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Egami Y, Matsunaga-Lee Y, Yano M, Nishino M. Visualization of residual gaps after linear ablation using the LUMIPOINT TM module: A case report. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00121-9. [PMID: 39304133 DOI: 10.1016/j.ipej.2024.09.006] [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: 03/22/2024] [Revised: 08/02/2024] [Accepted: 09/17/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Macroreentrant atrial tachycardia (ATs) through epicardial conduction is depicted as a focal AT on 3-D mapping, i.e., pseudo-focal AT. A new feature of the Rhythmia mapping system (Boston Scientific), the "LUMIPOINT module", can highlight all electrocardiograms (EGMs) above a threshold determined by an adjustable confidence slider (CS). Lowering the CS (L-CS) may highlight undetected electrograms (EGMs) at the nominal CS setting, potentially enabling visualization of the critical isthmus of pseudo-focal ATs. METHODS AND RESULTS This study included 3 ATs after linear ablation of two left atrial roof-dependent ATs (cases 1 and 2) and one peri-mitral flutter (case 3). All ATs were diagnosed as pseudo-focal AT according to an electrophysiological study and the Rhythmia mapping system with the LUMIPOINT module. The L-CS method consisted of the following steps: 1. Set the LUMIPOINT activation window to the time difference before and after the linear ablation line. 2. Highlight the two regions before and after the linear ablation line. 3. Gradually lower the CS value from the nominal setting of 85 % by 5-10 %. By the L-CS method in cases 1-3, the 2-sided highlighted areas before and after the prior linear ablation lesion gradually expanded and eventually fused. EGMs at the fusion sites of the highlighted areas exhibited fragmented EGMs with a low voltage, where a single-shot ablation terminated the targeted ATs. CONCLUSION The L-CS method was useful for the visualization of residual gaps and identification of targeted ablation sites in cases of pseudo-focal AT after linear ablation of macroreentrant ATs.
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Affiliation(s)
- Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | | | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | - Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan.
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Takigawa M, Miyazaki S, Sasano T. Impact of Ethanol Infusion to the Vein of Marshall in Atrial Fibrillation and Atrial Tachycardia. J Cardiovasc Dev Dis 2024; 11:183. [PMID: 39057606 PMCID: PMC11277033 DOI: 10.3390/jcdd11070183] [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: 05/12/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 07/28/2024] Open
Abstract
The ligament of Marshall is an epicardial structure characterized by its composition of fat, fibrous tissue, blood vessels, muscle bundles, nerve fibers, and ganglia. Its intricate network forms muscular connections with the coronary sinus and left atrium, alongside adjacent autonomic nerves and ganglion cells. This complexity plays a pivotal role in initiating focal electrical activities and sustaining micro- and macro-reentrant circuits, thereby contributing to the onset of atrial fibrillation and atrial tachycardia. However, endocardial ablation in this area may encounter challenges due to anatomical variations and insulation by fibrofatty tissue. Combining ethanol infusion into the vein of Marshall with radiofrequency ablation presents a promising strategy for effectively and safely eliminating this arrhythmogenic structure and terminating associated tachycardias.
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Affiliation(s)
- Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Department of Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
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Jiang H, Ruan Z, Ren Y, Ding X. Case report: Widely split P' waves in a patient with focal atrial tachycardia. Front Cardiovasc Med 2024; 10:1303200. [PMID: 38274317 PMCID: PMC10808459 DOI: 10.3389/fcvm.2023.1303200] [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: 09/27/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Background Widely split P waves in sinus rhythm have been reported previously. However, widely split P' waves in focal atrial tachycardia (AT) on a surface electrocardiogram (ECG) have rarely been reported. The electrophysiological mechanism is relatively difficult to clarify, requiring a electrophysiological study. Case summary A 67-year-old patient, who had undergone two radiofrequency ablations for atrial fibrillation, presented with recurrent palpitation. During the palpitation episode, the 12-lead ECG showed AT with a 3:1 atrioventricular conduction rate. P' waves were markedly prolonged in duration and widely split in morphology. An electrophysiological study showed that the tachycardia arose from the left atrial appendage (LAA) and was conducted through two distinct pathways. The impulse of one pathway was transmitted solely via the superior part of the atrium, including the Bachmann bundle. The second pathway was conducted via the coronary sinus and transmitted the impulse from the LAA to the ventricle. After the site showed that the earliest activation was ablated, repeated intravenous infusion of isoprenaline and programmed atrial stimulation did not induce tachycardia. Conclusion Widely split P' waves in AT indicate intra- and interatrial conduction blocks, which can be easily overlooked due to the presence of low-voltage areas. Therefore, an electrophysiological study is crucial for identifying the origin of the tachycardia and elucidating the mechanistic details.
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Affiliation(s)
| | | | | | - Xiangwei Ding
- Department of Cardiology, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou, China
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Yoshida K, Hasebe H, Hattori M, Hanaki Y, Tsumagari Y, Baba M, Nogami A, Takeyasu N. Unidirectional conduction characterizing epicardial connections in patients with atrial tachyarrhythmias. J Cardiovasc Electrophysiol 2023; 34:2262-2272. [PMID: 37712297 DOI: 10.1111/jce.16065] [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: 06/21/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Electrophysiological characteristics of epicardial connections (ECs) in atria and pulmonary veins (PVs) are unclear despite their important contributions to atrial fibrillation (AF). Unidirectional conduction associated with source-sink mismatch can occur in ECs due to their fine fibers with abrupt changes in orientation. We detailed the prevalence and electrophysiological characteristics of unidirectional conduction in the atria and investigated its association with the clinical manifestation of AF. METHODS This study retrospectively reviewed electrophysiological studies and radiofrequency catheter ablation in 261 consecutive patients with AF. RESULTS Unidirectional conduction was observed during ablation encircling the PVs in eight (3.1%) patients, and all occurred in the suspected (N = 4) or definitively (N = 4) recognized ECs. These ECs included three intercaval bundles, four septopulmonary bundles, and one Marshall bundle, and were first manifested in a second procedure in 6 (75%) patients. The unidirectional property was from PV to atrium (exit conduction) in all intercaval bundles and three septopulmonary bundles, and from atrium to PV (entrance conduction) in the remaining two bundles. Intercaval bundles acted as a limb of bi-atrial macro-reentrant tachycardia (50%, three of the six including previous cases). Ablation of the exit outside the PVs, including the right atrium, eliminated ECs in three (38%) patients. All patients remain free from arrhythmia recurrence after a mean 13-month follow-up. CONCLUSION A unidirectional conduction property was closely associated with the EC, as estimated by histological findings. Recognition of this fact by electrophysiologists may help to clarify mechanisms for AF and atrial tachycardia and guide the creation of efficient and safe ablation lesion sets.
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Affiliation(s)
- Kentaro Yoshida
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Cardiology, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Hideyuki Hasebe
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masayuki Hattori
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Cardiology, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Yuichi Hanaki
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuaki Tsumagari
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masako Baba
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
- Department of Cardiology, Ibaraki Prefectural Central Hospital, Kasama, Japan
| | - Akihiko Nogami
- Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Noriyuki Takeyasu
- Department of Cardiology, Ibaraki Prefectural Central Hospital, Kasama, Japan
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Baskovski E, Altin AT, Akyurek O, Kuru B, Korkmaz K, Ersoy İ, Kozluca V, Akbulut IM, Tutar E. Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience. J Interv Card Electrophysiol 2023; 66:1901-1910. [PMID: 36811816 DOI: 10.1007/s10840-023-01513-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Despite being increasingly observed in daily practice, epicardial atrial tachycardias (Epi AT) have not been extensively characterized. In the present study, we retrospectively characterize electrophysiological properties, electroanatomic ablation targeting, and outcomes of this ablation strategy. METHODS Patients who underwent scar-based macro-reentrant left atrial tachycardia mapping and ablation patients with at least one Epi AT, which had a complete endocardial map, were selected for the inclusion. Based on current electroanatomical knowledge, Epi ATs were classified based by utilization of following epicardial structures: Bachmann's bundle, septopulmonary bundle, vein of Marshall. Endocardial breakthrough (EB) sites were analyzed as well as entrainment parameters. EB site was targeted for initial ablation. RESULTS Among seventy-eight patients undergoing scar-based macro-reentrant left atrial tachycardia ablation, fourteen (17.8%) patients met the inclusion criteria for Epi AT and were included in the study. Sixteen Epi ATs were mapped, four utilizing Bachmann's bundle, five utilizing septopulmonary bundle, and seven utilizing vein of Marshall. Fractionated, low amplitude signals were present at EB sites. Rf terminated the tachycardia in ten patients; activation changed in five patients and in one patient atrial fibrillation ensued. During the follow-up, there were three recurrences. CONCLUSIONS Epicardial left atrial tachycardias are a distinct type of macro-reentrant tachycardias that can be characterized by activation and entrainment mapping, without need for epicardial access. Endocardial breakthrough site ablation reliably terminates these tachycardias with good long-term success.
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Affiliation(s)
- Emir Baskovski
- Cardiology Department, Ankara University, Ankara, Turkey.
| | | | - Omer Akyurek
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Busra Kuru
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Kubra Korkmaz
- Cardiology Department, Ankara University, Ankara, Turkey
| | - İbrahim Ersoy
- Faculty of Medicine, Afyonkarahisar Science of Health University, Afyonkarahisar, Turkey
| | - Volkan Kozluca
- Cardiology Department, Ankara University, Ankara, Turkey
| | | | - Eralp Tutar
- Cardiology Department, Ankara University, Ankara, Turkey
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Nakatani Y, Takigawa M, Ramirez FD, Nakashima T, André C, Goujeau C, Carapezzi A, Anzai T, Krisai P, Takagi T, Kamakura T, Konstantinos V, Cheniti G, Tixier R, Welte N, Chauvel R, Duchateau J, Pambrun T, Derval N, Sacher F, Hocini M, Haïssaguerre M, Jaïs P. Electrophysiologic Determinants of Isoelectric Intervals on Surface Electrocardiograms During Atrial Tachycardia: Insights From High-Density Mapping. JACC Clin Electrophysiol 2023; 9:2054-2066. [PMID: 37715740 DOI: 10.1016/j.jacep.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/14/2023] [Accepted: 06/25/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Substrate abnormalities can alter atrial activation during atrial tachycardias (ATs) thereby influencing AT-wave morphology on the surface electrocardiogram. OBJECTIVES This study sought to identify determinants of isoelectric intervals during ATs with complex atrial activation patterns. METHODS High-density activation maps of 126 ATs were studied. To assess the impact of the activated atrial surface on the presence of isoelectric intervals, this study measured the minimum activated area throughout the AT cycle, defined as the smallest activated area within a 50-millisecond period, by using signal processing algorithms (LUMIPOINT). RESULTS ATs with isoelectric intervals (P-wave ATs) included 23 macro-re-entrant ATs (40%), 26 localized-re-entrant ATs (46%), and 8 focal ATs (14%), whereas those without included 46 macro-re-entrant ATs (67%), 21 localized-re-entrant ATs (30%), and 2 focal ATs (3%). Multivariable regression identified smaller minimum activated area and larger very low voltage area as independent predictors of P-wave ATs (OR: 0.732; 95% CI: 0.644-0.831; P < 0.001; and OR: 1.042; 95% CI: 1.006-1.080; P = 0.023, respectively). The minimum activated area with the cutoff value of 10 cm2 provided the highest predictive accuracy for P-wave ATs with sensitivity, specificity, and positive and negative predictive values of 96%, 97%, 97%, and 95%, respectively. In re-entrant ATs, smaller minimum activated area was associated with lower minimum conduction velocity within the circuit and fewer areas of delayed conduction outside of the circuit (standardized β: 0.524; 95% CI: 0.373-0.675; P < 0.001; and standardized β: 0.353; 95% CI: 0.198-0.508; P < 0.001, respectively). CONCLUSIONS Reduced atrial activation area and voltage were associated with isoelectric intervals during ATs.
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Affiliation(s)
- Yosuke Nakatani
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Masateru Takigawa
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France.
| | - F Daniel Ramirez
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France; Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Takashi Nakashima
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Clémentine André
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Cyril Goujeau
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | | | - Tatsuhiko Anzai
- Department of Biostatistics, M and D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Philipp Krisai
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Takamitsu Takagi
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Tsukasa Kamakura
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Vlachos Konstantinos
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Ghassen Cheniti
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Romain Tixier
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Nicolas Welte
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Remi Chauvel
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Josselin Duchateau
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Thomas Pambrun
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Nicolas Derval
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Frédéric Sacher
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Meleze Hocini
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Michel Haïssaguerre
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
| | - Pierre Jaïs
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France; IHU LIRYC-Centre Hospitalier Universitaire Bordeaux, Universitaire Bordeaux, Institut National de la Santé et de la Recherche Médicale U1045, Pessac, France
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Kahle AK, Alken FA, Scherschel K, Meyer C. Prognostic implications of baseline rhythm during catheter ablation for atrial tachycardia. Clin Res Cardiol 2023:10.1007/s00392-023-02292-3. [PMID: 37710016 DOI: 10.1007/s00392-023-02292-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Atrial tachycardias (AT) occurring in patients after previous atrial fibrillation (AF) ablation are increasingly observed in clinical practice. Catheter ablation is the treatment of choice but an optimal workflow to improve patient outcome has not been defined. The purpose of this study was to assess procedural and clinical outcome depending on baseline rhythm at the beginning of AT ablation. METHODS A total of 380 patients (69 (61-75) years, 56.6% male) who underwent catheter ablation for consecutive AT after previous AF ablation were studied. RESULTS At the beginning of the procedure, 140 patients (36.8%) presented in sinus rhythm (SR), 208 (54.7%) with AT and 32 (8.4%) with AF. Patients in SR or with AT underwent shorter procedures (173 (132-213) minutes vs. 161 (120-203) minutes vs. 226 (154-249) minutes; p = 0.002) with more frequent termination to SR (87.9% vs. 81.3% vs. 56.3%; p < 0.001) than patients with AF. Acute procedural success did not differ between patients in SR or with AT but was higher compared to those with AF (96.4% vs. 97.1% vs. 87.5%; p = 0.033). During a follow-up of 290 (181-680) days, patients in baseline SR experienced arrhythmia recurrences less often (36.4% vs. 49.5% vs. 68.8%; p = 0.002) than patients with AT or AF. CONCLUSION Baseline rhythm during AT ablation predicts procedural and clinical outcome. Whereas acute procedural success does not differ between patients in SR or with AT, patients presenting in SR have a more favorable mid-term success rate.
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Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Fares-Alexander Alken
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
| | - Katharina Scherschel
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Christian Meyer
- Division of Cardiology, Angiology, Intensive Care Medicine, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217, Düsseldorf, Germany.
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Düsseldorf, Germany.
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8
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William J, Voskoboinik A. Epicardial Involvement in Roof-Dependent Macro-Re-Entrant Tachycardia: Finding the Missing Link. JACC Clin Electrophysiol 2023; 9:1540-1542. [PMID: 37204353 DOI: 10.1016/j.jacep.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Jeremy William
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia.
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9
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Lai Y, Ge W, Sang C, Macle L, Tang R, Long D, Dong J, Ma C. Epicardial connections and bi-atrial tachycardias: From anatomy to clinical practice. Pacing Clin Electrophysiol 2023; 46:895-903. [PMID: 37433176 DOI: 10.1111/pace.14778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/14/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Bi-atrial tachycardia (BiAT) is not rare after extensive atrial ablation or cardiac surgery. The complexity of bi-atrial reentrant circuits poses a great challenge for clinical practice. With recent advances in mapping technologies, we are now able to characterize atrial activation in detail. However, given the involvement of both atria and multiple epicardial conductions, endocardial mapping for BiATs is not easy to understand. Knowledge of the atrial myocardial architecture is the foundation for the clinical management of BiATs; as it is required to understand the possible mechanism of the tachycardia and identify the optimal target of ablation. In this review we summarize current knowledge about the anatomy of interatrial connections as well as other epicardial fibers and discuss the interpretation of electrophysiological findings and ablation strategies for BiATs.
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Affiliation(s)
- Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Weili Ge
- Department of Cardiology, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Zhejiang, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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10
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Takigawa M, Goya M, Ikenouchi T, Shimizu Y, Amemiya M, Kamata T, Nishimura T, Tao S, Takahashi Y, Miyazaki S, Sasano T. Confirmation of the achievement of linear lesions using "activation vectors" based on omnipolar technology. Heart Rhythm 2022; 19:1792-1801. [PMID: 35961492 DOI: 10.1016/j.hrthm.2022.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/06/2022] [Accepted: 07/15/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although differential pacing conventionally has been used to confirm the achievement of block across linear lesion sets, high-resolution mapping demonstrates that pseudo-block is observed in 20%-30% of cases. OBJECTIVES The purpose of this study was to examine the reliability and versatility of a method using "activation vectors" based on omnipolar technology to confirm the block line. METHODS Linear ablation was performed during pacing, with the HD Grid catheter (Abbott) placed beside the linear lesion opposite the pacing site. The endpoint of complete linear lesion was complete inversion of the activation vectors to the opposite direction. When inversion of the activation vectors was not observed after 10 minutes of radiofrequency (RF) application, high-resolution mapping was performed to assess whether complete block was achieved. RESULTS In 33 patients, 24 cavotricuspid isthmus lines, 11 mitral isthmus (MI) lines, 16 posterior lines, and 2 intercaval lines were performed using this method. Of the total of 53 lines, 10 (18.9%) required intermediate evaluation of the block line with high-resolution mapping because of the absence of inversion of activation vectors despite 10 minutes of RF application, resulting in incomplete block with endocardial gaps or epicardial conductions. Additional RF applications finally achieved inversion in direction of activation vectors in the 10 lines. In total, the present method can diagnose achievement of complete block line with 100% accuracy, whereas conventional differential pacing misdiagnosed incomplete block with epicardial conduction in posterior lines in 3 cases and in MI lines in 2 cases. CONCLUSION Confirmation of complete linear lesions using "activation vectors" based on omnipolar technology is a reliable and versatile method.
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Affiliation(s)
- Masateru Takigawa
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan.
| | - Masahiko Goya
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takashi Ikenouchi
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yuki Shimizu
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Miki Amemiya
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Tatsuaki Kamata
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takuro Nishimura
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Susumu Tao
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yoshihide Takahashi
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Shinsuke Miyazaki
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiology, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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11
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Kato K, Hasegawa S, Kikuchi S, Uehara Y, Ishiguro N, Tanaka A, Tominaga S, Goto H, Shibata N, Kametani R. Impact of high frequency stimulation to confirm a complete box isolation in catheter ablation of non-paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2022; 45:1194-1206. [PMID: 35989415 PMCID: PMC9826345 DOI: 10.1111/pace.14582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/04/2022] [Accepted: 07/20/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Pulmonary vein (PV) isolation (PVI) including the left atrial posterior wall (LAPW) (Box-PVI) is proposed as an additional strategy for non-paroxysmal atrial fibrillation (NPAF), however, the efficacy remains controversial. The more reliable and durable the Box-PVI we can create, the better the rhythm outcomes might be than with a conventional PVI alone. This study focused on the potential exit conduction of the box lesion and investigated whether the conventional Box-PVI would be sufficient. METHODS AND RESULTS We enrolled 350 consecutive patients with NPAF that underwent a conventional encircling Box-PVI and examined whether latent exit conduction and dormant "exit" conduction independently remained on the LAPW and in the PVs using high frequency stimulation (HFS) and an adenosine triphosphate (ATP) injection. All electrograms inside the box lesion were eliminated in all cases, however, HFS inside the box propagated outward in 23 cases (6.6%) without any exit conduction by conventional burst stimulation, and 24 cases (6.9%) exhibited only dormant "exit" conduction of the LAPW. Additional ablation where positive HFSs were observed created a complete bidirectional Box-PVI in 43 (41.3%) of the cases without a first pass Box-PVI. The recurrence rates depended on the groups classified according to the HFS response. CONCLUSION HFS delivered with an ATP injection on the LAPW and in the PVs following a Box-PVI could not only elucidate true exit block but also identified possible incomplete lesions or connections outside the ablation line, whose elimination could achieve a complete Box-PVI leading to a better rhythm outcome.
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Affiliation(s)
- Kazuo Kato
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Shin Hasegawa
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Shun Kikuchi
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Yukihiro Uehara
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Nobuo Ishiguro
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Akimitsu Tanaka
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Shimpei Tominaga
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Hiroko Goto
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Norihisa Shibata
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
| | - Ryosuke Kametani
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiJapan
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12
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Lu Y, Zei PC, Jiang C. Current Understanding of Atrial Fibrillation Recurrence After Atrial Fibrillation Ablation: From Pulmonary Vein to Epicardium. Pacing Clin Electrophysiol 2022; 45:1216-1224. [PMID: 35998211 DOI: 10.1111/pace.14581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/18/2022] [Accepted: 08/05/2022] [Indexed: 11/29/2022]
Abstract
Recurrence of atrial fibrillation (AF) after catheter ablation is common, with pulmonary vein (PV) reconnection considered the most likely cause. However, technologies such as contact force-sensing, irrigated catheters, and ablation index (AI)-guided ablation strategies have resulted in more durable PV isolation. As a result, it is difficult to predict which patients will develop AF recurrence despite durable PV isolation, with evolving non-PV atrial substrates thought to be a key contributor to late recurrences. Deciphering the complex mechanisms of AF recurrence beyond the cornerstone of PV isolation therefore remains challenging. Recently, there have been several important advances that may lead to better understanding and treatment of this challenging clinical entity: percutaneous epicardial access and mapping, late gadolinium enhancement magnetic resonance imaging (LGE-MRI), improvements in high-resolution electroanatomic mapping, and new ablation energy sources, specifically pulsed-field ablation. This review aims to synthesize the current literature in an effort to better understand arrhythmia mechanisms and treatment targets in patients with AF/Atrial tachycardia (AT) recurrence post-ablation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yu Lu
- Department of Cardiology, Sir Run Shaw Hospital, Hangzhou, China
| | - Paul C Zei
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Shaw Hospital, Hangzhou, China
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