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de Leon A, Hanson M, Alhammad N, Bakker D, Chacko S, Simpson C, Abdollah H, Baranchuk A, Redfearn D, Glover B, Enriquez A, Neira V. Half-Normal Saline vs Normal Saline for Cavotricuspid Isthmus-Dependent Atrial Flutter Ablation. CJC Open 2023; 5:965-970. [PMID: 38204850 PMCID: PMC10774089 DOI: 10.1016/j.cjco.2023.09.013] [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: 08/18/2023] [Accepted: 09/21/2023] [Indexed: 01/12/2024] Open
Abstract
Background Cavotricuspid isthmus (CTI) ablation requires permanent bidirectional block to prevent recurrence of typical atrial flutter (AFL). Catheter irrigation with half-normal saline (HNS) produces larger and deeper lesions in experimental models compared with normal saline (NS). This study was performed to compare the clinical efficacy and safety of HNS vs NS irrigation for typical AFL ablation. Methods Sixty patients undergoing catheter ablation of typical AFL were randomized 1:1 to NS or HNS irrigation. Endpoints included time to CTI block, acute reconnection, incidence of steam pops, and recurrence of AFL during follow-up. Results Baseline characteristics were comparable between both arms. The mean age of the patients was 68.5 ± 8.2 years, 20% were female, and 32% had atrial fibrillation before being enrolled. Bidirectional CTI block was obtained in all patients with no difference in time to CTI block between groups (6.4 ± 4.4 minutes vs 7.6 ± 4.5 minutes, respectively; P = 0.15). There was a trend to less acute reconnection in the HNS group compared with NS (13.3% vs 26.6%; P = 0.46). Steam pops occurred in 4 patients using HNS vs none in the NS group, but no major complications were observed. During the follow-up, rate of AFL recurrence was similar between groups (6.7% with HNS vs 10% with NS; P = 0.5). There was no difference in time to recurrence (7.6 ± 6.9 vs 4.9 ± 4.5 months; P = 0.6). Conclusions In this small pilot randomized controlled trial, there was no significant difference between HNS and NS for CTI ablation; however, HNS may increase the incidence of steam pops.
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Affiliation(s)
- Ana de Leon
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Matthew Hanson
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Nasser Alhammad
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - David Bakker
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Sanoj Chacko
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | | | - Hoshiar Abdollah
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Damian Redfearn
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Benedict Glover
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
| | - Victor Neira
- Division of Cardiology, Queen’s University, Kingston, Ontario, Canada
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Sumi H, Hoshiyama T, Morihisa K, Noda K, Kaneko S, Kanazawa H, Ishii M, Fujisue K, Sueta D, Takashio S, Usuku H, Matsushita K, Tsujita K. Effect of contact vector direction on achieving cavotricuspid isthmus block. Sci Rep 2023; 13:2579. [PMID: 36781935 PMCID: PMC9925428 DOI: 10.1038/s41598-023-29738-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Cavotricuspid isthmus (CTI) ablation is an important treatment strategy for CTI-dependent atrial flutter (AFL). The location of the catheter contact area is confirmed by the contact vector direction (CVD) through three-dimensional mapping during the procedure. However, the relationship between CVD during radiofrequency ablation and its efficacy in achieving CTI block has not been clarified. This study aimed to investigate the relationship between CVD and efficacy in achieving CTI block. CVDs during radiofrequency ablation were divided into proximal vectors against the distal tip (P-vector) and other vectors (normal-vector). In 39 patients who underwent CTI linear ablation, the CTIs were divided into two segments: the tricuspid valve area (anterior) and inferior vena cava area (posterior). The frequency of the residual conduction gap was compared between segments in which the P- and normal-vectors were observed. P-vectors were observed in 13 of the 78 segments. The median ablation index was not significantly different between segments in which the P-vector and normal-vector were observed (398.2 [384.2-402.2] vs. 393.3 [378.3-400.1], p = 0.15). However, residual conduction gaps were significantly more frequently observed in the segment in which the P-vector was observed than those in which only the normal-vector was observed (6/13, 46.2% vs. 3/65, 4.6%; p < 0.01). During a 6-month follow-up, two patients required a second session of ablation due to AFL recurrence. A residual conduction gap was observed in one patient at the site where the P-vector was observed in the first session. Avoiding the P-vector might be an important factor in improving CTI block and reducing AFL recurrence.
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Affiliation(s)
- Hitoshi Sumi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Tadashi Hoshiyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan.
| | - Kenji Morihisa
- Kumamoto Chuo Hospital, 1-5-1, Tainoshima Minami-Ku, Kumamoto, 862-0965, Japan
| | - Katsuo Noda
- Kumamoto Chuo Hospital, 1-5-1, Tainoshima Minami-Ku, Kumamoto, 862-0965, Japan
| | - Shozo Kaneko
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Koichiro Fujisue
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-Ku, Kumamoto, 860-8556, Japan
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Ho SY. Normal and Abnormal Atrial Anatomy Relevant to Atrial Flutters: Areas of Physiological and Acquired Conduction Blocks and Delays Predisposing to Re-entry. Card Electrophysiol Clin 2022; 14:375-384. [PMID: 36153120 DOI: 10.1016/j.ccep.2022.03.001] [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: 11/15/2022]
Abstract
This article reviews the structure of the atrial chambers to consider the anatomic bases for obstacles and barriers in atrial flutter. In particular, the complex myocardial arrangement and composition of the cavotricuspid isthmus could account for a slow zone of conduction. Prominent muscle bundles within the atria and interatrial, and myoarchitecture of the walls, could contribute to preferential conduction pathways. Alterations from tissue damage as part of aging, or from surgical interventions could lead to re-entry.
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Affiliation(s)
- S Yen Ho
- Royal Brompton Hospital, Imperial College London, Sydney Street, London SW3 6NP, United Kingdom.
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4
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Krist D, Linz D, Schotten U, Zeemering S, Leenen D. A Novel Laser Energy Ablation Catheter for Endocardial Cavo-Tricuspid Isthmus Ablation and Epicardial Ventricular Lesion Formation: An in vivo Proof-of-Concept Study. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:834856. [PMID: 35387364 PMCID: PMC8979165 DOI: 10.3389/fmedt.2022.834856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/08/2022] [Indexed: 11/24/2022] Open
Abstract
Aim This proof-of-concept study aimed to investigate atrial and ventricular lesion formation by a 20-mm linear laser ablation catheter, regarding lesion depth and tissue damage. Methods In total, 6 female swines underwent standard femoral vein access to introduce a novel 20-mm linear laser ablation catheter in the right atrium to perform endocardial cavotricuspid isthmus (CTI) ablations. The navigation took place under fluoroscopy with additional visualization by intracardiac echocardiograph. Via a sternotomy, epicardial ablations were performed on the surface of the left ventricle (LV), right ventricle (RV), and right atrial appendage (RAA). Procedural safety was assessed by registration of intraprocedural adverse events and by macroscopic examination of the excised hearts for the presence of charring or tissue disruption at the lesion site. Results Altogether 39 lesions were created, including 8 endocardial CTI (mean lesion length 20.6 ± 1.65 mm), 26 epicardial ventricle (mean lesion length LV: 25.3 ± 1.35 mm, RV: 24.9 ± 2.40 mm), and 5 epicardial appendage ablations (mean lesion length RAA: 26.0 ± 3.16 mm). Transmurality was achieved in all CTI and atrial appendage ablations, in 62% of the RV ablations and in none of the LV ablations. No perforation or steam pop occurred, and no animal died during the procedure. Conclusion In this porcine study, the 20-mm linear laser ablation catheter has shown excellent results for endocardial cavotricuspid isthmus ablation, and it resulted in acceptable lesion depth during atrial and ventricular epicardial ablation. The absence of tissue charring, steam pops, or microbubbles under the experimental conditions suggests a high degree of procedural safety.
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Affiliation(s)
- Dennis Krist
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
- *Correspondence: Dennis Krist
| | - Dominik Linz
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
- Department of Cardiology, Maastricht University Medical Centre +, Maastricht, Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Stef Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Dwayne Leenen
- Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
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Arnold R, Hofer E, Haas J, Sanchez-Quintana D, Plank G. Diversity and complexity of the cavotricuspid isthmus in rabbits: A novel scheme for classification and geometrical transformation of anatomical structures. PLoS One 2022; 17:e0264625. [PMID: 35231058 PMCID: PMC8887761 DOI: 10.1371/journal.pone.0264625] [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: 06/01/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to describe the morphology of the cavotricuspid isthmus (CTI) in detail and introduce a comprehensive scheme to describe the topology of this region based on functional considerations. This may lead to a better understanding of isthmus-dependent flutter and fibrillation and to improved intervention strategies. We used images of the cavotricuspid isthmus from 52 rabbits of both sexes with a median weight of 3.40 ± 0.93 kg. The area of the CTI was 124.25 ± 42.14 mm2 with 53.28 ± 21.13 mm2 covered by pectinate muscles connecting the terminal crest and the vestibule. Isthmus length decreased from inferolateral (13.09 ±2.14 mm) to central (9.85 ± 2.14 mm) to paraseptal (4.88 ± 1.96 mm) resembling the overall human geometry. Ramification sites of pectinate muscles were identified and six levels dividing the CTI from posterior to anterior were introduced. This allowed the classification of pectinate muscle segments based on the connected ramification level. To account for the high inter-individual variations in size and shape, the CTI was projected onto a normalized reference frame using bilinear transformation. Furthermore, two measures of complexity were introduced: (i) the ramification index, which reflects the total number of muscle segments connected to a ramification site and (ii) the complexity index, which reflects the type of ramification (branching or merging site). Topological analysis showed that the complexity of the pectinate muscle network decreases from inferolateral to paraseptal and that the number of electrically uncoupled parallel pathways increases in the central section between the terminal crest and the vestibule which introduces potential reentry pathways.
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Affiliation(s)
- Robert Arnold
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Ernst Hofer
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
| | - Josef Haas
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Damian Sanchez-Quintana
- Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Gernot Plank
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
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6
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Santoro A, Baiocchi C, Sisti N, Zacà V, Pondrelli CR, Falciani F, Lamberti F. Catheter inversion during cavotricuspid isthmus catheter ablation: The new shaft visualization catheter reduces fluoroscopy use. J Arrhythm 2021; 37:1311-1317. [PMID: 34621430 PMCID: PMC8485825 DOI: 10.1002/joa3.12596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 06/14/2021] [Accepted: 06/25/2021] [Indexed: 11/06/2022] Open
Abstract
AIMS Catheter ablation (CA) is the choice therapy of cavotricuspid isthmus (CTI) atrial flutter. The aim of this study was to describe our approach to improve the CTI ablation using a zero-fluoroscopy (ZF). The procedural difficulties could be related to anatomical characteristics of the CTI. METHODS One hundred eighty-eight patients that performed CA of CTI were retrospectively and consecutively evaluated between 2017 and 2019. The studied population was divided into two groups. Eighty-eight patients who were undergone CA using ablation catheter without shaft visualization catheter (NSV) were Group 1. One hundred patients were undergone CA using ablation catheter with a shaft visualization (SV); they were Group 2. The catheter was looped at the Eustachian ridge after 200 seconds of radiofrequencies (RF) without elimination of local electrogram. RESULTS A conduction line block of CTI was obtained in all patients of Group 2 using a ZF approach. In 16 patients of Group 1, the catheter inversion was obtained using fluoroscopy to avoid damages during its loop. In Group 2, a complete CTI block was obtained with a catheter inversion approach in ten patients without fluoroscopy, visualizing the shaft and the tip of the ablation catheter on the electroanatomic (EAM) map. In the overall population studied the use of SV had a linear correlation with the ZF approach (r = .629; P < .001). The duration of RF was lower in Group 2 than in Group 1 (Group 1: 27.8 ± 6.3 vs Group 2: 15.6 ± 7.2 minutes; P < .01). The procedure time between two groups was lower in Group 2 than in Group 1 (Group 1: 58.4 ± 22.4 vs Group 2: 42.2 ± 15.7 minutes; P < .01). No differences between two groups were documented regarding success and complications. CONCLUSIONS The visualization of the shaft's catheter on the EAM permitted the catheter inversion safely in order to overcome some complex CTI anatomy and obtain bidirectional block. The SV reduced procedure time, RF applications and fluoroscopy exposition during CTI ablation.
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Affiliation(s)
- Amato Santoro
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | - Claudia Baiocchi
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | - Nicolò Sisti
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | - Valerio Zacà
- Division of Cardiology Azienda Ospedaliera Universitaria Senese Siena Italy
| | | | | | - Filippo Lamberti
- Division of Medicine Cardiovascular Section San Eugenio Hospital Rome Italy
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7
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Kottmaier M, Deisenhofer I. Is ablation using high power short duration always suitable? Heart Rhythm O2 2020; 1:324-325. [PMID: 34113889 PMCID: PMC8183879 DOI: 10.1016/j.hroo.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Tscholl V, Kamieniarz P, Nagel P, Landmesser U, Attanasio P, Huemer M. The use of a high-power (50 W), ablation index-guided protocol for ablation of the cavotricuspid isthmus. J Arrhythm 2020; 36:1045-1050. [PMID: 33335623 PMCID: PMC7733584 DOI: 10.1002/joa3.12443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/30/2020] [Accepted: 09/18/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND High-power (HP) ablation protocols are increasingly used for ablation procedures to shorten procedural times and improve short- and long-term success. The ablation index (AI) combines contact force, power settings, and ablation time. It can be used in combination with HP protocols to guide operators toward standardized lesions. The purpose of this study was to evaluate both a HP and AI-guided strategy for ablation of the cavotricuspid isthmus (CTI) in patients with typical atrial flutter (AFL). METHODS In this single-center study, consecutive patients with typical AFL (n = 52, mean age 68.7 ± 8.3 years, 21/52 [40.4%] female) underwent AI-guided HP radiofrequency (RF) ablation of the CTI. Ablation was performed with 50 W and AI target values of 550 with a maximum ablation duration of 25 seconds per lesion. Target interlesion distance was ≤6 mm. Ablation was performed with a 3.5 mm porous tip Smarttouch SF catheter. RESULTS Acute CTI block was achieved in 52 of 52 patients (100%), and first-pass conduction block was achieved in 41 of 52 patients (80.4%). Spontaneous reconduction after 30 minutes waiting time occurred in 1 of 52 (1.9%) patient. Average ablation time until CTI block was 3:51 ± 1:40; 2:33 ± 1:01 minutes of bonus ablation pulses were applied after CTI block. An audible steam pop was noted in one patient (1.9%). No major complications occurred. After a mean follow-up of 193.7 ± 152.2 days, no patient showed recurrence of typical AFL. CONCLUSION In this pilot study, AI-guided HP ablation of the CTI was fast, safe, and effective.
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Affiliation(s)
- Verena Tscholl
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Paul Kamieniarz
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Patrick Nagel
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Ulf Landmesser
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Philipp Attanasio
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
| | - Martin Huemer
- Department of CardiologyCharité Universitaetsmedizin Berlin, Campus Benjamin FranklinBerlinGermany
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9
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Baccillieri MS, Rizzo S, De Gaspari M, Paradiso B, Thiene G, Verlato R, Basso C. Anatomy of the cavotricuspid isthmus for radiofrequency ablation in typical atrial flutter. Heart Rhythm 2019; 16:1611-1618. [DOI: 10.1016/j.hrthm.2019.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Indexed: 11/25/2022]
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10
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Anderson RH. The cavotricuspid isthmus in the setting of real cardiac anatomy. Heart Rhythm 2019; 16:1619-1620. [PMID: 31158495 DOI: 10.1016/j.hrthm.2019.05.034] [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: 05/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom.
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11
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Intra-procedural evaluation of the cavo-tricuspid isthmus anatomy with different techniques: comparison of angiography and intracardiac echocardiography. Heart Vessels 2019; 34:1703-1709. [PMID: 30953137 DOI: 10.1007/s00380-019-01394-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
Cavo-tricuspid isthmus (CTI) anatomies are highly variable, and specific anatomies lead to a difficult CTI ablation. This study aimed to compare the clinical utility of angiography and intracardiac echocardiography (ICE) in evaluating CTI anatomies, and to investigate the impact of the CTI anatomy on the procedure when the ablation tactic was adjusted to the anatomy. This study included 92 consecutive patients who underwent a CTI ablation. The CTI morphology was assessed with both right atrial angiography and ICE before the ablation, and the ablation tactic was adjusted to the anatomy. The mean CTI length was 34 ± 9 mm. On ICE imaging, 21 (23%) patients had a flat CTI, while 41 (45%) had a concave CTI with a mean depth of 5.6 ± 2.7 mm. The remaining 30 (32%) had a distinct pouch with a mean depth of 6.4 ± 2.3 mm, located at the posterior, middle, and anterior isthmus in 15, 14, and 1 patients, respectively. The Eustachian ridge (ER) was visualized in 46 (50%) patients. On angiography, a pouch and ER were detected in 22 and 15 patients, but not in the remaining 8 and 31, respectively. A complete CTI block line was created in all patients without any complications. The CTI anatomy did not significantly impact any procedural parameters. ICE was superior to angiography in evaluating the detailed CTI anatomy, especially pouches and the ER. An adjustment of the ablation tactic to the anatomy could overcome the procedural difficulties of the CTI ablation in cases with specific anatomies.
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12
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Shimizu Y, Yoshitani K, Murotani K, Kujira K, Kurozumi Y, Fukuhara R, Taniguchi R, Toma M, Miyamoto T, Kita Y, Takatsu Y, Sato Y. The deeper the pouch is, the longer the radiofrequency duration and higher the radiofrequency energy needed-Cavotricuspid isthmus ablation using intracardiac echocardiography. J Arrhythm 2018; 34:410-417. [PMID: 30167012 PMCID: PMC6111476 DOI: 10.1002/joa3.12075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/25/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to explore whether the pouch depth influenced the radiofrequency (RF) duration and total delivered RF energy for cavotricuspid isthmus (CTI) ablation and define the cutoff value for a deep pouch-specified ablation strategy. METHODS This study included 94 atrial fibrillation (AF) patients (56 males, age 68 ± 8.0 years). With intracardiac echocardiography, the isthmus length and pouch depth were precisely measured. After a standard AF ablation, all patients underwent the CTI ablation along the lateral isthmus. If bidirectional block could not be achieved, the ablation catheter was deflected more than 90 degrees to ablate inside the pouch (knuckle-curve ablation). RESULTS Seventy-two patients (76.6%) had a sub-Eustachian pouch. Bidirectional block could be achieved in all patients. By a univariate logistic regression analysis, only the pouch depth was significantly correlated with the RF duration (P = .005) and RF energy (P = .006). A multivariate logistic regression analysis also revealed the pouch depth was the sole factor that influenced the RF duration (P = .001) and RF energy (P = .001). Among the 72 patients, 21 patients needed a knuckle-curve ablation. Using a receiver operating characteristic curve, the optimal cutoff value of the pouch depth for a knuckle-curve ablation was 3.7 mm with a sensitivity of 90% and specificity of 69%. CONCLUSIONS The sub-Eustachian pouch depth was the sole factor that influenced the RF duration and energy in the CTI ablation. If the pouch was deeper than 3.7 mm, a deep pouch-specified ablation strategy would be needed.
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Affiliation(s)
- Yukiko Shimizu
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Kazuyasu Yoshitani
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Kenta Murotani
- Center for Clinical ResearchAichi Medical UniversityNagakuteJapan
| | - Kazuto Kujira
- Department of Cardiovascular MedicineToyohashi Heart CenterToyohashiJapan
| | - Yuma Kurozumi
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Rei Fukuhara
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Ryoji Taniguchi
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Masanao Toma
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Tadashi Miyamoto
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Yoshio Kita
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Yoshiki Takatsu
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
| | - Yukihito Sato
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiJapan
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Venier S, Andrade JG, Khairy P, Mondésert B, Dyrda K, Rivard L, Guerra PG, Dubuc M, Thibault B, Talajic M, Roy D, Macle L. Contact-force-guided vs. contact-force-blinded catheter ablation of typical atrial flutter: a prospective study. Europace 2018; 19:1043-1048. [PMID: 27377075 DOI: 10.1093/europace/euw137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/20/2016] [Indexed: 11/13/2022] Open
Abstract
Aims It remains unknown whether contact force (CF) sensing technology is of value for cavotricuspid isthmus (CTI) ablation. We prospectively evaluated procedural parameters and outcomes of CF-guided vs. CF-blinded CTI ablation for typical atrial flutter (AFL). Methods and results A total of 70 consecutive patients (62.5 ± 10.9 years) undergoing CTI ablation for AFL were prospectively enrolled, 35 in CF-blinded and 35 in CF-guided groups. A CF-sensing catheter (power 25-35 W) was used in all. In the CF-guided group, CF target range was 10-25 g, whereas in the CF-blinded group, the operator was blinded to CF. The isthmus was divided into anterior, middle, and posterior segments for region-specific CF analysis. The procedural endpoint of bidirectional isthmus block following a 20-min observation period was achieved in all. A trend towards lower fluoroscopy and procedure duration was observed when the CF-guided group was compared with the CF-blinded group. The total radiofrequency (RF) energy delivery time required to achieve bidirectional block was significantly lower in the CF-guided vs. CF-blinded group [10.0 min (IQR 8.3;15.1) vs. 15.9 min (IQR 9.6;24.7), P= 0.0020], with a significant inverse correlation between CF and total RF delivery time (r = -0.36; P= 0.0027). Mean CF measurements significantly increased from anterior to posterior anatomical zones of CTI in the CF-blinded group (ANOVA P= 0.0466). Conclusions Catheter ablation of AFL guided by real-time CF assessment results in a significant reduction in total RF delivery time. Real-time CF measurements facilitate the maintenance of homogenous efficient contact all along the CTI, particularly in the anterior segment where CF is generally lower.
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Choe WC, Sundaram S, Jordan JR, Mullins N, Boorman C, Davies A, Tiftickjian AC, Nath S. A novel 3D anatomic mapping approach using multipoint high-density voltage gradient mapping to quickly localize and terminate typical atrial flutter. J Interv Card Electrophysiol 2017; 49:319-326. [DOI: 10.1007/s10840-017-0275-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
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15
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Miyazaki S, Iwasawa J, Taniguchi H, Nakamura H, Hachiya H, Matsuda J, Takagi T, Watanabe T, Hirao K, Iesaka Y. Creating bidirectional conduction block in the cavotricuspid isthmus by cryothermal ablation with a short freeze time: Insight from the results with a 2-minute freeze cycle. Int J Cardiol 2016; 224:149-154. [PMID: 27657464 DOI: 10.1016/j.ijcard.2016.09.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Optimal freeze doses are unknown during cryothermal cavo-tricuspid isthmus (CTI) ablation. This study aimed to evaluate the feasibility of 2-minute freeze doses for CTI ablation. METHODS Forty-eight consecutive patients undergoing cryothermal CTI ablation following pulmonary vein isolation were enrolled. CTI ablation was performed with 2-minute freeze cycles and 8-mm tip cryocatheters. RESULTS Bidirectional CTI block was successfully achieved in 45(93.8%) patients with a median of 5.0[4.0-6.0] cryocatheter applications. The total procedure and fluoroscopic times were a median of 16.5[13.0-20.0] and 4.0[2.0-5.0]min, respectively. A crossover to radiofrequency was performed in 3 patients including 1 due to coronary spasms during the cryoapplication. The tip temperature when block was achieved was a median of -81.0[-73.3 - -84.0]°C. Application times from the start of the last application to achieving block were significantly longer in patients with acute conduction resumption than in those without (46.8±4.0 vs. 20.2±8.8s, p<0.0001), and the optimal cutoff point for predicting no acute resumption was 38.5s (sensitivity 100%, specificity 99.5%). Vasospastic angina occurred in 2 patients, during the procedure in 1 and after in another. Durability could be evaluated a median of 6.0[3.0-8.0] months after the procedure in 14 patients, and conduction resumption was observed in 8(57.1%). The majority of gaps were located at the inferior vena cava edge. CONCLUSIONS Acute CTI block was obtained by 2-minute freeze cycles with short procedure and fluoroscopic times. Care should be taken to avoid coronary spasms during the peri-procedural period. Additional cryoapplications might be required to improve conduction block durability.
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Affiliation(s)
- Shinsuke Miyazaki
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan.
| | - Jin Iwasawa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroshi Taniguchi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hiroaki Nakamura
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Junji Matsuda
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Takamitsu Takagi
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Tomonori Watanabe
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Tsuchiura, Ibaraki, Japan
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Clinical Anatomy of the Cavotricuspid Isthmus and Terminal Crest. PLoS One 2016; 11:e0163383. [PMID: 27682030 PMCID: PMC5040420 DOI: 10.1371/journal.pone.0163383] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/06/2016] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to provide useful information about the cavotricuspid isthmus (CTI) and surrounding areas morphology, which may help to plan CTI radio-frequency ablation. We examined 140 autopsied human hearts from Caucasian individuals of both sexes (29.3% females) with a mean age of 49.1±17.2 years. We macroscopically investigated the lower part of the right atrium, the CTI, the inferior vena cava ostium and the terminal crest. The paraseptal isthmus (18.5±4.0 mm) was significantly shorter than the central isthmus (p<0.0001), and the central isthmus (24.0±4.2 mm) was significantly shorter than the inferolateral isthmus (29.3±4.9 mm) (p<0.0001). Heart weight was positively correlated with all isthmus diameters. Three different sectors of CTI were distinguished: anterior, middle and posterior. The middle sector of the CTI presented a different morphology: trabeculae (N = 87; 62.1%), intertrabecular recesses (N = 35; 25.0%) and trabecular bridges (N = 18; 12.9%). A single sub-Eustachian recess was present in 48.6% of hearts (N = 68), and a double recess was present in 2.9% of hearts (N = 4) with mean depth = 5.6±1.8mm and diameter = 7.1±3.4mm. The morphology of the distal terminal crest was varied; 10 patterns of the distal terminal crest ramifications were noted. There were no statistically significant differences in any of the investigated CTI parameters between groups with different types of terminal crest ramifications. The presence of intertrabecular recesses (25.0%), trabecular bridges (12.9%) and sub-Eustachian recesses (48.6%) within the CTI can make ablation more difficult. We have presented the macroscopic patterns of final ramifications of the terminal crest within the quadrilateral CTI area.
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Capítulo 5. Utilidad del mapeo tridimensional en flutter auricular típico. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Anatomical Basis for the Cardiac Interventional Electrophysiologist. BIOMED RESEARCH INTERNATIONAL 2015; 2015:547364. [PMID: 26665006 PMCID: PMC4668306 DOI: 10.1155/2015/547364] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/28/2015] [Indexed: 12/11/2022]
Abstract
The establishment of radiofrequency catheter ablation techniques as the mainstay in the treatment of tachycardia has renewed new interest in cardiac anatomy. The interventional arrhythmologist has drawn attention not only to the gross anatomic details of the heart but also to architectural and histological characteristics of various cardiac regions that are relevant to the development or recurrence of tachyarrhythmias and procedural related complications of catheter ablation. In this review, therefore, we discuss some anatomic landmarks commonly used in catheter ablations including the terminal crest, sinus node region, Koch's triangle, cavotricuspid isthmus, Eustachian ridge and valve, pulmonary venous orifices, venoatrial junctions, and ventricular outflow tracts. We also discuss the anatomical features of important structures in the vicinity of the atria and pulmonary veins, such as the esophagus and phrenic nerves. This paper provides basic anatomic information to improve understanding of the mapping and ablative procedures for cardiac interventional electrophysiologists.
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Rodríguez-Mañero M, Schurmann P, Valderrábano M. Ligament and vein of Marshall: A therapeutic opportunity in atrial fibrillation. Heart Rhythm 2015; 13:593-601. [PMID: 26576705 DOI: 10.1016/j.hrthm.2015.10.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Moisés Rodríguez-Mañero
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Paul Schurmann
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas.
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Bencsik G. Novel strategies in the ablation of typical atrial flutter: role of intracardiac echocardiography. Curr Cardiol Rev 2015; 11:127-33. [PMID: 25308811 PMCID: PMC4356719 DOI: 10.2174/1573403x10666141013121843] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 09/25/2013] [Accepted: 04/05/2014] [Indexed: 11/22/2022] Open
Abstract
Radiofrequency ablation (RFA) of the cavo-tricuspid isthmus (CTI) is one of the most frequently performed procedures in electrophysiology. Despite a high success rate, ablation of the CTI can be unusually difficult in some cases. Multiple tools like angiography, 3D mapping, remote navigation and intracardiac echocardiography (ICE) have been introduced to facilitate typical flutter ablation. This review article summarizes the clinical value of different strategies and tools used for CTI ablation focusing on the importance of approaches utilizing ICE.
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Affiliation(s)
- Gábor Bencsik
- 2nd Department of Internal Medicine and Cardiology Centre, University of Szeged, Korányi fasor 6. 6724 Szeged, Hungary.
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Mori S, Nishii T, Takaya T, Kashio K, Kasamatsu A, Takamine S, Ito T, Fujiwara S, Kono AK, Hirata KI. Clinical structural anatomy of the inferior pyramidal space reconstructed from the living heart: Three-dimensional visualization using multidetector-row computed tomography. Clin Anat 2014; 28:878-87. [DOI: 10.1002/ca.22483] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 10/01/2014] [Accepted: 10/09/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Shumpei Mori
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Tatsuya Nishii
- Department of Radiology; Kobe University Graduate School of Medicine; Kobe Japan
| | - Tomofumi Takaya
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Kazuhiro Kashio
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Akira Kasamatsu
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Sachiko Takamine
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Tatsuro Ito
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Sei Fujiwara
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Atsushi K. Kono
- Department of Radiology; Kobe University Graduate School of Medicine; Kobe Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine; Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
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Matía Francés R, Hernández Madrid A, Delgado A, Carrizo L, Pindado C, Moro Serrano C, Zamorano Gómez JL. Characterization of the impact of catheter-tissue contact force in lesion formation during cavo-tricuspid isthmus ablation in an experimental swine model. Europace 2013; 16:1679-83. [PMID: 24225068 DOI: 10.1093/europace/eut351] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Catheter-tissue contact is critical for effective lesion creation. The objective of this study was to determine in an experimental swine model the pathological effects of cavo-tricuspid isthmus ablation using two systems that provide reliable measures of the pressure at the catheter tip during radiofrequency ablation procedures. METHODS AND RESULTS We performed the procedure in eight pigs in our experimental electrophysiology laboratory after right femoral vein dissection and insertion of a 12 Fr. introducer during general anaesthesia and endotracheal intubation. The target contact force during the applications was <10 grs. (axial or lateral), 10-20, 20-30, and >30 grs. in two pigs each. The power was set at 40 W and maximum target temperature at 45°C. We performed a radiofrequency line dragging from the tricuspid valve to the inferior vena cava in the eight pigs. Euthanasia of the animals was carried out a week after the procedure and a pathological examination of the lesions was performed. In the endocardial macroscopic analysis the extent of lesions, presence of thrombus, transmurality, and endothelial rupture was assessed. External surface was examined searching for transmural lesions. The mean contact force applied was 18.7 ± 8.4 grs. and the mean depth of the lesions was 3.6 ± 2 mm. Lesions were never transmural with average forces <10 grs., and the mean depth was very low (0.75 mm). To achieve transmural lesions contact forces of at least 20 grs. were required. We found a positive correlation (r = 0.85, P < 0.05) between the average force during the applications and depth of the lesions. CONCLUSION When ablating the cavo-tricuspid isthmus in a swine model, contact forces of at least 20 grs. are required to achieve transmural lesions. Catheter-tissue contact is critical for effective lesion creation. This information is important for improving ablation efficacy.
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Affiliation(s)
- Roberto Matía Francés
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | | | - Antonia Delgado
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | - Laura Carrizo
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | - Carlos Pindado
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
| | | | - José L Zamorano Gómez
- Cardiology Department, Ramón y Cajal Hospital, Ctra. Colmenar Km. 9,1, 28034 Madrid, Spain
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Yamashita S, Yamane T, Matsuo S, Ito K, Narui R, Hioki M, Tanigawa SI, Tokuda M, Inada K, Date T, Sugimoto KI, Yoshimura M. Unidirectional block on the mitral isthmus during radiofrequency application for perimitral atrial tachycardia. J Arrhythm 2013. [DOI: 10.1016/j.joa.2012.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Faletra FF, Muzzarelli S, Dequarti MC, Murzilli R, Bellu R, Ho SY. Imaging-based right-atrial anatomy by computed tomography, magnetic resonance imaging, and three-dimensional transoesophageal echocardiography: correlations with anatomic specimens. Eur Heart J Cardiovasc Imaging 2013; 14:1123-31. [PMID: 24028837 DOI: 10.1093/ehjci/jet081] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Nowadays computed tomography, cardiac magnetic resonance imaging, and tridimensional transoesophageal echocardiography provide anatomic images of right-atrial structures with an impressive richness of anatomical details. It is therefore surprising that these techniques are not routinely used as complementary tools in teaching anatomy. This review aims to fill this gap showing the normal anatomy of right atrium as displayed by these sophisticated imaging techniques. A better understanding of right-atrial anatomy is crucial for the treatment of primary right-atrium electrical disorders as well as for catheter-based interventions for structural heart disease. The success of these procedures is, in fact, related to an accurate anatomical pre-procedural assessment. In this review, we describe the normal anatomy and variants of those right-atrial structures relevant for both ablationists and interventionalists.
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Affiliation(s)
- Francesco Fulvio Faletra
- Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
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Castaño AP, Ruiz CA, Castillo A, Heidenreich E. Propagación de onda en un tejido cardiaco 3D usando dos modelos auriculares. REVISTA COLOMBIANA DE CARDIOLOGÍA 2013. [DOI: 10.1016/s0120-5633(13)70056-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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26
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Marcos-Alberca P, Sánchez-Quintana D, Cabrera JA, Farré J, Rubio JM, de Agustín JA, Almería C, Pérez-Isla L, Macaya C. Two-dimensional echocardiographic features of the inferior right atrial isthmus: the role of vestibular thickness in catheter ablation of atrial flutter. Eur Heart J Cardiovasc Imaging 2013; 15:32-40. [PMID: 23751506 DOI: 10.1093/ehjci/jet112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine the feasibility of transthoracic two-dimensional (2D)-echocardiography in defining the cavo-tricuspid isthmus (CTI) anatomy and its value concerning the ease of catheter ablation of isthmic atrial flutter (AF). METHODS CTI analysis was accomplished in 39 cases: 16 necropsy specimens and 23 patients. Sixteen were patients with isthmus-dependent AF and seven controls with other supraventricular re-entrant tachycardias. Two-dimensional transthoracic echocardiography and a right atrium angiogram were performed before radiofrequency catheter ablation (RFCA). RESULTS The measurements of the CTI with angiography were compared with those taken with echocardiography and correlation was excellent (r= 0.91; P < 0.0001). In normal patients, the dimension of the vestibular thickness was successfully compared and validated with the histological examination of the necropsy specimens: histology median 6.8 mm, range 4.4-10.5 vs. echo median 6.2 mm, range 5.4-8.7; P: NS. Vestibular thickness was greater in complex than in simple RFCA (13.6 ± 1.9 mm vs. 10.0 ± 2.3 mm; P = 0.01). When vestibular thickness ≥11.5 mm, the ablation prone to be complex (sensitivity 83.3%, specificity 80%, positive predictive value 71.4%, and negative predictive value 88.9%). CONCLUSIONS Two-dimensional transthoracic echocardiography clearly depicts the inferior isthmus and, displaying the thickness of the tricuspid vestibule, it was related with complexity of the ablation procedure in isthmus-dependent AF.
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Affiliation(s)
- Pedro Marcos-Alberca
- Cardiology Department, Instituto Cardiovascular, Hospital Clínico San Carlos, c/ Prof. Martín Lagos s/n. 28040 Madrid, Spain
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Tobón C, Ruiz-Villa CA, Heidenreich E, Romero L, Hornero F, Saiz J. A three-dimensional human atrial model with fiber orientation. Electrograms and arrhythmic activation patterns relationship. PLoS One 2013; 8:e50883. [PMID: 23408928 PMCID: PMC3569461 DOI: 10.1371/journal.pone.0050883] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/25/2012] [Indexed: 11/19/2022] Open
Abstract
The most common sustained cardiac arrhythmias in humans are atrial tachyarrhythmias, mainly atrial fibrillation. Areas of complex fractionated atrial electrograms and high dominant frequency have been proposed as critical regions for maintaining atrial fibrillation; however, there is a paucity of data on the relationship between the characteristics of electrograms and the propagation pattern underlying them. In this study, a realistic 3D computer model of the human atria has been developed to investigate this relationship. The model includes a realistic geometry with fiber orientation, anisotropic conductivity and electrophysiological heterogeneity. We simulated different tachyarrhythmic episodes applying both transient and continuous ectopic activity. Electrograms and their dominant frequency and organization index values were calculated over the entire atrial surface. Our simulations show electrograms with simple potentials, with little or no cycle length variations, narrow frequency peaks and high organization index values during stable and regular activity as the observed in atrial flutter, atrial tachycardia (except in areas of conduction block) and in areas closer to ectopic activity during focal atrial fibrillation. By contrast, cycle length variations and polymorphic electrograms with single, double and fragmented potentials were observed in areas of irregular and unstable activity during atrial fibrillation episodes. Our results also show: (1) electrograms with potentials without negative deflection related to spiral or curved wavefronts that pass over the recording point and move away, (2) potentials with a much greater proportion of positive deflection than negative in areas of wave collisions, (3) double potentials related with wave fragmentations or blocking lines and (4) fragmented electrograms associated with pivot points. Our model is the first human atrial model with realistic fiber orientation used to investigate the relationship between different atrial arrhythmic propagation patterns and the electrograms observed at more than 43000 points on the atrial surface.
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Affiliation(s)
- Catalina Tobón
- Instituto Interuniversitario de Investigación en Bioingeniería y Tecnología Orientada al Ser Humano (I3BH), Universitat Politècnica de València, Valencia, Spain
| | - Carlos A. Ruiz-Villa
- Departamento de Sistemas, Universidad de Caldas, Manizales, Caldas, Colombia
- Departamento de Informática y Computación, Universidad Nacional de Colombia Sede Manizales, Manizales, Caldas, Colombia
| | | | - Lucia Romero
- Instituto Interuniversitario de Investigación en Bioingeniería y Tecnología Orientada al Ser Humano (I3BH), Universitat Politècnica de València, Valencia, Spain
| | - Fernando Hornero
- Servicio Cirugía Cardiaca, Hospital General de Valencia, Valencia, Spain
| | - Javier Saiz
- Instituto Interuniversitario de Investigación en Bioingeniería y Tecnología Orientada al Ser Humano (I3BH), Universitat Politècnica de València, Valencia, Spain
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Ueda A, McCarthy KP, Sánchez-Quintana D, Yen Ho S. Right atrial appendage and vestibule: further anatomical insights with implications for invasive electrophysiology†. ACTA ACUST UNITED AC 2012. [DOI: 10.1093/europace/eus382] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WA. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging 2012; 13:1-46. [PMID: 22275509 DOI: 10.1093/ehjci/jer316] [Citation(s) in RCA: 352] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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BENCSIK GÁBOR, PAP RÓBERT, MAKAI ATTILA, KLAUSZ GERGELY, CHADAIDE SZÁMI, TRAYKOV VASSIL, FORSTER TAMÁS, SÁGHY LÁSZLÓ. Randomized Trial of Intracardiac Echocardiography During Cavotricuspid Isthmus Ablation. J Cardiovasc Electrophysiol 2012; 23:996-1000. [DOI: 10.1111/j.1540-8167.2012.02331.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Jacquemet V, Kappenberger L, Henriquez CS. Modeling atrial arrhythmias: impact on clinical diagnosis and therapies. IEEE Rev Biomed Eng 2012; 1:94-114. [PMID: 22274901 DOI: 10.1109/rbme.2008.2008242] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial arrhythmias are the most frequent sustained rhythm disorders in humans and often lead to severe complications such as heart failure and stroke. Despite the important insights provided by animal models into the mechanisms of atrial arrhythmias, direct translation of experimental findings to new therapies in patients has not been straightforward. With the advances in computer technology, large-scale electroanatomical computer models of the atria that integrate information from the molecular to organ scale have reached a level of sophistication that they can be used to interpret the outcome of experimental and clinical studies and aid in the rational design of therapies. This paper reviews the state-of-the-art of computer models of the electrical dynamics of the atria and discusses the evolving role of simulation in assisting the clinical diagnosis and treatment of atrial arrhythmias.
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Affiliation(s)
- Vincent Jacquemet
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.
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Jacobsen PK, Klein GJ, Gula LJ, Krahn AD, Yee R, Leong-Sit P, Mechulan A, Skanes AC. Voltage-guided ablation technique for cavotricuspid isthmus-dependent atrial flutter: refining the continuous line. J Cardiovasc Electrophysiol 2012; 23:672-6. [PMID: 22554221 DOI: 10.1111/j.1540-8167.2012.02342.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ablation of the cavotricuspid isthmus has become first-line therapy for "isthmus-dependent" atrial flutter. The goal of ablation is to produce bidirectional cavotricuspid isthmus block. Traditionally, this has been obtained by creation of a complete ablation line across the isthmus from the ventricular end to the inferior vena cava. This article describes an alternative method used in our laboratory. There is substantial evidence that conduction across the isthmus occurs preferentially over discrete separate bundles of tissue. Consequently, voltage-guided ablation targeting only these bundles with large amplitude atrial electrograms results in a highly efficient alternate method for the interruption of conduction across the cavotricuspid isthmus. Understanding the bundle structure of conduction over the isthmus facilitates more flexible approaches to its ablation and targeting maximum voltages in our hands has resulted in reduction of ablation time and fewer recurrences.
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Affiliation(s)
- Peter K Jacobsen
- Arrhythmia Service, University of Western Ontario, London, Ontario, Canada
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Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, Faletra FF, Franke A, Hung J, de Isla LP, Kamp O, Kasprzak JD, Lancellotti P, Marwick TH, McCulloch ML, Monaghan MJ, Nihoyannopoulos P, Pandian NG, Pellikka PA, Pepi M, Roberson DA, Shernan SK, Shirali GS, Sugeng L, Ten Cate FJ, Vannan MA, Zamorano JL, Zoghbi WA. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr 2012; 25:3-46. [PMID: 22183020 DOI: 10.1016/j.echo.2011.11.010] [Citation(s) in RCA: 473] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Sánchez C, Corrias A, Bueno-Orovio A, Davies M, Swinton J, Jacobson I, Laguna P, Pueyo E, Rodríguez B. The Na+/K+ pump is an important modulator of refractoriness and rotor dynamics in human atrial tissue. Am J Physiol Heart Circ Physiol 2012; 302:H1146-59. [PMID: 22198174 PMCID: PMC3311461 DOI: 10.1152/ajpheart.00668.2011] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 12/04/2011] [Indexed: 11/22/2022]
Abstract
Pharmacological treatment of atrial fibrillation (AF) exhibits limited efficacy. Further developments require a comprehensive characterization of ionic modulators of electrophysiology in human atria. Our aim is to systematically investigate the relative importance of ionic properties in modulating excitability, refractoriness, and rotor dynamics in human atria before and after AF-related electrical remodeling (AFER). Computer simulations of single cell and tissue atrial electrophysiology were conducted using two human atrial action potential (AP) models. Changes in AP, refractory period (RP), conduction velocity (CV), and rotor dynamics caused by alterations in key properties of all atrial ionic currents were characterized before and after AFER. Results show that the investigated human atrial electrophysiological properties are primarily modulated by maximal value of Na(+)/K(+) pump current (G(NaK)) as well as conductances of inward rectifier potassium current (G(K1)) and fast inward sodium current (G(Na)). G(NaK) plays a fundamental role through both electrogenic and homeostatic modulation of AP duration (APD), APD restitution, RP, and reentrant dominant frequency (DF). G(K1) controls DF through modulation of AP, APD restitution, RP, and CV. G(Na) is key in determining DF through alteration of CV and RP, particularly in AFER. Changes in ionic currents have qualitatively similar effects in control and AFER, but effects are smaller in AFER. The systematic analysis conducted in this study unravels the important role of the Na(+)/K(+) pump current in determining human atrial electrophysiology.
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Affiliation(s)
- Carlos Sánchez
- Communications Technology Group, I3A and IIS, University of Zaragoza, Zaragoza
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García-Cosío F, Pastor Fuentes A, Núñez Angulo A. Arrhythmias (IV). Clinical approach to atrial tachycardia and atrial flutter from an understanding of the mechanisms. Electrophysiology based on anatomy. Rev Esp Cardiol 2012; 65:363-75. [PMID: 22364957 DOI: 10.1016/j.recesp.2011.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 11/19/2011] [Indexed: 11/17/2022]
Abstract
In 2009, 2343 catheter ablation procedures were performed in Spain for focal atrial tachycardia or atrial flutter (typical and atypical), with a yearly growth rate of 8%, indicating the clinical importance of these arrhythmias. The classic categorization of atrial tachycardia and atrial flutter based on rate and morphological criteria has become almost irrelevant at a time when clinical electrophysiology may lead to curative intervention based on a definition of the mechanism, making it necessary to bring laboratory experience closer to clinical practice. In this review we outline our present understanding of atrial tachycardia mechanisms, both focal and macroreentrant, and attempt to establish the conceptual links with classic concepts that may help the clinician to make a differential diagnosis and establish therapeutic indications, including that of an electrophysiologic study. Some of the concepts may seem complex, but we thought it important to provide an overview of the electrophysiological methods that may eventually lead to the description of the anatomic bases of the arrhythmias; currently, these are easier to understand thanks to the virtual anatomic casts built using computerized navigation systems.
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Chen JY, Lin KH, Liou YM, Chang KC, Huang SKS. Usefulness of pre-procedure cavotricuspid isthmus imaging by modified transthoracic echocardiography for predicting outcome of isthmus-dependent atrial flutter ablation. J Am Soc Echocardiogr 2011; 24:1148-55. [PMID: 21764555 DOI: 10.1016/j.echo.2011.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Anatomic characteristics of the cavotricuspid isthmus (CTI) have been reported to be related to the outcome of atrial flutter ablation therapy. However, preprocedural evaluation of CTI anatomy using modified transthoracic echocardiography to guide atrial flutter ablation has not been well described. METHODS Transthoracic echocardiography was prospectively performed before atrial flutter ablation in 42 patients with typical CTI-dependent atrial flutter. A modified apical long-axis view was designed to visualize and evaluate anatomic characteristics of the CTI and Eustachian ridge (ER). A prominent ER, extending from the inferior vena cava to the interatrial septum, is defined as an extensive ER. RESULTS Twenty-eight patients had straightforward ablation procedures, and 14 patients had difficult ablation procedures. Two patients with difficult procedures had unsuccessful ablation. Multivariate analysis (using CTI length, the presence of a pouch or recess, ER morphology, and significant tricuspid regurgitation as variables) showed that the presence of extensive ER was the only independent predictor of a difficult ablation procedure. The ablation time in patients with extensive ER (n = 13) was significantly longer than in those patients with nonextensive ER (n = 29) (1,638.4 ± 1,548.3 vs 413.8 ± 195.5 sec, P = .015). The incidence of difficulty in achieving bidirectional isthmus block was also higher in patients with extensive ER (10 of 13 vs four of 29, P < .001). CONCLUSION Preprocedural transthoracic echocardiography using a modified apical long-axis view is useful to characterize the morphology of the CTI and the ER. An extensive ER is a strong predictor for difficult ablation of CTI-dependent atrial flutter.
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Affiliation(s)
- Jan-Yow Chen
- Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
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Anatomy of right atrial structures by real-time 3D transesophageal echocardiography. JACC Cardiovasc Imaging 2011; 3:966-75. [PMID: 20846634 DOI: 10.1016/j.jcmg.2010.03.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 03/18/2010] [Accepted: 03/23/2010] [Indexed: 12/31/2022]
Abstract
The rapid development of catheter ablation techniques for atrial arrhythmias has triggered a renewed interest in the anatomy of the right atrium. In particular, some atrial arrhythmias such as focal atrial arrhythmias or atrial flutter have been linked to the anatomic architecture of specific structures such as the crista terminalis or cavotricuspid isthmus. Real-time 3-dimensional transesophageal echocardiography (RT 3D TEE) is a recently developed technique that provides 3D images of unprecedented quality. Because the right atrium is very close to the transducer, this technique may provide high-quality images of those atrial structures involved in ablation procedures. This review describes a step-by-step approach for acquisition and processing of RT 3D TEE images of right atrial structures of relevance to electrophysiologists. For anatomical correlations of RT 3D TEE images, selected images of right atrial structures were matched to anatomical specimens.
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Yokokawa M, Tada H, Koyama K, Ino T, Naito S, Oshima S, Taniguchi K. The change in the tissue characterization detected by magnetic resonance imaging after radiofrequency ablation of isthmus-dependent atrial flutter. Int J Cardiol 2011; 148:30-5. [DOI: 10.1016/j.ijcard.2009.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 10/09/2009] [Indexed: 11/26/2022]
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Ozgun M, Maintz D, Bunck AC, Mönnig G, Eckardt L, Wasmer K, Heindel W, Botnar RM, Kirchhof P. Right atrial scar detection after catheter ablation: Comparison of 2D and high spatial resolution 3D-late enhancement magnetic resonance imaging. Acad Radiol 2011; 18:488-94. [PMID: 21277233 DOI: 10.1016/j.acra.2010.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Revised: 12/04/2010] [Accepted: 12/04/2010] [Indexed: 01/19/2023]
Abstract
RATIONALE AND OBJECTIVES To prospectively compare the diagnostic performance of two-dimensional (2D) and high spatial resolution three-dimensional (3D) late enhancement magnetic resonance imaging (MRI) for the detection of scar tissue caused by catheter ablation of the right atrium in patients with atrial flutter. MATERIALS AND METHODS Forty-seven patients were enrolled. In 16 patients, imaging of the cavotricuspid isthmus was performed before and after catheter ablation, 16 subjects were imaged before, and 15 after catheter ablation, resulting in a total of 63 examinations. MRI included a standard 2D breathhold and a high-resolution navigator-gated 3D T1-weighted gradient-echo inversion-recovery sequence in right and left anterior oblique views. Two readers assessed the subjective image quality on a 4-point scale (1 = excellent) and the presence of late enhancement (blinded/ in consensus). RESULTS The average image quality was 1.6 for both imaging approaches. In consensus reading, the sensitivity was 83% versus 100%, specificity 97% versus 89%, accuracy 90% versus 94%, positive predictive value 96% versus 89%, negative predictive value 86% versus 100% for 2D and 3D, respectively. The interobserver agreement was 0.86 for 2D and 0.78 for 3D imaging. CONCLUSIONS For the noninvasive identification of scars in the cavotricuspid isthmus after right atrial flutter, ablation 2D imaging was more consistent, whereas 3D sequences showed superior sensitivity for the depiction of late enhancement.
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Affiliation(s)
- Murat Ozgun
- Department of Radiology, St. Franziskus Hospital, Muenster, Germany.
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ILG KARLJ, KÜHNE MICHAEL, CRAWFORD THOMAS, CHUGH AMAN, JONGNARANGSIN KRIT, GOOD ERIC, PELOSI Jr FRANK, BOGUN FRANK, MORADY FRED, ORAL HAKAN. Randomized Comparison of Cavotricuspid Isthmus Ablation for Atrial Flutter Using an Open Irrigation-Tip versus a Large-Tip Radiofrequency Ablation Catheter. J Cardiovasc Electrophysiol 2011; 22:1007-12. [DOI: 10.1111/j.1540-8167.2011.02045.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Del Carpio Munoz F, Buescher TL, Asirvatham SJ. Teaching Points With 3-Dimensional Mapping of Cardiac Arrhythmia. Circ Arrhythm Electrophysiol 2011; 4:e1-3. [DOI: 10.1161/circep.110.960252] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Freddy Del Carpio Munoz
- From the Division of Cardiovascular Diseases (F.D.C.M.), Mayo Clinic-Franciscan Skemp, LaCrosse, WI; Division of Cardiovascular Diseases (T.L.B.), Mayo Clinic; Division of Cardiovascular Diseases (S.J.A.), Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN
| | - Traci L. Buescher
- From the Division of Cardiovascular Diseases (F.D.C.M.), Mayo Clinic-Franciscan Skemp, LaCrosse, WI; Division of Cardiovascular Diseases (T.L.B.), Mayo Clinic; Division of Cardiovascular Diseases (S.J.A.), Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN
| | - Samuel J. Asirvatham
- From the Division of Cardiovascular Diseases (F.D.C.M.), Mayo Clinic-Franciscan Skemp, LaCrosse, WI; Division of Cardiovascular Diseases (T.L.B.), Mayo Clinic; Division of Cardiovascular Diseases (S.J.A.), Department of Pediatrics and Adolescent Medicine (S.J.A.), Mayo Clinic, Rochester, MN
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Ozgun M, Kirchhof P, Bunck AC, Heindel W, Eckardt L, Maintz D. MRI of right atrial function after catheter ablation of atrial flutter. Acad Radiol 2010; 17:856-61. [PMID: 20471870 DOI: 10.1016/j.acra.2010.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Revised: 03/15/2010] [Accepted: 03/17/2010] [Indexed: 10/19/2022]
Abstract
RATIONALE AND OBJECTIVES Catheter ablation of the cavotricuspid isthmus (CTI) is an effective treatment of right atrial flutter. The objective of this study was to evaluate the changes in CTI length and right atrial (RA) function after radiofrequency ablation of isthmus-dependent atrial flutter (isthmus ablation). MATERIALS AND METHODS Magnetic resonance imaging was obtained in 14 patients (2 female, mean age 59 +/- 9) before and after isthmus ablation (mean delay 80 +/- 175 days) using steady-state free precession cine magnetic resonance imaging in right anterior oblique view orientation. Right atrial function (maximum/minimum right atrial volumes, stroke volume, ejection fraction) and maximum/minimum length of the CTI were measured. RESULTS After isthmus ablation, maximum RA volume decreased by 13% (P = .02) and minimum RA volume by 22% (P = .01), whereas stroke volume and ejection fraction did not increase significantly (P = .4 and .2, respectively). After ablation, the maximum length of the CTI showed a significant decrease of 19% (P < .001) and the minimum length a decrease of 24% (P < .001). A linear correlation between change in CTI length and number of energy applications during ablation could not be observed (r = .605, P = .22 for minimum length; r = .384, P = .18 for maximum length). After eliminating the outliers in the number of energy applications, a significant correlation between energy applications and change in CTI systolic length was found (r = .808, P = .008). CONCLUSION Magnetic resonance imaging to visualize right atrial size and function in right anterior oblique orientation was successfully performed and easy to evaluate for volumetric analysis and determination of CTI length. Scarring of the CTI with the use of catheter ablation leads to a significant and linear decrease in its length and to a subsequent reduction of right atrial volumes, whereas functional parameters such as stroke volume/ejection fraction did not change significantly.
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Models of cardiac tissue electrophysiology: progress, challenges and open questions. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2010; 104:22-48. [PMID: 20553746 DOI: 10.1016/j.pbiomolbio.2010.05.008] [Citation(s) in RCA: 290] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 04/09/2010] [Accepted: 05/19/2010] [Indexed: 01/03/2023]
Abstract
Models of cardiac tissue electrophysiology are an important component of the Cardiac Physiome Project, which is an international effort to build biophysically based multi-scale mathematical models of the heart. Models of tissue electrophysiology can provide a bridge between electrophysiological cell models at smaller scales, and tissue mechanics, metabolism and blood flow at larger scales. This paper is a critical review of cardiac tissue electrophysiology models, focussing on the micro-structure of cardiac tissue, generic behaviours of action potential propagation, different models of cardiac tissue electrophysiology, the choice of parameter values and tissue geometry, emergent properties in tissue models, numerical techniques and computational issues. We propose a tentative list of information that could be included in published descriptions of tissue electrophysiology models, and used to support interpretation and evaluation of simulation results. We conclude with a discussion of challenges and open questions.
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Yang Y, Varma N, Badhwar N, Tanel RE, Sundara S, Lee RJ, Lee BK, Tseng ZH, Marcus GM, Kim AM, Olgin JE, Scheinman MM. Prospective observations in the clinical and electrophysiological characteristics of intra-isthmus reentry. J Cardiovasc Electrophysiol 2010; 21:1099-106. [PMID: 20455984 DOI: 10.1111/j.1540-8167.2010.01778.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intra-isthmus reentry (IIR) is a circuit within the cavotricuspid isthmus (CTI). The purpose of this study is to prospectively define the electrogram and surface ECG characteristics of IIR, and its clinical implications. METHODS AND RESULTS Fourteen patients underwent electrophysiological studies and were found to have IIR. Detailed electrogram mapping of the CTI was available in all, electroanatomic mapping (EAM) in 8 of 14 (57%) patients. In all, entrainment mapping during tachycardia proved reentry, and showed that the anteroinferior CTI was out of the circuit and the septal CTI was in the circuit in 12 of 14 patients, whereas in 2, the circuit was confined within the mid and/or anteroinferior CTI. Fractionated potentials (FPs) spanning 34-71% of the tachycardia cycle length were recorded within the CTI in all, and double potentials were inscribed in 10 of 14 (71%). Analysis of the tricuspid annulus electrograms showed spontaneous shifts from a counterclockwise (CCW) to clockwise or fusion patterns. Surface ECGs showed either typical CCW pattern (12 patients) or atypical patterns (3 patients). The EAMs showed a focal pattern in 3, a CCW pattern in 5. The successful ablation site always occurred at the area with maximal FP duration. Over the same period, 33 of 384 (9%) patients who underwent ablation for CTI-dependent flutter had prior successful CTI ablation, 7 of 33 (21%) were found to have IIR during the redo procedure. CONCLUSIONS (1) Electrogram and ECG patterns of IIR frequently show atypical flutter. (2) IIR was successfully ablated in an area of the CTI associated with maximal duration of FPs. (3) IIR is a significant cause of "recurrent flutter" in patients with prior CTI ablation.
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Affiliation(s)
- Yanfei Yang
- University of California-San Francisco, San Francisco, California 94143-1354, USA
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Matsuyama TA, Ishibashi-Ueda H, Ikeda Y, Yamada Y, Okamura H, Noda T, Satomi K, Suyama K, Shimizu W, Aihara N, Kamakura S, Inoue S. The positional relationship between the coronary sinus musculature and the atrioventricular septal junction. Europace 2010; 12:719-25. [PMID: 20228078 DOI: 10.1093/europace/euq067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The atrioventricular (AV) septal junction includes the coronary sinus (CS) and the compact part of the AV node and its posterior extensions. It has been recognized as the target site for ablation therapy of the AV nodal reentrant tachycardia and its variant forms. Despite the clinical significance of this region, the arrangement of the musculature in the AV septal junction, including the CS, has not fully been elucidated. We tried to explore the histological muscular diversity within the AV septal junction. METHODS AND RESULTS Sixteen autopsied human hearts (seven women), mean age 59.8 years, without structural anomalies, were studied. We removed the whole AV septum, including the CS opening after the macroscopic measurements, and prepared serial sections parallel to mitral and tricuspid annuli (short-axis style) to elucidate the positional relationships between the compact AV node and the CS musculature. Out of 16 hearts, the CS musculature extended deeply into the AV septal junction in eight hearts. In the other eight hearts, the CS musculature was located above the AV septal junction. In the former group, we found that the offset of both annuli was wide (mean 3.8 +/- 1.4 vs. 2.4 +/- 1.1 mm), the distance between CS opening and membranous septum was long (mean 14.8 +/- 1.6 vs. 12.3 +/- 2.2 mm), and the CS opening level was lower and closer to the His bundle level (mean 2.8 +/- 1.9 vs. 5.8 +/- 2.9 mm) (P < 0.05). CONCLUSION The deep extension of CS musculature into the AV septal junction seems to increase the tissue non-uniformity in this area.
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Affiliation(s)
- Taka-aki Matsuyama
- Department of Pathology, National Cardiovascular Center, 5-7-1 Fujishirodai Suita-City, 565-8565 Osaka, Japan.
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Efficacy of bundle ablation for cavotricuspid isthmus-dependent atrial flutter: combination of the maximum voltage-guided ablation technique and high-density electro-anatomical mapping. J Interv Card Electrophysiol 2010; 28:39-44. [PMID: 20177759 DOI: 10.1007/s10840-010-9468-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 01/03/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Pathological studies have demonstrated that the cavotricuspid isthmus (CTI) is often composed of discrete muscle bundles, which are thought to be represented electrically as high-amplitude electrograms. Based on this observation, we visualized the bundles using an electro-anatomical mapping system (EAMS) and investigate the efficacy of bundle ablation which is an ablation method for selectively targeting high-voltage sites obtained by high-density electro-anatomical mapping along the CTI. METHODS Sixty patients with atrial flutter were randomly assigned to cavotricuspid isthmus ablation using a conventional anatomical approach (Group 1) or bundle ablation approach (Group 2). In Group 2, CTI was mapped in detail with EAMS, and we visualized the bundles that were 1.5 mV or more on a bipolar voltage map. Radiofrequency (RF) ablation was delivered sequentially from the maximum voltage site at the shortest distance of the bundle until bidirectional block was achieved. RESULTS Bidirectional block was achieved in all patients. Mean ablation times (Group 1, 1,392 + or - 960 s; Group 2, 638 + or - 342 s, p < 0.01), the mean number of RF applications (Group 1, 31.7 + or - 23.6; Group 2, 13.0 + or - 7.0, p < 0.01), and fluoroscopy times (Group 1, 50.4 + or - 28.3 min; Group 2, 42.3 + or - 21.3 min, p < 0.01) were significantly shorter in Group 2 than those in Group 1. CONCLUSION Bundle ablation at CTI is highly effective for achieving a bidirectional block requiring shorter ablation times, shorter fluoroscopy times, and fewer RF applications.
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Macedo PG, Kapa S, Mears JA, Fratianni A, Asirvatham SJ. Correlative anatomy for the electrophysiologist: ablation for atrial fibrillation. Part I: pulmonary vein ostia, superior vena cava, vein of Marshall. J Cardiovasc Electrophysiol 2010; 21:721-30. [PMID: 20158562 DOI: 10.1111/j.1540-8167.2010.01728.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ablation procedures for atrial fibrillation (AF) have become an established and increasingly used option for managing patients with symptomatic arrhythmia. The anatomic structures relevant to the pathogenesis of AF and ablation procedures are varied and include the pulmonary veins (PVs), other thoracic veins, the left atrial myocardium, and autonomic ganglia. Exact regional anatomic knowledge of these structures is essential to allow correlation with fluoroscopy and electrograms, and, importantly, to avoid complications from damage of adjacent structures within the chest. We have presented this information in a 2-part series. In the present article, we examine the general anatomic characteristics of the PVs, superior vena cava, and vein of Marshall. Features of particular relevance for the invasive electrophysiologist are pointed out. In a subsequent article, we discuss the regional anatomy of the left and right atria and anatomic considerations in preventing complications during AF ablation.
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Affiliation(s)
- Paula G Macedo
- Division of Cardiovascular Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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GAMI APOORS, EDWARDS WILLIAMD, LACHMAN NIRUSHA, FRIEDMAN PAULA, TALREJA DEEPAK, MUNGER THOMASM, HAMMILL STEPHENC, PACKER DOUGLASL, ASIRVATHAM SAMUELJ. Electrophysiological Anatomy of Typical Atrial Flutter: The Posterior Boundary and Causes for Difficulty with Ablation. J Cardiovasc Electrophysiol 2010; 21:144-149. [DOI: 10.1111/j.1540-8167.2009.01607.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Manusama R, Timmermans C, Pison L, Philippens S, Perez D, Rodriguez LM. Typical atrial flutter can effectively be treated using single one-minute cryoapplications: results from a repeat electrophysiological study. J Interv Card Electrophysiol 2009; 26:65-72. [PMID: 19521755 PMCID: PMC2746293 DOI: 10.1007/s10840-009-9405-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 04/01/2009] [Indexed: 11/30/2022]
Abstract
Purpose Catheter-based cryoablation (cryo) has proven to be as effective as radiofrequency energy (RF) ablation for the treatment of arrhythmias. Nevertheless, the duration of cryoapplications has been reported as being significantly longer than RF applications. Methods Thirty-seven consecutive patients (28 men; mean age 59 ± 14 years) with typical atrial flutter (AFL) underwent cryo of the cavotricuspid isthmus (CTI). Applications of 1 min were delivered with a 10-French, 10-mm tipped catheter (CryoCor™). If bidirectional CTI block was not obtained after 12 1-min applications, applications of 3 min were selectively delivered to areas of conduction breakthrough. The endpoint of the procedure was creation of bidirectional CTI block and non-inducibility of AFL. Results A median of 7 (range 3 to 12) 1-min applications were given along the CTI with a mean temperature of −88.6 ± 2.3°C. Mean fluoroscopy and procedure time were 27 ± 14 min and 110 ± 28 min respectively. Five patients required additional 3-min applications; in one patient an overextended ablation catheter prevented the completion of the index-procedure. The acute success rate of the index-procedure was 97%. In 12/24 patients, two with AFL recurrence, resumption of CTI conduction was found 4 months post-ablation. In all patients bidirectional CTI block was re-obtained after a median of one 1-min application. No additional AFL recurrences occurred, after a mean follow-up of 37 ± 3 (range 30 to 44) months. Conclusions Cryo of AFL can successfully be performed using the same application duration as used for RF ablation. Both acute and long-term results are comparable to RF ablation. AFL recurrences occurred in only a minority of patients with resumption of CTI conduction.
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Affiliation(s)
- Randy Manusama
- Department of Cardiology, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, P.O. Box 5800, AZ 6202, Maastricht, The Netherlands
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Abstract
Atrial flutter (AFL) is a common arrhythmia in clinical practice. Several experimental models, such as tricuspid regurgitation model, tricuspid ring model, sterile pericarditis model and atrial crush injury model, have provided important information about reentrant circuit and can test the effects of antiarrhythmic drugs. Human AFL has typical and atypical forms. Typical AFL rotates around the tricuspid annulus and uses the crista terminalis and sometimes sinus venosa as the boundary. The tricuspid isthmus is a slow conduction zone and the target of radiofrequency ablation. Atypical AFL may arise from the right or left atrium. Right AFL includes upper loop reentry, free wall reentry and figure-of-8 reentry. Left AFL includes mitral annular AFL, pulmonary vein-related AFL and left septal AFL. Radiofrequency ablation of the isthmus between the boundaries can eliminate these arrhythmias.
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Affiliation(s)
- Ching-Tai Tai
- Division of Cardiology, Department of Medicine, National Yang-Ming University School of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
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