature rise at the AW of the esophagus was significantly higher with SA relative to HPSD ablation (4.29°C vs. 3.13°C, p = .01). From the start of ablation, the average time to reach a maximum temperature as measured at the AW of the esophagus with SA was 36.49 ± 12.12 s, compared to 16.57 ± 4.54 s with HPSD ablation, p < .0001. Fit to a linear scale, a 0.37°C drop in temperature was seen for every 1 cm increase in distance from the site of ablation and thermistor location at the AW of the esophagus. CONCLUSION Both SA and HPSD ablation strategies resulted in markedly higher temperatures measured at the AW of the esophagus compared to the esophageal lumen, raising concern about the value of clinical intraluminal temperature monitoring. The temperature rise at the AW was lower with HPSD. A significant time delay was seen to reach the maximum measured temperature and a modest increase in distance between the site of ablation and thermistor location impacted the accuracy of monitored temperatures.
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Affiliation(s)
- Amneet Sandhu
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA.,Denver VA Medical Center, Section of Cardiology, Aurora, Colorado, USA
| | - Blair Holman
- Division of Bioengineering, University of Colorado, Boulder, Colorado, USA
| | - Steven Lammers
- Division of Bioengineering, University of Colorado, Boulder, Colorado, USA
| | - Lukasz Cerbin
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Christopher Barrett
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Rafay Sabzwari
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Lohit Garg
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Matthew M Zipse
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Alexis Z Tumolo
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Ryan G Aleong
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Johannes Von Alvensleben
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Michael Rosenberg
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - John J West
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
| | - Paul Varosy
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA.,Denver VA Medical Center, Section of Cardiology, Aurora, Colorado, USA
| | - Duy T Nguyen
- Mayo Clinic Foundation, Section of Electrophysiology, Rochester, Minnesota, USA
| | - William H Sauer
- Division of Cardiology, Section of Electrophysiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Wendy S Tzou
- Division of Cardiology, Section of Electrophysiology, University of Colorado Hospital, University of Colorado, Aurora, Colorado, USA
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Miraglia V, Bisignani A, Pannone L, Iacopino S, Chierchia GB, de Asmundis C. Cryoballoon Ablation Beyond Pulmonary Vein Isolation in the Setting of Persistent Atrial Fibrillation. Expert Rev Med Devices 2022; 19:431-439. [PMID: 35786107 DOI: 10.1080/17434440.2022.2096437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Catheter ablation has been demonstrated to be a safe and an effective treatment for drug resistant atrial fibrillation (AF); electrical isolation of pulmonary veins (PVI) is the main strategy in paroxysmal AF, since pulmonary vein triggers have a pivotal role in its pathogenesis; non-paroxysmal AF is a complex arrhythmia that results from the interplay of a substrate, namely AF-induced electrical and structural atrial remodeling, and a trigger that can be often found outside pulmonary veins, namely non-pulmonary veins triggers. AREAS COVERED The aim of this review is to provide a state-of-the-art overview of non-pulmonary veins triggers with special focus on cryoballoon (CB) catheter ablation. EXPERT OPINION Besides PVI, CB catheter ablation of non-pulmonary veins triggers is a novel and promising strategy for non-paroxysmal AF.
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Affiliation(s)
- Vincenzo Miraglia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Antonio Bisignani
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Saverio Iacopino
- Electrophysiology Unit, Maria Cecilia Hospital, Cotignola, Italy
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
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Aguilera J, Hutt E, Kaur S, Saliba WI, Tarakji KG, Baranowski B, Bhargava M, Kanj M, Cantillon DJ, Rickard J, Sroubek J, Nakagawa H, Wazni OM, Hussein AA. Outcomes of atrial fibrillation ablation in patients with or without silent pulmonary veins from prior ablation procedure. J Cardiovasc Electrophysiol 2022; 33:1994-2000. [PMID: 35689504 DOI: 10.1111/jce.15592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/15/2022] [Accepted: 05/01/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Pulmonary venous (PV) electrical recovery underlies most arrhythmia recurrences after atrial fibrillation (AF) ablation. Little is known about procedural profiles and outcomes of patients with electrically silent PVs upon redo ablation for AF. METHODS In a prospectively maintained registry, we enrolled 838 consecutive patients (2013-2016) undergoing redo ablation procedures. Ablation procedures targeted the PVs, the PV antra, and non-PV sites at operators' discretion. Procedural profiles and clinical outcomes were assessed. The primary outcome was freedom from AF after a 3-month blanking period. The secondary outcome was improvement in quality of life. RESULTS Most patients undergoing redo AF ablation (n = 684, 82%) had PV reconnection while the remaining 154 (18%) had electrically silent PVs. Patients with recurrent AF and electrically silent PVs were older (66 vs. 64 years, p = .02), had more prior ablation procedures (median 2 IQR 1-3 vs 1 IQR 1-2 p = .001), were more likely to have non-paroxysmal AF (62% vs. 49%, p = .004) and atrial flutter (48% vs. 29%, p = .001) and had significantly larger left atrial volumes (89 vs. 81 ml, p = .003). Patients with silent PVs underwent a more extensive non-PV ablation strategies with antral extension of prior ablation sets in addition to ablation of the roof, appendage, inferior to the right PVs, peri-mitral flutter lines, cavotricuspid isthmus lines and ablation in the coronary sinus. Upon one year of follow-up, patients with electrically silent PVs were less likely to remain free from recurrent atrial arrhythmias (64% vs. 76%, p = .008). Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. CONCLUSION Rhythm control with extensive ablation allowed maintenance of sinus rhythm in about two thirds of patients with silent PVs during redo AF ablation procedures. Regardless of PV reconnection status, redo ablation resulted in improvement in quality of life. This remains a challenging group of patients, highlighting the need to better understand non-PV mediated AF.
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Affiliation(s)
- Jose Aguilera
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erika Hutt
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Simrat Kaur
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid I Saliba
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Khaldoun G Tarakji
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bryan Baranowski
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mandeep Bhargava
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel J Cantillon
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - John Rickard
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hiroshi Nakagawa
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Oussama M Wazni
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ayman A Hussein
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, Ohio, USA
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Sakamoto K, Mukai Y, Kawai S, Nagaoka K, Inoue S, Takase S, Yakabe D, Ikeda S, Mannoji H, Nagayama T, Chishaki A, Tsutsui H. Intra-atrial activation pattern is useful to localize the areas of non-pulmonary vein triggers of atrial fibrillation. PLoS One 2022; 17:e0264894. [PMID: 35468171 PMCID: PMC9037930 DOI: 10.1371/journal.pone.0264894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background Pulmonary vein isolation (PVI) is an established ablation procedure for atrial fibrillation (AF), however, PVI alone is insufficient to suppress AF recurrence. Non-pulmonary vein (non-PV) trigger ablation is one of the promising strategies beyond PVI and has been shown to be effective in refractory/persistent AF cases. To make non-PV trigger ablation more standardized, it is essential to develop a simple method to localize the origin of non-PV triggers. Methods We retrospectively analyzed 37 non-PV triggers in 751 ablation sessions for symptomatic AF from January 2017 to December 2020. Regarding non-PV triggers, intra-atrial activation interval from the earliest in right atrium (RA) to proximal coronary sinus (CS) (RA-CSp) and that from the earliest in RA to distal CS (RA-CSd) obtained by a basically-positioned duodecapolar RA-CS catheter were compared among 3 originating non-PV areas [RA, atrial septum (SEP) and left atrium (LA)]. Results RA-CSp of RA non-PV trigger (56.4 ± 23.4 ms) was significantly longer than that of SEP non-PV (14.8 ± 25.6 ms, p = 0.019) and LA non-PV (-24.9 ± 27.9 ms, p = 0.0004). RA-CSd of RA non-PV (75.9 ± 32.1 ms) was significantly longer than that of SEP non-PV (34.2 ± 32.6 ms, p = 0.040) and LA non-PV (-13.3 ± 41.2 ms, p = 0.0008). RA-CSp and RA-CSd of SEP non-PV were significantly longer than those of LA non-PV (p = 0.022 and p = 0.016, respectively). Sensitivity and specificity of an algorithm to differentiate the area of non-PV trigger using RA-CSp (cut-off value: 50 ms) and RA-CSd (cut-off value: 0 ms) were 88% and 97% for RA non-PV, 81% and 73% for SEP non-PV, 65% and 95% for LA non-PV, respectively. Conclusions The analysis of intra-atrial activation sequences was useful to differentiate non-PV trigger areas. A simple algorithm to localize the area of non-PV trigger would be helpful to identify non-PV trigger sites in AF ablation.
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Affiliation(s)
- Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Yasushi Mukai
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
- Department of Cardiovascular Medicine, Japanese Red Cross Fukuoka Hospital, Okusu, Minami-ku, Fukuoka, Japan
- * E-mail:
| | - Shunsuke Kawai
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
- Department of Cardiovascular Medicine, Japanese Red Cross Fukuoka Hospital, Okusu, Minami-ku, Fukuoka, Japan
| | - Kazuhiro Nagaoka
- Department of Cardiology, St. Mary’s Hospital, Tsubuku-honmachi, Kurume, Fukuoka, Japan
| | - Shujiro Inoue
- Department of Cardiology, Aso Iizuka Hospital, Yoshio-machi, Iizuka, Fukuoka, Japan
| | - Susumu Takase
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Daisuke Yakabe
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
- Department of Cardiology, Kyushu Medical Center, Jigyohama, Chuo-ku, Fukuoka, Japan
| | - Shota Ikeda
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Hiroshi Mannoji
- Department of Cardiology, Hamanomachi Hospital, Nagahama, Chuo-ku, Fukuoka, Japan
| | - Tomomi Nagayama
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Akiko Chishaki
- Division of Cardiology, Fukuoka Dental College Hospital, Tamura, Sawara-ku, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Maidashi, Higashi-ku, Fukuoka, Japan
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17
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Kim D, Hwang T, Kim M, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Pak HN. Extra-Pulmonary Vein Triggers at de novo and the Repeat Atrial Fibrillation Catheter Ablation. Front Cardiovasc Med 2021; 8:759967. [PMID: 34805314 PMCID: PMC8600078 DOI: 10.3389/fcvm.2021.759967] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Extra-pulmonary vein triggers can play a significant role in atrial fibrillation recurrence after catheter ablation. We explored the characteristics of the extra-pulmonary vein (PV) triggers in de novo and repeat atrial fibrillation (AF) catheter ablation (AFCA). Methods: We included 2,118 patients who underwent a de novo AFCA (women 27.6%, 59.2 ± 10.9 years old, paroxysmal AF 65.9%) and 227 of them conducted repeat procedures. All included patients underwent isoproterenol provocation tests at the end of the procedure, and then we analyzed extra-PV triggers-related factors. Results: Extra-PV triggers were documented in 11.7% of patients undergoing de novo AFCA (1.22 ± 0.46 foci per patient) and 28.6% undergoing repeat AFCA (1.49 ± 0.73 foci per patient). Older age and higher LA volume index in de novo procedures and women, diabetes, and higher parasympathetic nerve activity (heart rate variability) in repeat-AFCA were independently associated with the existence of extra-PV triggers. The septum (19.9%), coronary sinus (14.7%), and superior vena cava (11.2%) were common extra-PV foci. Among 46 patients who were newly found to have mappable extra-PV triggers upon repeat procedures, 15 (32.6%) matched with the previous focal or empirical extra-PV ablation sites. The rate of AF recurrence was significantly higher in patients with extra-PV triggers than in those without after de novo (HR 1.91, 95% CI 1.54–2.38, p < 0.001) and repeat procedures (HR 2.68, 95% CI 1.63–4.42, p < 0.001). Conclusions: Extra-PV triggers were commonly found in AF patients with significant remodeling and previous empirical extra-PV ablation. The existence of extra-PV triggers was independently associated with poorer rhythm outcomes after the de novo and repeat AFCA.
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Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Taehyun Hwang
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Min Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, South Korea
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18
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De Martino G, Compagnucci P, Mancusi C, Vassallo E, Calvanese C, Della Ratta G, Librera M, Franciulli M, Marino L, Russo AD, Casella M. Stepwise endo-/epicardial catheter ablation for atrial fibrillation: The Mediterranea approach. J Cardiovasc Electrophysiol 2021; 32:2107-2115. [PMID: 34216076 PMCID: PMC8457187 DOI: 10.1111/jce.15151] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/28/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022]
Abstract
Background Outcomes of catheter ablation (CA) among patients with nonparoxysmal atrial fibrillation (AF) are largely disappointing. Objective We sought to evaluate the feasibility, effectiveness, and safety of a single‐stage stepwise endo‐/epicardial approach in patients with persistent/longstanding‐persistent AF. Methods We enrolled 25 consecutive patients with symptomatic persistent (n = 4) or longstanding‐persistent (n = 21) AF and at least one prior endocardial procedure, who underwent CA using an endo‐/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann's bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3‐month blanking period. The secondary outcome was patients' symptom status during follow‐up. Results The stepwise endo‐/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly (n = 6, 24%) or after AF organization into atrial tachycardia (n = 12, 48%). BB's ablation was commonly implicated in arrhythmia termination. After a median follow‐up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9‐month follow‐up (0% vs. 56%, p = .02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion A single‐stage endo‐/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding‐persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.
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Affiliation(s)
| | - Paolo Compagnucci
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Marche Polytechnic University, Ancona, Italy
| | - Carmine Mancusi
- Arrhythmology and Heart Failure Unit, Mediterranea Hospital, Naples, Italy
| | - Enrico Vassallo
- Arrhythmology and Heart Failure Unit, Mediterranea Hospital, Naples, Italy
| | - Claudia Calvanese
- Arrhythmology and Heart Failure Unit, Mediterranea Hospital, Naples, Italy
| | | | | | | | - Luigi Marino
- Cardiac Surgery Unit, Mediterranea Hospital, Naples, Italy
| | - Antonio Dello Russo
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Department of Clinical, Special, and Dental Sciences, Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Marche Polytechnic University, Ancona, Italy
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19
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Gianni C, Anannab A, Della Rocca DG, Salwan A, MacDonald B, Quintero Mayedo A, Mohanty S, Trivedi C, Di Biase L, Natale A. Recurrent Atrial Fibrillation with Isolated Pulmonary Veins: What to Do. Card Electrophysiol Clin 2021; 12:209-217. [PMID: 32451105 DOI: 10.1016/j.ccep.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
When patients have symptomatic recurrent atrial tachyarrhythmias after 2 months following pulmonary vein antral isolation, a repeat ablation should be considered. Patients might present with isolated pulmonary veins posterior wall. In these patients, posterior wall isolation is extended, and non-pulmonary vein triggers are actively sought and ablated. Moreover, in those with non-paroxysmal atrial fibrillation or a known higher prevalence of non-pulmonary vein triggers, empirical isolation of the superior vena cava, coronary sinus, and/or left atrial appendage might be performed. In this review, we will focus on ablation of non-pulmonary vein triggers, summarizing our current approach for their mapping and ablation.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.
| | - Alisara Anannab
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Electrophysiology Unit, Department of Cardiovascular Interventions, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | | | - Anu Salwan
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Bryan MacDonald
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | | | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Dell Medical School, University of Texas, Austin, TX, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; HCA National Medical Director of Cardiac Electrophysiology, USA; Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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20
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Szili-Torok T, Kis Z, Bhagwandien R, Wijchers S, Yap SC, Hoogendijk M, Dumas N, Haeusser P, Geczy T, Kong MH, Ruppersberg P. Functional electrographic flow patterns in patients with persistent atrial fibrillation predict outcome of catheter ablation. J Cardiovasc Electrophysiol 2021; 32:2148-2158. [PMID: 34041824 PMCID: PMC8453922 DOI: 10.1111/jce.15115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/19/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
Aims Electrographic flow (EGF) mapping is a method to detect action potential sources within the atria. In a double‐blinded retrospective study we evaluated whether sources detected by EGF are related to procedural outcome. Methods EGF maps were retrospectively generated using the Ablamap® software from unipolar data recorded with a 64‐pole basket catheter from patients who previously underwent focal impulse and rotor modulation‐guided ablation. We analyzed patient outcomes based on source activity (SAC) and variability. Freedom from atrial fibrillation (AF) was defined as no recurrence of AF, atypical flutter or atrial tachycardia at the follow‐up visits. Results EGF maps were from 123 atria in 64 patients with persistent or long‐standing persistent AF. Procedural outcome correlation with SAC peaked at >26%. S‐type EGF signature (source‐dependent AF) is characterized by stable sources with SAC > 26% and C‐type (source‐independent AF) is characterized by sources with SAC ≤ 26%. Cases with AF recurrence at 3‐, 6‐, or 12‐month follow‐up showed a median final SAC 34%; while AF‐free patients had sources with significantly lower median final SAC 21% (p = .0006). Patients with final SAC and Variability above both thresholds had 94% recurrence, while recurrence was only 36% for patients with leading source SAC and variability below threshold (p = .0001). S‐type EGF signature post‐ablation was associated with an AF recurrence rate 88.5% versus 38.1% with C‐type EGF signature. Conclusions EGF mapping enables the visualization of active AF sources. Sources with SAC > 26% appear relevant and their presence post‐ablation correlates with high rates of AF recurrence.
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Affiliation(s)
| | - Zsuzsanna Kis
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Sip Wijchers
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Mark Hoogendijk
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Nadege Dumas
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Philip Haeusser
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Tamas Geczy
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
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21
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Gianni C, Sanchez JE, Della Rocca DG, Al-Ahmad A, Horton RP, Di Biase L, Natale A. Intracardiac Echocardiography to Guide Catheter Ablation of Atrial Fibrillation. Card Electrophysiol Clin 2021; 13:303-311. [PMID: 33990269 DOI: 10.1016/j.ccep.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Intracardiac echocardiography (ICE) is a valuable tool and should be standard of care in any modern electrophysiology laboratory. Through real-time imaging of cardiac anatomy, ICE is used to guide electrophysiology procedures and monitor for complications. This article is a short overview of the application of real-time ICE imaging during atrial fibrillation ablation procedures.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | | | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Montefiore Medical Center, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; HCA National Medical Director of Cardiac Electrophysiology, Nashville, TN, USA; Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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22
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Gianni C, Gallinghouse GJ, Al-Ahmad A, Horton RP, Bailey SM, Burkhardt JD, Bassiouny MA, MacDonald BC, Quintero Mayedo A, Della Rocca DG, Mohanty S, Trivedi C, Di Biase L, Hranitzky PM, Sanchez JE, Natale A. Half-normal saline versus normal saline for irrigation of open-irrigated radiofrequency catheters in atrial fibrillation ablation. J Cardiovasc Electrophysiol 2021; 32:973-981. [PMID: 33442937 DOI: 10.1111/jce.14885] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/26/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The creation of effective and permanent lesions is a crucial factor in determining the success rate of atrial fibrillation (AF) ablation. By increasing the efficacy of radiofrequency (RF) energy-mediated lesion formation, half-normal saline (HNS) as an irrigant for open-irrigated ablation catheters has the potential to reduce procedural times and improve acute and long-term outcomes. METHODS This is a double-blind randomized clinical trial of 99 patients undergoing first-time RF catheter ablation for AF. Patients enrolled were randomly assigned in a 1:1 fashion to perform ablation using HNS or normal saline (NS) as an irrigant for the ablation catheter. RESULTS The use of HNS is associated with shorter RF times (26 vs. 33 min; p = .02) with comparable procedure times (104 vs. 104 min). The rate of acute pulmonary vein reconnections (16% vs. 18%) was comparable, with a median of 1 vein reconnection in the HNS arm versus 2 in the NS arm. There was no difference in procedure-related complications, including the incidence of postprocedural hyponatremia when using HNS. Over the 1-year follow-up, there is no significant difference between the HNS and NS with respect to the recurrence of any atrial arrhythmia (off antiarrhythmic drugs [AAD]: 47% vs. 52%; hazard ratio [HR]: 1.17, 95% confidence interval [CI]: 0.66-2.06; off/on AAD: 66% vs. 66%, HR: 1.06, 95% CI: 0.53-2.12), with a potential benefit of using HNS when considering the paroxysmal AF cohort (on/off AAD 73% vs. 62%, HR: 0.72, 95% CI: 0.19-2.70). CONCLUSIONS In a mixed cohort of patients undergoing first-time AF ablation, irrigation of open-irrigated RF ablation catheters with HNS is associated with shorter RF times, with a comparably low rate of procedure-related complications. In the long term, there is no significant difference with respect to the recurrence of any atrial arrhythmia. Larger studies with a more homogeneous population are necessary to determine whether HNS improves clinical outcomes.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Department of Biomedical Engineering, University of Texas, Austin, Texas, USA
| | - Shane M Bailey
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Mohamed A Bassiouny
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Bryan C MacDonald
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | | | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Dell Medical School, University of Texas, Austin, Texas, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA.,Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Patrick M Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,HCA National Medical Director of Cardiac Electrophysiology, USA.,Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA.,MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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23
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Tohoku S, Fukunaga M, Nagashima M, Korai K, Hirokami J, Yamamoto K, Takeo A, Niu H, Ando K, Hiroshima K. Clinical impact of eliminating nonpulmonary vein triggers of atrial fibrillation and nonpulmonary vein premature atrial contractions at initial ablation for persistent atrial fibrillation. J Cardiovasc Electrophysiol 2020; 32:224-234. [PMID: 33270298 DOI: 10.1111/jce.14830] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/29/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of nonpulmonary vein (PV) triggers ablation in persistent atrial fibrillation (PEAF) was suggested but it is still under debate. OBJECTIVES We aimed to assess the effectiveness of non-PV trigger-targeted ablation for patients with PEAF. METHODS Consecutive patients with PEAF undergoing catheter ablation (CA) between January 2015 and April 2017 were enrolled. Isoproterenol plus adenosine challenge was performed to provoke non-PV triggers. Non-PV triggers were defined as the trigger beats inducing AF (non-PV AF triggers) and/or frequent premature contractions (non-PV PACs) from other than PVs. Three groups were defined: Group 1 (n = 186) without non-PV triggers; Group 2 (n = 65) with non-PV triggers that could be completely eliminated with CA; Group 3 (n = 49) with non-PV triggers still inducible after CA. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence. RESULTS A total of 300 patients (230 males, age 64 ± 10) were enrolled. The mean follow-up period was 27 ± 10 months. Freedom from ATa recurrence at 1 and 2 years were significantly lower in Group 3 compared to the other two groups (Group 1; 74.7%, 67.2% vs. Group 2; 75.8%, 68.3% vs. Group 3: 52.1%, 38.6%, p = .0005), irrespective of the type of non-PV triggers (non-PV AF triggers vs. non-PV PACs). On multivariate analysis, unsuccessful elimination of non-PV triggers was an independent predictor for ATa recurrence (hazard ratio = 1.80, 95% confidence interval = 1.07-2.95, p = .026). CONCLUSION Successful non-PV triggers elimination can improve the ATa recurrence rate in PEAF ablation. ATa recurrence rate is higher, if non-PV AF triggers or even non-PV PACs remain in patients with PEAF.
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Affiliation(s)
- Shota Tohoku
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.,Abteilung für Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Cardioangiologisches Centrum Bethanien, Frankfurt Academy For Arrhythmias, Frankfurt am Main, Germany
| | - Masato Fukunaga
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Michio Nagashima
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kengo Korai
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Jun Hirokami
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kei Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Ayaka Takeo
- Department of Clinical Engineering, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Harushi Niu
- Department of Clinical Engineering, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenichi Hiroshima
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
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24
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Gianni C, Sanchez JE, Mohanty S, Trivedi C, Della Rocca DG, Al-Ahmad A, Burkhardt JD, Gallinghouse GJ, Hranitzky PM, Horton RP, Di Biase L, Natale A. High-Dose Dobutamine for Inducibility of Atrial Arrhythmias During Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2020; 6:1701-1710. [PMID: 33334450 DOI: 10.1016/j.jacep.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to compare the effect of high-dose dobutamine (DBT) with that of high-dose isoproterenol (IPN) in eliciting triggers during atrial fibrillation (AF) ablation. BACKGROUND High-dose IPN is commonly used to elicit triggers during AF ablation. However, it is not available worldwide and, in the United States, its cost per dose has significantly increased. DBT is a similarly nonselective β-agonist and, as such, is a potential alternative. METHODS This was a prospective, randomized 2×2 crossover study of patients undergoing AF ablation. Patients were assigned to receive IPN (20 to 30 μg/min for 10 min) followed by DBT (40 to 50 μg/kg/min for 10 min) or vice versa in a 1:1 fashion. The type, number, and location of triggers as well as heart rate, blood pressure, and side effects were noted. RESULTS Fifty patients were included in the study. Both drugs caused a significant increase in heart rate, with a consistently lower peak for DBT. Blood pressure significantly increased with DBT, while there was a significant reduction with IPN, despite phenylephrine support. Atrial arrhythmias induced during DBT were comparable to that induced during IPN. In patients with IPN-inducible outflow tract premature ventricular contractions, a similar effect was noted with DBT. No major complications occurred during either drug challenge. CONCLUSIONS High-dose DBT is safe and comparable to high-dose IPN in respect of eliciting AF triggers, with the advantage to maintain systemic pressure without the need of additional vasopressor support. This study supports the use of high-dose DBT in electrophysiology laboratories in which IPN is not readily available and for those patients in whom hypotension is a concern.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Dell Medical School, University of Texas, Austin, Texas, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - Patrick M Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Department of Biomedical Engineering, University of Texas, Austin, Texas, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Department of Biomedical Engineering, University of Texas, Austin, Texas, USA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; HCA National Medical Director of Cardiac Electrophysiology, Austin, Texas, USA; Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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25
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Association between the locations of non-pulmonary vein triggers and ablation outcomes in repeat procedures after cryoballoon ablation of paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2020; 62:381-389. [PMID: 33159266 DOI: 10.1007/s10840-020-00913-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/01/2020] [Indexed: 01/24/2023]
Abstract
PURPOSE We examined the characteristics of non-pulmonary vein (PV) triggers in repeat ablation after cryoballoon ablation for paroxysmal atrial fibrillation (PAF). METHODS This study evaluated 119 patients undergoing a second ablation procedure for recurrent atrial tachyarrhythmia (ATA) after cryoballoon PV isolation (CB-PVI) for PAF. RESULTS Fifty-three of 119 (45%) patients had PV reconnection. All reconnected PVs were isolated. No non-PV triggers were elicited in 42/119 (35%) patients (NNPV group). In 77/119 (65%) patients, 139 isoproterenol-induced non-PV triggers, including 45 triggers that initiated AF, were identified. Non-PV triggers initiating AF were observed at the superior vena cava (SVC), left atrial posterior wall (LAPW) including the PV antra, interatrial septum, right atrium, left atrial appendage/mitral anulus, and coronary sinus in 14 (12%), 10 (8%), 8 (7%), 7 (6%), 4 (3%), and 2 (2%) patients, respectively. Non-PV triggers originated from only the SVC and/or LAPW including the PV antra, and the SVC and/or LAPW was isolated in 18/119 (15%) patients (SVC/LAPW group). Non-PV triggers originating from other sites were focally ablated in 59/119 (50%) patients (OS group). During a median 461 days of follow-up, 39/42 (93%), 17/18 (94%), and 38/59 (64%) patients in the NNPV, SVC/LAPW, and OS groups, respectively, remained ATA recurrence-free. The recurrence rate was higher in the OS group than in the NNPV (P = 0.005) or SVC/LAPW groups (P = 0.042). CONCLUSIONS Over half of patients had non-PV triggers at subsequent ablation after CB-PVI. Non-PV triggers from the SVC/LAPW can be eliminated more successfully than triggers from other sites.
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26
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El Masri I, Kayali SM, Manolukas T, Levine YC. Role of Catheter Ablation as a First-Line Treatment for Atrial Fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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27
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Parameswaran R, Al-Kaisey AM, Kalman JM. Catheter ablation for atrial fibrillation: current indications and evolving technologies. Nat Rev Cardiol 2020; 18:210-225. [PMID: 33051613 DOI: 10.1038/s41569-020-00451-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
Catheter ablation for atrial fibrillation (AF) has emerged as an important rhythm-control strategy and is by far the most common cardiac ablation procedure performed worldwide. Current guidelines recommend the procedure in symptomatic patients with paroxysmal or persistent AF who are refractory or intolerant to antiarrhythmic drugs. The procedure might also be considered as a first-line approach in selected asymptomatic patients. Data from large registries indicate that AF ablation might reduce mortality and the risk of heart failure and stroke, but evidence from randomized controlled trials is mixed. Pulmonary vein isolation using point-by-point radiofrequency or with the cryoballoon remains the cornerstone technique in AF ablation. Additional atrial ablation can be performed in patients with persistent AF, but its benefits are largely unproven. Technological advances in the past decade have focused on achieving durable vein isolation, reducing procedure duration and improving safety. Numerous exciting new technologies are in various stages of development. In this Review, we discuss the relevant data to support the recommended and evolving indications for catheter ablation of AF, describe the different ablation techniques, and highlight the latest advances in technology that aim to improve its safety and efficacy. We also discuss lifestyle modification strategies to improve ablation outcomes.
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Affiliation(s)
- Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ahmed M Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Australia.
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28
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Gianni C, Natale A, Al-Ahmad A. Longstanding Persistent Atrial Fibrillation Ablation: How Do You Perform It? JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i2.3384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Longstanding-persistent atrial fibrillation is one of the most challenging arrhythmias to treat. While radiofrequency catheter ablation is highly effective in paroxysmal atrial fibrillation, pulmonary vein antral isolation (including posterior wall isolation) alone is not enough for nonparoxysmal atrial fibrillation, other targets should be sought in this population. In this case report, we will describe our approach in a typical patient presenting for a first-time ablation procedure for longstanding persistent atrial fibrillation.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute – St. David’s Medical Center – Austin (TX), USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute – St. David’s Medical Center – Austin (TX), USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute – St. David’s Medical Center – Austin (TX), USA
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29
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Della Rocca DG, Tarantino N, Trivedi C, Mohanty S, Anannab A, Salwan AS, Gianni C, Bassiouny M, Al‐Ahmad A, Romero J, Briceño DF, Burkhardt JD, Gallinghouse GJ, Horton RP, Di Biase L, Natale A. Non‐pulmonary vein triggers in nonparoxysmal atrial fibrillation: Implications of pathophysiology for catheter ablation. J Cardiovasc Electrophysiol 2020; 31:2154-2167. [DOI: 10.1111/jce.14638] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 12/24/2022]
Affiliation(s)
| | - Nicola Tarantino
- Arrhythmia Services, Department of Medicine, Montefiore Medical CenterAlbert Einstein College of MedicineBronx New York
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | | | - Alisara Anannab
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
- Department of Cardiovascular InterventionCentral Chest Institute of ThailandNonthaburi Thailand
| | - Anu S. Salwan
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | - Carola Gianni
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | - Mohamed Bassiouny
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | - Amin Al‐Ahmad
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | - Jorge Romero
- Arrhythmia Services, Department of Medicine, Montefiore Medical CenterAlbert Einstein College of MedicineBronx New York
| | - David F. Briceño
- Arrhythmia Services, Department of Medicine, Montefiore Medical CenterAlbert Einstein College of MedicineBronx New York
| | - J. David Burkhardt
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | | | - Rodney P. Horton
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
- Arrhythmia Services, Department of Medicine, Montefiore Medical CenterAlbert Einstein College of MedicineBronx New York
- Department of Clinical and Experimental MedicineUniversity of FoggiaFoggia Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia InstituteSt. David's Medical CenterAustin Texas
- Interventional ElectrophysiologyScripps ClinicLa Jolla California
- Department of Cardiology, MetroHealth Medical CenterCase Western Reserve University School of MedicineCleveland Ohio
- Division of CardiologyStanford UniversityStanford California
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30
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Briceño DF, Patel K, Romero J, Alviz I, Tarantino N, Della Rocca DG, Natale V, Zhang XD, Di Biase L. Beyond Pulmonary Vein Isolation in Nonparoxysmal Atrial Fibrillation: Posterior Wall, Vein of Marshall, Coronary Sinus, Superior Vena Cava, and Left Atrial Appendage. Card Electrophysiol Clin 2020; 12:219-231. [PMID: 32451106 DOI: 10.1016/j.ccep.2020.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The optimal ablation strategy for non-paroxysmal atrial fibrillation remains controversial. Non-PV triggers have been shown to have a major arrhythmogenic role in these patients. Common sources of non-PV triggers are: posterior wall, left atrial appendage, superior vena cava, coronary sinus, vein of Marshall, interatrial septum, crista terminalis/Eustachian ridge, and mitral and tricuspid valve annuli. These sites are targeted empirically in selected cases or if significant ectopy is noted (with or without a drug challenge), to improve outcomes in patients with non-paroxysmal atrial fibrillation. This article focuses on summarizing the current evidence and the approach to mapping and ablation of these frequent non-PV trigger sites.
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Affiliation(s)
- David F Briceño
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Kavisha Patel
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Nicola Tarantino
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | | | - Veronica Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Xiao-Dong Zhang
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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31
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Kashou AH, DeSimone CV, Asirvatham SJ, Kapa S. Left atrial dissection as a trigger for recurrent atrial fibrillation. HeartRhythm Case Rep 2020; 6:329-333. [PMID: 32577388 PMCID: PMC7300347 DOI: 10.1016/j.hrcr.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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32
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Anannab A, Gianni C, Della Rocca DG, Sahore Salwan A, Natale A, Al-Ahmad A. Catheter ablation is preferred over surgery for persistent atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2168-2171. [PMID: 32293063 DOI: 10.1111/jce.14497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 11/29/2022]
Abstract
There are important limitations that can hinder outcomes of surgical ablation in nonparoxysmal patients with atrial fibrillation (AF), which is the typical AF population undergoing concomitant cardiac surgery for valve or ischemic heart disease. Incomplete lesions with recovered conduction or gaps as well as arrhythmias originating from areas not targeted by surgical ablation are commonly seen at the time of recurrence. Therefore, while it might be reasonable to perform AF surgery in this cohort, it is important to know these limitations and establish adequate postoperative rhythm monitoring to detect recurrences, which can be effectively addressed by catheter ablation.
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Affiliation(s)
- Alisara Anannab
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas.,Electrophysiology Unit, Department of Cardiovascular Interventions, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | | | - Anu Sahore Salwan
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas.,HCA National Medical Director of Cardiac Electrophysiology, USA.,Interventional Electrophysiology, Scripps Clinic, La Jolla, California.,MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
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33
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Utility of a 64-pole basket catheter to detect non–pulmonary vein trigger in patients with paroxysmal atrial fibrillation. HeartRhythm Case Rep 2020; 6:98-101. [PMID: 32099799 PMCID: PMC7026565 DOI: 10.1016/j.hrcr.2019.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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34
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Takamiya T, Nitta J, Inaba O, Sato A, Ikenouchi T, Murata K, Inamura Y, Takahashi Y, Goya M, Hirao K. One-year outcomes after pulmonary vein isolation plus posterior wall isolation and additional non-pulmonary vein trigger ablation for persistent atrial fibrillation with or without contact force sensing: a propensity score-matched comparison. J Interv Card Electrophysiol 2020; 59:585-593. [DOI: 10.1007/s10840-019-00700-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
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35
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Terricabras M, Piccini JP, Verma A. Ablation of persistent atrial fibrillation: Challenges and solutions. J Cardiovasc Electrophysiol 2019; 31:1809-1821. [PMID: 31828883 DOI: 10.1111/jce.14311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 12/25/2022]
Abstract
Catheter ablation is commonly used for treatment of persistent atrial fibrillation (AF). Pulmonary vein isolation (PVI) is still the cornerstone for the procedure, however, outcomes are consistently lower compared to paroxysmal AF. It is hypothesized that it could be due to lack of durable lesions or the presence of non-PV targets that remain after PVI. Numerous advances in ablation catheter technologies and mapping systems may potentially achieve lower recurrence rates in the future. Ongoing research is required to discover the best technique for persistent AF ablation. The purpose of this review is to describe the new, developing technologies that may improve the outcome of this procedure in the persistent AF population.
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Affiliation(s)
- Maria Terricabras
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada
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36
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Rubio Campal JM, Sánchez Borque P, Miracle Blanco Á, Bravo Calero L, Crosa J, Tuñón Fernández J. A novel simple, fast, and safe approach for effective superior vena cava isolation using the third‐generation cryoballoon. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 43:62-67. [DOI: 10.1111/pace.13848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/19/2019] [Accepted: 11/25/2019] [Indexed: 12/20/2022]
Affiliation(s)
| | | | | | | | - Julián Crosa
- Fundación Jiménez Díaz‐ Quirónsalud Madrid Spain
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37
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Lupercio F, Lin AY, Aldaas OM, Romero J, Briceno D, Hoffmayer KS, Han FT, Di Biase L, Feld GK, Hsu JC. Role of adjunctive posterior wall isolation in patients undergoing atrial fibrillation ablation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2019; 58:77-86. [DOI: 10.1007/s10840-019-00634-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
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38
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Canpolat U, Mohanty S, Trivedi C, Chen Q, Ayhan H, Gianni C, Della Rocca DG, MacDonald B, Burkhardt JD, Bassiouny M, Gallinghouse GJ, Al-Ahmad A, Horton R, Di Biase L, Natale A. Association of fragmented QRS with left atrial scarring in patients with persistent atrial fibrillation undergoing radiofrequency catheter ablation. Heart Rhythm 2019; 17:203-210. [PMID: 31518722 DOI: 10.1016/j.hrthm.2019.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fragmented QRS (fQRS) on 12-lead electrocardiography is a noninvasive marker of intramyocardial conduction delay due to ventricular scarring that has not previously been studied in atrial fibrillation. OBJECTIVE The purpose of this study was to assess the association of fQRS with left atrial (LA) scarring in patients with persistent atrial fibrillation (PsAF) undergoing first catheter ablation. METHODS A total of 376 patients with PsAF were enrolled. Severity of LA scarring was assessed using electroanatomic mapping. Narrow fQRS was defined by the presence of an additional R wave (R') or notching in the nadir of the S wave, or the presence of >1 R' in 2 contiguous leads corresponding to inferior, lateral, or anterior myocardial regions. RESULTS Both any degree (97.3% vs 63.3%) and severe (42.2% vs 6.3%) LA scarring were higher in patients with fQRS. Age and fQRS were found to be independent predictors of severe LA scarring. At multiple ventricular regions, fQRS had diagnostic accuracy of 79.8% for prediction of severe LA scarring. Nonpulmonary vein triggers were more often detected and ablated in patients with fQRS and severe LA scarring (84.4% vs 70%; P = .001). Atrial tachyarrhythmia recurrence was observed in 131 patients (34.8%) during 18.9 ± 7.7 months of follow-up, which was significantly higher in patients with fQRS (53.2% vs 16.8%). In multivariate analysis, fQRS was found to be a significant predictor of recurrence (hazard ratio 4.65; 95% interval confidence 2.91-7.42; P <.001). CONCLUSION The study results showed that fQRS is a simple, available, and noninvasive marker, and that fQRS at multiple ventricular regions is significantly associated with the severity of LA scarring in PsAF patients.
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Affiliation(s)
- Ugur Canpolat
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Hacettepe University Faculty of Medicine, Department of Cardiology, Ankara, Turkey
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Dell Medical School, Austin, Texas
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Qiong Chen
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Cardiopulmonary Function Test, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Huseyin Ayhan
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Faculty of Medicine, Department of Cardiology, Yıldırım Beyazıt University, Ankara, Turkey
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | | | - Bryan MacDonald
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Mohamed Bassiouny
- 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
| | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Dell Medical School, Austin, Texas; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Cardiology, Stanford University, Stanford, California.
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Ciaccio EJ, Wan EY, Saluja DS, Acharya UR, Peters NS, Garan H. Addressing challenges of quantitative methodologies and event interpretation in the study of atrial fibrillation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 178:113-122. [PMID: 31416540 PMCID: PMC6748794 DOI: 10.1016/j.cmpb.2019.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/21/2019] [Accepted: 06/14/2019] [Indexed: 05/06/2023]
Abstract
Atrial fibrillation (AF) is the commonest arrhythmia, yet the mechanisms of its onset and persistence are incompletely known. Although techniques for quantitative assessment have been investigated, there have been few attempts to integrate this information to advance disease treatment protocols. In this review, key quantitative methods for AF analysis are described, and suggestions are provided for the coordination of the available information, and to develop foci and directions for future research efforts. Quantitative biologists may have an interest in this topic in order to develop machine learning and tools for arrhythmia characterization, but they may perhaps have a minimal background in the clinical methodology and in the types of observed events and mechanistic hypotheses that have thus far been developed. We attempt to address these issues via exploration of the published literature. Although no new data is presented in this review, examples are shown of current lines of investigation, and in particular, how electrogram analysis and whole-chamber quantitative modeling of the left atrium may be useful to characterize fibrillatory patterns of activity, so as to propose avenues for more efficacious acquisition and interpretation of AF data.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - U Rajendra Acharya
- Department of Electronics and Computer Engineering, Ngee Ann Polytechnic, Singapore
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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Patel K, Romero J, Di Biase L. Persistent atrial fibrillation: should we always ice the back of the left atrium? J Interv Card Electrophysiol 2019; 56:95-97. [PMID: 31342223 DOI: 10.1007/s10840-019-00586-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Kavisha Patel
- Division of Cardiology, Albert Einstein College of Medicine at Montefiore Hospital, 111 East 210th St, Bronx, NY, USA
| | - Jorge Romero
- Division of Cardiology, Albert Einstein College of Medicine at Montefiore Hospital, 111 East 210th St, Bronx, NY, USA
| | - Luigi Di Biase
- Division of Cardiology, Albert Einstein College of Medicine at Montefiore Hospital, 111 East 210th St, Bronx, NY, USA.
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Mouws EMJP, Kik C, van der Does LJME, Lanters EAH, Teuwen CP, Knops P, Bogers AJJC, de Groot NMS. Novel Insights in the Activation Patterns at the Pulmonary Vein Area. Circ Arrhythm Electrophysiol 2018; 11:e006720. [PMID: 30520348 DOI: 10.1161/circep.118.006720] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extensiveness of conduction delay and block at the pulmonary vein area (PVA) was quantified in a previous study. We hypothesized that the combination of lines of conduction block with multiple concomitantly entering sinus rhythm wavefronts at the PVA may result in increased arrhythmogenicity and susceptibility to atrial fibrillation (AF). METHODS Intraoperative high-density epicardial mapping of PVA (N≈450 sites, interelectrode distances: 2 mm) was performed during sinus rhythm in 327 patients (241 male [74%], 67±10 [21-84] years) with and without preoperative AF. For each patient, activation patterns at the PVA were quantified, including the location of entry sites of wavefronts, direction of propagation, and their relative activation times. The association between activation patterns and the presence of AF was examined. RESULTS Excitation of the PVA occurred via multiple consecutive wavefronts in the vast majority of patient (N=216, 81%). In total, 561 wavefronts were observed, which mostly propagated through the septal or paraseptal regions towards the PVA (N=461, 82%). A substantial dissociation of consecutive wavefronts was observed with Δactivation times of 10.6±8.8 (0-46) ms. No difference was observed in Δactivation times of consecutive wavefronts during sinus rhythm between patients without and with AF. An excitation-based risk factor model, including conduction delay ≥6 mm, conduction block ≥6 mm, and conduction delay and block ≥16 mm, wavefronts via the posteroinferior to posterosuperior regions and multiple opposing wavefronts, demonstrated a 5-fold risk of AF when multiple risk factors were present. CONCLUSIONS In contrast to previous findings, quantification of activation patterns at the PVA on high-resolution scale demonstrated complex patterns with often multiple entry sites and high interindividual variability. Altered patterns of activation, consisting of multiple opposing wavefronts combined with long lines of conduction slowing, were associated with the presence of AF.
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Affiliation(s)
- Elisabeth M J P Mouws
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.).,Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., C.K., A.J.J.C.B.)
| | - Charles Kik
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., C.K., A.J.J.C.B.)
| | - Lisette J M E van der Does
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Eva A H Lanters
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Christophe P Teuwen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., C.K., A.J.J.C.B.)
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (E.M.J.P.M., L.J.M.E.v.d.D., E.A.H.L., C.P.T., P.K., N.M.S.d.G.)
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Verma A, Macle L. Persistent Atrial Fibrillation Ablation: Where Do We Go From Here? Can J Cardiol 2018; 34:1471-1481. [PMID: 30404751 DOI: 10.1016/j.cjca.2018.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 01/16/2023] Open
Abstract
Catheter ablation is being used increasingly for the treatment of atrial fibrillation (AF). Pulmonary vein antral isolation is considered the "cornerstone" for the ablation of AF. This approach has demonstrated consistent rates of success for paroxysmal AF, but the rates of success for persistent AF are lower. There has long been a hypothesis that additional ablation beyond pulmonary vein isolation is required to achieve better outcomes in the population with persistent AF. However, large clinical trials have demonstrated recently that such approaches as empiric linear ablation and/or ablation of complex fractionated electrograms may add no benefit over pulmonary vein isolation alone in persistent AF. Furthermore, new technologies are improving the durability and outcome of pulmonary vein isolation alone. These observations have endorsed a search for new potential targets for adjuvant ablation, which currently include ablation of dynamic phenomena during AF such as rotational and focal activations, ablation of scar regions in the atria, isolation of the left atrial posterior wall, and ablation of nonpulmonary vein triggers. Whether any of these additional approaches will add to the success of ablation for persistent AF is unknown. Smaller study results are mixed. Only the performance of large-scale randomized trials will definitively answer whether additional ablation over pulmonary vein isolation alone with improve outcomes for persistent AF.
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Affiliation(s)
- Atul Verma
- Southlake Regional Health Centre, University of Toronto, Newmarket, Ontario, Canada.
| | - Laurent Macle
- Montréal Heart Institute, University of Montréal, Montréal, Québec, Canada
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