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Rivera A, Gewehr DM, Braga MAP, Carvalho PEP, Ternes CMP, Pantaleao AN, Hincapie D, Serpa F, Romero JE, d'Avila A. Adjunctive low-voltage area ablation for patients with atrial fibrillation: An updated meta-analysis of randomized controlled trials. J Cardiovasc Electrophysiol 2024; 35:1329-1339. [PMID: 38664888 DOI: 10.1111/jce.16290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/29/2024] [Accepted: 04/16/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The efficacy and safety of adjunctive low-voltage area (LVA) ablation on outcomes of catheter ablation (CA) for atrial fibrillation (AF) remains uncertain. METHODS PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing CA with versus without LVA ablation for patients with AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. Our primary endpoint was recurrence of atrial tachyarrhythmia (ATA), including AF, atrial flutter, or atrial tachycardia. We used R version 4.3.1 for all statistical analyses. RESULTS Our meta-analysis included 10 RCTs encompassing 1780 patients, of whom 890 (50%) were randomized to LVA ablation. Adjunctive LVA ablation significantly reduced recurrence of ATA (RR 0.76; 95% CI 0.67-0.88; p < .01) and reduced the number of redo ablation procedures (RR 0.54; 95% CI 0.35-0.85; p < .01), as compared with conventional ablation. Among 691 (43%) patients with documented LVAs on baseline substrate mapping, adjunctive LVA ablation substantially reduced ATA recurrences (RR 0.57; 95% CI 0.38-0.86; p < .01). There was no significant difference between groups in terms of periprocedural adverse events (RR 0.78; 95% CI 0.39-1.56; p = .49). CONCLUSIONS Adjunctive LVA ablation is an effective and safe strategy for reducing recurrences of ATA among patients who undergo CA for AF.
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Affiliation(s)
- André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Marcelo A P Braga
- Department of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro E P Carvalho
- Center for Coronary Artery Disease, Minneapolis Heart Institute Foundation, Minneapolis, USA
| | - Caique M P Ternes
- Postgraduate Program in Cardiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexandre N Pantaleao
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniela Hincapie
- Harvard Medical School, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts, USA
| | - Frans Serpa
- Division of Cardiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jorge E Romero
- Harvard Medical School, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts, USA
| | - André d'Avila
- Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Bussa R, Nudy M, Ahmed M, Bussa J, Wheaten S, Zimmerman E, Gonzalez MD, Naccarelli GV, Maheshwari A. Pulmonary vein isolation plus adjunctive therapy for the treatment of atrial fibrillation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2024; 67:523-537. [PMID: 37540340 DOI: 10.1007/s10840-023-01609-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/15/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the primary technique for ablation of atrial fibrillation (AF). It is unclear whether adjunctive therapies in addition to PVI can reduce atrial arrhythmia recurrence (AAR) compared to PVI alone in patients with AF. METHODS A meta-analysis of randomized controlled trials comparing PVI plus an adjunctive therapy (autonomic modulation, linear ablation, non-pulmonary vein trigger ablation, epicardial PVI [hybrid ablation], or left atrial substrate modification) to PVI alone was conducted. The primary outcome was AAR. Cumulative odd's ratios (OR) and 95% confidence intervals (CI) were calculated for each treatment type. RESULTS Forty-six trials were identified that included 8,500 participants. The mean age (± standard deviation) was 60.2 (±4.1) years, and 27.2% of all patients were female. The mean follow-up time was 14.6 months. PVI plus autonomic modulation and PVI plus hybrid ablation were associated with a relative 53.1% (OR 0.47; 95% CI 0.32 to 0.69; p < 0.001) and 59.1% (OR 0.41; 95% CI 0.23 to 0.75; p = 0.003) reduction in AAR, respectively, compared to PVI alone. All categories had at least moderate interstudy heterogeneity except for hybrid ablation. CONCLUSION Adjunctive autonomic modulation and epicardial PVI may improve the effectiveness of PVI. Larger, multi-center randomized controlled trials are needed to evaluate the efficacy of these therapies.
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Affiliation(s)
- Rahul Bussa
- Department of Internal Medicine, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - Matthew Nudy
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA, USA
- Department of Public Health Sciences, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Mohammad Ahmed
- Department of Internal Medicine, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Jatin Bussa
- Department of Biochemistry and Molecular Biology, University of Massachusetts Amherst, Amherst, MA, USA
| | - Sterling Wheaten
- Department of Internal Medicine, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Eric Zimmerman
- Department of Internal Medicine, Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Mario D Gonzalez
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA, USA
| | - Gerald V Naccarelli
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA, USA
| | - Ankit Maheshwari
- Division of Cardiology, Penn State Hershey Medical Center, Heart and Vascular Institute, Hershey, PA, USA
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Starek Z, Di Cori A, Betts TR, Clerici G, Gras D, Lyan E, Della Bella P, Li J, Hack B, Zitella Verbick L, Sommer P. Baseline left atrial low-voltage area predicts recurrence after pulmonary vein isolation: WAVE-MAP AF results. Europace 2023; 25:euad194. [PMID: 37470443 PMCID: PMC10410193 DOI: 10.1093/europace/euad194] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 07/21/2023] Open
Abstract
AIMS Electro-anatomical mapping may be critical to identify atrial fibrillation (AF) subjects who require substrate modification beyond pulmonary vein isolation (PVI). The objective was to determine correlations between pre-ablation mapping characteristics and 12-month outcomes after a single PVI-only catheter ablation of AF. METHODS AND RESULTS This study enrolled paroxysmal AF (PAF), early persistent AF (PsAF; 7 days-3 months), and non-early PsAF (>3-12 months) subjects undergoing de novo PVI-only radiofrequency catheter ablation. Sinus rhythm (SR) and AF voltage maps were created with the Advisor HD Grid™ Mapping Catheter, Sensor Enabled™ for each subject, and the presence of low-voltage area (LVA) (low-voltage cutoffs: 0.1-1.5 mV) was investigated. Follow-up visits were at 3, 6, and 12 months, with a 24-h Holter monitor at 12 months. A Cox proportional hazards model identified associations between mapping data and 12-month recurrence after a single PVI procedure. The study enrolled 300 subjects (113 PAF, 86 early PsAF, and 101 non-early PsAF) at 18 centres. At 12 months, 75.5% of subjects were free from AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence. Univariate analysis found that arrhythmia recurrence did not correlate with AF diagnosis, but LVA was significantly correlated. Low-voltage area (<0.5 mV) >28% of the left atrium in SR [hazard ratio (HR): 4.82, 95% confidence interval (CI): 2.08-11.18; P = 0.0003] and >72% in AF (HR: 5.66, 95% CI: 2.34-13.69; P = 0.0001) was associated with a higher risk of AF/AFL/AT recurrence at 12 months. CONCLUSION Larger extension of LVA was associated with an increased risk of arrhythmia recurrence. These subjects may benefit from substrate modification beyond PVI.
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Affiliation(s)
- Zdenek Starek
- International Clinical Research Center, St. Anne’s University Hospital Brno, Pekarska 664/53, Brno 60200, Czech Republic
- First Department of Internal Medicine/Cardioangiology, St. Anne’s Hospital, Masaryk University, Pekarska 664/53, Brno 60200, Czech Republic
| | - Andrea Di Cori
- Second Division of Cardiovascular Diseases, Cardiac-Thoracic and Vascular Department, New Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Timothy R Betts
- Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Gael Clerici
- Cardiology Department, Rhythmology Unit, Centre Hospitalier Universitaire de La Reunion, La Reunion, France
| | - Daniel Gras
- Department of Cardiology, Hopital Prive du Confluent, Nantes, France
| | - Evgeny Lyan
- Department of Cardiology, Section of Electrophysiology, Herz-und Gefäßzentrum Bad Bevensen, Bad Bevensen, Germany
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milano, Italy
| | | | | | | | - Philipp Sommer
- Department for Electrophysiology, Herz-und Diabetes Zentrum NRW, Bad Oeynhausen, Germany
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Cheng WH, Liao YC, Chen SA. Midline ablation beyond pulmonary vein isolation? "The MiLine study". Heart Rhythm 2023; 20:666-667. [PMID: 36736938 DOI: 10.1016/j.hrthm.2023.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Wen-Han Cheng
- Division of Cardiology, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, Yilan, Taiwan; Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ying-Chieh Liao
- Division of Cardiology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; Department of Post Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Post Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.
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Risk and benefit of extrapulmonary vein ablation in atrial fibrillation. Curr Opin Cardiol 2023; 38:1-5. [PMID: 36598443 DOI: 10.1097/hco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the recent development, benefit, and safety of extrapulmonary vein ablation for atrial fibrillation. RECENT FINDING Studies have shown that extrapulmonary vein ablation can help maintain normal sinus rhythm for patients with persistent atrial fibrillation. As prior strategies targeting anatomical lines and triggers are well utilized, novel techniques for substrate mapping have been rapidly developing. These strategies are well tolerated and could be chosen based on patients' conditions and physicians' experience. SUMMARY Extrapulmonary vein ablation could be safely and effectively performed for patients with atrial fibrillation. It provides further consolidation of normal sinus rhythm.
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Zhou Y, Zhang H, Yan P, Zhou P, Wang P, Li X. Efficacy of left atrial low-voltage area-guided catheter ablation of atrial fibrillation: An updated systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:993790. [DOI: 10.3389/fcvm.2022.993790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022] Open
Abstract
AimsThis study aimed to evaluate the efficacy of low-voltage area (LVA)-guided substrate modification catheter ablation in patients with atrial fibrillation (AF).MethodsSystematic searches of the PubMed, EMBASE, and Cochrane databases were performed from inception to July 2022 for all available studies. The effect estimates were combined with the Mantel–Haenszel random-effects model. Subgroup analyses, sensitivity analysis, and meta-regression were conducted to explore the sources of statistical heterogeneity.ResultsA total of 16 studies involving 1942 subjects (mean age: 61 ± 10 years, 69% male) were identified. All studies included patients with paroxysmal AF, non-paroxysmal AF, or both. At a mean follow-up of 18.9 months, patients who underwent LVA-guided substrate modification ablation had significantly higher freedom from all-atrial tachycardia recurrence than patients who underwent control ablation [67.7% vs. 48.9%, risk ratios (RR) 0.64, 95% confidence interval (CI) 0.55–0.76, P < 0.001], with 36% relative risk and 18.7% absolute risk reductions in all-atrial tachycardia recurrence. Subgroup analysis based on AF types demonstrated that the decreased risk of all-atrial tachycardia recurrence was present predominantly in non-paroxysmal AF compared with paroxysmal AF (RR 0.60, 95% CI 0.52–0.69 vs. RR 0.96, 95% CI 0.81–1.13).ConclusionLow-voltage area-guided substrate modification ablation combined with PVI appears to have a significant beneficial effect of improving freedom from all-atrial tachycardia recurrence, especially in patients with non-paroxysmal AF.
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Huo Y, Gaspar T, Schönbauer R, Wójcik M, Fiedler L, Roithinger FX, Martinek M, Pürerfellner H, Kirstein B, Richter U, Ulbrich S, Mayer J, Krahnefeld O, Agdirlioglu T, Zedda A, Piorkowski J, Piorkowski C. Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation. NEJM EVIDENCE 2022; 1:EVIDoa2200141. [PMID: 38319851 DOI: 10.1056/evidoa2200141] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Clinically effective ablation approaches for patients with persistent atrial fibrillation (AF) are still being debated. So far, ablation targets and strategies beyond pulmonary vein isolation (PVI) have failed to show systematic outcome improvement in randomized controlled clinical trials. METHODS: We conducted a multicenter, randomized trial to determine whether PVI plus individualized substrate ablation of atrial low-voltage myocardium improves outcome in patients with persistent AF. We randomly assigned 324 patients in a 1:1 ratio to receive PVI alone (163 patients; PVI only) or PVI plus substrate modification (161 patients; PVI+SM). The primary study end point was the first recurrence of an atrial arrhythmia longer than 30 seconds after single ablation, with 3 months blanking, using serial 7-day electrocardiogram recordings over 12 months of observation. Patients were also encouraged to receive implantable cardiac monitors. RESULTS: The primary study end point occurred in 75 PVI-only patients (50%) and in 54 PVI+SM patients (35%) (Kaplan–Meier event rate estimates: hazard ratio=0.62, 95% confidence interval [CI]=0.43 to 0.88, log rank P=0.006). Adverse events occurred in three PVI-only patients (1.8%) and in six PVI+SM patients (3.7%) (difference: −1.9 percentage points, 95% CI=−5.5 to 1.7 percentage points). Implant monitoring was used in 242 patients. Among them, 65 PVI-only patients (55%) versus 47 PVI+SM patients (39%) experienced recurrences (difference: 15 percentage points, 95% CI=3 to 28 percentage points). CONCLUSIONS: In this randomized trial, PVI plus individualized ablation of atrial low-voltage myocardium significantly improved outcomes in patients with persistent AF. (ClinicalTrials.gov number, NCT02732626.)
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Affiliation(s)
- Yan Huo
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Thomas Gaspar
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Robert Schönbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna
| | - Maciej Wójcik
- Department of Cardiology, Medical University in Lublin, Lublin, Poland
| | - Lukas Fiedler
- Department of Internal Medicine II, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- University Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Franz Xaver Roithinger
- Department of Internal Medicine II, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Martin Martinek
- Department of Internal Medicine 2, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Helmut Pürerfellner
- Department of Internal Medicine 2, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Bettina Kirstein
- Heart Center, University Hospital Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Utz Richter
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Stefan Ulbrich
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Julia Mayer
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Olaf Krahnefeld
- Department of Electrophysiology, Sana Kliniken Lübeck, Lübeck, Germany
| | - Tolga Agdirlioglu
- Department of Electrophysiology, Sana Kliniken Lübeck, Lübeck, Germany
| | - Angela Zedda
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
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Theofilis P, Oikonomou E, Antonopoulos AS, Siasos G, Tsioufis K, Tousoulis D. Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives. Biomedicines 2022; 10:biomedicines10092268. [PMID: 36140368 PMCID: PMC9496262 DOI: 10.3390/biomedicines10092268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.
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Affiliation(s)
- Panagiotis Theofilis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Alexios S. Antonopoulos
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
- Correspondence:
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