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Kautzner J, Peichl P, Paamand R, Carlson MD. Decreased Noise and Identification of Very Low Voltage Signals Using a Novel Electrophysiology Recording System. Eur Cardiol 2023; 18:e59. [PMID: 38023337 PMCID: PMC10658352 DOI: 10.15420/ecr.2022.37] [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: 08/28/2022] [Accepted: 07/18/2023] [Indexed: 12/01/2023] Open
Abstract
Aims The interpretation of intracardiac electrograms recorded from conventional electrophysiology recording systems is frequently impacted by powerline (50/60 Hz) noise and distortion due to notch filtering. This study compares unipolar electrograms recorded simultaneously from a conventional electrophysiology recording system and one of two 3D mapping systems (control system) with those from a novel system (ECGenius, CathVision ApS) designed to reduce noise without the need for conventional filtering. Methods Unipolar electrograms were recorded simultaneously from nine consecutive patients undergoing catheter ablation for AF (five patients), atrioventricular nodal re-entrant tachycardia (three patients), or ventricular tachycardia (one patient) over the course of 1 week in 2020. Results The noise spectral power of the novel system (49-51 Hz) was 6.1 ± 6.2 times lower than that of the control system. Saturation artefact following pacing (duration 97 ± 85 ms) occurred in eight control recordings and no novel system recordings (p<0.001). High frequency, low amplitude signals and fractionated electrograms apparent on unfiltered novel system unipolar recordings were not present on control recordings. Control system notch filtering obscured His bundle electrograms observable without such filtering using the novel system and induced electrogram distortion that was not present on novel system recordings. Signal saturation occurred in five of seven control system recordings but none of the novel system recordings. Conclusion In this study, novel system recordings exhibited less noise and fewer signal artefacts than the conventional control system and did not require notch filtering that distorted electrograms on control recordings. The novel recording system provided superior electrogram data not apparent with conventional systems.
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Affiliation(s)
- Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental MedicinePrague, Czech Republic
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental MedicinePrague, Czech Republic
| | | | - Mark D Carlson
- Department of Medicine, University Hospitals, Case Medical Center, Case Western Reserve UniversityCleveland, OH, US
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Huo Y, Gaspar T, Schönbauer R, Wójcik M, Fiedler L, Roithinger FX, Martinek M, Pürerfellner H, Kirstein B, Richter U, Ulbrich S, Mayer J, Krahnefeld O, Agdirlioglu T, Zedda A, Piorkowski J, Piorkowski C. Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation. NEJM EVIDENCE 2022; 1:EVIDoa2200141. [PMID: 38319851 DOI: 10.1056/evidoa2200141] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Clinically effective ablation approaches for patients with persistent atrial fibrillation (AF) are still being debated. So far, ablation targets and strategies beyond pulmonary vein isolation (PVI) have failed to show systematic outcome improvement in randomized controlled clinical trials. METHODS: We conducted a multicenter, randomized trial to determine whether PVI plus individualized substrate ablation of atrial low-voltage myocardium improves outcome in patients with persistent AF. We randomly assigned 324 patients in a 1:1 ratio to receive PVI alone (163 patients; PVI only) or PVI plus substrate modification (161 patients; PVI+SM). The primary study end point was the first recurrence of an atrial arrhythmia longer than 30 seconds after single ablation, with 3 months blanking, using serial 7-day electrocardiogram recordings over 12 months of observation. Patients were also encouraged to receive implantable cardiac monitors. RESULTS: The primary study end point occurred in 75 PVI-only patients (50%) and in 54 PVI+SM patients (35%) (Kaplan–Meier event rate estimates: hazard ratio=0.62, 95% confidence interval [CI]=0.43 to 0.88, log rank P=0.006). Adverse events occurred in three PVI-only patients (1.8%) and in six PVI+SM patients (3.7%) (difference: −1.9 percentage points, 95% CI=−5.5 to 1.7 percentage points). Implant monitoring was used in 242 patients. Among them, 65 PVI-only patients (55%) versus 47 PVI+SM patients (39%) experienced recurrences (difference: 15 percentage points, 95% CI=3 to 28 percentage points). CONCLUSIONS: In this randomized trial, PVI plus individualized ablation of atrial low-voltage myocardium significantly improved outcomes in patients with persistent AF. (ClinicalTrials.gov number, NCT02732626.)
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Affiliation(s)
- Yan Huo
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Thomas Gaspar
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Robert Schönbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna
| | - Maciej Wójcik
- Department of Cardiology, Medical University in Lublin, Lublin, Poland
| | - Lukas Fiedler
- Department of Internal Medicine II, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- University Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Franz Xaver Roithinger
- Department of Internal Medicine II, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Martin Martinek
- Department of Internal Medicine 2, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Helmut Pürerfellner
- Department of Internal Medicine 2, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Bettina Kirstein
- Heart Center, University Hospital Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Utz Richter
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Stefan Ulbrich
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Julia Mayer
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Olaf Krahnefeld
- Department of Electrophysiology, Sana Kliniken Lübeck, Lübeck, Germany
| | - Tolga Agdirlioglu
- Department of Electrophysiology, Sana Kliniken Lübeck, Lübeck, Germany
| | - Angela Zedda
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
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Frontera A, Limite LR, Pagani S, Cireddu M, Vlachos K, Martin C, Takigawa M, Kitamura T, Bourier F, Cheniti G, Pambrun T, Sacher F, Derval N, Hocini M, Quarteroni A, Della Bella P, Haissaguerre M, Jaïs P. Electrogram fractionation during sinus rhythm occurs in normal voltage atrial tissue in patients with atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:219-228. [PMID: 34919281 DOI: 10.1111/pace.14425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/08/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Electrogram (EGM) fractionation is often associated with diseased atrial tissue; however, mechanisms for fractionation occurring above an established threshold of 0.5 mV have never been characterized. We sought to investigate during sinus rhythm (SR) the mechanisms underlying bipolar EGM fractionation with high-density mapping in patients with atrial fibrillation (AF). METHODS Forty-five patients undergoing AF ablation (73% paroxysmal, 27% persistent) were mapped at high density (18562 ± 2551 points) during SR (Rhythmia). Only bipolar EGMs with voltages above 0.5 mV were considered for analysis. When fractionation (>40 ms and >4 deflections) was detected, we classified the mechanisms as slow conduction, wave-front collision, or a pivot point. The relationship between EGM duration and amplitude, and tissue anisotropy and slow conduction, was then studied using a computational model. RESULTS Of the 45 left atria analyzed, 133 sites of EGM fragmentation were identified with voltages above 0.5 mV. The most frequent mechanism (64%) was slow conduction (velocity 0.45 m/s ± 0.2) with mean EGM voltage of 1.1 ± 0.5 mV and duration of 54.9 ± 9.4 ms. Wavefront collision was the second most frequent (19%), characterized by higher voltage (1.6 ± 0.9 mV) and shorter duration (51.3 ± 11.3 ms). Pivot points (9%) were associated with the highest degree of fractionation with 70.7 ± 6.6 ms and 1.8 ± 1 mV. In 10 sites (8%) fractionation was unexplained. The EGM duration was significantly different among the 3 mechanisms (p = 0.0351). CONCLUSION In patients with a history of AF, EGM fractionation can occur at amplitudes > 0.5 mV when in SR in areas often considered not to be diseased tissue. The main mechanism of EGM fractionation is slow conduction, followed by wavefront collision and pivot sites. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Antonio Frontera
- Department of Arrhythmology, San Raffaele Hospital, Milan, 20132, Italy.,Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | | | - Stefano Pagani
- MOX, Department of Mathematics, Politecnico di Milano, Milan, Italy
| | - Manuela Cireddu
- Department of Arrhythmology, San Raffaele Hospital, Milan, 20132, Italy
| | - Kostantinos Vlachos
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | | | - Masateru Takigawa
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Takeshi Kitamura
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France
| | - Felix Bourier
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Ghassen Cheniti
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Thomas Pambrun
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France
| | - Frederic Sacher
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Nicolas Derval
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Meleze Hocini
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Alfio Quarteroni
- MOX, Department of Mathematics, Politecnico di Milano, Milan, Italy.,Professor Emeritus, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Paolo Della Bella
- Department of Arrhythmology, San Raffaele Hospital, Milan, 20132, Italy
| | - Michel Haissaguerre
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
| | - Pierre Jaïs
- Electrophysiology laboratories, Hopital Haut Leveque, Pessac, 33600, France.,LIRYC institute, Pessac, 33600, France
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Liu HT, Yang CH, Lee HL, Chang PC, Wo HT, Wen MS, Wang CC, Yeh SJ, Chou CC. Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients. PLoS One 2021; 16:e0260834. [PMID: 34855901 PMCID: PMC8638894 DOI: 10.1371/journal.pone.0260834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/17/2021] [Indexed: 11/30/2022] Open
Abstract
Background The therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients. Methods We retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn’t convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA. Results After a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation. Conclusions LVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.
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Affiliation(s)
- Hao-Tien Liu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chia-Hung Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Hui-Ling Lee
- Department of Anesthesia, Chang Gung Memorial Hospital, Taipei Branch, Taipei, Taiwan
| | - Po-Cheng Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Hung-Ta Wo
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Chieh Wang
- Department of Anesthesia, Chang Gung Memorial Hospital, Taipei Branch, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Anesthesia, Chang Gung Memorial Hospital, Taipei Branch, Taipei, Taiwan
| | - Chung-Chuan Chou
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- * E-mail:
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Atrial substrate characterization in patients with atrial fibrillation and hypertrophic cardiomyopathy: Evidence for an extensive fibrotic disease. J Electrocardiol 2021; 69:87-92. [PMID: 34619440 DOI: 10.1016/j.jelectrocard.2021.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Data regarding the left atrial (LA) electroanatomical substrate in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) are missing. In this electroanatomical mapping (EAM) study, we evaluated the extent of LA fibrosis and its impact on catheter ablation outcomes in patients with HCM and AF. MATERIALS AND METHODS High-density LA EAM was performed during AF in 28 consecutive patients with obstructive HCM and AF (42.9% displayed paroxysmal AF and 57.1% persistent AF). Propensity score (PS) matching analysis was performed to reduce the impact of potential confounding factors. PS were derived to match patients at a 1:1 ratio. Patients were matched according to age, sex and LA diameter. After PS, 28 non-HCM patients with AF were selected, and served as controls. Two different cut-off values of bipolar signal amplitude were investigated for fibrosis characterization (≤0.25 mV and ≤ 0.4 mV). HCM patients underwent pulmonary vein antral isolation (PVAI) and roof line, while non-HCM patients PVAI only. RESULTS After the 3-month blanking period, 10 HCM patients (35.7%) displayed atrial arrhythmia recurrence. HCM patients with arrhythmia recurrence showed significantly greater low voltage areas defined as either bipolar voltage ≤0.25 mV (22.5 ± 10% vs. 5.5 ± 6.4%, p = 0.001) or ≤ 0.4 mV (32 ± 13.9% vs. 5.9 ± 5.1%, p < 0.001). The presence of low voltage areas ≤0.4 mV greater than 14.1% of the total LA area also predicted arrhythmia recurrence with excellent sensitivity (100%) and specificity (100%). Univariate analysis revealed that the extent of LA fibrosis was the only predictor of AF recurrence. After PS matching with non-HCM patients, patients with HCM exhibited wider fibrotic regions ≤0.25 mV compared to non-HCM patients (p = 0.016). CONCLUSIONS High-density EAM reveals extensive LA fibrotic disease in patients with HCM, an event with certain implications in catheter ablation outcomes.
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Hwang J, Park HS, Han S, Lee CH, Kim IC, Cho YK, Yoon HJ, Chung JW, Kim H, Nam CW, Hur SH, Kim JY, Kim YS, Jang WS. Ablation of persistent atrial fibrillation based on high density voltage mapping and complex fractionated atrial electrograms: A randomized controlled trial. Medicine (Baltimore) 2021; 100:e26702. [PMID: 34397805 PMCID: PMC8341227 DOI: 10.1097/md.0000000000026702] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/07/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) catheter ablation. However, a PVI alone has been considered insufficient for persistent AF. This study aimed to evaluate the efficacy of persistent AF ablation targeting complex fractionated atrial electrogram (CFAE) areas within low voltage zones identified by high-resolution mapping in addition to the PVI. METHODS We randomized 50 patients (mean age 58.4 ± 9.5 years old, 86.0% males) with persistent AF to a PVI + CFAE group and PVI only group in a 1:1 ratio. CFAE and voltage mapping was performed simultaneously using a Pentaray Catheter with the CARTO3 CONFIDENSE module (Biosense Webster, CA, USA). The PVI + CFAE group, in addition to the PVI, underwent ablation targeting low voltage areas (<0.5 mV during AF) containing CFAEs. RESULTS The mean persistent AF duration was 24.0 ± 23.1 months and mean left atrial dimension 4.9 ± 0.5 cm. In the PVI + CFAE group, AF converted to atrial tachycardia (AT) or sinus rhythm in 15 patients (60%) during the procedure. The PVI + CFAE group had a higher 1-year AF free survival (84.0% PVI + CFAE vs 44.0 PVI only, P = .006) without antiarrhythmic drugs. However, there was no difference in the AF/AT free survival (60.0% PVI + CFAE vs 40.0% PVI only, P = .329). CONCLUSION Persistent AF ablation targeting CFAE areas within low voltage zones using high-density voltage mapping had a higher AF free survival than a PVI only. Although recurrence with AT was frequent in the PVI+CFAE group, the sinus rhythm maintenance rate after redo procedures was 76%.
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Affiliation(s)
- Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Cheol Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin wook Chung
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin Young Kim
- Department of Radiology, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular surgery, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
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Frontera A, Limite LR, Pagani S, Hadjis A, Cireddu M, Sala S, Tsitsinakis G, Paglino G, Peretto G, Lipartiti F, Bisceglia C, Radinovic A, D'Angelo G, Marzi A, Baratto F, Vergara P, DedÈ L, Gulletta S, Manzoni A, Mazzone P, Quarteroni A, Della Bella P. Characterization of cardiac electrogram signals in atrial arrhythmias. Minerva Cardiol Angiol 2021; 69:70-80. [PMID: 33691387 DOI: 10.23736/s2724-5683.20.05431-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite significant advancements in 3D cardiac mapping systems utilized in daily electrophysiology practices, the characterization of atrial substrate remains crucial for the comprehension of supraventricular arrhythmias. During mapping, intracardiac electrograms (EGM) provide specific information that the cardiac electrophysiologist is required to rapidly interpret during the course of a procedure in order to perform an effective ablation. In this review, EGM characteristics collected during sinus rhythm (SR) in patients with paroxysmal atrial fibrillation (pAF) are analyzed, focusing on amplitude, duration and fractionation. Additionally, EGMs recorded during atrial fibrillation (AF), including complex fractionated atrial EGMs (CFAE), may also provide precious information. A complete understanding of their significance remains lacking, and as such, we aimed to further explore the role of CFAE in strategies for ablation of persistent AF. Considering focal atrial tachycardias (AT), current cardiac mapping systems provide excellent tools that can guide the operator to the site of earliest activation. However, only careful analysis of the EGM, distinguishing low amplitude high frequency signals, can reliably identify the absolute best site for RF. Evaluating macro-reentrant atrial tachycardia circuits, specific EGM signatures correspond to particular electrophysiological phenomena: the careful recognition of these EGM patterns may in fact reveal the best site of ablation. In the near future, mathematical models, integrating patient-specific data, such as cardiac geometry and electrical conduction properties, may further characterize the substrate and predict future (potential) reentrant circuits.
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Affiliation(s)
- Antonio Frontera
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy -
| | | | - Stefano Pagani
- MOX, Department of Mathematics, Polytechnic of Milan, Milan, Italy
| | - Alexios Hadjis
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Manuela Cireddu
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Simone Sala
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Gabriele Paglino
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Felicia Lipartiti
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Andrea Radinovic
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giuseppe D'Angelo
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandra Marzi
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Baratto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Pasquale Vergara
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Luca DedÈ
- MOX, Department of Mathematics, Polytechnic of Milan, Milan, Italy
| | - Simone Gulletta
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrea Manzoni
- MOX, Department of Mathematics, Polytechnic of Milan, Milan, Italy
| | - Patrizio Mazzone
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alfio Quarteroni
- MOX, Department of Mathematics, Polytechnic of Milan, Milan, Italy.,Federal Polytechnic School of Lausanne, Lausanne, Switzerland
| | - Paolo Della Bella
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
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8
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Efremidis M, Bazoukis G, Vlachos K, Prappa E, Megarisiotou A, Dragasis S, Ramirez FD, Bourier F, Mililis P, Saplaouras A, Tse G, Liu T, Efremidis T, Kitsoulis P, Thomopoulos C, Sideris A, Letsas KP. Safety of catheter ablation of atrial fibrillation without pre- or peri-procedural imaging for the detection of left atrial thrombus in the era of uninterrupted anticoagulation. J Arrhythm 2021; 37:28-32. [PMID: 33664883 PMCID: PMC7896446 DOI: 10.1002/joa3.12466] [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: 08/04/2020] [Revised: 10/18/2020] [Accepted: 11/04/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The need for pre- or peri-procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus. PATIENTS AND METHODS Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days. RESULTS A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2-VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30-day post-discharged period. CONCLUSIONS Catheter ablation can be safely performed in low-risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.
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Affiliation(s)
- Michael Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos Vlachos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Efstathia Prappa
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasia Megarisiotou
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Stylianos Dragasis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - F. Daniel Ramirez
- Hôpital Cardiologique du Haut LévèqueCHU de Bordeaux and IHU‐LIRYCPessacFrance
| | - Felix Bourier
- Department of ElectrophysiologyGerman Heart CenterTechnical UniversityMunichGermany
| | - Panagiotis Mililis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasios Saplaouras
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Gary Tse
- Xiamen Cardiovascular HospitalXiamen UniversityXiamenPeople's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular DiseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinPeople's Republic of China
| | - Theodore Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Panagiotis Kitsoulis
- Laboratory of Anatomy‐Histology‐EmbryologySchool of MedicineUniversity of IoanninaIoanninaGreece
| | | | - Antonios Sideris
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
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Left Atrial Electroanatomical Voltage Mapping to Characterize Substrate and Guide Ablation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00833-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Simple hematological predictors of AF recurrence in patients undergoing atrial fibrillation ablation. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2019; 16:671-675. [PMID: 31645852 PMCID: PMC6790958 DOI: 10.11909/j.issn.1671-5411.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Backgound Red cell distribution width (RDW) and neutrophil-to-lymphocyte ratio (NLR) are simple hematologic indices that have been used to predict adverse outcomes in different clinical settings. The aim of our study is to determine whether RDW and NLR can predict atrial fibrillation (AF) recurrence in patients undergoing AF ablation. Methods Consecutive patients, without known hematological disorders, who underwent AF catheter ablation between January 2014 and April 2017 were enrolled into this study. Blood samples were taken one day before and five hours after the ablation procedure. Results A total of 346 patients (224 males (65%), mean age: 59 ± 11 years old) were included. After a mean follow up of 26.2 ± 12.1 months, 80 (23.1%) patients experienced late AF recurrence (defined as any recurrence after the blanking period of three months), while 97 (28%) patients experienced early AF recurrence during the blanking period. Univariate analysis showed that early arrhythmia recurrence, type of AF and NLR after the procedure were significantly associated with late AF recurrence, while early arrhythmia recurrence and NLR remained significant in multivariate analysis. RDW was not associated with late AF recurrence. None of the parameters above predicted early arrhythmia recurrence. Conclusions Simple and inexpensive hematological indices such as NLR should be evaluated for their ability to predict AF recurrence in patients undergoing catheter ablation in larger prospective studies.
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11
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Tzeis S, Asvestas D, Vardas P. Atrial Fibrosis: Translational Considerations for the Management of AF Patients. Arrhythm Electrophysiol Rev 2019; 8:37-41. [PMID: 30918665 PMCID: PMC6434500 DOI: 10.15420/aer.2018.79.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Fibrosis plays a fundamental role in the initiation and maintenance of AF, mainly due to enhanced automaticity and anisotropy-related re-entry. The identification and quantification of atrial fibrosis is achieved either preprocedurally by late gadolinium enhancement MRI or intraprocedurally using electroanatomic voltage mapping. The presence and extent of left atrial fibrosis among AF patients may influence relevant decision making regarding the need for anticoagulation, the adoption of rate versus rhythm control and mainly the type of ablation strategy that will be followed during interventional treatment. Several types of individualised substrate modifications targeting atrial fibrotic areas have been proposed, although their impact on patient outcome needs to be further investigated in adequately powered prospective randomised controlled clinical trials.
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Affiliation(s)
- Stylianos Tzeis
- Cardiology Department, Mitera General Hospital, Hygeia Group Athens, Greece
| | - Dimitrios Asvestas
- Cardiology Department, Mitera General Hospital, Hygeia Group Athens, Greece
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals Athens, Greece
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