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Goto K, Miyazaki S, Negishi M, Ikenouchi T, Yamamoto T, Kawamura I, Nishimura T, Takamiya T, Tao S, Takigawa M, Sasano T. Distribution of antral lesions with the novel size-adjustable cryoballoon for pulmonary vein isolation and the differences based on left atrial remodeling. J Cardiovasc Electrophysiol 2024. [PMID: 39169533 DOI: 10.1111/jce.16415] [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: 06/30/2024] [Revised: 07/29/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION The novel cryoballoon with 28 mm or 31 mm adjustable diameters, aims to achieve a wide antral pulmonary vein isolation (PVI). However, the distribution of antral lesions and their variations based on left atrial (LA) remodeling require further clarification. METHODS We evaluated 22 patients (67 [59.5-74.8] years, 19 males) who underwent PVI of atrial fibrillation (AF) (13 paroxysmal AF [PAF] and 9 non-PAF) using size-adjustable cryoballoons. LA electro-anatomical mapping was performed post-PVI with three-dimensional mapping systems. We assessed the shapes of the LA and pulmonary veins (PVs) and the distribution of isolated areas (IAs), comparing the results between PAF and non-PAF patients. RESULTS In the left PVs (LPVs), the distance between the PV orifice and IA edge (PVos-IA) was larger on the roof and posterior segments (~15 mm) but relatively smaller on the anterior segment near the PV ridge (<10 mm). For the right PVs (RPVs), it was more extensive in the posterior segment (10-15 mm). Comparing PAF and non-PAF, there were no significant differences in the PVos-IA except for the right posterior-carina segment, antrum IA (LPVs: 5.9 ± 1.6 vs. 5.8 ± 0.8 cm², p = .81; RPVs: 4.8 ± 2.3 vs. 4.8 ± 1.2 cm², p = .81), distances between the right and left IAs on the LA posterior wall (LAPW), and un-isolated LAPW area (9.0 ± 4.9 vs. 9.9 ± 2.5 cm², p = .62). No individual PVIs were observed in either group. Two patients exhibited overlapping IAs on the roof, and one patient who underwent 31 mm balloon applications for all PVs exhibited an LAPW isolation. CONCLUSION The size-adjustable cryoballoon achieved a wide antral PVI even in non-PAF patients.
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Affiliation(s)
- Kentaro Goto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Miho Negishi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Ikenouchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Iwanari Kawamura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuro Nishimura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomomasa Takamiya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Susumu Tao
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Odagiri F, Tokano T, Miyazaki T, Hirabayashi K, Ishi K, Abe H, Ishiwata S, Kakihara M, Maki M, Matsumoto H, Shimai R, Aikawa T, Takano S, Kimura Y, Kuroda S, Isogai H, Ozaki D, Shiozawa T, Yasuda Y, Takasu K, Iijima K, Takamura K, Matsubara T, Tabuchi H, Hayashi H, Yokoyama K, Sekita G, Sumiyoshi M, Nakazato Y, Minamino T. Clinical impact of cryoballoon posterior wall isolation using the cross-over technique in persistent atrial fibrillation. Pacing Clin Electrophysiol 2024. [PMID: 39132971 DOI: 10.1111/pace.15058] [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: 05/09/2024] [Revised: 06/22/2024] [Accepted: 08/03/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND AND AIMS Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW. METHODS This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of pulmonary vein isolation (PVI) + PWI (108 patients) or PVI-only (86 patients) using the CB. The cross-over technique was applied in all LAPWI. RESULTS For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (right to left [R→L] 4.3 ± 1.1 and left to right [L→R] 4.3 ± 1.1) and 9.1 ± 1.2 (R→L 4.6 ± 1.6 and L→R 4.5 ± 1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI + PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow-up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI + PWI group and 72.9% of the PVI-only group (p = .011). CONCLUSIONS LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.
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Affiliation(s)
- Fuminori Odagiri
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Takashi Tokano
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Tetsuro Miyazaki
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Koji Hirabayashi
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kai Ishi
- Department of Cardiology, Juntendo Tokyo Koto Geriatric Medical Center, Juntendo University School of Medicine, Koto-ku, Tokyo, Japan
| | - Hiroshi Abe
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Sayaki Ishiwata
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Midori Kakihara
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Masaaki Maki
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Hiroki Matsumoto
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ryosuke Shimai
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Tadao Aikawa
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Shintaro Takano
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni city, Shizuoka, Japan
| | - Yuki Kimura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Shunsuke Kuroda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Isogai
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Dai Ozaki
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Tomoyuki Shiozawa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni city, Shizuoka, Japan
| | - Yuki Yasuda
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kiyoshi Takasu
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Kenichi Iijima
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kazuhisa Takamura
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Tomomi Matsubara
- Department of Cardiology, Juntendo Tokyo Koto Geriatric Medical Center, Juntendo University School of Medicine, Koto-ku, Tokyo, Japan
| | - Haruna Tabuchi
- Department of Cardiology, Juntendo University Nerima Hospital, Nerima-ku, Tokyo, Japan
| | - Hidemori Hayashi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Ken Yokoyama
- Department of Cardiology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Gaku Sekita
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Masataka Sumiyoshi
- Department of Cardiology, Juntendo University Nerima Hospital, Nerima-ku, Tokyo, Japan
| | - Yuji Nakazato
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:921-1072. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Takemoto M, Antoku Y, Tsuchihashi T. Editorial to "Uncoupling endocardial bundles coupled by an epicardial bundle in the left atrium and pulmonary veins". J Arrhythm 2024; 40:788-789. [PMID: 39139874 PMCID: PMC11317674 DOI: 10.1002/joa3.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 05/06/2024] [Indexed: 08/15/2024] Open
Affiliation(s)
- Masao Takemoto
- Cardiovascular CentreSocial Medical Corporation Steel Memorial Yawata HospitalKitakyushuJapan
| | - Yoshibumi Antoku
- Cardiovascular CentreSocial Medical Corporation Steel Memorial Yawata HospitalKitakyushuJapan
| | - Takuya Tsuchihashi
- Cardiovascular CentreSocial Medical Corporation Steel Memorial Yawata HospitalKitakyushuJapan
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Nakatani Y, Take Y, Yoshimura S, Takizawa R, Goto K, Kaseno K, Haraguchi Y, Kimura K, Sasaki T, Miki Y, Nakamura K, Naito S. Catheter Ablation Approach Targeting Epicardial Connections to the Right Pulmonary Vein Antrum Detected before Pulmonary Vein Isolation. Heart Rhythm 2024:S1547-5271(24)03081-9. [PMID: 39069208 DOI: 10.1016/j.hrthm.2024.07.104] [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: 04/27/2024] [Revised: 07/05/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Epicardial connections from surrounding structures to the right pulmonary vein (PV) antrum impede PV isolation. OBJECTIVE This study aimed to evaluate the efficacy of an ablation approach targeting epicardial connections for right PV isolation. METHODS We prospectively enrolled 124 patients with atrial fibrillation undergoing initial PV isolation. We identified the activation breakthrough into the right PV antrum (BT-RPV) on the activation map created during high right atrial pacing before PV isolation. BT-RPV sites were targeted when right PV isolation was not achieved by wide antral circumferential ablation (WACA). RESULTS BT-RPV was observed in 83 cases (67%). PV isolation was achieved by WACA in all 41 cases without BT-RPV. Among cases with BT-RPV, PV isolation was achieved by WACA in 48 cases when all BT-RPV sites were covered by the PV isolation line. Conversely, PV isolation was completed by WACA in only 5 out of 35 cases when not all BT-RPV sites were covered. In cases where WACA failed, 35 sites were targeted for BT-RPV ablation. Initial BT-RPV ablation led to PV isolation at 20 sites, while the remaining 15 BT-RPV sites required repeat BT-RPV ablation. The ablated area of successful BT-RPV ablation was 0.9 [0.6-1.2] cm2, corresponding to the area activated within 15 [14-16] ms after BT-RPV emergence. Ablating the area activated within 14 ms after BT-RPV emergence was associated with successful PV isolation (sensitivity 91% and specificity 100%). CONCLUSION Ablation targeting BT-RPV sites is effective for right PV isolation. Extensive ablation is required to eliminate BT-RPV.
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Affiliation(s)
- Yosuke Nakatani
- Division of Non-Pharmacological Management of Cardiac Arrhythmias, Gunma University Graduate School of Medicine, Maebashi, Japan; Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan.
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Ryoya Takizawa
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yumiko Haraguchi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Koki Kimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Larsen BS, Biering-Sørensen T, Olsen FJ. Ischemic stroke and the emerging role of left atrial function. Expert Rev Cardiovasc Ther 2024; 22:289-300. [PMID: 38943632 DOI: 10.1080/14779072.2024.2370814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/18/2024] [Indexed: 07/01/2024]
Abstract
INTRODUCTION Ischemic stroke is a leading cause of morbidity and mortality worldwide. Emerging evidence suggests that left atrial (LA) dysfunction could play a role in the pathophysiology of ischemic stroke, as a possible contributor and as a predictive biomarker. AREAS COVERED This narrative review details the intricate relationship between LA function, atrial fibrillation (AF), and ischemic stroke. We discuss imaging techniques used to assess LA function, the mechanisms by which impaired LA function may contribute to stroke, and its potential as a prognostic marker of stroke. EXPERT OPINION There is a lack of evidence-based treatments of LA dysfunction in both primary and secondary stroke prevention. This is partly due to the lack of a practical clinical definition and unanswered questions concerning the clinical implications of LA dysfunction in patients without AF. Until such questions are resolved, addressing well-known cardiovascular risk factors, like hypertension and obesity, should be prioritized for preventing AF and ischemic stroke. These risk factors are closely tied to atrial remodeling, emphasizing the importance of targeting primary modifiable factors for preventing future morbidity and mortality.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
| | - Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Hellerup, Denmark
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Nyuta E, Takemoto M, Antoku Y, Mito T, Sakai T, Takiguchi T, Ikeda S, Koga T, Tsuchihashi T. Role of Sleep-Disordered Breathing and Epicardial Connections in the Recurrence of Atrial Fibrillation. Int Heart J 2024; 65:414-426. [PMID: 38749745 DOI: 10.1536/ihj.23-653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
The presence of epicardial connections (ECs) between the pulmonary veins (PVs) and atrium may contribute to atrial fibrillation (AF) recurrence. This study aimed to determine the impact of sleep-disordered breathing (SDB) on the presence of ECs and the interplay between SDB and ECs on AF recurrence.We retrospectively reviewed 400 consecutive non-valvular AF patients. Among them, 235 patients exhibiting a 3% oxygen desaturation index (ODI) of ≥ 10 events/hour underwent polysomnography to evaluate the SDB severity, measured by the apnea-hypopnea index (AHI). To facilitate the ablation of AF and ECs, a high-density mapping catheter (HDMC) was employed. AF recurrence was evaluated over a 12-month period post-AF ablation.The key findings included: 1) 63% of AF patients with ECs had SDB with an AHI ≥ 20 events/hour. 2) Despite achieving complete PV isolations and precise EC ablation using an HDMC, SDB presence was associated with an increased AF recurrence. 3) Continuous positive airway pressure therapy for SDB improved AF recurrence among the AF patients with both ECs and SDB (57% versus 73%; P = 0.016). 4) AHI (odds ratio [OR] = 1.91, ≥ 28.4 events/hour) and left atrial volume (LAV) (OR = 1.42, ≥ 128.3 mL) were independent predictors of the presence of ECs, and AHI (OR = 1.44, ≥ 27.8 events/hour) was an independent predictor of the presence of AF recurrence.It is essential for physicians to recognise the potential complexity of ECs and SDB in AF patients. Thus, screening and treating SDB in AF patients presenting with ECs might play a pivotal role in suppressing AF recurrence.
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Affiliation(s)
- Eiji Nyuta
- Cardiovascular Centre, Steel Memorial Yawata Hospital
| | | | | | | | - Togo Sakai
- Cardiovascular Centre, Steel Memorial Yawata Hospital
| | | | - Shota Ikeda
- Cardiovascular Centre, Steel Memorial Yawata Hospital
| | - Tokushi Koga
- Cardiovascular Centre, Steel Memorial Yawata Hospital
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Chen L, Huang SH, Wang TH, Tseng VS, Tsao HM, Tang GJ. Automatic 3D left atrial strain extraction framework on cardiac computed tomography. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 252:108236. [PMID: 38776829 DOI: 10.1016/j.cmpb.2024.108236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 05/15/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Strain analysis provides insights into myocardial function and cardiac condition evaluation. However, the anatomical characteristics of left atrium (LA) inherently limit LA strain analysis when using echocardiography. Cardiac computed tomography (CT) with its superior spatial resolution, has become critical for in-depth evaluation of LA function. Recent studies have explored the feasibility of CT-derived strain; however, they relied on manually selected regions of interest (ROIs) and mainly focused on left ventricle (LV). This study aimed to propose a first-of-its-kind fully automatic deep learning (DL)-based framework for three-dimensional (3D) LA strain extraction on cardiac CT. METHODS A total of 111 patients undergoing ECG-gated contrast-enhanced CT for evaluating subclinical atrial fibrillation (AF) were enrolled in this study. We developed a 3D strain extraction framework on cardiac CT images, containing a 2.5D GN-U-Net network for LA segmentation, axis-oriented 3D view extraction, and LA strain measure. The segmentation accuracy was evaluated using Dice similarity coefficient (DSC). The model-extracted LA volumes and emptying fraction (EF) were compared with ground-truth measurements using intraclass correlation coefficient (ICC), correlation coefficient (r), and Bland-Altman plot (B-A). The automatically extracted LA strains were evaluated against the LA strains measured from 2D echocardiograms. We utilized this framework to gauge the effect of AF burden on LA strain, employing the atrial high rate episode (AHRE) burden as the measurement parameter. RESULTS The GN-U-Net LA segmentation network achieved a DSC score of 0.9603 on the test set. The framework-extracted LA estimates demonstrated excellent ICCs of 0.949 (95 % CI: 0.93-0.97) for minimal LA volume, 0.904 (95 % CI: 0.86-0.93) for maximal LA volume, and 0.902 (95 % CI: 0.86-0.93) for EF, compared with expert measurements. The framework-extracted LA strains demonstrated moderate agreement with the LA strains based on 2D echocardiography (ICCs >0.703). Patients with AHRE > 6 min had significantly lower global strain and LAEF, as extracted by the framework than those with AHRE ≤ 6 min. CONCLUSION The promising results highlighted the feasibility and clinical usefulness of automatically extracting 3D LA strain from CT images using a DL-based framework. This tool could provide a 3D-based alternative to echocardiography for assessing LA function.
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Affiliation(s)
- Ling Chen
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sung-Hao Huang
- Division of Cardiology, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, No. 169, Xiao-She Road, Yilan, Taiwan.
| | - Tzu-Hsiang Wang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Vincent S Tseng
- Department of Computer Science, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
| | - Hsuan-Ming Tsao
- Division of Cardiology, Department of Internal Medicine, National Yang Ming Chiao Tung University Hospital, No. 169, Xiao-She Road, Yilan, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gau-Jun Tang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
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9
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Vio R, Forlin E, China P. Recurrences after Pulsed Field Ablation of Atrial Fibrillation: Incidence, Mechanisms, Predictors, and Comparison with Thermal Energy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:817. [PMID: 38793000 PMCID: PMC11123187 DOI: 10.3390/medicina60050817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Pulsed Field Ablation (PFA) is the latest and most intriguing technology for catheter ablation of atrial fibrillation, due to its capability to generate irreversible and cardiomyocytes-selective electroporation of cell membranes by delivering microsecond-lasting high-voltage electrical fields, leading to high expectations. The first trials to assess the clinical success of PFA, reported an arrhythmia-free survival at 1-year of 78.5%, while other trials showed less enthusiastic results: 66.2% in paroxysmal and 55.1% in persistent AF. Nevertheless, real world data are encouraging. The isolation of pulmonary veins with PFA is easily achieved with 100% acute success. Systematic invasive remapping showed a high prevalence of durable pulmonary vein isolation at 75 and 90 days (range 84-96%), which were significatively lower in redo procedures (64.3%). The advent of PFA is prompting a reconsideration of the role of the autonomic nervous system in AF ablation, as PFA-related sparing of the ganglionated plexi could lead to the still undetermined effect on late arrhythmias' recurrences. Moreover, a new concept of a blanking period could be formulated with PFA, according to its different mechanism of myocardial injury, with less inflammation and less chronic fibrosis. Finally, in this review, we also compare PFA with thermal energy.
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Affiliation(s)
- Riccardo Vio
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
| | - Enrico Forlin
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, 35128 Padua, Italy
| | - Paolo China
- Department of Cardiothoracic, Vascular Medicine and Intensive Care, Dell’Angelo Hospital, 30174 Mestre-Venice, Italy; (E.F.); (P.C.)
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10
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Wada T, Matsuo K, Takayama S, Ochi M, Arisuda Y, Akai H, Koide Y, Otsuka H, Kawamoto K, Tanakaya M, Katayama Y. Identification of epicardial connections can improve the success rate of first-pass right pulmonary vein isolation. Heart Rhythm O2 2024; 5:266-273. [PMID: 38840766 PMCID: PMC11148491 DOI: 10.1016/j.hroo.2024.03.011] [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] [Indexed: 06/07/2024] Open
Abstract
Background Epicardial connections between the right pulmonary vein (PV) and the right atrium have been reported. Objective The purpose of this study was to evaluate the usefulness of our new pulmonary vein isolation (PVI) strategy with identification of these epicardial connections. Methods Overall, 235 patients with atrial fibrillation were included. High-density mapping of the left atrium was performed to identify the earliest activation sites (EASs) before PVI in all patients. With our new strategy, if EASs around the right PV carina were identified, we ablated these sites and performed usual first-pass circumferential PVI. The patients were divided into 2 groups according to the ablation strategy. One hundred fifteen patients underwent first-pass PVI without information on EASs (nonanalyzed group), and 78 patients underwent ablation at EASs around the right PV carina in addition to PVI (analyzed group). After first-pass ablation around the PV antrum, remapping was performed. Results High-density mapping before PVI showed that the prevalence of EASs around the right PV carina was 10.9% in all patients (9.6% in the nonanalyzed group, 12.8% in the analyzed group; P = .74. The first-pass right PVI success rate was higher in the analyzed group than in the nonanalyzed group (93.6% vs 82.6%; P = .04). The radiofrequency application time for PVI was significantly shorter in the analyzed group than in the nonanalyzed group (45.6 ± 1.0 minutes vs 51.2 ± 0.9 minutes; P <.05). Conclusion Identification of epicardial connections before ablation could improve the success rate of first-pass right PVI.
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Affiliation(s)
- Tadashi Wada
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Keita Matsuo
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Shin Takayama
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Masahiko Ochi
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yurie Arisuda
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Hiroaki Akai
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuji Koide
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Hiroaki Otsuka
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Kenji Kawamoto
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Machiko Tanakaya
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yusuke Katayama
- Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
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11
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Zhang J, Cheng G, Deng C, Zhao A. Electrophysiologic mechanism and ablation strategy for macroreentrant biatrial tachycardias after Cox-maze procedures. Heart Rhythm 2024:S1547-5271(24)02331-2. [PMID: 38604587 DOI: 10.1016/j.hrthm.2024.03.1819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Different types of recurrent atrial tachycardia (AT) after Cox-maze procedures have been reported, whereas biatrial tachycardia (BiAT) has not been systematically analyzed. OBJECTIVE In this study, we retrospectively investigated the electrophysiologic characteristics of BiAT after Cox-maze procedures by use of an ultrahigh-density mapping system. METHODS Of a consecutive 76 patients who underwent catheter ablation of AT after Cox-maze procedures, 12 BiATs were identified. High-density activation mapping was performed in both the left atrium and right atrium in combination with entrainment pacing to confirm the circuit. RESULTS We classified these BiATs into 2 groups. In group 1 (7 patients), the bidirectional block of maze linear lesions to prevent the macroreentrant AT was achieved; the posterior interatrial connections were involved in the circuit. In group 2 (5 patients), the bidirectional block of maze linear lesions was not blocked, and the most common gap was located at the end of the linear lesion near the annulus. In group 1, all the ATs were terminated by targeting the corresponding left atrium end of the posterior interatrial connections. In group 2, the ATs were terminated by targeting the gap near the annulus. CONCLUSION The optimal ablation strategy for BiATs after the maze procedure should be based on detailed demonstration of the circuit by high-density mapping.
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Affiliation(s)
- Jinlin Zhang
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China.
| | - Guanghui Cheng
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China
| | - Chenggang Deng
- Department of Cardiology, Wuhan Asian Heart Hospital, Wuhan, China
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12
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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13
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Yang JD, Gao Y, Guo XG, Zhou GB, Liu X, Chen K, Ma J, Sun Q. Focal atrial tachycardias originating from the aorta-mitral continuity: Anatomical and electrophysiological characteristics. Heart Rhythm 2024:S1547-5271(24)02328-2. [PMID: 38588992 DOI: 10.1016/j.hrthm.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The aorta-mitral annulus conjunction (AMC) is an uncommon site of origin of focal atrial tachycardias (ATs). Hence, the electrophysiological and ablation target characteristics are poorly described. OBJECTIVE The purpose of this study was to describe the characteristics of AMC ATs in detail. METHODS The study enrolled 650 patients with ATs, 21 (3.2%) of whom had ATs originating from the AMC. A comprehensive evaluation, including electrocardiography, electrophysiology study, computed tomography scan, and intracardiac echocardiography, was performed. RESULTS The majority (19, 90.5%) of ATs occurred spontaneously. The mean age of this group was 48.9 ± 21.6 years, with 12 being female (57.1%). Seventeen patients had a typical biphasic P wave with a prominent positive component. The earliest activation site in the right atrium was near the His bundle, with average activation -10.3 ± 6.0 ms preceding the P wave. The successful ablation targets were distributed as follows: 1 case at 9 o'clock, 6 cases at 10 o'clock, 7 cases at 11 o'clock, 6 cases at 12 o'clock, and 1 case in the left coronary cusp. The local AMC potential differed from the commonly perceived annular potential and was characterized by a prominent A wave and a smaller V wave (atrial-to-ventricular ratio > 1). The angle of encroachment on the left atrial anterior wall, compressed by the left coronary cusp, was significantly smaller in the AMC ATs group than in the control group consisted of 40 patients who underwent coronary artery CT scans because of the chest pain but without atrial arrhythmias were randomly selected, which may have contributed to the arrhythmia substrate (141.7° ± 11.5° vs 155.2° ± 13.9°; P = .026). CONCLUSION A new strategy for mapping AMC ATs has been introduced. The ablation target should have an atrial-to-ventricular ratio of >1.
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Affiliation(s)
- Jian-du Yang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Gao
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Gang Guo
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gong-Bu Zhou
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Xu Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Ma
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Sun
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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14
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Liuba I, Santangeli P. The quest for achieving durable mitral isthmus block: probing the heights of the left lateral ridge. J Interv Card Electrophysiol 2024; 67:443-445. [PMID: 38109024 DOI: 10.1007/s10840-023-01693-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Ioan Liuba
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
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15
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Ratusznik J, Ratusznik F, Pękala JR, Krager E, Hołda M, Sarata V, Łazarz D, Raputa W, Tomaszewski KA. A meta-analysis of the accessory left atrial appendage and the left atrial diverticulum. Clin Anat 2024; 37:294-303. [PMID: 37621227 DOI: 10.1002/ca.24110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 06/22/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
Left atrial (LA) structures, including the accessory left atrial appendage (aLAA) and left atrial diverticulum, have been studied based on their prevalence, shape, and association with arrhythmia and thrombi formation. A pooled prevalence with morphometric data has not been determined in previous research. Our goal is to provide structured, clinically relevant information on said structures for clinical practitioners to use in their daily work. We propose that morphometric data of additional LA structures is necessary when considering the possible complications during cardiac interventions. We conducted a meta-analysis of all relevant studies which used electrocardiogram (ECG)-gated computed tomography (CT) imaging to determine the prevalence of LA structures and record their morphometric characteristics as well as the presence of thrombi. Data were extracted from 19 studies (n = 6643 hearts). The pooled prevalence estimate of left atrial diverticulum and/or aLAAs were reported from 14 studies and was 28.8%. The most common location noted was anterosuperior in the LA with 70.2% of structures found there. Data regarding thrombi presence in left atrial diverticulums or aLAAs were extracted from 11 studies and a thrombus was present in 0.2%. The prevalence rates of aLAAs and left atrial diverticulums are essential in performing uncomplicated cardiac interventions and reducing risk of electrophysiological procedures. Our findings show a considerable prevalence of LA structures in varying populations, provides information regarding the general characteristics of said structures, and does not support the previously theorized associated risk of thrombus formation in relation to LA structure presence.
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Affiliation(s)
- Jakub Ratusznik
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Filip Ratusznik
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub R Pękala
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Eirik Krager
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Hołda
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Victoria Sarata
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Dominik Łazarz
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Wiktor Raputa
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof A Tomaszewski
- International Evidence-Based Anatomy Working Group, Krakow, Poland
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
- Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
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16
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Sillett C, Razeghi O, Lee AWC, Solis Lemus JA, Roney C, Mannina C, de Vere F, Ananthan K, Ennis DB, Haberland U, Xu H, Young A, Rinaldi CA, Rajani R, Niederer SA. A three-dimensional left atrial motion estimation from retrospective gated computed tomography: application in heart failure patients with atrial fibrillation. Front Cardiovasc Med 2024; 11:1359715. [PMID: 38596691 PMCID: PMC11002108 DOI: 10.3389/fcvm.2024.1359715] [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: 12/21/2023] [Accepted: 03/08/2024] [Indexed: 04/11/2024] Open
Abstract
Background A reduced left atrial (LA) strain correlates with the presence of atrial fibrillation (AF). Conventional atrial strain analysis uses two-dimensional (2D) imaging, which is, however, limited by atrial foreshortening and an underestimation of through-plane motion. Retrospective gated computed tomography (RGCT) produces high-fidelity three-dimensional (3D) images of the cardiac anatomy throughout the cardiac cycle that can be used for estimating 3D mechanics. Its feasibility for LA strain measurement, however, is understudied. Aim The aim of this study is to develop and apply a novel workflow to estimate 3D LA motion and calculate the strain from RGCT imaging. The utility of global and regional strains to separate heart failure in patients with reduced ejection fraction (HFrEF) with and without AF is investigated. Methods A cohort of 30 HFrEF patients with (n = 9) and without (n = 21) AF underwent RGCT prior to cardiac resynchronisation therapy. The temporal sparse free form deformation image registration method was optimised for LA feature tracking in RGCT images and used to estimate 3D LA endocardial motion. The area and fibre reservoir strains were calculated over the LA body. Universal atrial coordinates and a human atrial fibre atlas enabled the regional strain calculation and the fibre strain calculation along the local myofibre orientation, respectively. Results It was found that global reservoir strains were significantly reduced in the HFrEF + AF group patients compared with the HFrEF-only group patients (area strain: 11.2 ± 4.8% vs. 25.3 ± 12.6%, P = 0.001; fibre strain: 4.5 ± 2.0% vs. 15.2 ± 8.8%, P = 0.001), with HFrEF + AF patients having a greater regional reservoir strain dyssynchrony. All regional reservoir strains were reduced in the HFrEF + AF patient group, in whom the inferior wall strains exhibited the most significant differences. The global reservoir fibre strain and LA volume + posterior wall reservoir fibre strain exceeded LA volume alone and 2D global longitudinal strain (GLS) for AF classification (area-under-the-curve: global reservoir fibre strain: 0.94 ± 0.02, LA volume + posterior wall reservoir fibre strain: 0.95 ± 0.02, LA volume: 0.89 ± 0.03, 2D GLS: 0.90 ± 0.03). Conclusion RGCT enables 3D LA motion estimation and strain calculation that outperforms 2D strain metrics and LA enlargement for AF classification. Differences in regional LA strain could reflect regional myocardial properties such as atrial fibrosis burden.
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Affiliation(s)
- Charles Sillett
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Orod Razeghi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Haematology, University of Cambridge, Cambridge, United Kingdom
| | - Angela W. C. Lee
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jose Alonso Solis Lemus
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Caroline Roney
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- School of Engineering and Materials Science, Queen Mary University of London, London, United Kingdom
| | - Carlo Mannina
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Felicity de Vere
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Kiruthika Ananthan
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Daniel B. Ennis
- Department of Radiology, Stanford University, Stanford, CA, United States
| | | | - Hao Xu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Alistair Young
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Ronak Rajani
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Turing Research and Innovation Cluster: Digital Twins, The Alan Turing Institute, London, United Kingdom
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18
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Kreidieh O, Hunter TD, Goyal S, Varley AL, Thorne C, Osorio J, Silverstein J, Varosy P, Metzl M, Leyton-Mange J, Singh D, Rajendra A, Moretta A, Zei PC. Predictors of first pass isolation of the pulmonary veins in real world ablations: An analysis of 2671 patients from the REAL-AF registry. J Cardiovasc Electrophysiol 2024; 35:440-450. [PMID: 38282445 DOI: 10.1111/jce.16190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION During atrial fibrillation ablation (AFA), achievement of first pass isolation (FPI) reflects effective lesion formation and predicts long-term freedom from arrhythmia recurrence. We aim to determine the clinical and procedural predictors of pulmonary vein FPI. METHODS We reviewed AFA procedures in a multicenter prospective registry of AFA (REAL-AF). A multivariate ordinal logistic regression, weighted by inverse proceduralist volume, was used to determine predictors of FPI. RESULTS A total of 2671 patients were included with 1806 achieving FPI in both vein sides, 702 achieving FPI in one, and 163 having no FPI. Individually, age, left atrial (LA) scar, higher power usage (50 W), greater posterior contact force, ablation index >350 posteriorly, Vizigo™ sheath utilization, nonstandard ventilation, and high operator volume (>6 monthly cases) were all related to improved odds of FPI. Conversely sleep apnea, elevated body mass index (BMI), diabetes mellitus, LA enlargement, antiarrhythmic drug use, and center's higher fluoroscopy use were related to reduced odds of FPI. Multivariate analysis showed that BMI > 30 (OR 0.78 [0.64-0.96]) and LA volume (OR per mL increase = 1.00 [0.99-1.00]) predicted lower odds of achieving FPI, whereas significant left atrial scarring (>20%) was related to higher rates of FPI. Procedurally, the use of high power (50 W) (OR 1.32 [1.05-1.65]), increasing force posteriorly (OR 2.03 [1.19-3.46]), and nonstandard ventilation (OR 1.26 [1.00-1.59]) predicted higher FPI rates. At a site level, high procedural volume (OR 1.89 [1.48-2.41]) and low fluoroscopy centers (OR 0.72 [0.61-0.84]) had higher rates of FPI. CONCLUSION FPI rates are affected by operator experience, patient comorbidities, and procedural strategies. These factors may be postulated to impact acute lesion formation.
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Affiliation(s)
- Omar Kreidieh
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tina D Hunter
- CTI Clinical Trial and Consulting, Covington, Kentucky, USA
| | | | - Allyson L Varley
- Heart Rhythm Clinical Research Solutions, Birmingham, Alabama, USA
| | | | - Jose Osorio
- Heart Rhythm Clinical Research Solutions, Birmingham, Alabama, USA
- Arrhythmia Institute at Grandview, Birmingham, Alabama, USA
| | | | - Paul Varosy
- Medicine-Cardiology, University of Colorado, Denver, Aurora, Colorado, USA
| | - Mark Metzl
- NorthShore University Health System, Bannockburn, Illinois, USA
| | | | - David Singh
- John A Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Anil Rajendra
- Arrhythmia Institute at Grandview, Birmingham, Alabama, USA
| | | | - Paul C Zei
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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19
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Gianni C, Al-Ahmad A. Pulmonary vein reconnection after pulsed field ablation: not a second time. J Interv Card Electrophysiol 2024; 67:231-232. [PMID: 37906314 DOI: 10.1007/s10840-023-01682-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/02/2023]
Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 IH N35 Suite 720, Austin, TX, 78705, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 IH N35 Suite 720, Austin, TX, 78705, USA.
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20
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Gu W, Liu W, Li J, Shen J, Liu R, Liang W, Luo X, Xiong N. Acute epicardial pulmonary vein reconnection: Nondurable transmural lesion or late manifestation of conduction through intercaval bundle. J Cardiovasc Electrophysiol 2024; 35:422-432. [PMID: 38205929 DOI: 10.1111/jce.16182] [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: 10/03/2023] [Revised: 12/20/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Acute pulmonary vein reconnection (PVR) via epicardial fibers can be found during observation period after PV isolation, the characteristics and related factors have not been fully studied. We aimed to investigate the prevalence, locations, electrogram characteristics, and ablation parameters related to acute epicardial pulmonary vein reconnection (AEPVR). METHODS Acute PVR was monitored during observation period after PV isolation. AEPVRs were mapped and distinguished from endocardial conduction gaps. The clinical, electrophysiological characteristics and lesion set parameters were compared between patients with and without PVR. They were also compared among AEPVR, gap-related reconnection, and epicardial PVR in repeat procedures. RESULTS A total of 56.1% acute PVR were AEPVR, which required a longer waiting period (p < .001) than endocardial gap. The majority of AEPVR were connections from the posterior PV carina to the left atrial posterior wall, followed by late manifestation of intercaval bundle conduction from the right anterior carina to right atrium. AEPVR was similar to epicardial PVR in redo procedures in distribution and electrogram characteristics. Smaller atrium (p < .001), lower impedance drop (p = .039), and ablation index (p = .028) on the posterior wall were independently associated with presence of AEPVR, while lower interlesion distance (p = .043) was the only predictor for AEPVR in acute PVR. An integrated model containing multiple lesion set parameters had the highest predictive ability for AEPVR in receiver operating characteristics analysis. CONCLUSIONS Epicardial reconduction accounted for the majority of acute PVR. AEPVR was associated with anatomic characteristics and multiple ablation-related parameters, which could be explained by nondurable transmural lesion or late manifestation of conduction through intercaval bundle.
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Affiliation(s)
- Wentao Gu
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weizhuo Liu
- Centre for Cardiopulmonary Translational Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
- Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jian Li
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Shen
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Rongchen Liu
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Weiguo Liang
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xinping Luo
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Nanqing Xiong
- Department of Cardiology, Huashan Hospital, Fudan University, Shanghai, China
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21
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Batko J, Jakiel R, Krawczyk-Ożóg A, Litwinowicz R, Hołda J, Bartuś S, Bartuś K, Hołda MK, Konieczyńska M. Definition and anatomical description of the left atrial appendage neck. Clin Anat 2024; 37:201-209. [PMID: 38031393 DOI: 10.1002/ca.24125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 11/05/2023] [Accepted: 11/12/2023] [Indexed: 12/01/2023]
Abstract
The left atrial appendage (LAA) is well known as a source of cardiac thrombus formation. Despite its clinical importance, the LAA neck is still anatomically poorly defined. Therefore, this study aimed to define the LAA neck and determine its morphometric characteristics. We performed three-dimensional reconstructions of the heart chambers based on contrast-enhanced electrocardiography-gated computed tomography scans of 200 patients (47% females, 66.5 ± 13.6 years old). The LAA neck was defined as a truncated cone-shaped canal bounded proximally by the LAA orifice and distally by the lobe origin and was present in 98.0% of cases. The central axis of the LAA neck was 14.7 ± 2.3 mm. The mean area of the LAA neck walls was 856.6 ± 316.7 mm2 . The LAA neck can be divided into aortic, arterial (the smallest), venous (the largest), and free surfaces. All areas have a trapezoidal shape with a broader proximal base. There were no statistically significant differences in the morphometric characteristics of the LAA neck between LAA types. Statistically significant differences between the sexes in the main morphometric parameters of the LAA neck were found in the central axis length and the LAA neck wall area. The LAA neck can be evaluated from computed tomography scans and their three-dimensional reconstructions. The current study provides a complex morphometric analysis of the LAA neck. The precise definition and morphometric details of the LAA neck presented in this study may influence the effectiveness and safety of LAA exclusion procedures.
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Affiliation(s)
- Jakub Batko
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
- CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Rafał Jakiel
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Agata Krawczyk-Ożóg
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
- Department of Cardiology and Cardiovascular Interventions, University Hospital in Cracow, Krakow, Poland
| | - Radosław Litwinowicz
- CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Jakub Hołda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital in Cracow, Krakow, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz K Hołda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
- Department of Diagnostic Medicine, John Paul II Hospital in Kraków, Krakow, Poland
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Małgorzata Konieczyńska
- Department of Diagnostic Medicine, John Paul II Hospital in Kraków, Krakow, Poland
- Department of Thromboembolic Diseases, Jagiellonian University Medical College, Cracow, Poland
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22
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Chen WT, Chung FP, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Lin CY, Chang TY, Kuo L, Wu CI, Liu CM, Liu SH, Hsieh YC, Li CH, Chen SA. Lower contact force predicts right pulmonary vein carina breakthrough after ablation index-guided pulmonary vein isolation using high-power short-duration. J Cardiovasc Electrophysiol 2024; 35:60-68. [PMID: 37888200 DOI: 10.1111/jce.16119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/30/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Carina breakthrough (CB) at the right pulmonary vein (RPV) can occur after circumferential pulmonary vein isolation (PVI) due to epicardial bridging or transient tissue edema. High-power short-duration (HPSD) ablation may increase the incidence of RPV CB. Currently, the surrogate of ablation parameters to predict RPV CB is not well established. This study investigated predictors of RPV CB in patients undergoing ablation index (AI)-guided PVI with HPSD. METHODS The study included 62 patients with symptomatic atrial fibrillation (AF) who underwent AI-guided PVI using HPSD. Patients were categorized into two groups based on the presence or absence of RPV CB. Lesions adjacent to the RPV carina were assessed, and CB was confirmed through residual voltage, low voltage along the ablation lesions, and activation wavefront propagation. RESULTS Out of the 62 patients, 21 (33.87%) experienced RPV CB (Group 1), while 41 (66.13%) achieved first-pass RPV isolation (Group 2). Despite similar AI and HPSD, patients with RPV CB had lower contact force (CF) at lesions adjacent to the RPV carina. Receiver operating characteristic (ROC) curve analysis identified CF < 10.5 g as a predictor of RPV CB, with 75.7% sensitivity and 56.2% specificity (area under the curve: 0.714). CONCLUSION In patients undergoing AI-guided PVI with HPSD, lower CF adjacent to the carina was associated with a higher risk of RPV CB. These findings suggest that maintaining higher CF during ablation in this region may reduce the occurrence of RPV CB.
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Affiliation(s)
- Wei-Tso Chen
- Department of Medicine, Division of Cardiology, Hualien Tzu Chi, Hospital, Hualien, Taiwan
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Shih-Lin Chang
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Li-Wei Lo
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Yu-Feng Hu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Tze-Fan Chao
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Jo-Nan Liao
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Chin-Yu Lin
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Ting-Yung Chang
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Ling Kuo
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Cheng-I Wu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Shin-Huei Liu
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming Chiao-Tung University School of Medicine, Taipei, Taiwan
| | - Yu-Cheng Hsieh
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Taichung Veterans General Hospital, Cardiovascular Center, Taichung, Taiwan
| | - Cheng-Hung Li
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Taichung Veterans General Hospital, Cardiovascular Center, Taichung, Taiwan
| | - Shih-Ann Chen
- Department of Medicine, Division of Cardiology, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Taichung Veterans General Hospital, Cardiovascular Center, Taichung, Taiwan
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23
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Segan L, Chieng D, Prabhu S, Hunt A, Watts T, Klys B, Voskoboinik A, Sugumar H, Ling LH, Lee G, Morton J, Pathak RK, Chandh Raja D, Sterns L, Ginks M, Sanders P, Kalman JM, Kistler PM. Posterior Wall Isolation Improves Outcomes for Persistent AF With Rapid Posterior Wall Activity: CAPLA Substudy. JACC Clin Electrophysiol 2023; 9:2536-2546. [PMID: 37702654 DOI: 10.1016/j.jacep.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Pulmonary vein isolation (PVI) is less effective in persistent atrial fibrillation (PerAF) than in paroxysmal atrial fibrillation (AF). However, the CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA randomized clinical trial) of PVI vs posterior wall isolation (PWI) did not support empiric PWI in PerAF. We examined pulmonary vein (PV) and posterior wall (PW) electrical characteristics to determine if select patients may benefit from additional PWI. OBJECTIVES This study sought to determine the impact of PV and PW electrical characteristics on AF ablation outcomes in the CAPLA randomized study. METHODS Participants in spontaneous AF at the time of ablation were included from the CAPLA study. The mean, shortest, and longest PV, PW, and left atrial (LA) appendage cycle length measurements were annotated preablation using a multipolar catheter for 100 consecutive cycles. Next, cardioversion was performed with a high-density LA voltage map completed. Cox proportional hazards regression was utilized to determine clinical and electroanatomic predictors of AF recurrence overall and according to ablation strategy. Follow-up included twice daily single-lead electrocardiograms or continuous monitoring for 12 months. RESULTS A total of 151 patients (27% female, age 65 ± 9 years, 18% long-standing PerAF, LA volume index 52 ± 16 mL/m2, median AF duration 5 months [IQR: 2-10 months]) were in AF on the day of procedure and were randomized to PVI alone (50%) or PVI+PWI (50%) according to the CAPLA randomized clinical trial protocol. Baseline clinical, echocardiographic, and electroanatomic parameters were comparable between groups (all P > 0.05) including PV and PW characteristics. After 12 months, freedom from AF off antiarrhythmic drug therapy was 51.7% in PVI and 49.7% in PVI+PWI (log-rank P = 0.564). Rapid PW activity was defined as less than the median of the shortest PW cycle length (140 ms) and rapid PV activity was defined as less than the median of the shortest PV cycle length (126 ms). In those with rapid PW activity, the addition of PWI was associated with greater arrhythmia-free survival (56.4%) vs PVI alone (38.6%) (HR: 0.78; 95% CI: 0.67-0.94; log-rank P = 0.030). Moreover, in those undergoing PVI only, the risk of AF recurrence was higher in those with rapid PW activity (55.3% vs 46.5% in slower PW activity; HR: 1.50, 95%CI 1.11-2.26; log-rank P = 0.036). Rapid PV activity and PV cycle length (individual PVs or average of all 4 PVs) were not associated with outcome (all P > 0.05) regardless of ablation strategy. There was no correlation between PW cycle length and posterior low voltage (r = -0.06, P = 0.496). The addition of PWI did not improve arrhythmia-free survival in subgroups with LA enlargement (LA volume index >34 mL/m2) (HR: 0.69; 95% CI: 0.39-1.25; P = 0.301), posterior low-voltage zone (HR: 1.06; 95% CI: 0.68-1.66; P = 0.807), or long-standing PerAF (HR: 1.10; 95% CI: 0.71-1.72; P = 0.669). CONCLUSIONS Rapid PW activity is associated with an increased risk of AF recurrence post-catheter ablation. The addition of PWI in this subgroup was associated with a significant improvement in freedom from AF compared with PVI alone. The presence of rapid PW activity may identify patients with PerAF likely to benefit from PWI.
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Affiliation(s)
- Louise Segan
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - David Chieng
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Sandeep Prabhu
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | | | - Troy Watts
- Royal Melbourne Hospital, Melbourne, Australia
| | - Brian Klys
- Melbourne Private Hospital, Melbourne, Australia
| | - Aleksandr Voskoboinik
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Hariharan Sugumar
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Liang-Han Ling
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Geoff Lee
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Joseph Morton
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Rajeev K Pathak
- Canberra Hospital, Canberra, Australia; Australian National University, Canberra, Australia
| | - Deep Chandh Raja
- Canberra Hospital, Canberra, Australia; Australian National University, Canberra, Australia
| | - Laurence Sterns
- Royal Jubilee Hospital, Vancouver Island, British Columbia, Canada
| | | | - Prashanthan Sanders
- Royal Adelaide Hospital, Adelaide, Australia; Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Jonathan M Kalman
- University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia
| | - Peter M Kistler
- Alfred Hospital, Melbourne, Australia; Baker Heart and Diabetes Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Australia; Melbourne Private Hospital, Melbourne, Australia.
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Sakai S, Takitsume A, Soeda T, Kawata H, Nishida T, Watanabe M. Differences in the feasibility, anatomical parameters predicting procedural difficulty, and isolation area of a left atrial posterior wall isolation using radiofrequency versus cryoballoon catheters. Pacing Clin Electrophysiol 2023; 46:1393-1402. [PMID: 37708321 DOI: 10.1111/pace.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/30/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUNDS The difficulty and outcome of the adjunctive left atrial posterior wall isolation (LAPWI) in patients with persistent atrial fibrillation (PersAF) may be affected by the ablation energy used. This study aimed to compare the completion rate, anatomical parameters predicting procedural difficulty, and the isolation area of a LAPWI between the use of radiofrequency (RFA) and cryoballoon ablation (CBA). METHODS We enrolled 95 and 93 patients with PersAF who underwent pulmonary vein isolation (PVI)+LAPWI using RFA (RF group) and CBA (CB group), respectively. Preoperative computed tomography was used to evaluate the anatomical features associated with an incomplete LAPWI. Post-ablation 3-dimensional maps were analyzed to quantify the isolation area. RESULTS The completion rate of the LAPWI was significantly higher in the RF group than the CB group without touch-up RFA (88.4% vs. 72.0%; p = .005). Predictors of incomplete LAPWI were a longer left inferior pulmonary vein (LIPV)-esophageal distance (p < .001) for RFA and a steeper angle of the LAPW (p < .001) and longer transverse LAPW diameter (p = .016) for CBA. The isolated non-PV area with RFA or CBA alone was significantly greater in the CB group than the RF group (27.5 ± 9.5 cm2 vs. 22.9 ± 6.9 cm2 ; p < .001). CONCLUSION The position of the esophagus at a distance from the LIPV was associated with an incomplete LAPWI using RFA, while a steeper angle of the LAPW and transverse enlargement of the LAPW were associated with that using CBA. The completion rate of the LAPWI was higher with RFA, but the isolation area outside of the PVs was greater with CBA.
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Affiliation(s)
- Satoshi Sakai
- Department of Cardiology, Nara Prefecture General Medical Center, Nara, Japan
| | - Akihiro Takitsume
- Department of Cardiology, Nara Prefecture General Medical Center, Nara, Japan
| | - Tsunenari Soeda
- Department of Cardiology, Nara Prefecture General Medical Center, Nara, Japan
| | - Hiroyuki Kawata
- Department of Cardiology, Nara Prefecture General Medical Center, Nara, Japan
| | - Taku Nishida
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
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Baskovski E, Altin AT, Akyurek O, Kuru B, Korkmaz K, Ersoy İ, Kozluca V, Akbulut IM, Tutar E. Electrophysiological characteristics of epicardial atrial tachycardias and endocardial breakthrough site targeting for ablation: a single center experience. J Interv Card Electrophysiol 2023; 66:1901-1910. [PMID: 36811816 DOI: 10.1007/s10840-023-01513-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Despite being increasingly observed in daily practice, epicardial atrial tachycardias (Epi AT) have not been extensively characterized. In the present study, we retrospectively characterize electrophysiological properties, electroanatomic ablation targeting, and outcomes of this ablation strategy. METHODS Patients who underwent scar-based macro-reentrant left atrial tachycardia mapping and ablation patients with at least one Epi AT, which had a complete endocardial map, were selected for the inclusion. Based on current electroanatomical knowledge, Epi ATs were classified based by utilization of following epicardial structures: Bachmann's bundle, septopulmonary bundle, vein of Marshall. Endocardial breakthrough (EB) sites were analyzed as well as entrainment parameters. EB site was targeted for initial ablation. RESULTS Among seventy-eight patients undergoing scar-based macro-reentrant left atrial tachycardia ablation, fourteen (17.8%) patients met the inclusion criteria for Epi AT and were included in the study. Sixteen Epi ATs were mapped, four utilizing Bachmann's bundle, five utilizing septopulmonary bundle, and seven utilizing vein of Marshall. Fractionated, low amplitude signals were present at EB sites. Rf terminated the tachycardia in ten patients; activation changed in five patients and in one patient atrial fibrillation ensued. During the follow-up, there were three recurrences. CONCLUSIONS Epicardial left atrial tachycardias are a distinct type of macro-reentrant tachycardias that can be characterized by activation and entrainment mapping, without need for epicardial access. Endocardial breakthrough site ablation reliably terminates these tachycardias with good long-term success.
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Affiliation(s)
- Emir Baskovski
- Cardiology Department, Ankara University, Ankara, Turkey.
| | | | - Omer Akyurek
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Busra Kuru
- Cardiology Department, Ankara University, Ankara, Turkey
| | - Kubra Korkmaz
- Cardiology Department, Ankara University, Ankara, Turkey
| | - İbrahim Ersoy
- Faculty of Medicine, Afyonkarahisar Science of Health University, Afyonkarahisar, Turkey
| | - Volkan Kozluca
- Cardiology Department, Ankara University, Ankara, Turkey
| | | | - Eralp Tutar
- Cardiology Department, Ankara University, Ankara, Turkey
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Hao D, Li H, Zhang Y, Zhang Q. MUE-CoT: multi-scale uncertainty entropy-aware co-training framework for left atrial segmentation. Phys Med Biol 2023; 68:215008. [PMID: 37567214 DOI: 10.1088/1361-6560/acef8e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/11/2023] [Indexed: 08/13/2023]
Abstract
Objective.Accurate left atrial segmentation is the basis of the recognition and clinical analysis of atrial fibrillation. Supervised learning has achieved some competitive segmentation results, but the high annotation cost often limits its performance. Semi-supervised learning is implemented from limited labeled data and a large amount of unlabeled data and shows good potential in solving practical medical problems.Approach. In this study, we proposed a collaborative training framework for multi-scale uncertain entropy perception (MUE-CoT) and achieved efficient left atrial segmentation from a small amount of labeled data. Based on the pyramid feature network, learning is implemented from unlabeled data by minimizing the pyramid prediction difference. In addition, novel loss constraints are proposed for co-training in the study. The diversity loss is defined as a soft constraint so as to accelerate the convergence and a novel multi-scale uncertainty entropy calculation method and a consistency regularization term are proposed to measure the consistency between prediction results. The quality of pseudo-labels cannot be guaranteed in the pre-training period, so a confidence-dependent empirical Gaussian function is proposed to weight the pseudo-supervised loss.Main results.The experimental results of a publicly available dataset and an in-house clinical dataset proved that our method outperformed existing semi-supervised methods. For the two datasets with a labeled ratio of 5%, the Dice similarity coefficient scores were 84.94% ± 4.31 and 81.24% ± 2.4, the HD95values were 4.63 mm ± 2.13 and 3.94 mm ± 2.72, and the Jaccard similarity coefficient scores were 74.00% ± 6.20 and 68.49% ± 3.39, respectively.Significance.The proposed model effectively addresses the challenges of limited data samples and high costs associated with manual annotation in the medical field, leading to enhanced segmentation accuracy.
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Affiliation(s)
- Dechen Hao
- School of Software, North University of China, Taiyuan Shanxi, People's Republic of China
| | - Hualing Li
- School of Software, North University of China, Taiyuan Shanxi, People's Republic of China
| | - Yonglai Zhang
- School of Software, North University of China, Taiyuan Shanxi, People's Republic of China
| | - Qi Zhang
- Department of Cardiology, The Second Hospital of Shanxi Medical University, Taiyuan Shanxi, People's Republic of China
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Mumtaz M, Jabeen S, Danial A, Chaychi MTM, Zaheer MK, Mumtaz A, Mumtaz T, Herweg B. Adjunct posterior wall isolation reduces the recurrence of atrial fibrillation in patients undergoing cryoballoon ablation: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2023; 34:2043-2052. [PMID: 37526224 DOI: 10.1111/jce.16028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/03/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Recurrence rates of atrial fibrillation (AF) remain high even after complete wide area circumferential pulmonary vein isolation (PVI). In recent years adjunct posterior wall isolation (PWI) has been performed in patients with more persistent forms of AF but the benefits remain unclear. AIM The objective of this meta-analysis was to evaluate the efficacy of adjunct posterior wall isolation in reducing recurrence rates of AF using cryoballoon ablation (CBA). METHODS We searched PubMed, Google Scholar, Clinicaltrials.gov and Cochrane CENTRAL. We included studies comparing PVI to PVI + PWI in patients with either persistent or paroxysmal AF (PAF) undergoing CBA. After data extraction and quality assessment of the studies, we assessed recurrence rates of atrial tachy-arrhythmias (AF, atrial flutter, and atrial tachycardia) as well as total ablation time and procedural adverse events. Risk ratio (RR), mean difference (MD), and 95% confidence interval (CI) were calculated using Review Manager. RESULTS Concomitant PWI exhibited a substantial reduction in the risk of AF recurrence (RR: 0.51; 95% CI: 0.42-0.63, p < .00001), as well as all atrial arrhythmias (RR: 0.58; 95% CI: 0.49-0.68, p < .00001). On subgroup analysis, in patients with only PAF, adjunct PWI resulted in significant reduction in recurrence risk of AF (RR: 0.56; 95% CI: 0.41-0.76, p = .0002) as well. There was no significant difference in adverse events between both groups (RR: 0.90; 95% CI: 0.44-1.86; p = .78), whereas total ablation time was significantly increased in PVI + PWI group (MD: 21.75; 95% CI: 11.13-32.37, p < .0001). CONCLUSION Adjunct PWI when compared to PVI alone decreases recurrence rates of atrial fibrillation after CBA of patients with persistent as well as paroxysmal atrial fibrillation.
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Affiliation(s)
- Mishal Mumtaz
- Department of medicine, Quaid-e-Azam Medical College Bahawalpur, Affiliated with University of Health Sciences Lahore, Lahore, Pakistan
| | - Sidra Jabeen
- Department of medicine, Liaquat National Hospital and Medical College, Affiliated with Jinnah Sindh Medical University Karachi, Karachi, Pakistan
| | - Ahmad Danial
- Department of medicine, Quaid-e-Azam Medical College Bahawalpur, Affiliated with University of Health Sciences Lahore, Lahore, Pakistan
| | - Muhammad Tayyab Muzaffar Chaychi
- Department of medicine, Quaid-e-Azam Medical College Bahawalpur, Affiliated with University of Health Sciences Lahore, Lahore, Pakistan
| | - Muhammad Kashan Zaheer
- Department of medicine, Liaquat National Hospital and Medical College, Affiliated with Jinnah Sindh Medical University Karachi, Karachi, Pakistan
| | - Aymen Mumtaz
- Department of medicine, CMH Lahore Medical and Dental College, Affiliated with National University of Medical Sciences, Pakistan
| | - Tayebah Mumtaz
- Department of Cardiovascular, St. Elizabeth's Medical Centre, Boston, Massachusetts, USA
| | - Bengt Herweg
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida, USA
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Gunawardene MA, Frommeyer G, Ellermann C, Jularic M, Leitz P, Hartmann J, Lange PS, Anwar O, Rath B, Wahedi R, Eckardt L, Willems S. Left Atrial Posterior Wall Isolation with Pulsed Field Ablation in Persistent Atrial Fibrillation. J Clin Med 2023; 12:6304. [PMID: 37834948 PMCID: PMC10573684 DOI: 10.3390/jcm12196304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Left atrial posterior wall isolation (LAPWI) may improve rhythm control in addition to pulmonary vein isolation (PVI) in persistent atrial fibrillation (persAF) patients undergoing catheter ablation (CA). However, LAPWI may be challenging when using thermal energy sources. OBJECTIVE This study aimed to investigate the efficacy and safety of LAPWI performed by non-thermal pulsed field ablation (PFA) in CA for persAF. METHODS Consecutive persAF patients from two German centers were prospectively enrolled. There were two study cohorts: (1) the LAPWI cohort, which included PFA-guided (re-)PVI with LAPWI for first-time and/or repeat ablation procedures; and (2) a comparative persAF cohort with a PFA PVI-only approach without LAPWI for first-time ablation within the same timeframe. Patients were followed up by routine Holter ECGs. RESULTS In total, 79 persistent AF patients were included in the study: 59/79 patients were enrolled in the LAPWI cohort, including 16/59 index (27%) and 43/59 repeat ablation procedures (73%). Sixteen patients (16/79; 21%) were in the PVI-only cohort without LAPWI. Of the patients treated with LAPWI, procedure time and fluoroscopy time was 91 ± 30 min and 15 ± 7 min, respectively. The acute PVI rate was 100% in all first-time ablation patients (32 patients (16 PVI only, 16 PVI plus LAPWI), 196/196 PVs). Of the 43 re-do patients in the LAPWI cohort, re-PVI was necessary in 33% (14/43) of patients (27 PVs; 1.9 PV per-patient); in 67% (29/43), all PVs were isolated, and antral ablation of the PV ostia was performed in 48% (14/29). LAPWI was performed successfully in all 59 (100%) patients of the LAPWI cohort. Two minor complications occurred. No esophageal lesion was detected in the LAPWI cohort (n = 33/59 (56%) patients underwent endoscopy). After 354 ± 197 days of follow-up, freedom from atrial arrhythmias was 79.3% (95-CI: 62-95%) in the complete LAPWI cohort (n = 14/59 (24%) on AAD: class Ic n = 9, class III n = 5). There was no difference regarding acute procedural and clinical outcome compared to the PVI-only cohort. CONCLUSION LAPWI guided by PFA is feasible and safe in patients undergoing CA for persAF and shows favorable outcomes. In the context of durable PVI, PFA-guided LAPWI may be an effective adjunctive treatment option.
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Affiliation(s)
- Melanie A. Gunawardene
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, 20099 Hamburg, Germany
- Semmelweis University, 1082 Budapest, Hungary
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 10178 Berlin, Germany
| | - Gerrit Frommeyer
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany; (C.E.)
| | - Christian Ellermann
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany; (C.E.)
| | - Mario Jularic
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, 20099 Hamburg, Germany
- Semmelweis University, 1082 Budapest, Hungary
| | - Patrick Leitz
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany; (C.E.)
| | - Jens Hartmann
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, 20099 Hamburg, Germany
- Semmelweis University, 1082 Budapest, Hungary
| | - Philipp Sebastian Lange
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany; (C.E.)
| | - Omar Anwar
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, 20099 Hamburg, Germany
- Semmelweis University, 1082 Budapest, Hungary
| | - Benjamin Rath
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany; (C.E.)
| | - Rahin Wahedi
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, 20099 Hamburg, Germany
- Semmelweis University, 1082 Budapest, Hungary
| | - Lars Eckardt
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany; (C.E.)
| | - Stephan Willems
- Department of Cardiology and Intensive Care Medicine, Asklepios Hospital St. Georg, 20099 Hamburg, Germany
- Semmelweis University, 1082 Budapest, Hungary
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 10178 Berlin, Germany
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Teixeira-Fonseca JL, Joviano-Santos JV, Machado FS, da Silva PL, Conceição MRL, Roman-Campos D. Isolated Left Atrium Morphofunctional Study of an Experimental Pulmonary Hypertension Model in Rats. Arq Bras Cardiol 2023; 120:e20230188. [PMID: 37878960 PMCID: PMC10548886 DOI: 10.36660/abc.20230188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/27/2023] [Accepted: 08/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The high incidence of atrial arrhythmias in pulmonary hypertension (PH) might be associated with poor prognosis, and the left atrium (LA) may play a role in this. An important finding in PH studies is that LA remodeling is underestimated. OBJECTIVE This study investigated LA morphology and mechanical function, as well as the susceptibility to develop arrhythmias in a monocrotaline-induced PH (MCT-PH) model. METHODS Wistar rats aged 4 weeks received 50 mg/kg of MCT. Electrocardiography and histology analysis were performed to evaluate the establishment of the MCT-PH model. The tissue was mounted in an isolated organ bath to characterize the LA mechanical function. RESULTS Compared with the control group (CTRL), the MCT-PH model presented LA hypertrophy and changes in cardiac electrical activity, as evidenced by increased P wave duration, PR and QT interval in MCT-PH rats. In LA isolated from MCT-PH rats, no alteration in inotropism was observed; however, the time to peak contraction was delayed in the experimental MCT-PH group. Finally, there was no difference in arrhythmia susceptibility of LA from MCT-PH animals after the burst pacing protocol. CONCLUSION The morphofunctional remodeling of the LA did not lead to increased susceptibility to ex vivo arrhythmia after application of the burst pacing protocol.
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Affiliation(s)
| | - Julliane Vasconcelos Joviano-Santos
- Faculdade de Ciências Médicas de Minas GeraisBelo HorizonteMGBrasil Faculdade de Ciências Médicas de Minas Gerais , Belo Horizonte , MG – Brasil
| | - Fabiana Silva Machado
- Universidade Federal de São PauloSão PauloSPBrasil Universidade Federal de São Paulo , São Paulo , SP – Brasil
| | - Polyana Leal da Silva
- Universidade Federal de São PauloSão PauloSPBrasil Universidade Federal de São Paulo , São Paulo , SP – Brasil
| | | | - Danilo Roman-Campos
- Universidade Federal de São PauloSão PauloSPBrasil Universidade Federal de São Paulo , São Paulo , SP – Brasil
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Moore BM, Al-Kaisy A, Joshi SB, Lui E, Grigg LE, Kalman JM. Noninvasive ECG imaging of the intrinsic atrial pacemaker and atrial activation in surgically repaired or palliated congenital heart disease. J Cardiovasc Electrophysiol 2023; 34:1859-1868. [PMID: 37526234 DOI: 10.1111/jce.16027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Sinus node location, function, and atrial activation are often abnormal in patients with congenital heart disease (CHD), due to anatomical, surgical, and acquired factors. We aimed to perform noninvasive electrocardiographic imaging (ECGI) of the intrinsic atrial pacemaker and atrial activation in patients with surgically repaired or palliated CHD, compared with control patients with structurally normal hearts. METHODS AND RESULTS Atrial ECGI was performed in eight CHD patients with prespecified diagnoses (Fontan circulation, dextro transposition of the great arteries post Mustard/Senning, tetralogy of Fallot), and three controls. Activation and propagation maps were constructed in presenting rhythm. Wavefront propagation was analyzed to identify (1) intrinsic atrial pacemaker breakout site, (2) morphological right atrial (RA) activation pattern, (3) morphological left atrial (LA) breakout sites (i.e., interatrial connections), (4) LA activation pattern, and (5) putative lines of block. Physiologically appropriate atrial activation and propagation maps were able to be constructed. In the majority of patients, atrial breakouts were in keeping with the sinus node, observed in a crescent-shaped distribution from the anterior superior vena cava to the posterior RA. Ectopic atrial pacemaker sites were demonstrated in the atriopulmonary (AP) Fontan patient (very diffuse posterolateral RA) and Mustard patient (very posterior RA competing with a low RA focus). RA propagation was laminar in controls, but suggested either a line of block or conduction slowing consistent with an atriotomy scar in the tetralogy of Fallot (TOF) patients. Putative lines of block were more complex and RA propagation more abnormal in the atrial switch and AP Fontan patients, compared with the TOF patients. RA activation in the extracardiac Fontan patients was relatively laminar. Earliest LA breakout was most commonly observed in the region of Bachmann's Bundle in both controls and CHD patients, except for posterior LA breakouts in two patients. LA activation was typically more homogeneous than RA activation in CHD patients. CONCLUSION ECGI can be utilized to create a noninvasive mapping model of atrial activation in postsurgical CHD, demonstrating atrial pacemaker location, putative lines of block and interatrial connections. Once validated invasively, this may have clinical implications in predicting risk of sinus node dysfunction and atrial arrhythmias, or in guiding catheter ablation.
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Affiliation(s)
- Benjamin M Moore
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ahmed Al-Kaisy
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Subodh B Joshi
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Elaine Lui
- Department of Medical Imaging, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Radiology, University of Melbourne, Melbourne, Victoria, Australia
| | - Leanne E Grigg
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Lee SR, Park HS, Kwon S, Choi EK, Oh S. Tailored ablation index based on left atrial wall thickness assessed by computed tomography for pulmonary vein isolation in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:1811-1819. [PMID: 37595097 DOI: 10.1111/jce.16026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Although left atrial wall thickness (LAWT) is known to be varied, a fixed target Ablation Index (AI) based pulmonary vein isolation (PVI) has been suggested in catheter ablation for atrial fibrillation (AF). We aimed to evaluate the efficacy and safety of PVI applying tailored AI based on LAWT assessed by cardiac computed tomography (CT). METHODS The thick segment was defined as the segment including ≥LAWT grade 3 (≥1.5 mm). The fixed AI strategy was defined as AI targets were 450 on the anterior/roof segments and 350 on the posterior/inferior/carina segments regardless of LAWT. The tailored AI strategy consisted of AI increasing the targets to 500 on the anterior/roof segments and to 400 on the posterior/inferior/carina segments when ablating the thick segment. After PVI, acute pulmonary vein (PV) reconnection, defined by the composite of residual potential and early reconnection, was evaluated. RESULTS A total of 156 patients (paroxysmal AF 72%) were consecutively included (86 for the fixed AI group and 70 for the tailored AI group). The tailored AI group showed a significantly lower rate of segments with acute PV reconnection than the fixed AI group (8% vs. 5%, p = .007). The tailored AI group showed a trend for shorter ablation time for PVI. One-year AF/atrial tachycardia free survival rate was similar in two groups (87.2% in the fixed AI group and 90.0% in the tailored AI group, p = .606). CONCLUSION Applying tailored AI based on the LAWT was a feasible and effective strategy to reduce acute PV reconnection after PVI.
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Affiliation(s)
- So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyoung-Seob Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Internal Medicine, Division of Cardiology, Dongsan Medical Center, Keimyung University, Daegu, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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32
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Durán E, García-Villalba M, Martínez-Legazpi P, Gonzalo A, McVeigh E, Kahn AM, Bermejo J, Flores O, Del Álamo JC. Pulmonary vein flow split effects in patient-specific simulations of left atrial flow. Comput Biol Med 2023; 163:107128. [PMID: 37352639 PMCID: PMC10529707 DOI: 10.1016/j.compbiomed.2023.107128] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/10/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023]
Abstract
Disruptions to left atrial (LA) blood flow, such as those caused by atrial fibrillation (AF), can lead to thrombosis in the left atrial appendage (LAA) and an increased risk of systemic embolism. LA hemodynamics are influenced by various factors, including LA anatomy and function, and pulmonary vein (PV) inflow conditions. In particular, the PV flow split can vary significantly among and within patients depending on multiple factors. In this study, we investigated how changes in PV flow split affect LA flow transport, focusing for the first time on blood stasis in the LAA, using a high-fidelity patient-specific computational fluid dynamics (CFD) model. We use an Immersed Boundary Method, simulating the flow in a fixed, uniform Cartesian mesh and imposing the movement of the LA walls with a moving Lagrangian mesh generated from 4D Computerized Tomography images. We analyzed LA anatomies from eight patients with varying atrial function, including three with AF and either a LAA thrombus or a history of Transient Ischemic Attacks (TIAs). Using four different flow splits (60/40% and 55/45% through right and left PVs, even flow rate, and same velocity through each PV), we found that flow patterns are sensitive to PV flow split variations, particularly in planes parallel to the mitral valve. Changes in PV flow split also had a significant impact on blood stasis and could contribute to increased risk for thrombosis inside the LAA, particularly in patients with AF and previous LAA thrombus or a history of TIAs. Our study highlights the importance of considering patient-specific PV flow split variations when assessing LA hemodynamics and identifying patients at increased risk for thrombosis and stroke. This knowledge is relevant to planning clinical procedures such as AF ablation or the implementation of LAA occluders.
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Affiliation(s)
- Eduardo Durán
- Department of Mechanical, Thermal and Fluids Engineering, Universidad de Málaga, Málaga, Spain; Department of Aerospace Engineering, University Carlos III of Madrid, Leganés, Spain.
| | | | - Pablo Martínez-Legazpi
- Department of Mathematical Physics and Fluids, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Alejandro Gonzalo
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States
| | - Elliot McVeigh
- Department of Bioengineering, University of California San Diego, La Jolla, CA, United States; Department of Radiology, University of California San Diego, La Jolla, CA, United States
| | - Andrew M Kahn
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, United States
| | - Javier Bermejo
- Gregorio Marañón University Hospital, Madrid, Spain; Spanish Cardiovascular Network (CIBERCV), Carlos III Health Institute, Madrid, Spain; Faculty of Medicine, Complutense University, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
| | - Oscar Flores
- Department of Aerospace Engineering, University Carlos III of Madrid, Leganés, Spain
| | - Juan Carlos Del Álamo
- Department of Mechanical Engineering, University of Washington, Seattle, WA, United States; Center for Cardiovascular Biology, University of Washington, Seattle, WA, United States; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, United States
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Nairn D, Eichenlaub M, Müller-Edenborn B, Huang T, Lehrmann H, Nagel C, Azzolin L, Luongo G, Figueras Ventura RM, Rubio Forcada B, Vallès Colomer A, Westermann D, Arentz T, Dössel O, Loewe A, Jadidi A. Differences in atrial substrate localization using late gadolinium enhancement-magnetic resonance imaging, electrogram voltage, and conduction velocity: a cohort study using a consistent anatomical reference frame in patients with persistent atrial fibrillation. Europace 2023; 25:euad278. [PMID: 37713626 PMCID: PMC10533207 DOI: 10.1093/europace/euad278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/10/2023] [Indexed: 09/17/2023] Open
Abstract
AIMS Electro-anatomical voltage, conduction velocity (CV) mapping, and late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) have been correlated with atrial cardiomyopathy (ACM). However, the comparability between these modalities remains unclear. This study aims to (i) compare pathological substrate extent and location between current modalities, (ii) establish spatial histograms in a cohort, (iii) develop a new estimated optimized image intensity threshold (EOIIT) for LGE-MRI identifying patients with ACM, (iv) predict rhythm outcome after pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF). METHODS AND RESULTS Thirty-six ablation-naive persistent AF patients underwent LGE-MRI and high-definition electro-anatomical mapping in sinus rhythm. Late gadolinium enhancement areas were classified using the UTAH, image intensity ratio (IIR >1.20), and new EOIIT method for comparison to low-voltage substrate (LVS) and slow conduction areas <0.2 m/s. Receiver operating characteristic analysis was used to determine LGE thresholds optimally matching LVS. Atrial cardiomyopathy was defined as LVS extent ≥5% of the left atrium (LA) surface at <0.5 mV. The degree and distribution of detected pathological substrate (percentage of individual LA surface are) varied significantly (P < 0.001) across the mapping modalities: 10% (interquartile range 0-14%) of the LA displayed LVS <0.5 mV vs. 7% (0-12%) slow conduction areas <0.2 m/s vs. 15% (8-23%) LGE with the UTAH method vs. 13% (2-23%) using IIR >1.20, with most discrepancies on the posterior LA. Optimized image intensity thresholds and each patient's mean blood pool intensity correlated linearly (R2 = 0.89, P < 0.001). Concordance between LGE-MRI-based and LVS-based ACM diagnosis improved with the novel EOIIT applied at the anterior LA [83% sensitivity, 79% specificity, area under the curve (AUC): 0.89] in comparison to the UTAH method (67% sensitivity, 75% specificity, AUC: 0.81) and IIR >1.20 (75% sensitivity, 62% specificity, AUC: 0.67). CONCLUSION Discordances in detected pathological substrate exist between LVS, CV, and LGE-MRI in the LA, irrespective of the LGE detection method. The new EOIIT method improves concordance of LGE-MRI-based ACM diagnosis with LVS in ablation-naive AF patients but discrepancy remains particularly on the posterior wall. All methods may enable the prediction of rhythm outcomes after PVI in patients with persistent AF.
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Affiliation(s)
- Deborah Nairn
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Martin Eichenlaub
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Björn Müller-Edenborn
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Taiyuan Huang
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heiko Lehrmann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Nagel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Luca Azzolin
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Giorgio Luongo
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | | | | | | | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Arentz
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | - Amir Jadidi
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Arrhythmia Division, Department of Cardiology, Heart Center Lucerne, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Hashimoto K, Kimura T, Seki Y, Ibe S, Yamashita T, Miyama H, Fujisawa T, Katsumata Y, Fukuda K, Takatsuki S. Delineation of conduction gaps of linear lesions during atrial fibrillation ablation using ultra-high-density mapping. Europace 2023; 25:euad188. [PMID: 37395219 PMCID: PMC10350393 DOI: 10.1093/europace/euad188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
AIMS Linear lesions are routinely created by radiofrequency catheter ablation. Unwanted electrical conduction gaps can be produced and are often difficult to ablate. This study aimed to clarify the characteristics of conduction gaps during atrial fibrillation ablation by analysing bidirectional activation maps using a high-density mapping system (RHYTHMIA). METHODS AND RESULTS This retrospective study included 31 patients who had conduction gaps along pulmonary vein (PV) isolation or box ablation lesions. Activation maps were sequentially created during pacing from the coronary sinus and PV to reveal the earliest activation site, defined by the entrance and exit. The locations, length between the entrance and exit (gap length), and direction were analysed. Thirty-four bidirectional activation maps were drawn: 21 were box isolation lesions (box group), and 13 were PV isolation lesions (PVI group). Among the box group, nine conduction gaps were present in the roof region and 12 in the bottom region, while nine in right PV and four in left PV among the PVI group. Gap lengths in the roof region were longer than those in the bottom region (26.8 ± 11.8 vs. 14.5 ± 9.8 mm; P = 0.022), while those in right PV tended to longer than those in left PV (28.0 ± 15.3 vs. 16.8 ± 8.0 mm, P = 0.201). CONCLUSION The entrances and exits of electrical conduction gaps were separated, especially in the roof region, indicating that epicardial conduction might contribute to gap formation. Identifying the bidirectional conduction gap might indicate the location and direction of epicardial conduction.
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Affiliation(s)
- Kenji Hashimoto
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Takehiro Kimura
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yuta Seki
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Susumu Ibe
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Terumasa Yamashita
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Hiroshi Miyama
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Taishi Fujisawa
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yoshinori Katsumata
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
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Sousa PA, Barra S, Saleiro C, Khoueiry Z, Adão L, Primo J, Lagrange P, Lebreiro A, Fonseca P, Pereira M, Puga L, Oliveiros B, Elvas L, Gonçalves L. Ostial vs. wide area circumferential ablation guided by the Ablation Index in paroxysmal atrial fibrillation. Europace 2023; 25:euad160. [PMID: 37345859 PMCID: PMC10286571 DOI: 10.1093/europace/euad160] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023] Open
Abstract
AIMS Pulmonary vein isolation (PVI) guided by the Ablation Index (AI) has shown high acute and mid-term efficacy in the treatment of paroxysmal atrial fibrillation (AF). Previous data before the AI-era had suggested that wide-area circumferential ablation (WACA) was preferable to ostial ablation. However, with the use of AI, we hypothesize that ostial circumferential ablation is non-inferior to WACA and can improve outcomes in paroxysmal AF. METHODS AND RESULTS Prospective, multicentre, non-randomized, non-inferiority study of consecutive patients were referred for paroxysmal AF ablation from January 2020 to September 2021. All procedures were performed using the AI software, and patients were separated into two different groups: WACA vs. ostial circumferential ablation. Acute reconnection, procedural data, and 1-year arrhythmia recurrence were assessed. During the enrolment period, 162 patients (64% males, mean age of 60 ± 11 years) fulfilled the study inclusion criteria-81 patients [304 pulmonary vein (PV)] in the WACA group and 81 patients (301 PV) in the ostial group. Acute PV reconnection was identified in 7.9% [95% confidence interval (CI), 4.9-11.1%] of PVs in the WACA group compared with 3.3% (95% CI, 1.8-6.1%) of PVs in the ostial group [P < 0.001 for non-inferiority; adjusted odds ratio 0.51 (95% CI, 0.23-0.83), P = 0.05]. Patients in the WACA group had longer ablation (35 vs. 29 min, P = 0.001) and procedure (121 vs. 102 min, P < 0.001) times. No significant difference in arrhythmia recurrence was seen at 1-year of follow-up [11.1% in WACA vs. 9.9% in ostial, hazard ratio 1.13 (95% CI, 0.44-1.94), P = 0.80 for superiority]. CONCLUSION In paroxysmal AF patients treated with tailored AI-guided PVI, ostial circumferential ablation is not inferior to WACA with regard to acute PV reconnection, while allowing quicker procedures with less ablation time.
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Affiliation(s)
- Pedro A Sousa
- Pacing and Electrophysiology Unit, Department of Cardiology, Coimbra’s Hospital and University Center, Morada: Praceta Prof Mota Pinto, Coimbra 3000-075, Portugal
| | - Sérgio Barra
- Department of Cardiology, Hospital da Luz Arrábida, V. N. Gaia, Portugal
| | - Carolina Saleiro
- Pacing and Electrophysiology Unit, Department of Cardiology, Coimbra’s Hospital and University Center, Morada: Praceta Prof Mota Pinto, Coimbra 3000-075, Portugal
| | - Ziad Khoueiry
- Department of Cardiology, Clinique Saint Pierre, Perpignan, France
| | - Luís Adão
- Department of Cardiology, University Hospital Center of São João, Porto, Portugal
| | - João Primo
- Department of Cardiology, Vila Nova de Gaia and Espinho Hospital Center, V. N. Gaia, Portugal
| | | | - Ana Lebreiro
- Department of Cardiology, University Hospital Center of São João, Porto, Portugal
| | - Paulo Fonseca
- Department of Cardiology, Vila Nova de Gaia and Espinho Hospital Center, V. N. Gaia, Portugal
| | | | - Luís Puga
- Pacing and Electrophysiology Unit, Department of Cardiology, Coimbra’s Hospital and University Center, Morada: Praceta Prof Mota Pinto, Coimbra 3000-075, Portugal
| | | | - Luís Elvas
- Pacing and Electrophysiology Unit, Department of Cardiology, Coimbra’s Hospital and University Center, Morada: Praceta Prof Mota Pinto, Coimbra 3000-075, Portugal
| | - Lino Gonçalves
- Pacing and Electrophysiology Unit, Department of Cardiology, Coimbra’s Hospital and University Center, Morada: Praceta Prof Mota Pinto, Coimbra 3000-075, Portugal
- ICBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Nestelberger T, Alfadhel M, McAlister C, Saw J. Follow Up imaging After Left Atrial Appendage Occlusion-Something or Nothing and for How Long? Card Electrophysiol Clin 2023; 15:157-168. [PMID: 37076228 DOI: 10.1016/j.ccep.2023.01.004] [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: 04/21/2023]
Abstract
Routine postprocedural imaging with transesophageal echocardiography or cardiac computed tomography angiography is the most commonly used imaging modality for follow-up surveillance usually performed 1 to 6 months after the procedure. Imaging enables recognition of well-suited and sealed devices in the left atrial appendage as well as of potential harmful complications such as peri-device leaks, device-related thrombus, and device embolization, which may lead to further surveillance observation with recurrent imaging, reinitiation of oral anticoagulants, or additional interventional procedures.
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Affiliation(s)
- Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Vancouver General Hospital, Basel, British Columbia, Canada; University of British Columbia, 2775 Laurel Street, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada.
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37
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Arguelles E, Mihalatos D, Leung A, Colangelo RG, Jayam V, Fujikura K. Congenital Absence of the Left Atrial Appendage: Role of Multimodality Imaging. CASE (PHILADELPHIA, PA.) 2023; 7:220-225. [PMID: 37396472 PMCID: PMC10307590 DOI: 10.1016/j.case.2023.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Congenital abLAA is extremely rare. AbLAA can occasionally present with other coexisting cardiac anomalies. Knowledge of abLAA is necessary to fully exclude thrombus prior to cardioversion. Inability to visualize LAA despite careful searching should raise suspicion for abLAA. CCT is an excellent noninvasive imaging tool to visualize the LAA.
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Affiliation(s)
| | | | | | | | | | - Kana Fujikura
- Correspondence: Kana Fujikura, MD, PhD, Division of Cardiovascular Imaging, St. Francis Hospital & Heart Center, 100 Port Washington Boulevard, Roslyn, NY 11576.
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Vila M, Rivolta MW, Barrios Espinosa CA, Unger LA, Luik A, Loewe A, Sassi R. Recommender system for ablation lines to treat complex atrial tachycardia. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 231:107406. [PMID: 36787660 DOI: 10.1016/j.cmpb.2023.107406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Planning the optimal ablation strategy for the treatment of complex atrial tachycardia (CAT) is a time consuming task and is error-prone. Recently, directed network mapping, a technology based on graph theory, proved to efficiently identify CAT based solely on data of clinical interventions. Briefly, a directed network was used to model the atrial electrical propagation and reentrant activities were identified by looking for closed-loop paths in the network. In this study, we propose a recommender system, built as an optimization problem, able to suggest the optimal ablation strategy for the treatment of CAT. METHODS The optimization problem modeled the optimal ablation strategy as that one interrupting all reentrant mechanisms while minimizing the ablated atrial surface. The problem was designed on top of directed network mapping. Considering the exponential complexity of finding the optimal solution of the problem, we introduced a heuristic algorithm with polynomial complexity. The proposed algorithm was applied to the data of i) 6 simulated scenarios including both left and right atrial flutter; and ii) 10 subjects that underwent a clinical routine. RESULTS The recommender system suggested the optimal strategy in 4 out of 6 simulated scenarios. On clinical data, the recommended ablation lines were found satisfactory on 67% of the cases according to the clinician's opinion, while they were correctly located in 89%. The algorithm made use of only data collected during mapping and was able to process them nearly real-time. CONCLUSIONS The first recommender system for the identification of the optimal ablation lines for CAT, based solely on the data collected during the intervention, is presented. The study may open up interesting scenarios for the application of graph theory for the treatment of CAT.
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Affiliation(s)
- Muhamed Vila
- Università degli Studi di Milano, Via Celoria 18, Milan, 20133, Italy
| | - Massimo W Rivolta
- Università degli Studi di Milano, Via Celoria 18, Milan, 20133, Italy.
| | - Cristian A Barrios Espinosa
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Kaiserstr. 12, Karlsruhe, 76131, Germany
| | - Laura A Unger
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Kaiserstr. 12, Karlsruhe, 76131, Germany
| | - Armin Luik
- Medizinische Klinik IV, Städtisches Klinikum Karlsruhe, Moltkestraße 90, Karlsruhe, 76133, Germany
| | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Kaiserstr. 12, Karlsruhe, 76131, Germany
| | - Roberto Sassi
- Università degli Studi di Milano, Via Celoria 18, Milan, 20133, Italy
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Chen J, Zhang J, Debattista K, Han J. Semi-Supervised Unpaired Medical Image Segmentation Through Task-Affinity Consistency. IEEE TRANSACTIONS ON MEDICAL IMAGING 2023; 42:594-605. [PMID: 36219664 DOI: 10.1109/tmi.2022.3213372] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Deep learning-based semi-supervised learning (SSL) algorithms are promising in reducing the cost of manual annotation of clinicians by using unlabelled data, when developing medical image segmentation tools. However, to date, most existing semi-supervised learning (SSL) algorithms treat the labelled images and unlabelled images separately and ignore the explicit connection between them; this disregards essential shared information and thus hinders further performance improvements. To mine the shared information between the labelled and unlabelled images, we introduce a class-specific representation extraction approach, in which a task-affinity module is specifically designed for representation extraction. We further cast the representation into two different views of feature maps; one is focusing on low-level context, while the other concentrates on structural information. The two views of feature maps are incorporated into the task-affinity module, which then extracts the class-specific representations to aid the knowledge transfer from the labelled images to the unlabelled images. In particular, a task-affinity consistency loss between the labelled images and unlabelled images based on the multi-scale class-specific representations is formulated, leading to a significant performance improvement. Experimental results on three datasets show that our method consistently outperforms existing state-of-the-art methods. Our findings highlight the potential of consistency between class-specific knowledge for semi-supervised medical image segmentation. The code and models are to be made publicly available at https://github.com/jingkunchen/TAC.
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40
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Kuniewicz M, Budnicka K, Dusza M, Jakob N, Cholewa N, Defonseka R, Gosnell M, Wadhwa T, Walocha J, Dobrzynski H, Hołda M. Gross anatomic relationship between the human left atrial appendage and the left ventricular summit region: implications for catheter ablation of ventricular arrhythmias originating from the left ventricular summit. J Interv Card Electrophysiol 2023; 66:301-310. [PMID: 35262858 DOI: 10.1007/s10840-022-01172-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The left ventricular summit (LVS) is a source of difficult-to-treat arrhythmias because of anatomical limitations. The aim of this study was to perform detailed research of the left atrial appendage (LAA) anatomy of cadaveric hearts to analyze their complex anatomy and coverage of the LVS. METHODS AND RESULTS Eighty human formalin fixed hearts (mean age 44.4 ± 15.5, 27.5% females) were investigated. Each LAA size, type, and its relationship to the LVS were analyzed, as well as possible access sites for mapping/ablating electrode. Four types of LAA were observed over two LVS sites that are either accessible or not. The highest coverage over an inaccessible LVS area was observed in the Broccoli type, followed by the Windsock then the Chicken Wing and finally the Cactus types; over the accessible area of the LVS was observed in the Windsock, then in the Chicken Wing, then in the Cactus, and finally in the Broccoli types. The attainable coverage for electrode access is diminished from 25 to 65% because of the complex pectinate muscles and sharp angles. The highest density of the LAA floor made by pectinate muscles can be found in the Broccoli type (p < 0.005), while the Chicken Wing had the highest number of paper-thin-like pouches. CONCLUSIONS The LAA appears to be a promising entry for ablation-qualified patients with the LV summit originate arrhythmias. The complex internal structure of the LAA may complicate ablation procedures. More prominent appendages are promising in more extensive mapping areas over the LVS.
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Affiliation(s)
- M Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland. .,Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland.
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Dusza
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Cholewa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - R Defonseka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - T Wadhwa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - H Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - M Hołda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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Jin S, Lin W, Fang X, Liao H, Zhan X, Fu L, Jiang J, Ye X, Liu H, Chen Y, Pu S, Wu S, Deng H, Xue Y. High-Power, Short-Duration Ablation under the Guidance of Relatively Low Ablation Index Values for Paroxysmal Atrial Fibrillation: Long-Term Outcomes and Characteristics of Recurrent Atrial Arrhythmias. J Clin Med 2023; 12:jcm12030971. [PMID: 36769620 PMCID: PMC9917927 DOI: 10.3390/jcm12030971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the difference in effectiveness and safety of high-power, short-duration (HPSD) radiofrequency catheter ablation (RFA) guided by relatively low ablation index (AI) values and conventional RFA in paroxysmal atrial fibrillation (PAF) patients. METHODS The HPSD RFA strategy (40-50 W, AI 350-400 for anterior, 320-350 for posterior wall; n = 547) was compared with the conventional RFA strategy (25-40 W, without AI; n = 396) in PAF patients who underwent their first ablation. Propensity-score matching analyses were used to compare the outcomes of the two groups while controlling for confounders. RESULTS After using propensity-score matching analysis, the HPSD group showed a higher early recurrence rate (22.727% vs. 13.636%, p = 0.003), similar late recurrence rate, and comparable safety (p = 0.604) compared with the conventional group. For late recurrent atrial arrhythmia types, the rate of regular atrial tachycardia was significantly higher in the HPSD group (p = 0.013). Additionally, the rate of chronic pulmonary vein reconnection and non-pulmonary vein triggers during repeat procedures was similar in both groups. CONCLUSIONS For PAF patients, compared with the conventional RFA strategy, the HPSD RFA strategy at relatively low AI settings had a higher early recurrence rate, similar long-term success rate, and comparable safety.
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Affiliation(s)
- Shuyu Jin
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Weidong Lin
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xianhong Fang
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hongtao Liao
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xianzhang Zhan
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Lu Fu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Junrong Jiang
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xingdong Ye
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huiyi Liu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Yanlin Chen
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Sijia Pu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Shulin Wu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hai Deng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (H.D.); (Y.X.)
| | - Yumei Xue
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (H.D.); (Y.X.)
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High-power short-duration versus low-power long-duration ablation guided by the ablation index. Int J Cardiol 2023; 370:209-214. [PMID: 36228764 DOI: 10.1016/j.ijcard.2022.10.013] [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: 06/10/2022] [Revised: 09/21/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022]
Abstract
AIMS To compare the two different ablation strategies, both guided by the Ablation Index (AI), in the setting of atrial fibrillation (AF) ablation: high-power short-duration (HPSD) ablation using 40 W on the posterior wall and 50 W elsewhere versus low-power long-duration (LPLD) using 25 W posteriorly and 35 W elsewhere. METHODS Prospective, multicenter nonrandomized, noninferiority study of consecutive patients referred for paroxysmal AF ablation from January 2018 to July 2019. Ablation was guided by the AI (≥500 for anterior segments, ≥450 for the roof and inferior segments and 400 posteriorly) and an interlesion distance (ILD) ≤ 6 mm. Patients were separated into two groups: HPSD vs LPLD. Acute reconnection (after adenosine trial) and 2-year outcomes were assessed. RESULTS 160 patients (61% males, median age of 62 [IQR 51-69] years), fulfilled the study inclusion criteria - 80 patients (316 pulmonary veins [PV]) in the HPSD group and 80 patients (314 PV) in the LPLD. The probability of acute PV reconnection was similar between both groups: 2.2% in HPSD, 95%CI 0.6% to 3.8% vs. 3.4% in LPLD, 95%CI 1.4% to 5.4%; p < 0.001 for noninferiority. Median PV ablation time (20 min vs 30 min, p < 0.01) and procedure duration (80 min vs 100 min, p < 0.001) were shorter in the HPSD group. After a median follow-up of 26 months, arrhythmia recurrence was similar between groups (17.5% in HPSD group vs. 18.8% in LPLD group, p = 0.79). CONCLUSIONS In paroxysmal AF patients treated with the Ablation Index, a HPSD strategy is noninferior to the more standard LPLD ablation, while allowing for quicker procedures with shorter ablation times.
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Bohnen M, Weber R, Minners J, Eichenlaub M, Jadidi A, Müller-Edenborn B, Neumann FJ, Arentz T, Lehrmann H. 3D mapping of phrenic nerve course for radiofrequency pulmonary vein isolation. J Cardiovasc Electrophysiol 2023; 34:90-98. [PMID: 36217994 DOI: 10.1111/jce.15703] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Phrenic nerve (PN) injury is a rare but severe complication of radiofrequency (RF) pulmonary vein isolation (PVI). The objective of this study was to characterize the typical intracardiac course of the PN with a three-dimensional electroanatomic mapping system, to quantify the need for modification of the ablation trajectory to avoid delivering an ablation lesion on sites with PN capture, and to identify very circumscribed areas of common PNC on the routine ablation trajectory of a RF-PVI, allowing fast and effective PN screening for everyday usage. METHODS We enrolled 137 consecutive patients (63 ± 9 years, 64% men) undergoing PVI. A detailed high output (20 mA) pace-mapping protocol was performed in the right (RA) and left atrium (LA) and adjacent vasculature. RESULTS The right PN was most commonly captured in the superior vena cava at a lateral (50%) or posterolateral (23%) position before descending along the RA either straight (29%) or with a posterolateral bend (20%). In the LA, beginning deep within the right superior pulmonary vein (RSPV), the right PN is most frequently detectable anterolateral (31%), then descends to the lateral proximal RSPV (23%), and further towards the lateral antral region (15%) onto the medial LA wall (12%). To avoid delivering an ablation lesion on sites with PN capture, modification of ablation trajectory was necessary in 23% of cases, most commonly in the lateral RSPV antrum (81%). No PN injury occurred. CONCLUSION PN mapping frequently reveals the close proximity of the PN to the ablation trajectory during PVI, particularly in the lateral RSPV antrum. Routine PN pacing should be considered during RF PVI procedures.
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Affiliation(s)
- Marius Bohnen
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Reinhold Weber
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Jan Minners
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Martin Eichenlaub
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Amir Jadidi
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Björn Müller-Edenborn
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Thomas Arentz
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Heiko Lehrmann
- Cardiac Arrhythmia Service, Department of Cardiovascular Medicine II, University-Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
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Gu W, Liu W, Li J, Shen J, Pan J, Wu B, Shi H, Luo X, Xiong N. Anatomy-based characteristics of far-field SVC electrograms in right superior pulmonary veins after isolation. SCAND CARDIOVASC J 2022; 56:224-230. [PMID: 35792722 DOI: 10.1080/14017431.2022.2095015] [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] [Indexed: 10/17/2022]
Abstract
Background. Far-field electrograms from superior vena cava (SVC) can be present in right superior pulmonary vein (RSPV) after pulmonary vein (PV) isolation. Objectives. To analyze the characteristics of far-field SVC potentials in RSPV after PV isolation and the local anatomy difference between patients with and without the potentials. Methods. Patients undergoing PV isolation were retrospectively reviewed, contrast-enhanced computed tomography (CT) was performed before procedure for observing the anatomical relationship between RSPV and SVC. The prevalence and characteristics of far-field SVC electrograms were described and compared to far-field left atrial potentials at the nearest point along the linear ablation lesion. The anatomical proximity of RSPV and SVC on a 2-dimensional horizontal CT view was compared between patients with and without far-field SVC potentials. Results. Far-field SVC electrograms were observed in 35/92(38%) patients with an amplitude of 0.24 ± 0.11 mV and a major deflection slope of 0.051 ± 0.036 mV, both significantly higher than far-field left atrial electrograms (p < .001). In patients with far-field SVC electrograms, 83% had connected RSPV-SVC, defined as distance between RSPV and SVC endocardium less than 3 mm at the layer of RSPV ostium roof, while in patients without far-field SVC electrograms, 70% had disconnected RSPV-SVC. Conclusions. Far-field SVC electrograms appeared in RSPV had a prevalence higher than previously reported and a sharper major deflection compared to far-field left atrial electrograms. Connected RSPV-SVC on CT was associated with the presence of far-field SVC electrograms.
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Affiliation(s)
- Wentao Gu
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Weizhuo Liu
- Department of Critical Care Medicine, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jian Li
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Jun Shen
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Jiawei Pan
- Department of Radiology, Huashan Hospital Fudan University, Shanghai, China
| | - Bangwei Wu
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Haiming Shi
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Xinping Luo
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
| | - Nanqing Xiong
- Department of Cardiology, Huashan Hospital Fudan University, Shanghai, China
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Yang J, Song C, Ding H, Chen M, Sun J, Liu X. Numerical study of the risk of thrombosis in the left atrial appendage of chicken wing shape in atrial fibrillation. Front Cardiovasc Med 2022; 9:985674. [PMID: 36505384 PMCID: PMC9732567 DOI: 10.3389/fcvm.2022.985674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/07/2022] [Indexed: 11/26/2022] Open
Abstract
Atrial fibrillation (AF) is a common and life-threatening disease. For the patients with AF, more than 90% of the thrombi are formed in the left atrial appendage (LAA), thrombus dislodgement can cause vascular embolism, making them is becoming a high-risk group for stroke. Therefore, identifying the patients with high risk of thrombosis is crucial for advanced stroke warning. To better investigate the mechanism behind thrombus formation in the LAA, this study reconstructed the 3-D Left Atrium (LA) models of six AF volunteer patients by corresponding Computed Tomography (CT) images. Combine the advantages of Computational Fluid Dynamics (CFD), the blood flow field in LA both in AF and sinus heart rate states were studied. The risk of thrombus was evaluated based on the blood viscosity, shear rate thrombus prediction model and Time Average Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI), and Relative Residence Time (RRT) values. The results showed that the left atrium had lower blood flow velocity and TAWSS values at the LAA in both AF and sinus rhythm, thus the LAA is the most thrombogenic region in the LA. Besides, the RRT value of LAA was generally higher in AF than in sinus rhythm. Therefore, AF carries a higher risk of thrombosis.
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Affiliation(s)
- Jun Yang
- School of Energy and Power Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Chentao Song
- School of Energy and Power Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Huirong Ding
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mu Chen
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Sun
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Jian Sun,
| | - Xiaohua Liu
- School of Aeronautics and Astronautics, Shanghai Jiao Tong University, Shanghai, China,Key Laboratory (Fluid Machinery and Engineering Research Base) of Sichuan Province, Xihua University, Chengdu, China,Xiaohua Liu,
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Tore D, Faletti R, Biondo A, Carisio A, Giorgino F, Landolfi I, Rocco K, Salto S, Santonocito A, Ullo F, Anselmino M, Fonio P, Gatti M. Role of Cardiovascular Magnetic Resonance in the Management of Atrial Fibrillation: A Review. J Imaging 2022; 8:300. [PMID: 36354873 PMCID: PMC9696856 DOI: 10.3390/jimaging8110300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 08/30/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia, and its prevalence is growing with time. Since the introduction of catheter ablation procedures for the treatment of AF, cardiovascular magnetic resonance (CMR) has had an increasingly important role for the treatment of this pathology both in clinical practice and as a research tool to provide insight into the arrhythmic substrate. The most common applications of CMR for AF catheter ablation are the angiographic study of the pulmonary veins, the sizing of the left atrium (LA), and the evaluation of the left atrial appendage (LAA) for stroke risk assessment. Moreover, CMR may provide useful information about esophageal anatomical relationship to LA to prevent thermal injuries during ablation procedures. The use of late gadolinium enhancement (LGE) imaging allows to evaluate the burden of atrial fibrosis before the ablation procedure and to assess procedural induced scarring. Recently, the possibility to assess atrial function, strain, and the burden of cardiac adipose tissue with CMR has provided more elements for risk stratification and clinical decision making in the setting of catheter ablation planning of AF. The purpose of this review is to provide a comprehensive overview of the potential applications of CMR in the workup of ablation procedures for atrial fibrillation.
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Affiliation(s)
- Davide Tore
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Andrea Biondo
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Andrea Carisio
- Department of Radiology, Humanitas Gradenigo Hospital, 10126 Turin, Italy
| | - Fabio Giorgino
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Ilenia Landolfi
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Katia Rocco
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Sara Salto
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Ambra Santonocito
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Federica Ullo
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
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Han S, Liu M, Jia R, Cen Z, Guo R, Liu G, Cui K. Left atrial appendage function and structure predictors of recurrent atrial fibrillation after catheter ablation: A meta-analysis of observational studies. Front Cardiovasc Med 2022; 9:1009494. [PMCID: PMC9632352 DOI: 10.3389/fcvm.2022.1009494] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background The results of studies evaluating the left atrial appendage (LAA) function and structure as predictors of atrial fibrillation (AF) recurrence after catheter ablation (CA) are contradictory. Therefore, we performed a meta-analysis to assess whether the LAA function and structure can predict the recurrence of AF after CA. Methods The PubMed, EMBASE, Web of Science, and Cochrane library databases were used to conduct a comprehensive literature search. Finally, 37 studies encompassing 11 LAA parameters were included in this meta-analysis. Results Compared with those in the non-recurrence group, the recurrence group had increased LAA volume (SMD 0.53, 95% CI [0.36, 0.71] p < 0.00001), LAA volume index, LAA orifice area, and LAA orifice short/long axis and decreased LAA emptying flow velocity (SMD -0.54, 95% CI [-0.68, -0.40], P < 0.00001), LAA filling flow velocity, and LAA ejection fraction, while there was no significant difference in LAA morphology or LAA depth. Conclusion Large LAA structure of pre-ablation (LAA volume, orifice area, orifice long/short axis, and volume index) and decreased LAA function of pre-ablation (LAA emptying flow velocity, filling flow velocity, ejection fraction, and LASEC) increase the odds of AF recurrence after CA. Systematic review registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022324533].
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Affiliation(s)
- Shaojie Han
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Interventional Operating Room, Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruikun Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhifu Cen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ran Guo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Guobin Liu
- Department of Cardiology, The First People’s Hospital of Jintang County, Chengdu, China
- *Correspondence: Guobin Liu,
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Guobin Liu,
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Rossi S, Abdala L, Woodward A, Vavalle JP, Henriquez CS, Griffith BE. Rule-based definition of muscle bundles in patient-specific models of the left atrium. Front Physiol 2022; 13:912947. [PMID: 36311246 PMCID: PMC9597256 DOI: 10.3389/fphys.2022.912947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia encountered clinically, and as the population ages, its prevalence is increasing. Although the CHA2DS2- VASc score is the most used risk-stratification system for stroke risk in AF, it lacks personalization. Patient-specific computer models of the atria can facilitate personalized risk assessment and treatment planning. However, a challenge faced in creating such models is the complexity of the atrial muscle arrangement and its influence on the atrial fiber architecture. This work proposes a semi-automated rule-based algorithm to generate the local fiber orientation in the left atrium (LA). We use the solutions of several harmonic equations to decompose the LA anatomy into subregions. Solution gradients define a two-layer fiber field in each subregion. The robustness of our approach is demonstrated by recreating the fiber orientation on nine models of the LA obtained from AF patients who underwent WATCHMAN device implantation. This cohort of patients encompasses a variety of morphology variants of the left atrium, both in terms of the left atrial appendages (LAAs) and the number of pulmonary veins (PVs). We test the fiber construction algorithm by performing electrophysiology (EP) simulations. Furthermore, this study is the first to compare its results with other rule-based algorithms for the LA fiber architecture definition available in the literature. This analysis suggests that a multi-layer fiber architecture is important to capture complex electrical activation patterns. A notable advantage of our approach is the ability to reconstruct the main LA fiber bundles in a variety of morphologies while solving for a small number of harmonic fields, leading to a comparatively straightforward and reproducible approach.
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Affiliation(s)
- Simone Rossi
- Department of Mathematics, UNC Chapel Hill, Chapel Hill, NC, United States
| | - Laryssa Abdala
- Department of Mathematics, UNC Chapel Hill, Chapel Hill, NC, United States
| | - Andrew Woodward
- Advanced Medical Imaging Lab, UNC Chapel Hill, Chapel Hill, NC, United States
| | - John P. Vavalle
- Department of Medicine, UNC Chapel Hill, Chapel Hill, NC, United States
| | - Craig S. Henriquez
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Boyce E. Griffith
- Department of Mathematics, UNC Chapel Hill, Chapel Hill, NC, United States
- Department of Biomedical Engineering, UNC Chapel Hill, Chapel Hill, NC, United States
- McAllister Heart Institute, UNC Chapel Hill, Chapel Hill, NC, United States
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49
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Wada T, Katayama Y. Identification of interatrial epicardial connections between the right-sided pulmonary veins and right atrium using coherent map. J Cardiol Cases 2022; 27:27-31. [PMID: 36618847 PMCID: PMC9808440 DOI: 10.1016/j.jccase.2022.09.012] [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: 07/22/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 12/15/2022] Open
Abstract
A 43-year-old man underwent circumferential pulmonary vein isolation (PVI) for persistent atrial fibrillation. Although first-pass circumferential PV antrum ablation was performed, complete PVI was not obtained. A gap map showed the site of earliest activation was the right-sided PV carina, which was the same site of breakthrough on the left atrium map before ablation. Using a coherent map enabled us easily and clearly to evaluate the breakthrough sites. To identify whether the conduction from the right PV carina connected to adjacent structures, an activation map was obtained during pacing from the right PV carina. This revealed that the site of earliest activation was the posterior right atrium (RA) and implied a direct connection between the right-sided PVs and RA. The first radiofrequency (RF) application in the posterior RA resulted in only temporary isolation of the right-sided PVs with bi-directional block. Therefore, we performed a second set of RF applications to the right PV carina. PVI was obtained immediately after initiating the second set of applications and no further reconnection was observed. Learning objective Pulmonary vein isolation (PVI) is widely accepted as an atrial fibrillation ablation procedure. Previous anatomical studies have revealed the presence of epicardial muscular bundles/fibers connecting the right-sided PVs and right atrium. In some patients, the presence of epicardial connections (ECs) precludes successful first-pass PVI. Identification and elimination of these connections is imperative to achieve complete PVI. The coherent map was useful for evaluating ECs.
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Affiliation(s)
- Tadashi Wada
- Corresponding author at: Department of Cardiovascular Medicine, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni city, Yamaguchi 740-8510, Japan.
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Quintana RA, Dong T, Vajapey R, Reyaldeen R, Kwon DH, Harb S, Wang TKM, Klein AL. Preprocedural Multimodality Imaging in Atrial Fibrillation. Circ Cardiovasc Imaging 2022; 15:e014386. [PMID: 36256725 DOI: 10.1161/circimaging.122.014386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with increased risk of heart failure, stroke, and death. In current medical practice, multimodality imaging is routinely used in the management of AF. Twenty-one years ago, the ACUTE trial (Assessment of Cardioversion Using Transesophageal Echocardiography) results were published, and the management of AF changed forever by incorporating transesophageal echocardiography guided cardioversion of patients in AF for the first time. Current applications of multimodality imaging in AF in 2022 include the use of transesophageal echocardiography and computed tomography before cardioversion to exclude left atrial thrombus and in left atrial appendage occlusion device implantation. Transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance are clinically used for AF ablation planning. The decision to use a particular imaging modality in AF is based on patient's characteristics, guideline recommendation, institutional preferences, expertise, and cost. In this first of 2-part review series, we discuss the preprocedural role of echocardiography, computed tomography, and cardiac magnetic resonance in the AF, with regard to their clinical applications, relevant outcomes data and unmet needs, and highlights future directions in this rapidly evolving field.
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Affiliation(s)
- Raymundo A Quintana
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (R.A.Q.)
| | - Tiffany Dong
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Ramya Vajapey
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Reza Reyaldeen
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Serge Harb
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
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