1
|
Vonderlin N, Siebermair J, Mahabadi AA, Dobrev D, Rassaf T, Wakili R, Kochhaeuser S. Outcome after ablation of atypical atrial flutter: Is induction a feasible approach? INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2024; 54:101489. [PMID: 39238839 PMCID: PMC11375277 DOI: 10.1016/j.ijcha.2024.101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/18/2024] [Accepted: 08/08/2024] [Indexed: 09/07/2024]
Abstract
Background Atypical atrial flutter (AAF) is an increasingly relevant clinical problem. Despite advancements in mapping and ablation techniques, the general management of these patients remain challenging especially when mapping cannot be performed during ongoing arrhythmia. There are no data whether induction of AAF is a feasible approach in these cases. Methods We retrospectively analyzed patients who underwent catheter ablation of AAF and compared procedural results between patients with ongoing tachycardia when starting the procedure and patients with induced AAF. Results We analyzed 97 ablation procedures performed in 76 patients with a mean follow-up of 13.2 ± 12.2 months. In 68 procedures (70.1 %) AAF was ongoing at the beginning of the procedure and in 29 cases (29.9 %) AAF had to be induced.There was no statistically significant difference regarding acute procedural success. The recurrence rate of any arrhythmia during follow-up was significantly higher after ablation of ongoing AAF compared to induced AAF (63.2 % vs. 42.9 %; p = 0.047) driven by a significant higher rate of AAF-recurrence (57.4 % vs. 34.5 %; p = 0.039). The number of ablated tachycardias per patient as well as the number of de-novo tachycardias found during re-ablation showed no significant difference between both groups. Conclusion Starting a procedure with ongoing arrhythmia did not result in better short- or mid-term outcome in patients undergoing AAF ablation. Furthermore, based on our results inducing AAF seems a legitimate approach for AAF ablation in patients presenting in sinus rhythm.
Collapse
Affiliation(s)
- N Vonderlin
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
- German Centre for Cardiovascular Research (DZHK), Germany
| | - J Siebermair
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
- German Centre for Cardiovascular Research (DZHK), Germany
| | - A A Mahabadi
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
| | - D Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Germany
- Department of Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX, United States
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
| | - T Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
| | - R Wakili
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
- German Centre for Cardiovascular Research (DZHK), Germany
- Department of Medicine and Cardiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - S Kochhaeuser
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University of Essen Medical School, University Duisburg-Essen, Essen, Germany
- Department of Cardiology, Niels Stensen Kliniken, Marienhospital Osnabrück, Osnabrück, Germany
| |
Collapse
|
2
|
Ghazzal BZ, Refaat MM. Atypical atrial flutter ablation: The clinical impact of high-density mapping. J Cardiovasc Electrophysiol 2024. [PMID: 39075790 DOI: 10.1111/jce.16382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Accepted: 07/17/2024] [Indexed: 07/31/2024]
Affiliation(s)
- Bahjat Z Ghazzal
- Department of Internal Medicine, Division of Cardiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Marwan M Refaat
- Department of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
3
|
Zhou D, Zhang B, Zeng C, Yin X, Guo X. A novel approach to terminate roof-dependent atrial flutter with epicardial conduction through septopulmonary bundle. BMC Cardiovasc Disord 2024; 24:340. [PMID: 38970012 PMCID: PMC11225292 DOI: 10.1186/s12872-024-03941-9] [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: 01/22/2024] [Accepted: 05/14/2024] [Indexed: 07/07/2024] Open
Abstract
Atrial flutter, a prevalent cardiac arrhythmia, is primarily characterized by reentrant circuits in the right atrium. However, atypical forms of atrial flutter present distinct challenges in terms of diagnosis and treatment. In this study, we examine three noteworthy clinical cases of atypical atrial flutter, which offer compelling evidence indicating the implication of the lesser-known Septopulmonary Bundle (SPB). This inference is based on the identification of distinct electrocardiographic patterns observed in these patients and their favorable response to catheter ablation, which is a standard treatment for atrial flutter. Remarkably, in each case, targeted ablation at the anterior portion of the left atrial roof effectively terminated the arrhythmia, thus providing further support for the hypothesis of SPB involvement. These insightful observations shed light on the potential significance of the SPB in the etiology of atypical atrial flutter and introduce a promising therapeutic target. We anticipate that this paper will stimulate further exploration into the role of the SPB in atrial flutter and pave the way for the development of targeted ablation strategies.
Collapse
Affiliation(s)
- Dongchen Zhou
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou City, Zhejiang Province, 310002, China
| | - Biqi Zhang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou City, Zhejiang Province, 310002, China
| | - Cong Zeng
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou City, Zhejiang Province, 310002, China
| | - Xiang Yin
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou City, Zhejiang Province, 310002, China
| | - Xiaogang Guo
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Shangcheng District, Hangzhou City, Zhejiang Province, 310002, China.
| |
Collapse
|
4
|
Sink J, Culler K, Uppalapati L, Lancki N, Peigh G, Lohrmann G, Elsayed M, Carneiro H, Baman J, Pfenniger A, Patil KD, Verma N, Arora R, Kim SS, Chicos AB, Lin AC, Knight BP, Passman RS. Association between high-density mapping of atypical atrial flutter, clinical outcomes and healthcare utilization. J Cardiovasc Electrophysiol 2024. [PMID: 38965878 DOI: 10.1111/jce.16355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 06/07/2024] [Accepted: 06/20/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Success of atypical atrial flutter (AAFL) ablation has historically been limited by difficulty mapping the complex re-entrant circuits involved. While high-density (HD) mapping has become commonplace in clinical practice, there are limited data on outcomes of HD versus non-HD mapping for AAFL ablation. OBJECTIVE To compare clinical outcomes and healthcare utilization using HD mapping versus non-HD mapping for AAFL ablation. METHODS Retrospective analysis of all AAFL procedures between 2005 and 2022 at an academic medical center was conducted. Procedures utilizing a 16-electrode HD Grid catheter and Precision mapping system were compared to procedures using prior generation 10-20 electrode spiral catheters and the Velocity system (Abbott, IL). Cox regression models and Poisson regression models were utilized to examine procedural and healthcare utilization outcomes. Models were adjusted for left ventricular ejection fraction, CHA2DS2-VASc, and history of prior ablation. RESULTS There were 108 patients (62% HD mapping) included in the analysis. Baseline clinical characteristics were similar between groups. Use of HD mapping was associated with a higher rate of AAFL circuit delineation (92.5% vs. 76%; p = .014) and a greater adjusted procedure success rate, defined as non-inducibility at procedure end, (aRR (95% CI) 1.26 (1.02-1.55) p = .035) than non-HD mapping. HD mapping was also associated with a lower rate of ED visits (aIRR (95% CI) 0.32 (0.14-0.71); p = .007) and hospitalizations (aIRR (95% CI) 0.32 (0.14-0.68); p = .004) for AF/AFL/HF through 1 year. While there was a lower rate of recurrent AFL through 1 year among HD mapping cases (aHR (95% CI) 0.60 (0.31-1.16) p = .13), statistical significance was not met likely due to the low sample size and higher rate of ambulatory rhythm monitoring in the HD group (61% vs. 39%, p = .025). CONCLUSION Compared to non-HD mapping, AAFL ablation with HD mapping is associated with improvements in the ability to define the AAFL circuit, greater procedural success, and a reduction in the number of ED visits and hospitalization for AF/AFL/HF.
Collapse
Affiliation(s)
- Joshua Sink
- Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kasen Culler
- Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Nicola Lancki
- Department of Preventative Medicine, Northwestern University, Chicago, Illinois, USA
| | - Graham Peigh
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Graham Lohrmann
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Mahmoud Elsayed
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Herman Carneiro
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Jayson Baman
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Anna Pfenniger
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Kaustubha D Patil
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Nishant Verma
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rishi Arora
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Susan S Kim
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | | | - Albert C Lin
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Bradley P Knight
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| | - Rod S Passman
- Division of Cardiology, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
5
|
Preda A, Bonvicini E, Coradello E, Testoni A, Gigli L, Baroni M, Carbonaro M, Vargiu S, Varrenti M, Colombo G, Paolucci M, Mazzone P, Guarracini F. The Fluoroless Future in Electrophysiology: A State-of-the-Art Review. Diagnostics (Basel) 2024; 14:182. [PMID: 38248058 PMCID: PMC10814721 DOI: 10.3390/diagnostics14020182] [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: 12/16/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/23/2024] Open
Abstract
Fluoroscopy has always been the cornerstone imaging method of interventional cardiology procedures. However, radiation exposure is linked to an increased risk of malignancies and multiorgan diseases. The medical team is even more exposed to X-rays, and a higher incidence of malignancies was reported in this professional group. In the last years, X-ray exposure has increased rapidly, involving, above all, the medical team and young patients and forcing alternative fluoroless imaging methods. In cardiac electrophysiology (EP) and pacing, the advent of 3D electroanatomic mapping systems with dedicated catheters has allowed real-time, high-density reconstruction of both heart anatomy and electrical activity, significantly reducing the use of fluoroscopy. In addition, the diffusion of intracardiac echocardiography has provided high anatomical resolution of moving cardiac structures, providing intraprocedural guidance for more complex catheter ablation procedures. These methods have largely demonstrated safety and effectiveness, allowing for a dramatic reduction in X-ray delivery in most arrhythmias' ablations. However, some technical concerns, as well as higher costs, currently do not allow their spread out in EP labs and limit their use to only procedures that are considered highly complex and time-consuming and in young patients. In this review, we aim to update the current employment of fluoroless imaging in different EP procedures, focusing on its strengths and weaknesses.
Collapse
Affiliation(s)
- Alberto Preda
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Eleonora Bonvicini
- Division of Cardiology, Department of Medicine, Verona University Hospital, 37129 Verona, Italy
| | - Elena Coradello
- Division of Cardiology, Department of Medicine, Verona University Hospital, 37129 Verona, Italy
| | - Alessio Testoni
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Lorenzo Gigli
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Matteo Baroni
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marco Carbonaro
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Sara Vargiu
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marisa Varrenti
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Giulia Colombo
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Marco Paolucci
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy (M.C.); (P.M.)
| |
Collapse
|
6
|
Hopman LHGA, van Pouderoijen N, Mulder MJ, van der Laan AM, Bhagirath P, Nazarian S, Niessen HWM, Ferrari VA, Allaart CP, Götte MJW. Atrial Ablation Lesion Evaluation by Cardiac Magnetic Resonance: Review of Imaging Strategies and Histological Correlations. JACC Clin Electrophysiol 2023; 9:2665-2679. [PMID: 37737780 DOI: 10.1016/j.jacep.2023.08.013] [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: 07/21/2023] [Accepted: 08/09/2023] [Indexed: 09/23/2023]
Abstract
Cardiac magnetic resonance (CMR) imaging is a valuable noninvasive tool for evaluating tissue response following catheter ablation of atrial tissue. This review provides an overview of the contemporary CMR strategies to visualize atrial ablation lesions in both the acute and chronic postablation stages, focusing on their strengths and limitations. Moreover, the accuracy of CMR imaging in comparison to atrial lesion histology is discussed. T2-weighted CMR imaging is sensitive to edema and tends to overestimate lesion size in the acute stage after ablation. Noncontrast agent-enhanced T1-weighted CMR imaging has the potential to provide more accurate assessment of lesions in the acute stage but may not be as effective in the chronic stage. Late gadolinium enhancement imaging can be used to detect chronic atrial scarring, which may inform repeat ablation strategies. Moreover, novel imaging strategies are being developed, but their efficacy in characterizing atrial lesions is yet to be determined. Overall, CMR imaging has the potential to provide virtual histology that aids in evaluating the efficacy and safety of catheter ablation and monitoring of postprocedural myocardial changes. However, technical factors, scanning during arrhythmia, and transmurality assessment pose challenges. Therefore, further research is needed to develop CMR strategies to visualize the ablation lesion maturation process more effectively.
Collapse
Affiliation(s)
| | | | - Mark J Mulder
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Pranav Bhagirath
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Saman Nazarian
- Penn Cardiovascular Institute, Penn Heart and Vascular Center, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, USA
| | - Hans W M Niessen
- Department of Pathology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Victor A Ferrari
- Penn Cardiovascular Institute, Penn Heart and Vascular Center, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania, USA
| | | | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands.
| |
Collapse
|
7
|
Raymond-Paquin A, Pillai A, Myadam R, Mankad P, Lovejoy S, Koneru JN, Ellenbogen KA. Atypical atrial flutter catheter ablation in the era of high-density mapping. J Interv Card Electrophysiol 2023; 66:1807-1815. [PMID: 36645578 DOI: 10.1007/s10840-023-01475-2] [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: 11/04/2022] [Accepted: 01/10/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Mapping and ablating atypical atrial flutters (AAFLs) have evolved greatly with advances in high-density 3D mapping systems over the last years. METHODS The objectives are to evaluate the feasibility of AAFL catheter ablation based on high-density mapping and minimizing entrainment and to better characterize AAFL circuits. Consecutive patients who underwent AAFL ablation using the EnSite Precision™ system and HD Grid™ mapping catheter (Abbott, Chicago, IL) between 06/2018 and 1/2022 were included. Mitral isthmus-dependent and roof-dependent AAFLs were classified as conventional circuits. All other AAFL circuits were classified as non-conventional circuits and were defined based on the location of the critical isthmus. RESULTS Sixty-two patients underwent AAFL ablation (mean age 68±11 years). A total of 95 AAFLs were mapped and 92 (97%) were successfully ablated. Fifty-three (85%) patients had a previous AF/AFL ablation. Forty-four (46%) AAFL circuits were classified as conventional and 51 (54%) as non-conventional. Conventional AAFL circuits had longer critical isthmuses (19.0±9.0 vs 10.8±6.3mm, p<0.001), a lower prevalence of slow conduction at the critical isthmus (59% vs 86%, p=0.005), and a longer radiofrequency time to AAFL termination (117±119 vs 51±66 s, p=0.002). Entrainment was attempted in 19 (20%) flutters and its use declined significantly over the study period. Procedural success rates remained high whether entrainment was used or not. Freedom of any atrial tachycardia was 65% over a follow-up of 13.8±9.0 months. CONCLUSIONS AAFL catheter ablation can be achieved with high procedural success rate using a contemporary strategy based on high-density mapping alone. Non-conventional circuits are frequent and present unique electrophysiological characteristics.
Collapse
Affiliation(s)
- Alexandre Raymond-Paquin
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA.
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Bélanger Street, Montreal, Quebec, H1T 1C8, Canada.
| | - Ajay Pillai
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Rahul Myadam
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Pranav Mankad
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Jayanthi N Koneru
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
8
|
Risk factors and Management of Mitral Annular Atrial Flutter After Mitral Valve Surgery. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00696-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|