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van Hunnik A, Sobota V, Zeemering S, Opacic D, Scaf B, D’Alessandro E, Oyaert K, Kuiper M, Diness JG, Sørensen US, Milnes JT, van der Heyden MAG, Jespersen T, Schotten U, Verheule S. Analysis of drug-induced and spontaneous cardioversions reveals similar patterns leading to termination of atrial fibrillation. Front Physiol 2024; 15:1399037. [PMID: 39092426 PMCID: PMC11291310 DOI: 10.3389/fphys.2024.1399037] [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: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 08/04/2024] Open
Abstract
Introduction The mechanisms leading to the conversion of atrial fibrillation (AF) to sinus rhythm are poorly understood. This study describes the dynamic behavior of electrophysiological parameters and conduction patterns leading to spontaneous and pharmacological AF termination. Methods Five independent groups of goats were investigated: (1) spontaneous termination of AF, and drug-induced terminations of AF by various potassium channel inhibitors: (2) AP14145, (3) PA-6, (4) XAF-1407, and (5) vernakalant. Bi-atrial contact mapping was performed during an open chest surgery and intervals with continuous and discrete atrial activity were determined. AF cycle length (AFCL), conduction velocity and path length were calculated for each interval, and the final conduction pattern preceding AF termination was evaluated. Results AF termination was preceded by a sudden episode of discrete activity both in the presence and absence of an antiarrhythmic drug. This episode was accompanied by substantial increases in AFCL and conduction velocity, resulting in prolongation of path length. In 77% ± 4% of all terminations the conduction pattern preceding AF termination involved medial to lateral conduction along Bachmann's bundle into both atria, followed by anterior to posterior conduction. This finding suggests conduction block in the interatrial septum and/or pulmonary vein area as final step of AF termination. Conclusion AF termination is preceded by an increased organization of fibrillatory conduction. The termination itself is a sudden process with a critical role for the interplay between spatiotemporal organization and anatomical structure.
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Affiliation(s)
- Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Vladimír Sobota
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- IHU-LIRYC, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
- Institute de Mathématiques de Bordeaux, University of Bordeaux, Talence, France
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Dragan Opacic
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Billy Scaf
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Elisa D’Alessandro
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Karel Oyaert
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Marion Kuiper
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | | | | | | | | | - Thomas Jespersen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
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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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3
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Seo JH, Cho SY, Park JH, Seo JY, Lee HY, Kim DJ. Intraoperative sudden arrhythmias in cervical spine surgery adjacent to the stellate ganglion: A case report. World J Clin Cases 2023; 11:5789-5796. [PMID: 37727714 PMCID: PMC10505998 DOI: 10.12998/wjcc.v11.i24.5789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/07/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Atrial arrhythmias such as paroxysmal supraventricular tachycardia (PSVT) and atrial flutter (AF) are common in the perioperative setting. They commonly resolve spontaneously. However, occasionally, they may continually progress to fatal arrhythmias or cause complications. Therefore, prompt and appropriate management is important. CASE SUMMARY A 46-year-old female patient diagnosed with cervical C6-7 radiculopathy characterized by decreased sensation in the right third, fourth and fifth fingers underwent C6-7 anterior cervical disc fusion surgery. Electrocardiography showed PSVT and ventricular tachycardia during C6-7 disc retraction. However, the patient remained stable. Initial treatment with esmolol and lidocaine for ventricular tachycardia was ineffective. Carotid massage and Valsalva maneuver were attempted but PSVT did not resolve. The surgery was paused, and the patient's fraction of inspired oxygen was set to 100%. Adenosine was administered for pharmacological management of PSVT. The arrhythmia temporarily resolved. However, it then transformed into AF. Diltiazem was administered, which briefly decreased blood pressure, which immediately recovered. Surgery resumed while the patient was in normal sinus rhythm. She was discharged safely on postoperative day 6 without complications or abnormalities. Currently, she is living a healthy life without arrhythmia recurrence. CONCLUSION Ganglia associated with cardiac arrhythmias in the surgical site should be identified during cervical spine surgery.
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Affiliation(s)
- Jong-Hun Seo
- Department of Neurosurgery, Chosun University Hospital, Gwangju 61453, South Korea
| | - Su-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
| | - Ji-Hwan Park
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
| | - Jin-Young Seo
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju 61453, South Korea
| | - Hyun-Young Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chosun University, Gwangju 61453, South Korea
| | - Dong-Joon Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chosun University, Gwangju 61453, South Korea
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4
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Lee S, Khrestian C, Laurita D, Juzbasich D, Wallick D, Waldo A. Validation of a new species for studying postoperative atrial fibrillation: Swine sterile pericarditis model. Pacing Clin Electrophysiol 2023; 46:1003-1009. [PMID: 37377345 DOI: 10.1111/pace.14765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/02/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND The canine sterile pericarditis model associated with atrial inflammation is an experimental counterpart of postoperative atrial fibrillation (POAF). However, the use of canines for research is restricted by ethics committees in many countries, and social acceptance is declining. OBJECTIVE To validate the feasibility of the swine sterile pericarditis model as an experimental counterpart to study POAF. METHODS Seven domestic pigs (35-60 kg) underwent initial pericarditis surgery. On two or more postoperative days in the closed-chest state, we performed electrophysiological measurements of pacing threshold and atrial effective refractory period (AERP) while pacing from the right atrial appendage (RAA) and the posterior left atrium (PLA). The inducibility of POAF (>5 min) by burst pacing was determined in both the conscious and anesthetized closed-chest state. These data were compared to previously published canine sterile pericarditis data for validation. RESULTS The pacing threshold increased from day 1 to day 3 (2 ± 0.1 to 3.3 ± 0.6 mA in the RAA, 2.5 ± 0.1 to 4.8 ± 0.2 mA in the PLA). Also, the AERP increased from day 1 to day 3 (118 ± 8 to 157 ± 16 ms in the RAA; 98 ± 4 to 124 ± 2 ms in the PLA, both p < .05). Induction of sustained POAF occurred in 43% (POAF CL range 74-124 ms). All electrophysiologic data from the swine model were consistent with the canine model with respect to (1) the range of both pacing threshold and AERP; (2) the progressive increase in threshold and AERP over time; (3) a 40%-50% incidence of POAF. CONCLUSION A newly developed swine sterile pericarditis model demonstrated electrophysiologic properties consistent with the canine model and patients after open heart surgery.
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Affiliation(s)
- Seungyup Lee
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Celeen Khrestian
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Laurita
- Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dragan Juzbasich
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Don Wallick
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Albert Waldo
- Departments of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
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5
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Keshri R, Ranjan R. Morphological study of musculi pectinati and crista terminalis with its applied significance in the human adult cadaver. NATIONAL JOURNAL OF CLINICAL ANATOMY 2023. [DOI: 10.4103/njca.njca_235_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
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6
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Patel RS, Khayata M, De Ponti R, Bagliani G, Leonelli FM. Relationships Between Atrial Flutter and Fibrillation: The Border Zone. Card Electrophysiol Clin 2022; 14:421-434. [PMID: 36153124 DOI: 10.1016/j.ccep.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Atrial flutter and fibrillation have been inextricably linked in the study of electrophysiology. With astute clinical observation, advanced diagnostic equipment in the Electrophysiology Laboratory, and thoughtful study of animal models, the mechanism and inter-relationship between the 2 conditions have been elucidated and will be reviewed in this article. Though diagnosis and management of these conditions have many similarities, the mechanisms by which they develop and persist are quite unique.
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Affiliation(s)
- Ritesh S Patel
- University of South Florida Morsani, College of Medicine, Division of Cardiovascular Diseases, 4202 E Fowler Avenue, Tampa, FL 33620, USA
| | - Mohamed Khayata
- University of South Florida Morsani, College of Medicine, Division of Cardiovascular Diseases, 4202 E Fowler Avenue, Tampa, FL 33620, USA
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, 21100, Varese, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, 21100, Varese, Italy
| | - Giuseppe Bagliani
- Cardiology And Arrhythmology Clinic, University Hospital "Ospedali Riuniti", Via Conca 71, 60126, Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Via Conca 71, 60126, Ancona, Italy
| | - Fabio M Leonelli
- University of South Florida Morsani, College of Medicine, Division of Cardiovascular Diseases, 4202 E Fowler Avenue, Tampa, FL 33620, USA; James A Haley Veterans Hospital, Tampa, FL, USA.
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7
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van Schie MS, de Groot NMS. Clinical Relevance of Sinus Rhythm Mapping to Quantify Electropathology Related to Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e11. [PMID: 35846426 PMCID: PMC9277615 DOI: 10.15420/aer.2022.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022] Open
Abstract
Progression of AF is accompanied by structural and electrical remodelling, resulting in complex electrical conduction disorders. This is defined as electropathology and it increases with the progression of AF. The severity of electropathology, thus, defines the stage of AF and is a major determinant of effectiveness of AF therapy. As specific features of AF-related electropathology are still unknown, it is essential to first quantify the electrophysiological properties of atrial tissue and then to examine the inter- and intra-individual variation during normal sinus rhythm. Comparison of these parameters between patients with and without a history of AF unravels quantified electrophysiological features that are specific to AF patients. This can help to identify patients at risk for early onset or progression of AF. This review summarises current knowledge on quantified features of atrial electrophysiological properties during sinus rhythm and discusses its relevance in identifying AF-related electropathology.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Natasja MS de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
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8
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Waranugraha Y, Rizal A, Rohman MS, Tsai CT, Chiu FC. Prophylactic Cavotricuspid Isthmus Ablation in Atrial Fibrillation without Documented Typical Atrial Flutter: A Systematic Review and Meta-analysis. Arrhythm Electrophysiol Rev 2022; 11:e10. [PMID: 35846424 PMCID: PMC9277616 DOI: 10.15420/aer.2021.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 12/28/2021] [Indexed: 11/04/2022] Open
Abstract
Background: The advantage of prophylactic cavotricuspid isthmus (CTI) ablation for AF patients without documented atrial flutter is still unclear. The present study aimed to evaluate the role of prophylactic CTI ablation in this population. Methods: A systematic review and meta-analysis study was conducted. The overall effects estimation was conducted using random effects models. The pooled effects were presented as the risk difference and standardised mean difference for dichotomous and continuous outcomes, respectively. Results: A total of 1,476 patients from four studies were included. The risk of atrial tachyarrhythmias following a successful catheter ablation procedure was greater in the pulmonary vein isolation + CTI ablation group than pulmonary vein isolation alone group (34.8% versus 28.2%; risk difference 0.08; 95% CI [0.00–0.17]; p=0.04). Prophylactic CTI ablation was associated with a higher recurrent AF rate (33.8% versus 27.1%; risk difference 0.07; 95% CI [0.01–0.13]; p=0.02). Additional prophylactic CTI ablation to pulmonary vein isolation significantly increased the radio frequency application time (standardised mean difference 0.52; 95% CI [0.04–1.01]; p=0.03). Conclusion: This study suggested that prophylactic CTI ablation was an ineffective and inefficient approach in AF without documented typical atrial flutter patients.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Brawijaya, Malang, Indonesia
| | - Ardian Rizal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Brawijaya, Malang, Indonesia
| | - Mohammad Saifur Rohman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Brawijaya, Malang, Indonesia
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
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Romito G, Summerfield N, Baron Toaldo M. Presumptive vagally-mediated atrial flutter in a dog. J Vet Cardiol 2021; 39:46-50. [PMID: 34973471 DOI: 10.1016/j.jvc.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022]
Abstract
An asymptomatic nine-year-old Dobermann Pinscher underwent a screening for dilated cardiomyopathy. Echocardiography revealed left ventricular eccentric hypertrophy and systolic dysfunction; the rest of the echocardiographic parameters were within normal limits. Holter monitoring demonstrated sinus rhythm as the dominant cardiac rhythm during the first hours of the recording. Then, during a period of physiologically enhanced vagal tone (sleep), spontaneous development of atrial flutter (AFL) associated with variable ventricular response was documented. Alternation between AFL and paroxysmal atrial fibrillation was also observed. Subsequently, during a period of physiological increase of sympathetic tone (physical activity/excitement), spontaneous conversion of AFL to sinus rhythm occurred. In light of these findings, a presumptive diagnosis of vagal AFL was made. The images here described allow us to study the onset, behavior and termination of this intriguing electrocardiographic entity.
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Affiliation(s)
- G Romito
- Department of Veterinary Medical Sciences, Alma Mater Studiorum - University of Bologna, Via Tolara di Sopra 50, 40064 Ozzano dell'Emilia, Italy.
| | | | - M Baron Toaldo
- Division of Cardiology, Vetsuisse Faculty University of Zurich, Winterthurerstrasse 260, 8057, Zurich, Switzerland
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10
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van Staveren LN, van Schaagen FRN, de Groot NMS. Epi-endocardial asynchrony during atrial flutter followed by atrial fibrillation. HeartRhythm Case Rep 2021; 7:191-194. [PMID: 33786319 PMCID: PMC7987922 DOI: 10.1016/j.hrcr.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Frank R N van Schaagen
- Department of Cardio-Thoracic surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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11
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Freudenberger T, Kranz B, Lehmann W, Schäfer K, Münter K, Lee K, Ellinor PT, Hucker WJ. Identification of two preclinical canine models of atrial fibrillation to facilitate drug discovery. Heart Rhythm 2020; 18:632-640. [PMID: 33346136 DOI: 10.1016/j.hrthm.2020.12.015] [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: 07/10/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia occurring in humans, and new treatment strategies are critically needed. The lack of reliable preclinical animal models of AF is a major limitation to drug development of novel antiarrhythmic compounds. OBJECTIVE The purpose of this study was to provide a comprehensive head-to-head assessment of 5 canine AF models. METHODS Five canine models were evaluated for the efficacy of AF induction and AF duration. We tested 2 acute models: short-term atrial tachypacing (AT) for 6 hours with analysis of AF at hourly increments, and carbachol injection into a cardiac fat pad followed by short-term AT. We also tested 3 chronic models: pacemaker implantation followed by either 4 weeks of AT and subsequent atrial burst pacing or intermittent long-term AT for up to 4-5 months to generate AF ≥4.5 hours, and finally ventricular tachypacing to induce heart failure followed by atrial burst pacing to induce AF. RESULTS Careful evaluation showed that acute AT, AT for 4 weeks, and the heart failure model all were unsuccessful in generating reproducible AF episodes of sufficient duration to study antiarrhythmic drugs. In contrast, intermittent long-term AT generated AF lasting ≥4.5 hours in ∼30% of animals. The acute model using carbachol and short-term AT resulted in AF induction of ≥15 minutes in ≥75% of animals, thus enabling testing of antiarrhythmic drugs. CONCLUSION Intermittent long-term AT and the combination of local carbachol injection with successive short-term AT may contribute to future drug development efforts for AF treatment.
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Affiliation(s)
- Till Freudenberger
- Bayer AG, Research and Development, Pharmaceuticals, Wuppertal, Germany.
| | - Beate Kranz
- Bayer AG, Research and Development, Pharmaceuticals, Wuppertal, Germany
| | - Waldemar Lehmann
- Bayer AG, Research and Development, Pharmaceuticals, Wuppertal, Germany
| | - Katja Schäfer
- Bayer AG, Research and Development, Pharmaceuticals, Wuppertal, Germany
| | - Klaus Münter
- Bayer AG, Research and Development, Pharmaceuticals, Wuppertal, Germany
| | - Kichang Lee
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Patrick T Ellinor
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts; The Broad Institute of MIT and Harvard, Cambridge, Massachusetts.
| | - William J Hucker
- Cardiac Arrhythmia Service & Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
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12
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Kharbanda RK, Knops P, van der Does LJME, Kik C, Taverne YJHJ, Roos‐Serote MC, Heida A, Oei FBS, Bogers AJJC, de Groot NMS. Simultaneous Endo-Epicardial Mapping of the Human Right Atrium: Unraveling Atrial Excitation. J Am Heart Assoc 2020; 9:e017069. [PMID: 32808551 PMCID: PMC7660792 DOI: 10.1161/jaha.120.017069] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/25/2020] [Indexed: 11/23/2022]
Abstract
Background The significance of endo-epicardial asynchrony (EEA) and atrial conduction block (CB), which play an important role in the pathophysiology of atrial fibrillation (AF) during sinus rhythm is poorly understood. The aim of our study was therefore to examine 3-dimensional activation of the human right atrium (RA). Methods and Results Eighty patients (79% men, 39% history of AF) underwent simultaneous endo-epicardial sinus rhythm mapping of the inferior, middle and superior RA. Areas of CB were defined as conduction delays of ≥12 ms, EEA as activation time differences of opposite electrodes of ≥15 ms and transmural CB as CB at similar endo-epicardial sites. CB was more pronounced at the endocardium (all locations P<0.025). Amount, extensiveness and severity of CB was higher at the superior RA. Transmural CB at the inferior RA was associated with a higher incidence of post-operative AF (P=0.03). EEA occurred up to 84 ms and was more pronounced at the superior RA (superior: 27 ms [interquartile range, 18.3-39.3], versus mid-RA: 20.3 ms [interquartile range, 0-29.9], and inferior RA: 0 ms [interquartile range, 0-21], P<0.001). Hypertension (P=0.009), diabetes mellitus (P=0.018), and hypercholesterolemia (P=0.015) were associated with a higher degree of EEA. CB (P=0.007) and EEA (P=0.037) were more pronounced in patients with a history of persistent AF compared with patients without AF history. Conclusions This study provides important insights into complex atrial endo-epicardial excitation. Significant differences in conduction disorders between the endo- and epicardium and a significant degree of EEA are already present during sinus rhythm and are more pronounced in patients with cardiovascular risk factors or a history of persistent AF.
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Affiliation(s)
- Rohit K. Kharbanda
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | - Paul Knops
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | | | - Charles Kik
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | | | | | - Annejet Heida
- Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
| | - Frans B. S. Oei
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic SurgeryErasmus Medical CenterRotterdamThe Netherlands
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Romero J, Patel K, Briceno D, Lakkireddy D, Gabr M, Diaz JC, Alviz I, Polanco D, Della Rocca DG, Mohanty P, Mohanty S, Trivedi C, Natale A, Di Biase L. Cavotricuspid isthmus line in patients undergoing catheter ablation of atrial fibrillation with or without history of typical atrial flutter: A meta-analysis. J Cardiovasc Electrophysiol 2020; 31:1987-1995. [PMID: 32530541 DOI: 10.1111/jce.14614] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/21/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is the mainstay of catheter ablation (CA) for paroxysmal atrial fibrillation (AF). However, for persistent and long-standing persistent AF, there are no established strategies to improve the success rate of CA. Despite studies indicating that prophylactic cavotricuspid isthmus (CTI) ablation provides no or limited incremental benefit in patients with AF, it is still routinely performed worldwide. OBJECTIVE We sought to examine whether CTI ablation for AF is associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone in patients with and without typical atrial flutter (AFL). METHODS A systematic review of PubMed, Cochrane, and Embase was performed for clinical studies including AF patients, reporting outcomes of CTI + PVI versus PVI alone. The primary efficacy endpoint was recurrence of all-atrial arrhythmias. RESULTS Five studies comprising 1400 patients undergoing CTI + PVI versus PVI alone were included; 1110 patients had AF without AFL, and 290 patients had coexistent AF and AFL. After a mean follow-up of 14.4 ± 4.8 months, CTI + PVI was not associated with improvement in recurrence of all-atrial arrhythmias when compared with PVI alone (risk ratio [RR]: 1.29; 95% confidence interval [CI]: 0.93-1.79;p = .13). In the subgroup analysis, there were no differences between both groups in patients with AF without AFL (RR: 1.55; 95% CI: 0.96-2.48; p = .07), and in patients with AF and AFL (RR: 0.91; 95% CI: 0.6-1.39; p = .68). CONCLUSION In AF patients, irrespective of the presence of typical AFL, additional CTI ablation is not associated with improvement in recurrence of all-atrial arrhythmias, compared with PVI alone.
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Affiliation(s)
- Jorge Romero
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Kavisha Patel
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - David Briceno
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | | | - Mohamed Gabr
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Juan C Diaz
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Isabella Alviz
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Dalvert Polanco
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | | | - Prasant Mohanty
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
| | - Luigi Di Biase
- Department of Medicine, Division of Cardiology, Cardiac Arrhythmia Center, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA.,Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA
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14
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Higuchi S, Ejima K, Shoda M, Kanai M, Kataoka S, Yazaki K, Yagishita D, Yoshida A, Tanino S, Saito C, Yagishita Y, Arai K, Ashihara K, Hagiwara N. Right atrial conduction time for predicting coexistent typical atrial flutter in patients with paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2355-2362. [PMID: 32557919 DOI: 10.1111/jce.14623] [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: 04/27/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Screening of coexistent typical atrial flutter (AFL) in patients with atrial fibrillation (AF) is sometimes challenging. This study investigated whether a prolonged right atrial conduction time (RACT) estimated by tissue Doppler imaging (TDI) predicts patients with concomitant AFL and AF. METHODS AND RESULTS We retrospectively analyzed 398 patients (mean age: 61.6 years, 73.4% men) undergoing catheter ablation of paroxysmal AF. The patients were classified into two groups according to whether they had evidence of AFL (N = 122, 30.7%) determined by a clinical observation (N = 68), induction during procedures (N = 33), or AFL recurrence after procedures (N = 21) or not (N = 276, 69.3%). The preoperative RACT, defined as a longer duration between the onset of the P-wave and peak A'-wave on the right atrial lateral wall or septal wall, and total atrial conduction time (TACT), defined as the same time duration on the left atrial lateral wall, were evaluated in all patients. Patients with evidence of AFL had a significantly longer RACT than those without AFL (p < .001). A multiple logistic regression and receiver operator characteristics curve analysis revealed the ratio of the RACT and TACT (RACT/TACT) was the independent and most superior accurate cofounder for predicting evidence of AFL (area under the curve: 0.867). When adding a discriminator of an RACT/TACT ≧ 93% into the conventional screening, 98.4% of the patients with evidence of AFL were estimated to be treated during the initial procedures. CONCLUSION The estimated RACT/TACT using the TDI may be useful for predicting patients with concomitant AFL in patients with AF.
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Affiliation(s)
- Satoshi Higuchi
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Koichiro Ejima
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Miwa Kanai
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shohei Kataoka
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kyoichiro Yazaki
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Daigo Yagishita
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Ayano Yoshida
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Sae Tanino
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Chihiro Saito
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yoshimi Yagishita
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kotaro Arai
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
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15
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Houck CA, Lanters EAH, Heida A, Taverne YJHJ, van de Woestijne PC, Knops P, Roos-Serote MC, Roos-Hesselink JW, Bogers AJJC, de Groot NMS. Distribution of Conduction Disorders in Patients With Congenital Heart Disease and Right Atrial Volume Overload. JACC Clin Electrophysiol 2020; 6:537-548. [PMID: 32439038 DOI: 10.1016/j.jacep.2019.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/06/2019] [Accepted: 12/05/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This study sought to quantify characteristics of atrial conduction disorders in patients with right atrial (RA) volume overload. BACKGROUND Patients with an interatrial shunt are prone to developing atrial fibrillation (AF), which may be related to conduction disorders occurring due to atrial stretch. METHODS Thirty-one patients undergoing surgery for an interatrial shunt (49 ± 14 years of age) underwent epicardial sinus rhythm mapping of the RA, Bachmann's bundle (BB), and left atrium (LA). Conduction delay (CD) was defined as interelectrode conduction time (CT) of 7 to 11 ms and conduction block (CB) as CT ≥12 ms. Prevalence of CD or CB (percentage of mapped region), length of lines, and severity of CB (75th percentile of CTs ≥12 ms) were analyzed. RESULTS All patients had some degree of CD and CB. Prevalence of CD and CB was higher in the RA and BB than in the LA (p < 0.0083 after Bonferroni correction). The longest CB line within each patient was found in the RA in most patients (52%). Interindividual variation in prevalence and lengths of lines was considerable. CB was more severe in the RA than in the LA (p < 0.0083). Within the RA, conduction disorders were more prevalent and more severe in the intercaval region than in the RA free wall (p < 0.05). CONCLUSIONS In patients with an interatrial shunt, conduction disorders during sinus rhythm are most pronounced in the RA-particularly the intercaval region-and BB. Knowledge of the conduction during sinus rhythm is essential to determine the relevance of conduction disorders for initiation and perpetuation of AF.
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Affiliation(s)
- Charlotte A Houck
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva A H Lanters
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annejet Heida
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Paul Knops
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | | | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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16
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Matthews GDK, Grace AA. Unmasking Adenosine: The Purinergic Signalling Molecule Critical to Arrhythmia Pathophysiology and Management. Arrhythm Electrophysiol Rev 2020; 8:240-248. [PMID: 32685154 PMCID: PMC7358948 DOI: 10.15420/aer.2019.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Adenosine was identified in 1929 and immediately recognised as having a potential role in therapy for arrhythmia because of its negative chronotropic and dromotropic effects. Adenosine entered mainstream use in the 1980s as a highly effective agent for the termination of supraventricular tachycardia (SVT) involving the atrioventricular node, as well as for its ability to unmask the underlying rhythm in other SVTs. Adenosine has subsequently been found to have applications in interventional electrophysiology. While considered a safe agent because of its short half-life, adenosine may provoke arrhythmias in the form of AF, bradyarrhythmia and ventricular tachyarrhythmia. Adenosine is also associated with bronchospasm, although this may reflect irritant-induced dyspnoea rather than true obstruction. Adenosine is linked to numerous pathologies relevant to arrhythmia predisposition, including heart failure, obesity, ischaemia and the ageing process itself. This article examines 90 years of experience with adenosine in the light of new European Society of Cardiology guidelines for the management of SVT.
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Affiliation(s)
- Gareth DK Matthews
- Cambridge University NHS Foundation Trust, Cambridge, UK; Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew A Grace
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK; Department of Biochemistry, University of Cambridge, Cambridge, UK
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17
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Riad FS, Waldo AL. Revisiting an Underrecognized Strategy for Rhythm Management: Hybrid Therapy for Patients who Convert from Atrial Fibrillation to Flutter on Antiarrhythmic Drugs. J Innov Card Rhythm Manag 2019; 10:3842-3847. [PMID: 32477703 PMCID: PMC7252707 DOI: 10.19102/icrm.2019.101005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/11/2019] [Indexed: 11/25/2022] Open
Abstract
Atrial fibrillation (AF) is often treated with antiarrhythmic drugs (AADs) or catheter ablation. In a unique subset of patients, AF can convert to atrial flutter (AFL) after the initiation of an AAD. It has previously been shown that, in this subset of patients, cavotricuspid isthmus (CTI) ablation followed by the continuation of the AAD regimen has an unusually high rate of successfully maintaining sinus rhythm. This is an underrecognized approach toward rhythm management in such patients. However, the reason(s) for such a high degree of efficacy with this hybrid therapeutic approach are unclear. We suggest that conversion from AF to AFL selects for a group of patients in whom AF is particularly responsive to the effects of the AAD. Since CTI ablation is essentially curative of AFL, the combination of both techniques results in a high efficacy of sinus rhythm maintenance. Further investigation is required to confirm these hypotheses.
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Affiliation(s)
- Fady S Riad
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Albert L Waldo
- Division of Cardiovascular Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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18
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Mouws EM, van der Does LJ, Kik C, Lanters EA, Teuwen CP, Knops P, Bogers AJ, de Groot NM. Impact of the arrhythmogenic potential of long lines of conduction slowing at the pulmonary vein area. Heart Rhythm 2019; 16:511-519. [DOI: 10.1016/j.hrthm.2018.10.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Indexed: 10/28/2022]
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19
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Pak HN. Catheter Ablation of Long-standing Persistent Atrial Fibrillation: a Reckless Challenge or a Way to Real Cure? Korean Circ J 2019; 49:134-145. [PMID: 30693681 PMCID: PMC6351275 DOI: 10.4070/kcj.2018.0418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/10/2018] [Indexed: 11/11/2022] Open
Abstract
Long-standing persistent atrial fibrillation (L-PeAF) is a category in which rhythm control is attempted while atrial fibrillation (AF) is maintained for more than 1 year. Because AF is a progressive disease and L-PeAF accompanies significant electrical and structural remodeling of atria, it is difficult to restore and maintain sinus rhythm in patients with L-PeAF. Nonetheless, the rhythm outcome is being increasingly improved by the development of sophisticated mapping devices, highly efficient catheters, and evidence-based ablation strategies, and the rational choice of patient selection criteria. This review discusses the evolution of the rhythm control outcome of L-PeAF and its future direction of development.
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Affiliation(s)
- Hui Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea.
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20
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De Bortoli A, Shi LB, Ohm OJ, Hoff PI, Schuster P, Solheim E, Chen J. Incidence and clinical predictors of subsequent atrial fibrillation requiring additional ablation after cavotricuspid isthmus ablation for typical atrial flutter. SCAND CARDIOVASC J 2017; 51:123-128. [DOI: 10.1080/14017431.2017.1304570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alessandro De Bortoli
- Clinic of Internal Medicine, Telemark Regional Hospital, Skien, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Li-Bin Shi
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Ole-Jørgen Ohm
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Per Ivar Hoff
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Peter Schuster
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Eivind Solheim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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21
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Why Do Computer Programs Misdiagnose Flutter? Am J Med 2016; 129:e289-e290. [PMID: 27448489 DOI: 10.1016/j.amjmed.2016.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/20/2016] [Accepted: 06/20/2016] [Indexed: 11/22/2022]
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22
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Porres-Aracama JM, Cerezuela JL, García-Urra F, Luque-Lezcano O, Herrero V. Dual-chamber implantable cardioverter-defibrillator. Is it useful in patient with permanent atrial fibrillation? Clin Case Rep 2016; 4:747-51. [PMID: 27525075 PMCID: PMC4974419 DOI: 10.1002/ccr3.608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 04/09/2016] [Accepted: 05/23/2016] [Indexed: 11/25/2022] Open
Abstract
In patients with permanent atrial fibrillation (AF) and implantable cardioverter–defibrillator (ICD) implant indication, a single‐chamber device is the choice because AF does not provide interesting information for the treatment. It is very unusual to find patients with permanent AF that coexist with atrial tachycardia with various degree of Atrioventricular block.
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Affiliation(s)
- José M Porres-Aracama
- Arrhythmia Unit Critical Care Department Hospital U Donostia San Sebastian Gipuzkoa Spain
| | | | - Francisco García-Urra
- Arrhythmia Unit Critical Care Department Hospital U Donostia San Sebastian Gipuzkoa Spain
| | - Oscar Luque-Lezcano
- Arrhythmia Unit Critical Care Department Hospital U Donostia San Sebastian Gipuzkoa Spain
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23
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Paroxysmal atrial fibrillation in seven dogs with presumed neurally-mediated syncope. J Vet Cardiol 2016; 18:1-9. [DOI: 10.1016/j.jvc.2015.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 09/29/2015] [Accepted: 10/20/2015] [Indexed: 11/17/2022]
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24
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Pellman J, Sheikh F. Atrial fibrillation: mechanisms, therapeutics, and future directions. Compr Physiol 2016; 5:649-65. [PMID: 25880508 DOI: 10.1002/cphy.c140047] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, affecting 1% to 2% of the general population. It is characterized by rapid and disorganized atrial activation leading to impaired atrial function, which can be diagnosed on an EKG by lack of a P-wave and irregular QRS complexes. AF is associated with increased morbidity and mortality and is a risk factor for embolic stroke and worsening heart failure. Current research on AF support and explore the hypothesis that initiation and maintenance of AF require pathophysiological remodeling of the atria, either specifically as in lone AF or secondary to other heart disease as in heart failure-associated AF. Remodeling in AF can be grouped into three categories that include: (i) electrical remodeling, which includes modulation of L-type Ca(2+) current, various K(+) currents and gap junction function; (ii) structural remodeling, which includes changes in tissues properties, size, and ultrastructure; and (iii) autonomic remodeling, including altered sympathovagal activity and hyperinnervation. Electrical, structural, and autonomic remodeling all contribute to creating an AF-prone substrate which is able to produce AF-associated electrical phenomena including a rapidly firing focus, complex multiple reentrant circuit or rotors. Although various remodeling events occur in AF, current AF therapies focus on ventricular rate and rhythm control strategies using pharmacotherapy and surgical interventions. Recent progress in the field has started to focus on the underlying substrate that drives and maintains AF (termed upstream therapies); however, much work is needed in this area. Here, we review current knowledge of AF mechanisms, therapies, and new areas of investigation.
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Affiliation(s)
- Jason Pellman
- Department of Medicine, University of California, San Diego, La Jolla, California, USA
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25
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Suita K, Fujita T, Hasegawa N, Cai W, Jin H, Hidaka Y, Prajapati R, Umemura M, Yokoyama U, Sato M, Okumura S, Ishikawa Y. Norepinephrine-Induced Adrenergic Activation Strikingly Increased the Atrial Fibrillation Duration through β1- and α1-Adrenergic Receptor-Mediated Signaling in Mice. PLoS One 2015. [PMID: 26203906 PMCID: PMC4512675 DOI: 10.1371/journal.pone.0133664] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common arrhythmias among old people. It causes serious long-term health problems affecting the quality of life. It has been suggested that the autonomic nervous system is involved in the onset and maintenance of AF in human. However, investigation of its pathogenesis and potential treatment has been hampered by the lack of suitable AF models in experimental animals. OBJECTIVES Our aim was to establish a long-lasting AF model in mice. We also investigated the role of adrenergic receptor (AR) subtypes, which may be involved in the onset and duration of AF. METHODS AND RESULTS Trans-esophageal atrial burst pacing in mice could induce AF, as previously shown, but with only a short duration (29.0 ± 8.1 sec). We found that adrenergic activation by intraperitoneal norepinephrine (NE) injection strikingly increased the AF duration. It increased the duration to more than 10 minutes, i.e., by more than 20-fold (656.2 ± 104.8 sec; P<0.001). In this model, a prior injection of a specific β1-AR blocker metoprolol and an α1-AR blocker prazosin both significantly attenuated NE-induced elongation of AF. To further explore the mechanisms underlying these receptors' effects on AF, we assessed the SR Ca(2+) leak, a major trigger of AF, and consequent spontaneous SR Ca(2+) release (SCR) in atrial myocytes. Consistent with the results of our in-vivo experiments, both metoprolol and prazosin significantly inhibited the NE-induced SR Ca(2+) leak and SCR. These findings suggest that both β1-AR and α1-AR may play important roles in the development of AF. CONCLUSIONS We have established a long-lasting AF model in mice induced by adrenergic activation, which will be valuable in future AF study using experimental animals, such as transgenic mice. We also revealed the important role of β1- and α1-AR-mediated signaling in the development of AF through in-vivo and in-vitro experiments.
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MESH Headings
- Adrenergic alpha-Antagonists/pharmacology
- Adrenergic beta-Antagonists/pharmacology
- Animals
- Atrial Fibrillation/chemically induced
- Atrial Fibrillation/physiopathology
- Calcium Signaling/drug effects
- Cells, Cultured
- Disease Models, Animal
- Heart Conduction System/drug effects
- Heart Conduction System/physiopathology
- Injections, Intraperitoneal
- Male
- Metoprolol/pharmacology
- Mice
- Mice, Inbred C57BL
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/physiology
- Norepinephrine/administration & dosage
- Norepinephrine/toxicity
- Prazosin/pharmacology
- Receptors, Adrenergic, alpha-1/drug effects
- Receptors, Adrenergic, alpha-1/physiology
- Receptors, Adrenergic, beta-1/drug effects
- Receptors, Adrenergic, beta-1/physiology
- Sarcoplasmic Reticulum/drug effects
- Sympathetic Nervous System/drug effects
- Sympathetic Nervous System/physiopathology
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Affiliation(s)
- Kenji Suita
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takayuki Fujita
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- * E-mail: (TF); (YI)
| | - Nozomi Hasegawa
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Wenqian Cai
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Huiling Jin
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuko Hidaka
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Rajesh Prajapati
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masanari Umemura
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Utako Yokoyama
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Motohiko Sato
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Physiology, Aichi Medical University School of Medicine, Aichi, Japan
| | - Satoshi Okumura
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Physiology, Tsurumi University School of Dental Medicine, Yokohama, Japan
| | - Yoshihiro Ishikawa
- Cardiovascular Research Institute, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- * E-mail: (TF); (YI)
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26
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Abstract
Atrial fibrillation is a very common clinical problem with a high prevalence that is expected to rise over time because of increasing risk factors (eg, age, obesity, hypertension). This high prevalence is also associated with high cost, because atrial fibrillation represents about 1% of overall health care spending. The management of atrial fibrillation involves multiple facets: (1) management of underlying disease if present and the management of atrial fibrillation risk factors, (2) prevention of thromboembolism, (3) control of the ventricular rate during atrial fibrillation, and (4) restoration and maintenance of normal sinus rhythm.
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Affiliation(s)
- Talal Moukabary
- Clinical Electrophysiology, Penn State Heart and Vascular Institute, Milton S. Hershey Medical Center, Penn State University, 500 University Drive, Hershey, PA 17033, USA
| | - Mario D Gonzalez
- Clinical Electrophysiology, Penn State Heart and Vascular Institute, Milton S. Hershey Medical Center, Penn State University, 500 University Drive, Hershey, PA 17033, USA.
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27
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Park J, Pak HN. Elimination Of Triggers Without An Additional Substrate Modification Is Not Sufficient In Patients With Persistent Atrial Fibrillation. J Atr Fibrillation 2015; 7:1207. [PMID: 27957155 DOI: 10.4022/jafib.1207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is a multifactorial disease with complex pathophysiology. Although restoring sinus rhythm delays the progression of atrial remodeling, non-pharmacologic intervention, such as radiofrequency catheter ablation (RFCA), should be done based on the background pathophysiology of the disease. While circumferential pulmonary vein isolation (CPVI) has been known to be the cornerstone of AF catheter ablation, a clinical recurrence rate after CPVI is high in patients with persistent AF (PeAF). Step-wise linear ablation, complex fractionate atrial electrogram (CFAE)-guided ablation, rotor ablation, ganglionate plexus ablation, and left atrial appendage isolation may improve the ablation success rate after CPVI. But, there are still substantial AF recurrences after such liberal atrial substrate ablation, and current ablation techniques regarding substrate modification still have limitations. Therefore, more understanding about AF pathophysiology and early precise intervention may improve clinical outcome of AF management. Keeping in mind "more touch, more scar," operators should generate most efficient substrate modification to achieve better long-term clinical outcome.
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Affiliation(s)
- Junbeom Park
- Yonsei University Health System, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Yonsei University Health System, Seoul, Republic of Korea
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Barra S, Griffith M, Heck P. Is atrial fibrillation so common after supraventricular arrhythmia ablation as to require prophylactic treatment? Europace 2014; 17:1-2. [DOI: 10.1093/europace/euu315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Walters TE, Kalman JM. Development of atrial fibrillation after atrial flutter ablation: more a question of when than whether. J Cardiovasc Electrophysiol 2014; 25:821-823. [PMID: 24762080 DOI: 10.1111/jce.12446] [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] [Indexed: 11/27/2022]
Affiliation(s)
- Tomos E Walters
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
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Miyazaki S, Takigawa M, Taniguchi H, Kuwahara T, Kusa S, Okubo K, Nakamura H, Hachiya H, Hirao K, Takahashi A, Iesaka Y. Prevalence of atrial flutter in patients with and without arrhythmogenic superior vena cava during pulmonary vein isolation. Int J Cardiol 2014; 172:e157-8. [PMID: 24412465 DOI: 10.1016/j.ijcard.2013.12.072] [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: 10/07/2013] [Accepted: 12/22/2013] [Indexed: 10/25/2022]
Affiliation(s)
| | | | | | - Taishi Kuwahara
- Cardiovascular Center, Yokosuka Kyosai Hospital, Kanagawa, Japan
| | - Shigeki Kusa
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Kenji Okubo
- Cardiovascular Center, Yokosuka Kyosai Hospital, Kanagawa, Japan
| | | | - Hitoshi Hachiya
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Yoshito Iesaka
- Cardiovascular Center, Tsuchiura Kyodo Hospital, Ibaraki, Japan
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Park J, Park CH, Lee HJ, Wi J, Uhm JS, Pak HN, Lee M, Kim YJ, Joung B. Left atrial wall thickness rather than epicardial fat thickness is related to complex fractionated atrial electrogram. Int J Cardiol 2014; 172:e411-3. [PMID: 24439855 DOI: 10.1016/j.ijcard.2013.12.255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 12/30/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Junbeom Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chul Hwan Park
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye-Jeong Lee
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Wi
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moonhyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Lee G, Kumar S, Teh A, Madry A, Spence S, Larobina M, Goldblatt J, Brown R, Atkinson V, Moten S, Morton JB, Sanders P, Kistler PM, Kalman JM. Epicardial wave mapping in human long-lasting persistent atrial fibrillation: transient rotational circuits, complex wavefronts, and disorganized activity. Eur Heart J 2013; 35:86-97. [PMID: 23935092 DOI: 10.1093/eurheartj/eht267] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To characterize the nature of atrial fibrillation (AF) activation in human persistent AF (PerAF) using modern tools including activation, directionality analyses, complex-fractionated electrogram, and spectral information. BACKGROUND The mechanism of PerAF in humans is uncertain. METHODS AND RESULTS High-density epicardial mapping (128 electrodes/6.75 cm(2)) of the posterior LA wall (PLAW), LA and RA appendage (LAA, RAA), and RSPV-LA junction was performed in 18 patients with PerAF undergoing open heart surgery. Continuous 10 s recordings were analysed offline. Activation patterns were characterized into four subtypes (i) wavefronts (broad or multiple), (ii) rotational circuits (≥2 rotations of 360°), (iii) focal sources with centrifugal activation of the entire mapping area, or (iv) disorganized activity [isolated chaotic activation(s) that propagate ≤3 bipoles or activation(s) that occur as isolated beats dissociated from the activation of adjacent bipole sites]. Activation at a total of 36 regions were analysed (14 PLAW, 3 RSPV-LA, 12 LAA, and 7 RAA) creating a database of 2904 activation patterns. In the majority of maps, activation patterns were highly heterogeneous with multiple unstable activation patterns transitioning from one to another during each recording. A mean of 3.8 ± 1.6 activation subtypes was seen per map. The most common patterns seen were multiple wavefronts (56.2 ± 32%) and disorganized activity (24.2 ± 30.3%). Only 2 of 36 maps (5.5%) showed a single stable activation pattern throughout the 10-s period. These were stable planar wavefronts. Three transient rotational circuits were observed. Two of the transient circuits were located in the posterior left atrium, while the third was located on the anterior surface of the LAA. Focal activations accounted for 11.3 ± 14.2% of activations and were all short-lived (≤2 beats), with no site demonstrating sustained focal activity. CONCLUSION Human long-lasting PerAF is characterized by heterogeneous and unstable patterns of activation including wavefronts, transient rotational circuits, and disorganized activity.
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Affiliation(s)
- Geoffrey Lee
- The Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia
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Catheter ablation of atrial fibrillation guided by complex fractionated atrial electrogram mapping with or without pulmonary vein isolation. J Arrhythm 2012. [DOI: 10.1016/j.joa.2012.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Melduni RM, Cullen MW. Role of Left Ventricular Diastolic Dysfunction in Predicting Atrial Fibrillation Recurrence after Successful Electrical Cardioversion. J Atr Fibrillation 2012; 5:654. [PMID: 28496792 PMCID: PMC3602956 DOI: 10.4022/jafib.654] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Revised: 09/04/2012] [Accepted: 10/24/2012] [Indexed: 12/14/2022]
Abstract
The role of left ventricular (LV) diastolic dysfunction in predicting atrial fibrillation (AF) recurrence after successful electrical cardioversion is largely unknown. Studies suggest that there may be a link between abnormal LV compliance and the initial development, and recurrence of AF after electrical cardioversion. Although direct-current cardioversion (DCCV) is a well-established and highly effective method to convert AF to sinus rhythm, it offers little else beyond immediate rate control because it does not address the underlying cause of AF. Preservation of sinus rhythm after successful cardioversion still remains a challenge for clinicians. Despite the use of antiarrhythmic drugs and serial cardioversions, the rate of AF recurrence remains high in the first year. Current evidence suggests that diastolic dysfunction, which is associated with atrial volume and pressure overload, may be a mechanism underlying the perpetuating cycle of AF recurrence following successful electrical cardioversion. Diastolic dysfunction is considered to be a defect in the ability of the myofibrils, which have shortened against a load in systole to eject blood into the high-pressure aorta, to rapidly or completely return to their resting length. Consequently, LV filling is impaired and the non-compliant left ventricle is unable to fill at low pressures. As a result, left atrial and pulmonary vein pressure rises, and electrical and structural remodeling of the atrial myocardium ensues, creating a vulnerable substrate for AF. In this article, we review the current evidence highlighting the association of LV diastolic dysfunction with AF recurrence after successful electrical cardioversion and provide an approach to the management of LV diastolic dysfunction to prevent AF recurrence.
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Atienza F, Martins RP, Jalife J. Translational research in atrial fibrillation: a quest for mechanistically based diagnosis and therapy. Circ Arrhythm Electrophysiol 2012; 5:1207-15. [PMID: 23022707 DOI: 10.1161/circep.111.970335] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Felipe Atienza
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
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MEDI CAROLINE, TEH ANDREWW, ROBERTS-THOMSON KURT, MORTON JOSEPHB, KISTLER PETERM, KALMAN JONATHANM. Right Atrial Remodeling is More Advanced in Patients with Atrial Flutter Than with Atrial Fibrillation. J Cardiovasc Electrophysiol 2012; 23:1067-72. [DOI: 10.1111/j.1540-8167.2012.02364.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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TAKAMI MITSURU, YOSHIDA AKIHIRO, FUKUZAWA KOJI, TAKEI ASUMI, KANDA GAKU, TAKAMI KAORU, KUMAGAI HIROYUKI, TANAKA SATOKO, ITOH MITSUAKI, IMAMURA KIMITAKE, FUJIWARA RYUDO, SUZUKI ATSUSHI, HIRATA KENICHI. Rate-Dependent and Site-Specific Conduction Block at the Posterior Right Atrium and Drug Effects Evaluated Using a Noncontact Mapping System in Patients with Typical Atrial Flutter. J Cardiovasc Electrophysiol 2012; 23:827-34. [DOI: 10.1111/j.1540-8167.2012.02313.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kim JB, Choi S, Joung B, Lee MH, Kim SS. The effects of a bidirectional cavo-tricuspid isthmus block in persistent atrial fibrillation. Yonsei Med J 2012; 53:76-82. [PMID: 22187235 PMCID: PMC3250333 DOI: 10.3349/ymj.2012.53.1.76] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Hybrid therapy with catheter ablation of the cavo-tricuspid isthmus (CTI) and continuation of anti-arrhythmic drugs (AAD), or electrical cardioversion with AADs might be alternative treatments for patients with persistent atrial fibrillation (AF). The goal of study was to assess the long term success rate of hybrid therapy for persistent AF compared to antiarrhythmic medication therapy after electrical cardioversion and identify the independent risk factors associated with recurrence after hybrid therapy. MATERIALS AND METHODS A total of 32 patients with persistent AF who developed atrial flutter after the administration of a class Ic or III anti-arrhythmic drug were enrolled. This group was compared with a group (33 patients) who underwent cardioversion and received direct current cardioversion with AADs. Baseline data were collected, and electrocardiogram and symptom driven Holter monitoring were performed every 2-4 months. RESULTS There was no significant difference in the baseline characteristics between the groups. The 12 month atrial arrhythmia free survival was better in the hybrid group, 49.0% vs. 33.1%, p=0.048. However, during a mean 55.7+/- 43.0 months of follow up, the improved survival rate regressed (p=0.25). A larger left atrium size was an independent risk factor for the recurrence of AF after adjusting for confounding factors. CONCLUSION Despite favorable outcome during 12 month, the CTI block with AADs showed outcomes similar to AAD therapy after electrical cardioversion over a 12 month follow up period. Minimal substrate modification with AADs might be an alternative treatment for persistent AF with minimal atrial remodeling.
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Affiliation(s)
- Jin-Bae Kim
- Cardiology Division, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Seonghoon Choi
- Cardiology Division, Kang-Nam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Boyoung Joung
- Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Moon-Hyoung Lee
- Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Soon Kim
- Cardiology Division, Yonsei Cardiovascular Center and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Berenfeld O, Jalife J. Complex fractionated atrial electrograms: is this the beast to tame in atrial fibrillation? Circ Arrhythm Electrophysiol 2011; 4:426-8. [PMID: 21846887 DOI: 10.1161/circep.111.964841] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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40
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Atienza F, Calvo D, Almendral J, Zlochiver S, Grzeda KR, Martínez-Alzamora N, González-Torrecilla E, Arenal A, Fernández-Avilés F, Berenfeld O. Mechanisms of fractionated electrograms formation in the posterior left atrium during paroxysmal atrial fibrillation in humans. J Am Coll Cardiol 2011; 57:1081-92. [PMID: 21349400 DOI: 10.1016/j.jacc.2010.09.066] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 08/12/2010] [Accepted: 09/15/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this paper was to study mechanisms of formation of fractionated electrograms on the posterior left atrial wall (PLAW) in human paroxysmal atrial fibrillation (AF). BACKGROUND The mechanisms responsible for complex fractionated atrial electrogram formation during AF are poorly understood. METHODS In 24 patients, we induced sustained AF by pacing from a pulmonary vein. We analyzed transitions between organized patterns and changes in electrogram morphology leading to fractionation in relation to interbeat interval duration (systolic interval [SI]) and dominant frequency. Computer simulations of rotors helped in the interpretation of the results. RESULTS Organized patterns were recorded 31 ± 18% of the time. In 47% of organized patterns, the electrograms and PLAW activation sequence were similar to those of incoming waves during pulmonary vein stimulation that induced AF. Transitions to fractionation were preceded by significant increases in electrogram duration, spike number, and SI shortening (R(2) = 0.94). Similarly, adenosine infusion during organized patterns caused significant SI shortening leading to fractionated electrograms formation. Activation maps during organization showed incoming wave patterns, with earliest activation located closest to the highest dominant frequency site. Activation maps during transitions to fragmentation showed areas of slowed conduction and unidirectional block. Simulations predicted that SI abbreviation that heralds fractionated electrograms formation might result from a Doppler effect on wave fronts preceding an approaching rotor or by acceleration of a stationary or meandering, remotely located source. CONCLUSIONS During induced AF, SI shortening after either drift or acceleration of a source results in intermittent fibrillatory conduction and formation of fractionated electrograms at the PLAW.
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Affiliation(s)
- Felipe Atienza
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Schotten U, Verheule S, Kirchhof P, Goette A. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev 2011; 91:265-325. [PMID: 21248168 DOI: 10.1152/physrev.00031.2009] [Citation(s) in RCA: 852] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atrial fibrillation (AF) is an arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some aspects of the morphological and electrophysiological alterations promoting AF have been studied extensively in animal models. Atrial tachycardia or AF itself shortens atrial refractoriness and causes loss of atrial contractility. Aging, neurohumoral activation, and chronic atrial stretch due to structural heart disease activate a variety of signaling pathways leading to histological changes in the atria including myocyte hypertrophy, fibroblast proliferation, and complex alterations of the extracellular matrix including tissue fibrosis. These changes in electrical, contractile, and structural properties of the atria have been called "atrial remodeling." The resulting electrophysiological substrate is characterized by shortening of atrial refractoriness and reentrant wavelength or by local conduction heterogeneities caused by disruption of electrical interconnections between muscle bundles. Under these conditions, ectopic activity originating from the pulmonary veins or other sites is more likely to occur and to trigger longer episodes of AF. Many of these alterations also occur in patients with or at risk for AF, although the direct demonstration of these mechanisms is sometimes challenging. The diversity of etiological factors and electrophysiological mechanisms promoting AF in humans hampers the development of more effective therapy of AF. This review aims to give a translational overview on the biological basis of atrial remodeling and the proarrhythmic mechanisms involved in the fibrillation process. We pay attention to translation of pathophysiological insights gained from in vitro experiments and animal models to patients. Also, suggestions for future research objectives and therapeutical implications are discussed.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, University Maastricht, Maastricht, The Netherlands.
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NAVARRETE ANTONIO, CONTE FRANK, MORAN MICHAEL, ALI ISHTI, MILIKAN NATHAN. Ablation of Atrial Fibrillation at the Time of Cavotricuspid Isthmus Ablation in Patients With Atrial Flutter Without Documented Atrial Fibrillation Derives a Better Long-Term Benefit. J Cardiovasc Electrophysiol 2011; 22:34-8. [DOI: 10.1111/j.1540-8167.2010.01845.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rokutan H, Anker SD, Springer J. In vivomodels of cardiac diseases: application to drug development and screening. Expert Opin Drug Discov 2009; 5:65-78. [DOI: 10.1517/17460440903460299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Nishida K, Michael G, Dobrev D, Nattel S. Animal models for atrial fibrillation: clinical insights and scientific opportunities. Europace 2009; 12:160-72. [PMID: 19875395 DOI: 10.1093/europace/eup328] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. A variety of animal models have been used to study the pathophysiology of AF, including molecular basis, ion-current determinants, anatomical features, and macroscopic mechanisms. In addition, animal models play a key role in the development of new therapeutic approaches, whether drug-based, molecular therapeutics, or device-related. This article discusses the various types of animal models that have been used for AF research, reviews the principle mechanisms governing atrial arrhythmias in each model, and provides some guidelines for model selection for various purposes.
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Affiliation(s)
- Kunihiro Nishida
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Montreal, Quebec, Canada
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Roberts-Thomson KC, John B, Worthley SG, Brooks AG, Stiles MK, Lau DH, Kuklik P, Shipp NJ, Kalman JM, Sanders P. Left atrial remodeling in patients with atrial septal defects. Heart Rhythm 2009; 6:1000-6. [PMID: 19493703 DOI: 10.1016/j.hrthm.2009.03.050] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Information regarding left atrial (LA) substrate in conditions predisposing to atrial fibrillation (AF) is limited. OBJECTIVE This study sought to characterize the left atrial remodeling that results from chronic atrial stretch caused by atrial septal defect (ASD). METHODS Eleven patients with hemodynamically significant ASDs and 12 control subjects were studied. The following were evaluated using multipolar catheters: effective refractory period (ERP) at 7 sites, P-wave duration (PWD), conduction time, and inducibility of AF. LA electroanatomic maps were created to determine atrial activation, and regional conduction and voltage abnormalities. RESULTS Patients with ASDs showed significant LA enlargement (P <0.001), unchanged or prolonged atrial ERPs, increase in LA conduction times (P = 0.03), prolonged PWD (P <0.001), regional conduction slowing (P <0.001), greater number of double potentials or fractionated electrograms (P <0.0001), reduced atrial voltage (P <0.001), and more frequent electrical scar (P = 0.005) compared with control subjects. In addition, patients with ASDs showed a greater propensity for sustained AF with single extrastimuli (4 of 11 vs. 0 of 12, P = 0.04). CONCLUSION ASDs are associated with chronic left atrial stretch, which results in remodeling characterized by LA enlargement, loss of myocardium, and electrical scar that results in widespread conduction abnormalities but with no change or an increase in ERP. These abnormalities were associated with a greater propensity for sustained AF.
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Affiliation(s)
- Kurt C Roberts-Thomson
- Cardiovascular Research Centre, Department of Cardiology, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
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LO LIWEI, TAI CHINGTAI, LIN YENNJIANG, CHANG SHIHLIN, WONGCHAROEN WANWARANG, TUAN TACHUAN, UDYAVAR AMEYAR, HU YUFENG, UENG KUOCHANG, TSAI WENCHIN, CHANG CHIENJUNG, TSAO HSUANMING, HIGA SATOSHI, CHEN SHIHANN. Characteristics of the Cavotricuspid Isthmus in Predicting Recurrent Conduction in the Long-Term Follow-Up. J Cardiovasc Electrophysiol 2009; 20:39-43. [DOI: 10.1111/j.1540-8167.2008.01269.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Laurent V, Fauchier L, Pierre B, Grimard C, Babuty D. Incidence and predictive factors of atrial fibrillation after ablation of typical atrial flutter. J Interv Card Electrophysiol 2008; 24:119-25. [PMID: 18982436 DOI: 10.1007/s10840-008-9323-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 09/15/2008] [Indexed: 11/27/2022]
Affiliation(s)
- Valérie Laurent
- Pôle CTVH, Centre Hospitalier Universitaire Trousseau, 37044 Tours Cedex 1, France
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Govindan M, Catanchin A, Camm AJ. The place of hybrid therapies with drugs to supplement nonpharmacological therapies in atrial fibrillation. J Cardiovasc Pharmacol 2008; 52:210-21. [PMID: 18806601 DOI: 10.1097/fjc.0b013e3181799677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, and its prevalence continues to rise as the aged population increases. Comparative studies of rhythm control and rate control have been equivocal; however, the benefits of rhythm control may have been offset by the limitations of antiarrhythmic drugs. More recently, nonpharmacological therapies have emerged that provide hope of more effective rhythm control. Catheter ablation techniques have gained favour with high success rates in specialized centers, although these techniques are not without complications and require considerable expertise. Pacing therapies designed to reduce harmful right ventricular pacing and increase physiological pacing have shown benefit in AF patients with bradycardia. Despite this progress, no single modality confers benefit for all patients. Strategies to combine these treatment modalities in a hybrid approach has shown increasing promise for subgroups of AF patients.
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Affiliation(s)
- Malini Govindan
- Division of Cardiac and Vascular Sciences, St Georges Hospital University of London, London, UK.
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Blake GE, Lakkireddy D. Atrial Septal Defect and Atrial Fibrillation: The Known and Unknown. J Atr Fibrillation 2008; 1:45. [PMID: 28496588 DOI: 10.4022/jafib.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 05/19/2008] [Accepted: 08/25/2008] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is a common complication in patients with atrial septal defects (ASDs). The link between AF and ASD is fairly complex and entails modifications in electrophysiologic, contractile and structural properties, at the cellular and tissue level, of both atria, mainly due to chronic atrial stretch and dilation. Surgical repair or percutaneous closure of ASDs are equally effective in reducing mortality and symptoms but limited in preventing or curbing AF, unless combined with an arrhythmia-specific procedure. Transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) have improved the safety and success of the above procedures. Finally, clearer understanding of the pathophysiology of AF in patients with ASD (and CHF, in general) has led to target-specific advances in medical management.
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Affiliation(s)
- George E Blake
- Mid America Cardiology @ University of Kansas Hospital, Kansas City, KS
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