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Compagnucci P, Valeri Y, Conti S, Volpato G, Cipolletta L, Parisi Q, D'Angelo L, Campanelli F, Carboni L, Sgarito G, Natale A, Casella M, Dello Russo A. Technological advances in ventricular tachycardia catheter ablation: the relentless quest for novel solutions to old problems. J Interv Card Electrophysiol 2024; 67:855-864. [PMID: 38087147 DOI: 10.1007/s10840-023-01705-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/20/2023] [Indexed: 06/12/2024]
Abstract
BACKGROUND Several novel technologies allowing catheter ablation (CA) with a favorable safety/efficacy profile have been recently developed, but not yet extensively clinically tested in the setting of ventricular tachycardia CA. METHODS In this technical report, we overview technical aspects and preclinical/clinical information concerning the application of three novel CA technologies in the ventricular milieu: a pulsed field ablation (PFA) generator (CENTAURI™, Galaxy Medical) to be used with linear, contact force-sensing radiofrequency ablation catheters; a contact force-sensing radiofrequency ablation catheter equipped with six thermocouples and three microelectrodes (QDOT Micro™, Biosense-Webster), allowing high-resolution mapping and temperature-controlled CA; and a flexible and mesh-shaped irrigation tip, contact force-sensing radiofrequency ablation catheter (Tactiflex, Abbott). We also report three challenging VT cases in which CA was performed using these technologies. RESULTS The CENTAURI system was used with the Tacticath™ (Abbott) ablation catheter to perform ventricular PFA in a patient with advanced heart failure, electrical storm, and a deep intramural septal substrate. Microelectrode mapping using QDOT Micro™ helped to refine substrate assessment in a VT patient with congenitally corrected transposition of the great arteries, and allowed the identification of the critical components of the VT circuit, which were successfully ablated. Tactiflex™ was used in two challenging CA cases (one endocardial and one epicardial), allowing acute and mid-term control of VT episodes without adverse events. CONCLUSION The ideation and development of novel technologies initially intended to treat atrial arrhythmias and successfully implemented in the ventricular milieu is contributing to the progressive improvement in the clinical benefits derived from VT CA, making this procedure key for successful management of increasingly complex patients.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy.
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
| | - Sergio Conti
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Leonardo D'Angelo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
| | - Francesca Campanelli
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
| | - Laura Carboni
- Cardiac Surgery Anesthesia and Critical Care Unit, University Hospital "Ospedali Riuniti,", Ancona, Italy
| | - Giuseppe Sgarito
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy
| | - Andrea Natale
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, USA
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
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Compagnucci P, Volpato G, Cipolletta L, Parisi Q, Valeri Y, Campanelli F, D'Angelo L, Ciliberti G, Stronati G, Carboni L, Giovagnoni A, Guerra F, Natale A, Casella M, Dello Russo A. Posterior wall ablation for persistent atrial fibrillation: Very-high-power short-duration versus standard-power radiofrequency ablation. Heart Rhythm O2 2024; 5:374-384. [PMID: 38984361 PMCID: PMC11228279 DOI: 10.1016/j.hroo.2024.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
Background Posterior wall ablation (PWA) is commonly added to pulmonary vein isolation (PVI) during catheter ablation (CA) of persistent atrial fibrillation (AF). Objective The purpose of this study was to compare PVI plus PWA using very-high-power short-duration (vHPSD) vs standard-power (SP) ablation index-guided CA among consecutive patients with persistent AF and to determine the voltage correlation between microbipolar and bipolar mapping in AF. Methods We compared 40 patients undergoing PVI plus PWA using vHPSD to 40 controls receiving PVI plus PWA using SP. The primary efficacy endpoint was recurrence of atrial tachyarrhythmias after a 3-month blanking period. The primary safety outcome was a composite of major complications within 30 days after CA. In the vHPSD group, high-density mapping of the posterior wall was performed using both a multipolar catheter and microelectrodes on the tip of the ablation catheter. Results PVI was more commonly obtained with vHPSD compared to SP ablation (98%vs 75%; P = .007), despite shorter procedural and fluoroscopy times (P <.001). Survival free from recurrent atrial tachyarrhythmias at 18 months was 68% and 47% in the vHPSD and SP groups, respectively (log-rank P = .071), without major adverse events. The vHPSD approach was significantly associated with reduced risk of recurrent AF at multivariable analysis (hazard ratio 0.39; P = .030). Microbipolar voltage cutoffs of 0.71 and 1.69 mV predicted minimum bipolar values of 0.16 and 0.31 mV in AF, respectively, with accuracies of 0.67 and 0.88. Conclusion vHPSD PWA plus PVI may be faster and as safe as SP CA among patients with persistent AF, with a trend for superior efficacy. Adapted voltage cutoffs should be used for identifying atrial low-voltage areas with microbipolar mapping.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Francesca Campanelli
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Leonardo D'Angelo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Giulia Stronati
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Carboni
- Cardiac Surgery Anesthesia and Critical Care Unit, Marche University Hospital, Ancona, Italy
| | - Andrea Giovagnoni
- Department of Radiology, University Hospital "Ospedali Riuniti," Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
- Department of Interventional Electrophysiology, Scripps Clinic, San Diego, California
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
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Compagnucci P, Casella M. Atrial tachyarrhythmia recurrence after cryobaloon ablation: does thickness imply failure? J Interv Card Electrophysiol 2024; 67:681-683. [PMID: 38261099 DOI: 10.1007/s10840-024-01747-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024]
Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy.
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
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Dello Russo A, D'Angelo L, Compagnucci P, Cipolletta L, Parisi Q, Valeri Y, Campanelli F, Volpato G, Carboni L, Ciliberti G, Stronati GE, Barbarossa A, La Piscopia V, Bondavalli B, Guerra F, Natale A, Casella M. High-power short-duration catheter ablation of atrial fibrillation: is it really a new era? Comparison between new and old radiofrequency contact force-sensing catheters. J Interv Card Electrophysiol 2024; 67:549-557. [PMID: 37584862 DOI: 10.1007/s10840-023-01612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND The clinical performance of high-power, short-duration (HPSD) pulmonary vein isolation (PVI) with the novel flexible tip TactiFlex™ (TFSE) catheter, as compared to standard-power, long-duration (SPLD) PVI using the TactiCath™ (TCSE) catheter among patients undergoing catheter ablation (CA) of atrial fibrillation (AF) is currently unknown. METHODS We conducted a prospective, observational, single-centre study including 40 consecutive patients undergoing PVI for paroxysmal/persistent AF, using HPSD ablation with the novel TFSE catheter (HPSD/TFSE group). Based on propensity score-matching, forty patients undergoing SPLD PVI with the TCSE catheter were identified (SPLD/TCSE group). In the HPSD/TFSE group, RF lesions were performed by delivering 40-50 W for 10-20 s, while in the SPLD/TCSE group, RF power was 30-35 W, targeting a lesion size index (LSI) of 4.0-5.5. The co-primary study outcomes were time required to complete PVI and first pass isolation (FPI). RESULTS PVI was achieved in 100% of patients in both groups, and no major adverse events were observed. Remarkably, PVI time was shorter in the HPSD/TFSE, compared to the SPLD/TCSE group(9 [7-9] min vs. 50 [37-54] min; p < 0.001), while FPI rate was non-significantly higher in the former group(91% [146/160] vs 83% [134/160]; p = 0.063). Shorter procedural (108 [91-120] min vs. 173 [139-187] min, p < 0.001), total RF (9 [7-11] min vs. 43 [32-53] min, p < 0.001), fluoroscopy times(15 [10-19] min vs. 18 [13-26] min, p = 0.014), and lower DAP (1461 [860-2181] vs. 7200 [3400-20,800], p < 0.001) were recorded in the HPSD/TFSE group. A higher average impedance drop was obtained with HPSD/TFSE CA(17[17-18]Ω vs. 16 [15-17] Ω, p < 0.001). CONCLUSIONS In our initial clinical experience, HPSD PVI with the TFSE catheter proved faster than SPLD PVI with the TCSE catheter, at least equally effective in terms of FPI, and it was associated with greater impedance drop.
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Affiliation(s)
- Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Leonardo D'Angelo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy.
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Francesca Campanelli
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Carboni
- Cardiac Surgery Anesthesia and Critical Care Unit, University Hospital "Ospedali Riuniti", Ancona, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
| | - Giulia Emily Stronati
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
| | - Valentina La Piscopia
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
| | - Barbara Bondavalli
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX, USA
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Via Conca 71, 60126, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
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Bai Y, Jia R, Wang X, Chan J, Cui K. Association of left atrial wall thickness with recurrence after cryoballoon ablation of paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2024; 67:657-667. [PMID: 37966658 DOI: 10.1007/s10840-023-01691-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/05/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Transmural injury plays a role in successful atrial fibrillation ablation. The effect of left atrial wall thickness (LAWT) on the efficacy of radiofrequency ablation has been identified, but data on the relationship between LAWT and cryoballoon for paroxysmal atrial fibrillation (PAF) are lacking. We aim to explore the relationship between LAWT and recurrence after cryoballoon ablation (CBA). METHODS We studied 364 patients (mean age 62 years) with PAF who underwent a second-generation CBA and pre-procedure cardiac CTA. LAWT and left atrial volume index (LAVI) were obtained based on pre-procedure cardiac CTA measurements. Follow-up was at least 12 months and predictors of atrial tachyarrhythmia recurrence during follow-up were assessed. RESULTS Patients were followed up for a median of 19 (12-28) months, with an atrial tachyarrhythmia-free rate of 77.5% after cryoablation. Greater LAVI (50.0 ± 19.6 mL/m2 vs. 44.3 ± 15.4 mL/m2, P = 0.018) and greater LAWT (1.67 ± 0.24 vs. 1.46 ± 0.25 mm, P < 0.001) were associated with atrial tachyarrhythmia recurrence. The mean LAWT of PV antrum correlated with TTI (R = 0.252, P < 0.001). Adding LAWT to the established risk model improved both the discrimination and reclassification effects (IDI: 0.099, 95% CI: 0.065-0.134, P < 0.001; NRI: 0.685, 95% CI: 0.455-0.915, P < 0.001). In a multivariable Cox proportional hazard model, the mean LAWT of PV antrum (hazard ratio [HR]:3.657, 95%CI: 2.319-5.765, P < 0.001) was an independent predictor of atrial tachyarrhythmia recurrence after cryoablation. CONCLUSIONS The mean LAWT of PV antrum, obtained from preoperative measurements on CT, was associated with atrial tachyarrhythmia recurrence after cryoablation.
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Affiliation(s)
- Yixuan Bai
- Department of Cardiology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Ruikun Jia
- Department of Cardiology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Xinmeng Wang
- Department of Cardiology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Juan Chan
- Department of Cardiology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.
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Zhang L, van Schie MS, Xiang H, Liao R, Zheng J, Knops P, Taverne YJHJ, de Groot NMS. Identification of Atrial Transmural Conduction Inhomogeneity Using Unipolar Electrogram Morphology. J Clin Med 2024; 13:1015. [PMID: 38398329 PMCID: PMC10889286 DOI: 10.3390/jcm13041015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Structural remodeling plays an important role in the pathophysiology of atrial fibrillation (AF). It is likely that structural remodeling occurs transmurally, giving rise to electrical endo-epicardial asynchrony (EEA). Recent studies have suggested that areas of EEA may be suitable targets for ablation therapy of AF. We hypothesized that the degree of EEA is more pronounced in areas of transmural conduction block (T-CB) than single-sided CB (SS-CB). This study examined the degree to which SS-CB and T-CB enhance EEA and which specific unipolar potential morphology parameters are predictive for SS-CB or T-CB. (2) Methods: Simultaneous endo-epicardial mapping in the human right atrium was performed in 86 patients. Potential morphology parameters included unipolar potential voltages, low-voltage areas, potential complexity (long double and fractionated potentials: LDPs and FPs), and the duration of fractionation. (3) Results: EEA was mostly affected by the presence of T-CB areas. Lower potential voltages and more LDPs and FPs were observed in T-CB areas compared to SS-CB areas. (4) Conclusion: Areas of T-CB could be most accurately predicted by combining epicardial unipolar potential morphology parameters, including voltages, fractionation, and fractionation duration (AUC = 0.91). If transmural areas of CB indeed play a pivotal role in the pathophysiology of AF, they could theoretically be used as target sites for ablation.
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Affiliation(s)
- Lu Zhang
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
| | - Mathijs S. van Schie
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
| | - Hongxian Xiang
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
| | - Rongheng Liao
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
| | - Jiahao Zheng
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
| | - Yannick J. H. J. Taverne
- Translational Cardiothoracic Surgery Research Lab, Department of Cardiothoracic Surgery, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands
| | - Natasja M. S. de Groot
- Department of Cardiology, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands (J.Z.); (N.M.S.d.G.)
- Signal Processing Systems, Department of Microelectronics, Faculty of Electrical Engineering, Mathematics and Computer Sciences, Delft University of Technology, 2628CD Delft, The Netherlands
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Sun J, Chen S, Liang M, Zhang Q, Zhang P, Sun M, Ding J, Jin Z, Han Y, Wang Z. Bachmann's Bundle Modification in Addition to Circumferential Pulmonary Vein Isolation for Atrial Fibrillation: A Novel Ablation Strategy. Cardiol Res Pract 2023; 2023:2870188. [PMID: 37927390 PMCID: PMC10624549 DOI: 10.1155/2023/2870188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/17/2023] [Accepted: 06/23/2023] [Indexed: 11/07/2023] Open
Abstract
Background Bachmann's bundle (BB) is the main pathway of interatrial connection that could be involved in the development of atrial fibrillation (AF). Based on this hypothesis, we raised a novel ablation strategy, BB modification in addition to circumferential pulmonary vein isolation (CPVI-BB) in patients with AF. Methods A retrospective cohort of patients with AF who underwent CPVI-BB or CPVI alone from March 2018 to July 2021 was enrolled in our study. Propensity score matching was performed in patients with paroxysmal AF and persistent AF, respectively, to reduce the risk of selection bias between the treatment strategies (CPVI-BB or CPVI alone). The primary endpoint was overall freedom from atrial arrhythmia recurrence through 12 months of follow-up. Results Our propensity score-matched cohort included 82 patients with paroxysmal AF (CPVI group: n = 41; CPVI-BB group: n = 41) and 168 patients with persistent AF (CPVI group: n = 84; CPVI-BB group: n = 84). Among patients with persistent AF, one-year freedom from atrial arrhythmia recurrence rate was 83.3% in the CPVI-BB group and 70.2% in the CPVI group (log-rank P = 0.047). Among patients with paroxysmal AF, no significant difference was found in the primary endpoint between two groups (85.4% in the CPVI-BB group vs. 80.5% in the CPVI group; log-rank P = 0.581). In addition, procedure-related complications and recurrence of atrial tachycardia or atrial flutter were similar between the two treatment groups, regardless of the type of AF. Conclusions BB modification in addition to CPVI is an effective approach in increasing the maintenance of sinus rhythm in patients with persistent AF, while it does not improve the clinical outcomes of radiofrequency catheter ablation in patients with paroxysmal AF.
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Affiliation(s)
- Jiaqi Sun
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Sanbao Chen
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Ming Liang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Qi Zhang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Ping Zhang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Mingyu Sun
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Jian Ding
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Zhiqing Jin
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Zulu Wang
- Department of Cardiology, The General Hospital of Northern Theater Command, Shenyang, China
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Grossi S, Bianchi F, Blandino A, Pintor C, Tomasello A, Mabritto B, Musumeci G. Combination of percutaneous left appendage epicardial ligation and endo-epicardial atrial fibrillation ablation. Front Cardiovasc Med 2023; 10:1224924. [PMID: 37876773 PMCID: PMC10590910 DOI: 10.3389/fcvm.2023.1224924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Atrial fibrillation (AF) is the main cause of cardioembolic stroke. In high-bleeding-risk patients, long-life anticoagulation therapy is not permitted, and left atrial appendage (LAA) closure may be considered. LAA is also a critical substrate for AF. Epicardial LAA occlusion has several advantages: LAA ligation results in a favorable electrical and structural atrial remodeling, which decreases AF recurrence. Endocardial ablation alone is not efficient for all patients, and new evidence shows better outcomes in patients affected by persistent AF after a combined hybrid endo-epicardial ablation. Considering the synergic potential of these techniques, in this case series, they were both combined in a single procedure. Methods and results We describe the treatment of 5 patients referred for refractory AF ablation and LAA closure. All patients had high thrombotic and previous major hemorrhage, with relative contraindication to life-long therapy with anticoagulation. A combined procedure of LAA ligation and endo-epicardial ablation was scheduled with short-term anticoagulation. LAA closure was performed with an epicardial approach using the LARIAT system. Then, LA mapping and ablation were performed, endocardially and then epicardially.All procedures were concluded without complications.At follow-up, in all patients, transesophageal echocardiography showed the complete occlusion of the LAA; therefore, anticoagulation therapy was interrupted. All patients were asymptomatic, and in the sinus rhythm, no hemorrhage or ischemic events occurred. Conclusion The combination of percutaneous LAA ligation and endo-epicardial ablation was revealed to be feasible and safe and might represent a new approach for the treatment of refractory AF in patients with indication of LAA occlusion.
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Affiliation(s)
- Stefano Grossi
- Cardiology Department, AO Ordine Mauriziano, Turin, Italy
| | | | | | - Chiara Pintor
- Biosense Webster Italy, Johnson&Johnson MedTech Italy, Pomezia (RM), Italy
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9
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Park H, Park JW, Kim D, Yu HT, Kim TH, Uhm JS, Joung B, Lee MH, Hwang C, Pak HN. Comparison of pulmonary vein isolation using cryoballoon, high-power short-duration, and conventional radiofrequency ablation for atrial fibrillation: a propensity score-weighted study. Front Cardiovasc Med 2023; 10:1238363. [PMID: 37876772 PMCID: PMC10590885 DOI: 10.3389/fcvm.2023.1238363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023] Open
Abstract
Background The comparative efficacy, saftey, and heart rate variability (HRV) parameters after pulmonary vein isolation using cryoballoon (Cryo-PVI), high-power short-duration (HPSD-PVI), and conventional radiofrequency ablation (conventional-PVI) for atrial fibrillation (AF) is unclear. Materials and methods In this propensity score-weighted, retrospective analysis of a single-center cohort, we analyzed 3,395 patients (26.2% female, 74.5% paroxysmal AF) who underwent AF catheter ablation without an empirical left atrial ablation. Procedural factors, recurrence rates, complication rates, and the post-procedural HRV parameters were compared across the Cryo-PVI (n = 625), HPSD-PVI (n = 748), and conventional-PVI (n = 2,022) groups. Results Despite the shortest procedural time in the Cryo-PVI group (74 min for Cryo-PVI vs. 104 min for HPSD-PVI vs. 153 min for conventional-PVI, p < 0.001), the major complication (p = 0.906) and clinical recurrence rates were similar across the three ablation groups (weighted log-rank, p = 0.824). However, the Cryo-PVI group was associated with a significantly lower risk of recurrent AF in patients with paroxysmal AF [weighted hazard ratio (WHR) 0.57, 95% confidence interval (CI) 0.37-0.86], whereas it was associated with a higher risk of recurrent AF in patients with persistent AF (WHR 1.41, 95% CI 1.06-1.89, p for interaction of <0.001) compared with the conventional-PVI group. In the subgroup analysis for the HRV, the Cryo-PVI group had the highest low-frequency-to-high-frequency ratio at 1-year post-procedure, whereas the HPSD-PVI group had the lowest low-frequency-to-high-frequency ratio at 1-year post-procedure (p < 0.001). Conclusions The Cryo-PVI group had better rhythm outcomes in patients with paroxysmal AF but worse rhythm outcomes in patients with persistent AF and a higher long-term post-procedural sympathetic nervous activity and sympatho-vagal balance compared with the conventional-PVI group.
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Affiliation(s)
| | - Je-Wook Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
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10
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Tonko JB, Silberbauer J, Mann I. How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block. Europace 2023; 25:euad283. [PMID: 37713215 PMCID: PMC10558061 DOI: 10.1093/europace/euad283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
Electrical conduction through cardiac muscle fibres separated from the main myocardial wall by layers of interposed adipose tissue are notoriously difficult to target by endocardial ablation alone. They are a recognised important cause for procedural failure due to the difficulties of delivering sufficient energy via the endocardial radiofrequency catheter to reach the outer epicardial layer without risking adverse events of the otherwise thin walled atria. Left atrial ablations for atrial fibrillation (AF) and tachycardia are commonly affected by the presence of several epicardial structures, with the septo-pulmonary bundle (SPB), Bachmann's bundle, and the ligament of Marshall all posing substantial challenges for endocardial procedures. Delivery of a transmural lesion set is essential for sustained pulmonary vein isolation and for conduction block across linear atrial lines which in turn has been described to translate into a reduced AF/atrial tachycardia recurrence rate. To overcome the limitations of endocardial-only approaches, surgical ablation techniques for epicardial or combined hybrid endo-epicardial ablations have been described to successfully target these connections. Yet, these techniques confer an increase in procedure complexity, duration, cost, and morbidity. Alternatively, coronary venous system ethanol ablation has been successfully employed by sub-selecting the vein of Marshall to facilitate mitral isthmus line block, although this approach is naturally limited to this area by the coronary venous anatomy. Increased awareness of the pathophysiological relevance of these epicardial structures and their intracardiac conduction patterns in the era of high-resolution 3D electro-anatomical mapping technology has allowed greater understanding of their contribution to the persistence of AF as well as failure to achieve transmural block by traditional ablation approaches. This might translate into novel catheter ablation strategies with procedural success rates comparable to surgical 'cut-and-sew' techniques. This review aims to give an overview of percutaneous catheter ablation strategies to target the SPB, an important cause of failed block across the roof line and isolation of the left atrial posterior wall and/or the pulmonary veins. Existing and investigational technologies will be discussed and an outlook of future approaches provided.
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Affiliation(s)
- Johanna Bérénice Tonko
- Institute for Cardiovascular Science, University College London, 5 University Street, WC1E 6JF London, UK
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - John Silberbauer
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
| | - Ian Mann
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK
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11
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Huo Y, Gaspar T, Schönbauer R, Wójcik M, Fiedler L, Roithinger FX, Martinek M, Pürerfellner H, Kirstein B, Richter U, Ulbrich S, Mayer J, Krahnefeld O, Agdirlioglu T, Zedda A, Piorkowski J, Piorkowski C. Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation. NEJM EVIDENCE 2022; 1:EVIDoa2200141. [PMID: 38319851 DOI: 10.1056/evidoa2200141] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Clinically effective ablation approaches for patients with persistent atrial fibrillation (AF) are still being debated. So far, ablation targets and strategies beyond pulmonary vein isolation (PVI) have failed to show systematic outcome improvement in randomized controlled clinical trials. METHODS: We conducted a multicenter, randomized trial to determine whether PVI plus individualized substrate ablation of atrial low-voltage myocardium improves outcome in patients with persistent AF. We randomly assigned 324 patients in a 1:1 ratio to receive PVI alone (163 patients; PVI only) or PVI plus substrate modification (161 patients; PVI+SM). The primary study end point was the first recurrence of an atrial arrhythmia longer than 30 seconds after single ablation, with 3 months blanking, using serial 7-day electrocardiogram recordings over 12 months of observation. Patients were also encouraged to receive implantable cardiac monitors. RESULTS: The primary study end point occurred in 75 PVI-only patients (50%) and in 54 PVI+SM patients (35%) (Kaplan–Meier event rate estimates: hazard ratio=0.62, 95% confidence interval [CI]=0.43 to 0.88, log rank P=0.006). Adverse events occurred in three PVI-only patients (1.8%) and in six PVI+SM patients (3.7%) (difference: −1.9 percentage points, 95% CI=−5.5 to 1.7 percentage points). Implant monitoring was used in 242 patients. Among them, 65 PVI-only patients (55%) versus 47 PVI+SM patients (39%) experienced recurrences (difference: 15 percentage points, 95% CI=3 to 28 percentage points). CONCLUSIONS: In this randomized trial, PVI plus individualized ablation of atrial low-voltage myocardium significantly improved outcomes in patients with persistent AF. (ClinicalTrials.gov number, NCT02732626.)
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Affiliation(s)
- Yan Huo
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Thomas Gaspar
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Robert Schönbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna
| | - Maciej Wójcik
- Department of Cardiology, Medical University in Lublin, Lublin, Poland
| | - Lukas Fiedler
- Department of Internal Medicine II, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- University Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Franz Xaver Roithinger
- Department of Internal Medicine II, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Martin Martinek
- Department of Internal Medicine 2, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Helmut Pürerfellner
- Department of Internal Medicine 2, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Bettina Kirstein
- Heart Center, University Hospital Schleswig-Holstein Lübeck, Lübeck, Germany
| | - Utz Richter
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Stefan Ulbrich
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Julia Mayer
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
| | - Olaf Krahnefeld
- Department of Electrophysiology, Sana Kliniken Lübeck, Lübeck, Germany
| | - Tolga Agdirlioglu
- Department of Electrophysiology, Sana Kliniken Lübeck, Lübeck, Germany
| | - Angela Zedda
- Department of Electrophysiology, Heart Center, Dresden University of Technology, Dresden, Germany
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12
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Van Schie MS, Knops P, Zhang L, Van Schaagen FRN, Taverne YJHJ, De Groot NMS. Detection of endo-epicardial atrial low-voltage areas using unipolar and omnipolar voltage mapping. Front Physiol 2022; 13:1030025. [PMID: 36277177 PMCID: PMC9582746 DOI: 10.3389/fphys.2022.1030025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Low-voltage areas (LVA) can be located exclusively at either the endocardium or epicardium. This has only been demonstrated for bipolar voltages, but the value of unipolar and omnipolar voltages recorded from either the endocardium and epicardium in predicting LVAs at the opposite layer remains unknown. The goal of this study was therefore to compare simultaneously recorded endo-epicardial unipolar and omnipolar potentials and to determine whether their voltage characteristics are predictive for opposite LVAs.Methods: Intra-operative simultaneous endo-epicardial mapping (256 electrodes, interelectrode distances 2 mm) was performed during sinus rhythm at the right atrium in 93 patients (67 ± 9 years, 73 male). Cliques of four electrodes (2 × 2 mm) were used to define maximal omnipolar (Vomni,max) and unipolar (Vuni,max) voltages. LVAs were defined as Vomni,max ≤0.5 mV or Vuni,max ≤1.0 mV.Results: The majority of both unipolar and omnipolar LVAs were located at only the endocardium (74.2% and 82.0% respectively) or epicardium (52.7% and 47.6% respectively). Of the endocardial unipolar LVAs, 25.8% were also located at the opposite layer and 47.3% vice-versa. In omnipolar LVAs, 18.0% of the endocardial LVAs were also located at the epicardium and 52.4% vice-versa. The combination of epicardial Vuni,max and Vomni,max was most accurate in identifying dual-layer LVAs (50.4%).Conclusion: Unipolar and omnipolar LVAs are frequently located exclusively at either the endocardium or epicardium. Endo-epicardial LVAs are most accurately identified using combined epicardial unipolar and omnipolar voltages. Therefore, a combined endo-epicardial unipolar and omnipolar mapping approach is favoured as it may be more indicative of possible arrhythmogenic substrates.
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Affiliation(s)
| | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Lu Zhang
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | | | | | - Natasja M. S. De Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
- *Correspondence: Natasja M. S. De Groot,
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13
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Tonko J, Manoharan K, Amin R, Silberbauer J. Management of pericardial bleeding complications in percutaneous endo-epicardial catheter ablation for atrial fibrillation: A case for intrapericardial tranexamic acid? HeartRhythm Case Rep 2022; 8:820-824. [PMID: 36620365 PMCID: PMC9811024 DOI: 10.1016/j.hrcr.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Johanna Tonko
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Brighton, United Kingdom,Institute for Cardiovascular Sciences, Centre for Translational Electrophysiology, University College London, London, United Kingdom,Address reprint requests and correspondence: Dr Johanna B. Tonko, Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Eastern Rd, Brighton BN2 5BE, UK.
| | - Karthik Manoharan
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Brighton, United Kingdom
| | - Reshma Amin
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Brighton, United Kingdom
| | - John Silberbauer
- Department of Cardiology, Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Foundation Trust, Brighton, United Kingdom
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14
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Compagnucci P, Casella M, Bagliani G, Capestro A, Volpato G, Valeri Y, Cipolletta L, Parisi Q, Molini S, Misiani A, Russo AD. Atrial Flutter in Particular Patient Populations. Card Electrophysiol Clin 2022; 14:517-532. [PMID: 36153131 DOI: 10.1016/j.ccep.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
"Despite being one of the best understood cardiac arrhythmias, the clinical meaning of atrial flutter varies according to the specific context, and its optimal treatment may be limited by both the suboptimal response to rate/rhythm control drugs and by the complexity of the underlying substrate. In this article, we present a state-of-the-art overview of mechanisms, prognostic impact, and medical/interventional management options for atrial flutter in several specific patient populations, including heart failure, cardiomyopathies, muscular dystrophies, posttransplant patients, patients with respiratory disorders, athletes, and subjects with preexcitation, aiming to stimulate further research in this challenging field and facilitate appropriate patient care."
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy.
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Giuseppe Bagliani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Alessandro Capestro
- Department of Pediatric and Congenital Cardiology and Cardiac Surgery, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Silvano Molini
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Agostino Misiani
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, Ancona 60126, Italy; Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
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15
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Compagnucci P, Dello Russo A, Bergonti M, Anselmino M, Zucchelli G, Gasperetti A, Cipolletta L, Volpato G, Ascione C, Ferraris F, Valeri Y, Bongiorni MG, Natale A, Tondo C, De Ferrari GM, Casella M. Ablation Index Predicts Successful Ablation of Focal Atrial Tachycardia: Results of a Multicenter Study. J Clin Med 2022; 11:jcm11071802. [PMID: 35407408 PMCID: PMC8999753 DOI: 10.3390/jcm11071802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/19/2022] [Accepted: 03/21/2022] [Indexed: 02/05/2023] Open
Abstract
A radiofrequency energy lesion transmurality marker incorporating power, contact force, and time (Ablation Index, AI) was shown to be associated with outcomes of catheter ablation (CA) of multiple arrhythmias, but was never systematically assessed in the CA of focal atrial tachycardias (AT). We aimed to evaluate the role of AI as a predictor of outcomes in focal AT CA, and therefore, retrospectively included 45 consecutive patients undergoing CA for focal AT in four referral electrophysiology laboratories. Clinical and procedural information were collected. For each patient, maximum and mean (by averaging maximum AI values for each radiofrequency ablation lesion) AI were measured. The primary outcome was focal AT-free survival, and was systematically assessed with periodical Holter monitors or cardiac implantable electronic devices. CA was acutely effective in each case; however, 20% (n = 9) of the study population experienced a focal AT recurrence over a median follow-up of 288 days. Both maximum and mean AI values were significantly higher among patients without AT recurrences (maximum AI = 568 ± 91, mean AI = 426 ± 105) than in patients with AT relapses (maximum AI = 447 ± 142, mean AI = 352 ± 76, p = 0.036, and p = 0.028, respectively). The optimal cutoffs associated with freedom from recurrences were 461 for maximum AI (sensitivity, 0.89; specificity, 0.56) and 301 for mean AI (sensitivity, 0.97; specificity, 0.44). In a time-to-event analysis, maximum AI was significantly associated with survival free from AT recurrence (p = 0.001), whereas mean AI was not (p = 0.08). In summary, maximum AI is the best procedural parameter associated with the outcomes of CA for focal AT, and may help standardize the procedural approach.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
- Correspondence:
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Marco Bergonti
- Operation Unit of Arrhythmology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 20138 Milan, Italy; (M.B.); (C.A.); (C.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Matteo Anselmino
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (M.A.); (F.F.); (G.M.D.F.)
| | - Giulio Zucchelli
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy; (G.Z.); (M.G.B.)
| | - Alessio Gasperetti
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Ciro Ascione
- Operation Unit of Arrhythmology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 20138 Milan, Italy; (M.B.); (C.A.); (C.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Federico Ferraris
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (M.A.); (F.F.); (G.M.D.F.)
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy;
| | - Maria Grazia Bongiorni
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy; (G.Z.); (M.G.B.)
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX 78705, USA;
| | - Claudio Tondo
- Operation Unit of Arrhythmology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 20138 Milan, Italy; (M.B.); (C.A.); (C.T.)
- Department of Clinical Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (M.A.); (F.F.); (G.M.D.F.)
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy; (A.D.R.); (L.C.); (G.V.); (Y.V.); (M.C.)
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, 60126 Ancona, Italy
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16
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Tailoring the Ablative Strategy for Atrial Fibrillation: A State-of-the-Art Review. Cardiol Res Pract 2022; 2022:9295326. [PMID: 35449606 PMCID: PMC9017557 DOI: 10.1155/2022/9295326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/15/2021] [Accepted: 01/29/2022] [Indexed: 12/15/2022] Open
Abstract
In spite of technological progress and the improving skills of operators, atrial fibrillation (AF) ablation results appear to date to be at a plateau. In any case, the superiority of ablation over pharmacological therapy in terms of effectiveness, reduction of hospitalizations, and improvement has been well demonstrated in recent randomized trials. Triggers, substrate, and modulating factors (elements of Coumel’s triangle) play different roles in paroxysmal and persistent AF, so induction and perpetuation mechanisms of arrhythmia may be different in each patient. Although effective ablative strategies are available for the treatment of paroxysmal AF triggers and persistent AF substrates, an adequate clinical evaluation of the patient is crucial in order to increase the chances of success. Recognizing triggers allows not only performing an effective ablation but also to avoid unnecessary lesions and at the same time reducing the risk of complications. AF beginning and triggers could be recorded by 12-lead ECG, continuous Holter monitoring, or implantable devices. In case of an unsuccessful noninvasive evaluation, nonpulmonary vein triggers should be investigated with an electrophysiological study. Persistent AF needs more effort to perform an accurate substrate characterization. Among the many methods proposed, recently the use of high-density mapping and multipolar catheters seems of particular benefit in order to clarify the arrhythmia mechanisms. Surgical and hybrid techniques allow to treat regions such as the posterior wall or Bachmann’s bundle, which is fundamental for an ablative strategy that goes beyond just pulmonary vein isolation. Too often, patients are referred to electrophysiology laboratories without adequate preprocedural screening and planning in order to submit them to a standard “ready-made” procedure. The accurate search for triggers in paroxysmal AF and the correct recognition of the link between a possible underlying heart disease and the substrate in persistent AF could allow us to tailor the interventional approach in order to overcome the current plateau, increasing ablative procedure success and minimizing complications.
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17
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Casella M, Compagnucci P, Conti MA, Falanga U, Volpato G, Fogante M, Cipolletta L, Misiani A, Molini S, Giovagnoni A, Dello Russo A. Recurrence of atrial fibrillation post-ablation: which is the most effective approach for detection? Minerva Cardiol Angiol 2022; 70:628-638. [PMID: 35212506 DOI: 10.23736/s2724-5683.22.05859-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last 20 years, catheter ablation of atrial fibrillation (AF) has evolved from a research tool into a fundamental therapeutic measure, with the potential to improve symptoms, quality of life, and even risk of major adverse cardiac events (among patients with heart failure and a reduced ejection fraction). Notwithstanding the tremendous evolution in techniques and tools, risk of AF recurrences post-ablation is not negligible, and a comprehensive structured follow-up is highly needed to deliver optimal patient care. In this follow-up process, monitoring of heart rhythm is quintessential to detect recurrences, and may be accomplished by means of symptoms-triggered, intermittent, or continuous monitors. In recent years, the development and widespread adoption of implantable cardiac monitors, by allowing continuous long-term rhythm assessment, has surged to become the gold-standard strategy, both in research settings and in clinical practice. In this review, we both summarize the present state-of-the art on the detection of post-ablation AF recurrences, and provide future perspectives on this emerging yet often neglected topic, aiming to give practical hints for evidence-based, personalized patient care.
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Affiliation(s)
- Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy.,Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy - .,Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Manuel A Conti
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Umberto Falanga
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Marco Fogante
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Agostino Misiani
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Silvano Molini
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Andrea Giovagnoni
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital Ospedali Riuniti, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
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18
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De Martino G, Compagnucci P, Dello Russo A, Casella M. One-year outcomes of the Mediterranea technique for longstanding persistent atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:3108. [PMID: 34455646 DOI: 10.1111/jce.15225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Department of Biomedical Sciences and Public Health, University Hospital "Ospedali Riuniti" and Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Department of Biomedical Sciences and Public Health, University Hospital "Ospedali Riuniti" and Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Department of Clinical, Special, and Dental Sciences, University Hospital "Ospedali Riuniti" and Marche Polytechnic University, Ancona, Italy
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19
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Wang NC. Periods of observation following combined epicardial and endocardial ablation for non-paroxysmal atrial fibrillation: Navigating the sea of hybrid convergent procedures. J Cardiovasc Electrophysiol 2021; 32:3107. [PMID: 34427957 DOI: 10.1111/jce.15224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Norman C Wang
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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