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Turagam MK, Neuzil P, Petru J, Funasako M, Koruth JS, Skoda J, Kralovec S, Reddy VY. AF ablation using a novel "single-shot" map-and-ablate spherical array pulsed field ablation catheter: 1-Year outcomes of the first-in-human PULSE-EU trial. Heart Rhythm 2024; 21:1218-1226. [PMID: 38768840 DOI: 10.1016/j.hrthm.2024.04.102] [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: 04/05/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND During pulsed field ablation (PFA), electrode-tissue proximity optimizes lesion quality. A novel "single-shot" map-and-ablate spherical multielectrode PFA array catheter that is able to verify electrode-tissue contact was recently studied in a first-in-human trial of atrial fibrillation (AF). OBJECTIVE The aim of this study was to report lesion durability data, safety, and 12-month effectiveness outcomes. METHODS The spherical PFA catheter, an all-in-one mapping and ablation system, was used to render anatomy and to deliver biphasic pulses (ungated 1.7 kV pulses; ∼40 seconds/application). Ablation sites included pulmonary veins (PVs) and, in selected patients, posterior wall and mitral isthmus. Follow-up was invasive remapping at ∼3 months, electrocardiograms, Holter monitoring at 6 and 12 months, and symptomatic and scheduled transtelephonic monitoring. The primary and secondary efficacy end points were acute PV isolation (PVI), PVI durability, and atrial arrhythmia recurrence. RESULTS In the 48-patient AF cohort (paroxysmal, 48%; persistent, 52%), lesion sets included PVI (n = 48; 1.2 applications/PV), posterior wall (n = 20; 3.6 applications/posterior wall), and mitral isthmus (n = 11; 2.9 applications/mitral isthmus). Lesions were acutely successful for all 187 of 187 PVs (100%), 20 of 20 posterior walls (100%), and 10 of 11 mitral isthmuses (91%). Pulse delivery time, left atrial catheter dwell time, and procedure time were 61.5 ± 32.8 seconds, 53.9 ± 26.5 minutes, and 87.8 ± 29.8 minutes, respectively. Remapping (43/48 patients [89.5%]) revealed that 158 of 169 PVs (93.5%) were durably isolated. The only complication was a drug-responsive pericarditis. The 1-year Kaplan-Meier estimates of freedom from atrial arrhythmia were 84.2% (paroxysmal AF) and 80.0% (persistent AF). CONCLUSION The single-shot spherical array PFA catheter can safely achieve durable lesions, translating into good clinical efficacy.
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Affiliation(s)
| | | | - Jan Petru
- Homolka Hospital, Prague, Czech Republic
| | | | - Jacob S Koruth
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jan Skoda
- Homolka Hospital, Prague, Czech Republic
| | | | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York; Homolka Hospital, Prague, Czech Republic.
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Anter E, Mansour M, Nair DG, Sharma D, Taigen TL, Neuzil P, Kiehl EL, Kautzner J, Osorio J, Mountantonakis S, Natale A, Hummel JD, Amin AK, Siddiqui UR, Harlev D, Hultz P, Liu S, Onal B, Tarakji KG, Reddy VY. Dual-energy lattice-tip ablation system for persistent atrial fibrillation: a randomized trial. Nat Med 2024:10.1038/s41591-024-03022-6. [PMID: 38760584 DOI: 10.1038/s41591-024-03022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/26/2024] [Indexed: 05/19/2024]
Abstract
Clinical outcomes of catheter ablation for atrial fibrillation (AF) are suboptimal due, in part, to challenges in achieving durable lesions. Although focal point-by-point ablation allows for the creation of any required lesion set, this strategy necessitates the generation of contiguous lesions without gaps. A large-tip catheter, capable of creating wide-footprint ablation lesions, may increase ablation effectiveness and efficiency. In a randomized, single-blind, non-inferiority trial, 420 patients with persistent AF underwent ablation using a large-tip catheter with dual pulsed field and radiofrequency energies versus ablation using a conventional radiofrequency ablation system. The primary composite effectiveness endpoint was evaluated through 1 year and included freedom from acute procedural failure and repeat ablation at any time, plus arrhythmia recurrence, drug initiation or escalation or cardioversion after a 3-month blanking period. The primary safety endpoint was freedom from a composite of serious procedure-related or device-related adverse events. The primary effectiveness endpoint was observed for 73.8% and 65.8% of patients in the investigational and control arms, respectively (P < 0.0001 for non-inferiority). Major procedural or device-related complications occurred in three patients in the investigational arm and in two patients in the control arm (P < 0.0001 for non-inferiority). In a secondary analysis, procedural times were shorter in the investigational arm as compared to the control arm (P < 0.0001). These results demonstrate non-inferior safety and effectiveness of the dual-energy catheter for the treatment of persistent AF. Future large-scale studies are needed to gather real-world evidence on the impact of the focal dual-energy lattice catheter on the broader population of patients with AF. ClinicalTrials.gov identifier: NCT05120193 .
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Affiliation(s)
- Elad Anter
- Shamir Medical Center, Be'er Ya'Akov, Israel.
| | | | - Devi G Nair
- St. Bernards Medical Center & Arrhythmia Research Group, Jonesboro, AR, USA
| | | | | | | | | | | | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, TX, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - John D Hummel
- Division of Cardiology, Ohio State University, Columbus, OH, USA
| | - Anish K Amin
- Riverside Methodist Hospital, Upper Arlington, OH, USA
| | | | | | | | | | | | | | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, NY, USA
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Deneke T, Kutyifa V, Hindricks G, Sommer P, Zeppenfeld K, Carbucicchio C, Pürerfellner H, Heinzel FR, Traykov VB, De Riva M, Pontone G, Lehmkuhl L, Haugaa K. Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology. Europace 2024; 26:euae108. [PMID: 38743765 PMCID: PMC11104536 DOI: 10.1093/europace/euae108] [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: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.
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Affiliation(s)
- Thomas Deneke
- Clinic for Rhythmology at Klinikum Nürnberg Campus Süd, University Hospital of the Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Helmut Pürerfellner
- Department of Clinical Electrophysiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Frank R Heinzel
- Städtisches Klinikum Dresden, Department of Cardiology, Angiology and Intensive Care Medicine, Dresden, Germany
| | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Marta De Riva
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Lukas Lehmkuhl
- Department of Radiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Germany
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Sanders P, Healy S, Emami M, Kotschet E, Miller A, Kalman JM. Initial clinical experience with the balloon-in-basket pulsed field ablation system: acute results of the VOLT CE mark feasibility study. Europace 2024; 26:euae118. [PMID: 38701222 PMCID: PMC11098042 DOI: 10.1093/europace/euae118] [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: 04/02/2024] [Accepted: 04/29/2024] [Indexed: 05/05/2024] Open
Abstract
AIMS Pulsed field ablation (PFA) for the treatment of atrial fibrillation (AF) potentially offers improved safety and procedural efficiencies compared with thermal ablation. Opportunities remain to improve effective circumferential lesion delivery, safety, and workflow of first-generation PFA systems. In this study, we aim to evaluate the initial clinical experience with a balloon-in-basket, 3D integrated PFA system with a purpose-built form factor for pulmonary vein (PV) isolation. METHODS AND RESULTS The VOLT CE Mark Study is a pre-market, prospective, multi-centre, single-arm study to evaluate the safety and effectiveness of the Volt™ PFA system for the treatment of paroxysmal (PAF) or persistent AF (PersAF). Feasibility sub-study subjects underwent phrenic nerve evaluation, endoscopy, chest computed tomography, and cerebral magnetic resonance imaging. Study endpoints were the rate of primary serious adverse event within 7 days and acute procedural effectiveness. A total of 32 subjects (age 61.6 ± 9.6 years, 65.6% male, 84.4% PAF) were enrolled and treated in the feasibility sub-study and completed a 30-day follow-up. Acute effectiveness was achieved in 99.2% (127/128) of treated PVs (96.9% of subjects, 31/32) with 23.8 ± 4.2 PFA applications/subject. Procedure, fluoroscopy, LA dwell, and transpired ablation times were 124.6 ± 28.1, 19.8 ± 8.9, 53.0 ± 21.0, and 48.0 ± 19.9 min, respectively. Systematic assessments of initial safety revealed no phrenic nerve injury, pulmonary vein stenosis, or oesophageal lesions causally related to the PFA system and three subjects with silent cerebral lesions (9.4%). There were no primary serious adverse events. CONCLUSION The initial clinical use of the Volt PFA System demonstrates acute safety and effectiveness in the treatment of symptomatic, drug refractory AF.
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Affiliation(s)
- Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia
| | - Stewart Healy
- Department of Cardiology, Victorian Heart Hospital, Clayton, Victoria, Australia
| | - Mehrdad Emami
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia
| | - Emily Kotschet
- Department of Cardiology, Victorian Heart Hospital, Clayton, Victoria, Australia
| | | | - Jonathan M Kalman
- Department of Cardiology, University of Melbourne, Royal Melbourne Hospital and Baker Institute, Parkville, Victoria, Australia
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Saglietto A, Bertello E, Barra M, Ferraro I, Rovera C, Orzan F, De Ferrari GM, Anselmino M. MRI pattern characterization of cerebral cardioembolic lesions following atrial fibrillation ablation. Front Cardiovasc Med 2024; 11:1327567. [PMID: 38327489 PMCID: PMC10847299 DOI: 10.3389/fcvm.2024.1327567] [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: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
Background Recognizing etiology is essential for treatment and secondary prevention of cerebral ischemic events. A magnetic resonance imaging (MRI) pattern suggestive of an embolic etiology has been described but, to date, there are no uniformly accepted criteria. Aim The purpose of the study is to describe MRI features of ischemic cerebral lesions occurring after transcatheter ablation of atrial fibrillation (AF). Methods A systematic review and meta-analysis of studies performing brain imaging investigations before and after AF transcatheter ablation was performed. The incidence of cerebral ischemic lesions after AF transcatheter ablation was the primary endpoint. The co-primary endpoints were the prevalence of the different neuroimaging features regarding the embolic cerebral ischemic lesions. Results A total of 25 studies, encompassing 3,304 patients, were included in the final analysis. The incidence of ischemic cerebral lesions following AF transcatheter ablation was 17.2% [95% confidence interval (CI) 12.2%-23.8%], of which a minimal fraction was symptomatic [0.60% (95% CI 0.09%-3.9%)]. Only 1.6% of the lesions (95% CI 0.9%-3.0%) had a diameter >10 mm, and in 20.5% of the cases the lesions were multiple (95% CI 17.1%-24.4%). Brain lesions were equally distributed across the two hemispheres and the different lobes; cortical location was more frequent [64.0% (95% CI 42.9%-80.8%)] while the middle cerebral artery territory was the most involved 37.0% (95% CI 27.3-48.0). Conclusions The prevailing MRI pattern comprises a predominance of small (<10 mm) cortical lesions, more prevalent in the territory of the middle cerebral artery.
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Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Eleonora Bertello
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Barra
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ilenia Ferraro
- Division of Cardiology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Chiara Rovera
- Department of Cardiology, Civic Hospital of Chivasso, Chivasso, Italy
| | - Fulvio Orzan
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Division of Cardiology, Cardiovascular and Thoracic Department, “Città della Salute e della Scienza” Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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6
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Nakashima T, Morimoto M, Nagase M, Shibahara T, Ono D, Yamada T, Tanabe G, Suzuki K, Yamaura M, Ido T, Takahashi S, Okura H, Aoyama T. Complete atrioventricular block following internal electrical cardioversion during atrial fibrillation ablation. J Electrocardiol 2024; 82:118-124. [PMID: 38128156 DOI: 10.1016/j.jelectrocard.2023.12.005] [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: 08/10/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Complete atrioventricular block (C-AVB) following internal electrical cardioversion (IEC) during atrial fibrillation (AF) ablation has not been fully investigated. We aimed to determine the prevalence and predictors of C-AVB following IEC during AF ablation. METHODS C-AVB (non-conducted sinus impulse after IEC) and ventricular pause (VP) (the interval between IEC and the QRS complex) following the first attempt of IEC, and baseline electrocardiographic parameters were investigated in patients who underwent first-time AF ablation. RESULTS We investigated the first attempt of IEC in 124 patients (mean age:70 ± 11 years, 81 men, 99 non-paroxysmal AF). AF was terminated in 109/124 (88%) patients, with a VP of 1590 [1014-2208] (maximum, 8780) ms. Transient C-AVB following IEC occurred in 14/109 (13%) patients. The VP was longer in patients with transient C-AVB than in those without transient C-AVB (2418 [1693-4425] vs. 1530 [876-2083] ms, p = 0.002). In multivariate analysis, the left atrial diameter (Odds ratio [OR]:1.21; 95% confidence interval (95%CI):1.06-1.39; p = 0.005) and preexisting intraventricular conduction abnormality (OR:9.22; 95%CI:1.60-53.3; p = 0.013) were predictors of transient C-AVB following IEC. CONCLUSION Left atrial diameter and preexisting intraventricular conduction abnormalities were predictors of transient C-AVB following IEC during AF ablation.
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Affiliation(s)
- Takashi Nakashima
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan; Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan.
| | - Mikihito Morimoto
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Masaru Nagase
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Taro Shibahara
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Daiju Ono
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Takehiro Yamada
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Gen Tanabe
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Keita Suzuki
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Makoto Yamaura
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan; Department of Molecular Pathophysiology, Shinshu University Graduate School of Medicine, Matsumoto, Nagano 390-8621, Japan
| | - Takahisa Ido
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan; Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shigekiyo Takahashi
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan
| | - Hiroyuki Okura
- Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Takuma Aoyama
- Department of Cardiology, Central Japan International Medical Center, Minokamo, Gifu, Japan; Department of Cardiology, Graduate School of Medicine, Gifu University, Gifu, Japan; Department of Molecular Pathophysiology, Shinshu University Graduate School of Medicine, Matsumoto, Nagano 390-8621, Japan
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Yamaji K, Iwanaga Y, Kakehi K, Fujita K, Kawamura T, Hirase C, Ueno M, Nakazawa G. Prognostic Significance of Asymptomatic Cerebral Infarction in Patients After Cardiac Catheterization. Int Heart J 2024; 65:13-20. [PMID: 38296566 DOI: 10.1536/ihj.23-382] [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: 02/08/2024]
Abstract
Recent studies have showed that asymptomatic cerebral infarction (ACI) developed in a reasonable number of patients after cardiac catheterization. However, no study has investigated the long-term prognostic impact of ACI after cardiac catheterization. We investigated whether ACI after cardiac catheterization affects long-term mortality and subsequent cardiovascular events.We retrospectively enrolled patients who underwent cardiac catheterization before cardiac surgery and cerebral diffusion-weighted magnetic resonance imaging (DWI). The incidence and clinical features of ACI were investigated. The long-term prognosis, including all-cause mortality and subsequent major cardiovascular events (MACE; all-cause mortality, stroke, acute myocardial infarction, fatal arrhythmia, and hospitalized heart failure), was also assessed.A total of 203 patients were enrolled. Of these, 10.3% had ACI diagnosed by DWI. There were no differences in baseline characteristics between patients with and without ACI, except more frequent history of symptomatic stroke in patients with ACI. In the Kaplan-Meier analysis during a median follow-up of 1009 days, the patients with ACI showed worse mortality and a slightly higher occurrence of MACE compared with those without ACI (P = 0.01 and P = 0.08, respectively). In addition, ACI was a prognostic marker independent of age, surgery type, and history of stroke.ACI after cardiac catheterization frequently developed and was also associated with long-term prognosis. It may be an independent prognostic marker in high-risk patients who underwent subsequent cardiac surgery.
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Affiliation(s)
- Kenji Yamaji
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
- Division of Cardiology, Pref Osaka Saiseikai Izuo Hospital
| | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
- Department of Cardiology, Sakurabashi-Watanabe Hospital
| | - Kazuyoshi Kakehi
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | - Kosuke Fujita
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | - Takayuki Kawamura
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | | | - Masafumi Ueno
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
| | - Gaku Nakazawa
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine
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Bao W, Hu X, Ge L, Tang S, Zhao X, Huang S, Liu C, Li F, Zhang C, Li C. Establishment and Validation of the Nomogram Model and the Probability of Silent Cerebral Infarction After Ablation Atrial Fibrillation. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07530-4. [PMID: 38103153 DOI: 10.1007/s10557-023-07530-4] [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] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND The objective of this study is to establish and validate a nomogram model for predicting the probability of silent cerebral infarction following ablation of atrial fibrillation. METHODS AND RESULTS A retrospective observational study was conducted on the data of 238 patients with atrial fibrillation who underwent radiofrequency ablation in our hospital from October 2019 to December 2022. LASSO regression and multivariate logistics regression analysis were used to assess the independent risk factors for silent cerebral infarction after ablation. The AUC of the predictive model was 0.733 (95% CI, 0.649-0.816) and the internal validation (bootstrap = 1000) of the bootstrap method was 0.733 (95% CI 0.646-0.813). The Hosmer-Lemeshow test yields an insignificant p-value of X-squared = 10.212 and p-value = 0.2504, thus indicating an insignificant difference between predicted and observed values and good calibration results. The clinical impact curve (CIC) and clinical decision curve also prove that this graph is useful in the clinical setting. CONCLUSION We developed an easy-to-use nomogram model to predict the probability of silent cerebral infarction following radiofrequency ablation of atrial fibrillation. This model can provide a valid assessment of the probability of postoperative silent cerebral infarction in patients undergoing radiofrequency ablation of atrial fibrillation.
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Affiliation(s)
- Wei Bao
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Xiaoqin Hu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Liqi Ge
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Shiyun Tang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Xinliang Zhao
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Shuo Huang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Chen Liu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Fei Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Chaoqun Zhang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China.
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9
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Uyanik M, Yildirim U, Avci B, Soylu K. Assessment of silent brain injury in patients undergoing elective percutaneous coronary intervention due to chronic total occlusion. Scand Cardiovasc J Suppl 2023; 57:25-30. [PMID: 36443919 DOI: 10.1080/14017431.2022.2150786] [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: 11/30/2022]
Abstract
Objective: Silent brain infarcts (SBI) are thromboembolic complications associated with cardiac surgery, diagnostic angiography, and percutaneous interventions. Serum neuron-specific enolase (NSE) is the proven biomarker for measuring neuronal damage. This study aimed to evaluate the incidence of SBI, defined as elevated NSE after coronary chronic total occlusion (CTO) intervention and elective coronary stenting. Design: The study population consisted of two patient groups: the CTO group included consecutive patients with coronary CTO intervention, and the control group consisted of patients who underwent elective coronary intervention. NSE blood levels were measured before and 12-18 h after the procedure. NSE blood levels of >20 ng/mL were considered SBI. Results: A total of 108 patients were included in the study. Of these, 55 (50.9%) had SBI after the procedure. The SBI rate was 59.7% in the CTO group and 39.1% in the control group. Patients with SBI were more likely to have diabetes mellitus, hyperlipidemia, higher HbA1c, higher total stent length, and longer procedural time. Multivariate logistic regression analysis showed that CTO procedure (odds ratio [OR]: 3.129; 95% confidence interval [CI]: 1.246-7.858; p < 0.015) and diabetes mellitus (OR: 2.93; 95% CI: 1.185-7.291; p < 0.020) are independent predictors of SBI. Conclusion: Our data suggest that SBI occurs more frequently after CTO intervention than after non-CTO intervention. Intervention complexity and patient clinical characteristics may explain the increased incidence.
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Affiliation(s)
- Muhammet Uyanik
- Faculty of Medicine, Department of Cardiology, Ondokuz Mayıs University, Samsun, Turkey
| | - Ufuk Yildirim
- Faculty of Medicine, Department of Cardiology, Ondokuz Mayıs University, Samsun, Turkey
| | - Bahattin Avci
- Faculty of Medicine, Department of Biochemistry, Ondokuz Mayıs University, Samsun, Turkey
| | - Korhan Soylu
- Faculty of Medicine, Department of Cardiology, Ondokuz Mayıs University, Samsun, Turkey
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10
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Fink T, Sciacca V, Neven K, Didenko M, Sommer P, Sohns C. Pulsed field ablation for atrial fibrillation - Lessons from magnetic resonance imaging. Pacing Clin Electrophysiol 2023; 46:1586-1594. [PMID: 37943015 DOI: 10.1111/pace.14864] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/19/2023] [Accepted: 10/21/2023] [Indexed: 11/10/2023]
Abstract
Pulsed field ablation (PFA) is a promising technology for the treatment of atrial fibrillation (AF). Due to its unique tissue selectivity, PFA potentially bears superior characteristics as compared to established thermal energy sources in AF ablation procedures. Cardiovascular magnetic resonance imaging (CMR) using late gadolinium enhancement (LGE) is an established tool in the analysis of myocardial fibrosis representing atrial cardiomyopathy as well as ablation-induced atrial scar formation following catheter ablation with thermal energy. Mechanisms of atrial lesion formation differ between thermal ablation and electroporation and its impact on results of CMR imaging are not fully understood until now. In this review article, the potential of CMR imaging for PFA lesion assessment and available data are discussed. Further, additional needs to adopt imaging approaches to the cellular mechanisms of electroporation are considered.
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Affiliation(s)
- Thomas Fink
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany
- Dept. of Medicine, Witten/Herdecke University, Witten, Germany
| | - Maxim Didenko
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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11
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Arslan U, Erdoğan G, Yenerçağ M, Aksan G, Uçar M, Görgün S, Akpinar ÇK, Öztürk O, Yontar OC, Karagöz A. Direct transcatheter aortic valve implantation (TAVI) decreases silent cerebral infarction when compared to routine balloon valvuloplasty. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2029-2039. [PMID: 37358708 DOI: 10.1007/s10554-023-02895-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 06/05/2023] [Indexed: 06/27/2023]
Abstract
PURPOSE Silent cerebral infarctions (SCI), as determined by neuron-specific enolase (NSE) elevations, may develop after the transcatheter aortic valve implantation (TAVI) procedure. Our aim in this study was to compare the SCI rates between patients who underwent routine pre-dilatation balloon aortic valvuloplasty (pre-BAV) and patients who underwent direct TAVI without pre-BAV. METHODS A total of 139 consecutive patients who underwent TAVI in a single center using the self-expandable Evolut-R valve (Medtronic, Minneapolis, Minnesota, USA) were included in the study. The first 70 patients were included in the pre-BAV group, and the last 69 patients were included in the direct TAVI group. SCI was detected by serum NSE measurements performed at baseline and 12 h after the TAVI. New NSE elevations > 12 ng/mL after the procedure were counted as SCI. In addition, SCI was scanned by MRI (magnetic resonance imaging) in eligible patients. RESULTS TAVI procedure was successful in all of the study population. Post-dilatation rates were higher in the direct TAVI group. Post-TAVI NSE positivity (SCI) was higher in the routine pre-BAV group (55(78.6%) vs. 43(62.3%) patients, p = 0.036) and NSE levels were also higher in this group (26.8 ± 15.0 vs. 20.5 ± 14.8 ng/ml, p = 0.015). SCI with MRI was found to be significantly higher in the pre-BAV group than direct TAVI group (39(55.1%) vs. 31(44.9%) patients). The presence of atrial fibrillation and diabetes mellitus (DM), total cusp calcification volume, calcification at arcus aorta, routine pre-BAV and failure at first try of the prosthetic valve implantation were significantly higher in SCI (+) group. In the multivariate analysis, presence of DM, total cusp calcification volume, calcification at arcus aorta, routine pre-BAV and failure at first try of the prosthetic valve implantation were significantly associated with new SCI development. CONCLUSIONS Direct TAVI procedure without pre-dilation seems to be an effective method and avoidance of pre-dilation decreases the risk of SCI development in patients undergoing TAVI with a self-expandable valve.
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Affiliation(s)
- Uğur Arslan
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey.
| | - Güney Erdoğan
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
| | - Mustafa Yenerçağ
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
| | - Gökhan Aksan
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
| | - Melisa Uçar
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
| | - Selim Görgün
- Department of Microbiology, Samsun University Samsun Training and Research Hospital, Samsun, Turkey
| | - Çetin Kürşat Akpinar
- Department of Neurology, Samsun University Samsun Training and Research Hospital, Samsun, Turkey
| | - Onur Öztürk
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
| | - Osman Can Yontar
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
| | - Ahmet Karagöz
- Department of Cardiology, Samsun University Samsun Training and Research Hospital, Baris Bulvari, No: 199, Samsun, 55400, Turkey
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12
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Zhang J, Li S, Sang C, Ma C. Atrial fibrillation catheter ablation associated silent cerebral emboli: A narrative review. Pacing Clin Electrophysiol 2023; 46:1124-1133. [PMID: 37578003 DOI: 10.1111/pace.14779] [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: 01/03/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
The incidence of silent cerebral emboli (SCE) associated with atrial fibrillation catheter ablation (AFCA) is much higher than that of stroke/transient ischemic attack (TIA). Interventional electrophysiologists have been increasingly alerted to asymptomatic cerebral infarction over the years. Plentiful studies revealed that diagnostic definitions, detection modalities, energy sources, ablation strategies, perioperative anticoagulation regimens, and patient-related factors were associated with the risk of AFCA-associated SCE. Studies related to non-interventional procedures found that SCE may prompt stroke, cognitive decline, and dementia later in life, suggesting a possible role of AFCA-associated SCE in the cognitive function of patients with AF. However, there is no consistent evidence for this view to date. Given that the majority of patients with AF being elderly and the increased risk of cognitive impairment in AF itself, efforts should be made to minimize the occurrence of AFCA-associated SCE.
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Affiliation(s)
- Jingrui Zhang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Beijing Anzhen Hospital affiliated Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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13
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Calvert P, Kollias G, Pürerfellner H, Narasimhan C, Osorio J, Lip GYH, Gupta D. Silent cerebral lesions following catheter ablation for atrial fibrillation: a state-of-the-art review. Europace 2023; 25:euad151. [PMID: 37306314 PMCID: PMC10259069 DOI: 10.1093/europace/euad151] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Atrial fibrillation is associated with neurocognitive comorbidities such as stroke and dementia. Evidence suggests that rhythm control-especially if implemented early-may reduce the risk of cognitive decline. Catheter ablation is highly efficacious for restoring sinus rhythm in the setting of atrial fibrillation; however, ablation within the left atrium has been shown to result in MRI-detected silent cerebral lesions. In this state-of-the-art review article, we discuss the balance of risk between left atrial ablation and rhythm control. We highlight suggestions to lower the risk, as well as the evidence behind newer forms of ablation such as very high power short duration radiofrequency ablation and pulsed field ablation.
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Affiliation(s)
- Peter Calvert
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
| | | | | | - Calambur Narasimhan
- Department of Cardiac Electrophysiology, AIG Hospitals, 1-66/AIG/2 to 5, Mindspace Road, Gachibowli Hyderabad, Telangana 500032, India
| | - Jose Osorio
- Grandview Medical Center, Arrhythmia Institute at Grandview, 3686 Grandview Parkway Suite 720, Birmingham, AL 35243, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
- Danish Centre for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Thomas Drive, Liverpool L14 3PE, UK
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14
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Verma A, Haines DE, Boersma LV, Sood N, Natale A, Marchlinski FE, Calkins H, Sanders P, Packer DL, Kuck KH, Hindricks G, Onal B, Cerkvenik J, Tada H, DeLurgio DB. Pulsed Field Ablation for the Treatment of Atrial Fibrillation: PULSED AF Pivotal Trial. Circulation 2023; 147:1422-1432. [PMID: 36877118 PMCID: PMC10158608 DOI: 10.1161/circulationaha.123.063988] [Citation(s) in RCA: 119] [Impact Index Per Article: 119.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Pulsed field ablation uses electrical pulses to cause nonthermal irreversible electroporation and induce cardiac cell death. Pulsed field ablation may have effectiveness comparable to traditional catheter ablation while preventing thermally mediated complications. METHODS The PULSED AF pivotal study (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF) was a prospective, global, multicenter, nonrandomized, paired single-arm study in which patients with paroxysmal (n=150) or persistent (n=150) symptomatic atrial fibrillation (AF) refractory to class I or III antiarrhythmic drugs were treated with pulsed field ablation. All patients were monitored for 1 year using weekly and symptomatic transtelephonic monitoring; 3-, 6-, and 12-month ECGs; and 6- and 12-month 24-hour Holter monitoring. The primary effectiveness end point was freedom from a composite of acute procedural failure, arrhythmia recurrence, or antiarrhythmic escalation through 12 months, excluding a 3-month blanking period to allow recovery from the procedure. The primary safety end point was freedom from a composite of serious procedure- and device-related adverse events. Kaplan-Meier methods were used to evaluate the primary end points. RESULTS Pulsed field ablation was shown to be effective at 1 year in 66.2% (95% CI, 57.9 to 73.2) of patients with paroxysmal AF and 55.1% (95% CI, 46.7 to 62.7) of patients with persistent AF. The primary safety end point occurred in 1 patient (0.7%; 95% CI, 0.1 to 4.6) in both the paroxysmal and persistent AF cohorts. CONCLUSIONS PULSED AF demonstrated a low rate of primary safety adverse events (0.7%) and provided effectiveness consistent with established ablation technologies using a novel irreversible electroporation energy to treat patients with AF. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04198701.
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Affiliation(s)
- Atul Verma
- McGill University Health Centre, Montreal, Canada (A.V.)
| | | | - Lucas V. Boersma
- St. Antonius Hospital, Nieuwegein and Amsterdam UMC, the Netherlands (L.V.B.)
| | - Nitesh Sood
- Southcoast Health Center, Fall River, MA (N.S.)
| | | | | | | | | | | | | | | | - Birce Onal
- Medtronic, Inc, Minneapolis, MN (B.O., J.C.)
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15
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Bodagh N, Kotadia I, Gharaviri A, Zelaya F, Birns J, Bhalla A, Sommerville P, Niederer S, O’Neill M, Williams SE. The Impact of Atrial Fibrillation Treatment Strategies on Cognitive Function. J Clin Med 2023; 12:3050. [PMID: 37176490 PMCID: PMC10179566 DOI: 10.3390/jcm12093050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023] Open
Abstract
There is increasing evidence to suggest that atrial fibrillation is associated with a heightened risk of dementia. The mechanism of interaction is unclear. Atrial fibrillation-induced cerebral infarcts, hypoperfusion, systemic inflammation, and anticoagulant therapy-induced cerebral microbleeds, have been proposed to explain the link between these conditions. An understanding of the pathogenesis of atrial fibrillation-associated cognitive decline may enable the development of treatment strategies targeted towards the prevention of dementia in atrial fibrillation patients. The aim of this review is to explore the impact that existing atrial fibrillation treatment strategies may have on cognition and the putative mechanisms linking the two conditions. This review examines how components of the 'Atrial Fibrillation Better Care pathway' (stroke risk reduction, rhythm control, rate control, and risk factor management) may influence the trajectory of atrial fibrillation-associated cognitive decline. The requirements for further prospective studies to understand the mechanistic link between atrial fibrillation and dementia and to develop treatment strategies targeted towards the prevention of atrial fibrillation-associated cognitive decline, are highlighted.
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Affiliation(s)
- Neil Bodagh
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Irum Kotadia
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Ali Gharaviri
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Fernando Zelaya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Jonathan Birns
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Ajay Bhalla
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Peter Sommerville
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- St Thomas’ Hospital, Guys and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EH, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
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16
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PV Isolation Using a Spherical Array PFA Catheter: Application Repetition and Lesion Durability (PULSE-EU Study). JACC Clin Electrophysiol 2023; 9:638-648. [PMID: 36828771 DOI: 10.1016/j.jacep.2023.01.009] [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: 12/21/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Preclinical studies have revealed that pulsed field ablation (PFA) lesion dimensions increase with repetitive applications at a similar electric field. OBJECTIVES This study investigated whether pulmonary vein isolation (PVI) durability varies with single vs repetitive pulsed field (PF) applications. METHODS Atrial fibrillation patients underwent PVI using a spherical multielectrode array PFA catheter delivered with a 19-F deflectable sheath under intracardiac echocardiographic guidance. Esophagogastroduodenoscopy and brain magnetic resonance imaging were performed within 1 to 3 days, and invasive remapping at ∼2 to 3 months. RESULTS The patient cohort (n = 21; age 63 ± 11 years; 67% women) underwent PVI in either of 2 groups: group 1 (n = 11)-single PF application/PV; and group 2 (n = 10)-3 PF applications/PV. In both groups, PVI was acutely successful in all (100%) patients. Despite significantly longer pulse delivery times (75.2 ± 7.4 s/patient vs 24.5 ± 5.5 s/patient) the procedure times (73.2 ± 13.7 minutes vs 93.7 ± 18.5 minutes) were shorter with group 2 vs group 1. There was no stroke/transient ischemic attack, pericardial effusion, phrenic nerve injury, or esophageal complications. Esophagogastroduodenoscopy was normal in both groups of patients (n = 9). Screening brain magnetic resonance imaging revealed asymptomatic cerebral lesions (diffusion weighted imaging+/ fluid attenuated inversion recovery-) in 3 of 16 (18.7%) patients. PV remapping revealed durable PVI in 62.5% PVs in group 1 (n = 10), compared with all 100% PVs in group 2 (n = 9); this translates to all PVs being durably isolated in 30% vs 100% (P < 0.05) of patients in groups 1 and 2, respectively. CONCLUSIONS In his first-in-human trial, the "single-shot" spherical array PFA catheter was shown to safely isolate PVs. Repetitive PF application is key for lesion consolidation to maximize PVI durability.
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17
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Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update. Can J Cardiol 2023; 39:200-209. [PMID: 36435326 DOI: 10.1016/j.cjca.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.
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18
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Lavalle C, Magnocavallo M, Vetta G, Piro A, Borrelli A, Grimaldi M, Rossillo A, Notarstefano P, Carreras G, Addonisio L, Dello Russo A, Perna F, Castro A, Grossi S, Pandozi C, Pappalardo A, Sgarito G, Forleo GB. Rationale and study design of the Italian Registry in the setting of Atrial Fibrillation Ablation with Rivaroxaban - IRIS. Minerva Cardiol Angiol 2023; 71:91-99. [PMID: 35080355 DOI: 10.23736/s2724-5683.21.05832-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Catheter ablation (CA) of atrial fibrillation (AF) is used routinely to establish rhythm control. There is mounting evidence that CA procedures should be performed during continuous oral anticoagulation and direct oral anticoagulants (DOACs) are considered the first anticoagulation strategy. Few real-life data are now available and even less in the Italian panorama. METHODS IRIS is an Italian multicenter, non-interventional, prospective study which will be enrolled consecutive AF patients eligible for CA and treated with Rivaroxaban; patients in treatment with Rivaroxaban proceeded directly to CA while Rivaroxaban-naive patients were scheduled for CA after 4 weeks of uninterrupted anticoagulation unless the exclusion of atrial thrombi. Rivaroxaban was uninterrupted or shortly uninterrupted (<24 hours) prior CA, in line with routinely practice of each operator. Patients will be followed on continuous anticoagulation for 1 month after the ablation. The primary efficacy outcome is the cumulative incidence of all-cause death and systemic embolism while the primary safety outcome is the incidence of major bleeding events. The secondary outcomes are represented by non-major bleeding events. All events must be occurred within the first 30 days after the procedure. RESULTS Two hundred fifty patients are expected to be enrolled and the study is estimated to be completed by the end of 2022. Up to now 56 patients have been enrolled. CONCLUSIONS This study is the first large Italian prospective study on the management of Rivaroxaban in patients undergoing CA of AF. It aims to depict a comprehensive view of anticoagulation strategy prior CA in several Italian electrophysiology labs.
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Affiliation(s)
- Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy -
| | - Michele Magnocavallo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Giampaolo Vetta
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University, Rome, Italy
| | | | - Massimo Grimaldi
- Department of Cardiology, F. Miulli Regional General Hospital, Acquaviva delle Fonti, Bari, Italy
| | | | | | - Giovanni Carreras
- Department of Cardiology, S. Maria University Hospital, Terni, Italy
| | - Luigi Addonisio
- Department of Cardiology, Misericordia Hospital, Grosseto, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Department of Biomedical Science and Public Health, Ospedali Riuniti University Hospital, Marche Polytechnic University, Ancona, Italy
| | - Francesco Perna
- Department of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | | | - Stefano Grossi
- Division of Cardiology, Mauriziano Umberto I Hospital, Turin, Italy
| | - Claudio Pandozi
- Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Augusto Pappalardo
- Division of Cardiology, Unit of Cardiac Arrhythmias, San Camillo Hospital, Rome, Italy
| | - Giuseppe Sgarito
- Division of Cardiology, ARNAS Benfratelli Civic Hospital, Palermo, Italy
| | - Giovanni B Forleo
- Unit of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco University Hospital, Milan, Italy
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19
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Lee AC, Voskoboinik A, Cheung CC, Yogi S, Tseng ZH, Moss JD, Dewland TA, Lee BK, Lee RJ, Hsia HH, Marcus GM, Vedantham V, Chieng D, Kistler PM, Dillon W, Vittinghoff E, Gerstenfeld EP. A Randomized Trial of High vs Standard Power Radiofrequency Ablation for Pulmonary Vein Isolation. JACC Clin Electrophysiol 2023. [PMID: 37495318 DOI: 10.1016/j.jacep.2022.12.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND High-power, short duration (HPSD) radiofrequency ablation (RFA) is a commonly used strategy for pulmonary vein isolation (PVI). OBJECTIVES This study sought to compare HPSD with standard power, standard duration (SPSD) RFA in patients undergoing PVI. METHODS Patients with paroxysmal or persistent (<1 year) atrial fibrillation (AF) were randomized to HPSD (50 W) or SPSD (25-30 W) RFA to achieve PVI. Outcomes assessed included time to achieve PVI (primary), left atrial dwell time, total procedure time, first-pass isolation, PV reconnection with adenosine, procedure complications including asymptomatic cerebral emboli (ACE), and freedom from atrial arrhythmias. RESULTS Sixty patients (median age 66 years; 75% male) with paroxysmal (57%) or persistent (43%) AF were randomized to HPSD (n = 29) or SPSD (n = 31). Median time to achieve PVI was shorter with HPSD vs SPSD (87 minutes vs 126 minutes; P = 0.003), as was left atrial dwell time (157 minutes vs 180 minutes; P = 0.04). There were no differences in first-pass isolation (79% vs 76%; P = 0.65) or PV reconnection with adenosine (12% vs 20%; P = 0.26) between groups. At 12 months, recurrent atrial arrhythmias occurred less in the HPSD group compared with the SPSD group (n = 3 of 29 [10%] vs n = 11 of 31 [35%]; HR: 0.26; P = 0.027). There was a trend toward more ACE with HPSD RFA (40% HPSD vs 17% SPSD; P = 0.053). CONCLUSIONS In patients undergoing AF ablation, HPSD compared with SPSD RFA results in shorter time to achieve PVI, greater freedom from AF at 12 months, and a trend toward increased ACE.
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20
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Jing Y, Xu J, Chen B, Xia D, Xia D, Tian Y, Xia W, Lu C, Wu Y. Superior mesenteric artery embolism after radiofrequency ablation in regularly anticoagulated patients with paroxysmal atrial fibrillation: a case report. BMC Cardiovasc Disord 2023; 23:56. [PMID: 36710320 PMCID: PMC9885642 DOI: 10.1186/s12872-023-03066-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/12/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Superior mesenteric artery embolism (SMAE) is a rare cause of acute abdomen, and the fatality rate is extremely high if it is not diagnosed and treated in time. Due to the lack of knowledge and experience of nonspecialist physicians, it is easy to misdiagnose. Radiofrequency ablation (RFA) has become the first-line treatment strategy for atrial fibrillation (AF). Thromboembolic events are some of the major complications after RFA, whereas SMAE is rarely reported. CASE PRESENTATION A 70 year-old woman with paroxysmal AF who regularly took anticoagulant drugs for 3 months experienced abdominal pain after RFA. At the outset, she was misdiagnosed as mechanical intestinal obstruction. When the patient presented with blood in the stool, abdominal enhancement computed tomography was conducted and showed a small bowel perforation. Immediate laparotomy was performed, and the final diagnosis was SMAE. CONCLUSION It is suggested that for unexplained abdominal pain after RFA of AF, the possibility of SMAE should be considered, and a targeted examination should be carried out in time to confirm the diagnosis and give appropriate treatment.
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Affiliation(s)
- Yongle Jing
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Jianqiang Xu
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Bingwei Chen
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Dasheng Xia
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Dachuan Xia
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Yunpeng Tian
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Wei Xia
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Chengzhi Lu
- grid.417024.40000 0004 0605 6814Department of Cardiology, Tianjin First Central Hospital, No. 24, Fukang Road, 300192 Tianjin, China
| | - Yuli Wu
- grid.417024.40000 0004 0605 6814Department of Anesthesiology, Tianjin First Central Hospital, No. 24, Fukang Road, Tianjin, 300192 China
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21
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Zenger B, Rizzi S, Steinberg BA, Ranjan R, Bunch TJ. This is Your Brain, and This is Your Brain on Atrial Fibrillation: The Roles of Cardiac Malperfusion Events and Vascular Dysfunction in Cognitive Impairment. Arrhythm Electrophysiol Rev 2023; 12:e01. [PMID: 36845168 PMCID: PMC9945461 DOI: 10.15420/aer.2022.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/14/2022] [Indexed: 02/03/2023] Open
Abstract
AF is an independent and strong predictor of long-term cognitive decline. However, the mechanism for this cognitive decline is difficult to define and likely multifactorial, leading to many different hypotheses. Examples include macro- or microvascular stroke events, biochemical changes to the blood-brain barrier related to anticoagulation, or hypo-hyperperfusion events. This review explores and discusses the hypothesis that AF contributes to cognitive decline and dementia through hypo-hyperperfusion events occurring during cardiac arrhythmias. We briefly explain several brain perfusion imaging techniques and further examine the novel findings associated with changes in brain perfusion in patients with AF. Finally, we discuss the implications and areas requiring more research to further understand and treat patients with cognitive decline related to AF.
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Affiliation(s)
- Brian Zenger
- School of Medicine, University of Utah, Salt Lake City, UT, US
| | - Scott Rizzi
- Department of Internal Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - Benjamin A Steinberg
- School of Medicine, University of Utah, Salt Lake City, UT, US
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - Ravi Ranjan
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
| | - T Jared Bunch
- School of Medicine, University of Utah, Salt Lake City, UT, US
- Division of Cardiovascular Medicine, University of Utah Health Sciences, Salt Lake City, UT, US
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22
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Miyamoto K, Kanaoka K, Ohta Y, Yoh M, Takahashi H, Tonegawa‐Kuji R, Miyazaki Y, Shimamoto K, Wakamiya A, Ueda N, Nakajima K, Kamakura T, Wada M, Ishibashi K, Inoue Y, Nagase S, Aiba T, Narai A, Nakase T, Koga M, Fukuda T, Kataoka N, Takagi M, Kusano K. A multicenter prospective randomized study comparing the incidence of periprocedural cerebral embolisms caused by catheter ablation of atrial fibrillation between cryoballoon and radiofrequency ablation (Embo-Abl study): Study design. Clin Cardiol 2022; 46:214-222. [PMID: 36413635 PMCID: PMC9933100 DOI: 10.1002/clc.23949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although catheter ablation (CA) has become a standard therapeutic approach to atrial fibrillation (AF), it imposes a low but relevant risk of thromboembolic complications of around 0.5%-1%, including ischemic strokes, and has an additional risk of clinically silent cerebral embolisms (SCEs) of 10%-40%. Both cryoballoon (CB) and radiofrequency (RF) ablation are routinely used clinically worldwide, yet there are few prospective data comparing the incidence of cerebral embolism after CA of AF between CB and RF ablation. METHODS The aim of the Embo-Abl study will be to compare the incidence of cerebral embolisms on 3 T diffusion-weighted image magnetic resonance imaging (MRI) after CA of AF between CB and RF ablation in patients with AF in a prospective, multicenter, open-label, controlled, randomized fashion. The primary endpoint of the Embo-Abl study will be the occurrence of MRI-detected SCE 1-3 days after CA. The patients will be registered and randomly assigned to either the CB or RF ablation group in a 1:1 ratio. The study cohort will include 230 patients with AF from a multicenter in Japan. RESULTS The results of this study are currently under investigation. CONCLUSION The Embo-Abl study will be the first to compare the incidence of periprocedural cerebral embolisms caused by CA of AF between CB and RF ablation in a prospective, multicenter, randomized, controlled fashion.
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Affiliation(s)
- Koji Miyamoto
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Koshiro Kanaoka
- Center for Cerebral and Cardiovascular Disease Information, Open Innovation CenterNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yasutoshi Ohta
- Department of RadiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Masue Yoh
- Department of Medicine IIKansai Medical UniversityMoriguchiJapan
| | - Hiroki Takahashi
- Department of Medicine IIKansai Medical UniversityMoriguchiJapan
| | - Rena Tonegawa‐Kuji
- Center for Cerebral and Cardiovascular Disease Information, Open Innovation CenterNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yuichiro Miyazaki
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Keiko Shimamoto
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Akinori Wakamiya
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Nobuhiko Ueda
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kenzaburo Nakajima
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Tsukasa Kamakura
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Mitsuru Wada
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Kohei Ishibashi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yuko Inoue
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Satoshi Nagase
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Takeshi Aiba
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Akihisa Narai
- New Development GroupHashimoto Electronic Industry Co., LtdMatsusakaJapan
| | - Tomohiro Nakase
- New Development GroupHashimoto Electronic Industry Co., LtdMatsusakaJapan
| | - Masatoshi Koga
- Department of Cerebrovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Tetsuya Fukuda
- Department of RadiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Naoya Kataoka
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Masahiko Takagi
- Department of Medicine IIKansai Medical UniversityMoriguchiJapan
| | - Kengo Kusano
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
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23
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Reinsch N, Füting A, Höwel D, Bell J, Lin Y, Neven K. Cerebral safety after pulsed field ablation for paroxysmal atrial fibrillation. Heart Rhythm 2022; 19:1813-1818. [PMID: 35718318 DOI: 10.1016/j.hrthm.2022.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pulsed field ablation (PFA) is a novel, nonthermal ablation modality that can ablate myocardial tissue with minimal effects on surrounding tissue. Preclinical data show an absence of cerebral emboli after extensive PFA. However, clinical data on silent cerebral lesions (SCLs) and/or silent cerebral events (SCEs) after PFA are lacking. OBJECTIVES The purpose of this study was to investigate the occurrence of neurological deficits and SCL and/or SCE after PFA in paroxysmal atrial fibrillation (AF) using National Institutes of Health Stroke Scale (NIHSS) scores and magnetic resonance imaging (MRI). METHODS In patients with symptomatic paroxysmal AF, pulmonary vein isolation (PVI) using PFA was performed. NIHSS scores were assessed before and 2 days and 30 days after PVI. One day after PVI, patients underwent cerebral 1.5-T MRI scanning using diffusion-weighted imaging and fluid-attenuated inversion recovery sequences to document the occurrence of SCL/SCE. RESULTS PFA was performed in 30 patients (age 63 ± 10 years). No patient showed neurological deficits. All NIHSS scores showed the minimum value of 0. Cerebral MRI scans were normal in 29 of 30 patients (97%). In 1 patient (3%), a single 7-mm cerebellar lesion was observed. Forty days after the procedure, follow-up cerebral MRI scan showed complete regression of the lesion. CONCLUSION In patients treated with PFA for symptomatic paroxysmal AF, the incidence of MRI-detected asymptomatic thromboembolic cerebral events or lesions was as low as 3%. No neurological deficits occurred in any of the patients.
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Affiliation(s)
- Nico Reinsch
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany.
| | - Anna Füting
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Dennis Höwel
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - John Bell
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Yali Lin
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
| | - Kars Neven
- Department of Electrophysiology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Medicine, Witten/Herdecke University, Witten, Germany
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24
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Bodagh N, Yap R, Kotadia I, Sim I, Bhalla A, Somerville P, O'Neill M, Williams SE. Impact of catheter ablation versus medical therapy on cognitive function in atrial fibrillation: a systematic review. J Interv Card Electrophysiol 2022; 65:271-286. [PMID: 35380337 PMCID: PMC9550702 DOI: 10.1007/s10840-022-01196-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 12/22/2022]
Abstract
PURPOSE Atrial fibrillation is associated with an increased risk of cognitive impairment. It is unclear whether the restoration of sinus rhythm with catheter ablation may modify this risk. We conducted a systematic review of studies comparing cognitive outcomes following catheter ablation with medical therapy (rate and/or rhythm control) in atrial fibrillation. METHODS Searches were performed on the following databases from their inception to 17 October 2021: PubMed, OVID Medline, Embase and Cochrane Library. The inclusion criteria comprised studies comparing catheter ablation against medical therapy (rate and/or rhythm control in conjunction with anticoagulation where appropriate) which included cognitive assessment and/or a diagnosis of dementia as an outcome. RESULTS A total of 599 records were screened. Ten studies including 15,886 patients treated with catheter ablation and 42,684 patients treated with medical therapy were included. Studies which compared the impact of catheter ablation versus medical therapy on quantitative assessments of cognitive function yielded conflicting results. In studies, examining new onset dementia during follow-up, catheter ablation was associated with a lower risk of subsequent dementia diagnosis compared to medical therapy (hazard ratio: 0.60 (95% confidence interval 0.42-0.88, p < 0.05)). CONCLUSION The accumulating evidence linking atrial fibrillation with cognitive impairment warrants the design of atrial fibrillation treatment strategies aimed at minimising cognitive decline. However, the impact of catheter ablation and atrial fibrillation medical therapy on cognitive decline is currently uncertain. Future studies investigating atrial fibrillation treatment strategies should include cognitive outcomes as important clinical endpoints.
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Affiliation(s)
- Neil Bodagh
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Reuben Yap
- Princess Royal University Hospital, Orpington, UK
| | - Irum Kotadia
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Iain Sim
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Ajay Bhalla
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | | | - Mark O'Neill
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Guys and St. Thomas' NHS Foundation Trust, London, UK
| | - Steven E Williams
- King's College London, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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25
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Yokoyama M, Tokuda M, Tokutake K, Sato H, Oseto H, Yokoyama K, Kato M, Narui R, Tanigawa SI, Yamashita S, Yoshimura M, Yamane T. Effect of air removal with extracorporeal balloon inflation on incidence of asymptomatic cerebral embolism during cryoballoon ablation of atrial fibrillation: A prospective randomized study. IJC HEART & VASCULATURE 2022; 40:101020. [PMID: 35434257 PMCID: PMC9010628 DOI: 10.1016/j.ijcha.2022.101020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 11/04/2022]
Abstract
Background It was previously reported, based on a retrospective study, that preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation reduced the incidence of asymptomatic cerebral embolism (ACE). The present study aims to compare the incidence of ACE between a conventional and pre-inflation method during cryoballoon ablation in a prospective randomized controlled study. Methods A total of 98 atrial fibrillation patients were enrolled and randomized into conventional and pre-inflation groups. Patients in the pre-inflation group received balloon massaging with preliminary extracorporeal balloon inflation in saline water before the cryoballoon was inserted into the body. Results The baseline characteristics were similar between the two groups. Post-procedural 3-Tesla MRI revealed CE in 27.6% of patients. Symptomatic CE only occurred in two patients in the pre-inflation group. One patient had transient dysarthria and mild muscle weakness in one hand; the other patient complained of transient left upper limb weakness, left lower limb paresthesia and dysarthria. The incidence of ACE detected by cerebral MRI did not differ between the two groups to a statistically significant extent (conventional vs. pre-inflation; 22.9% vs. 29.2%; P = 0.49). In the multivariable analysis, eGFR was independently associated with the presence of ACE (odds ratio 0.95; 95% confidence interval 0.907–0.995; P = 0.03). Conclusion In this prospective randomized study, the preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation had no impact on the incidence of ACE.
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26
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Haraguchi Y, Nakamura K, Inoue M, Sasaki T, Minami K, Yoshimura S, Naito S. Antiphospholipid Syndrome Diagnosed as a Result of the Occurrence of an Ischemic Stroke After a Successful Catheter Ablation of Atrial Fibrillation and Continuous Direct Oral Anticoagulants. Int Heart J 2022; 63:153-158. [DOI: 10.1536/ihj.21-475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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27
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Improvement of Retinal Microcirculation after Pulmonary Vein Isolation in Patients with Atrial Fibrillation—An Optical Coherence Tomography Angiography Study. Diagnostics (Basel) 2021; 12:diagnostics12010038. [PMID: 35054205 PMCID: PMC8774642 DOI: 10.3390/diagnostics12010038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: To evaluate retinal and optic nerve head (ONH) perfusion in patients with atrial fibrillation (AF) before and after catheter ablation of AF with pulmonary vein isolation (PVI). Methods: 34 eyes of 34 patients with AF and 35 eyes of 35 healthy subjects were included in this study. Flow density data were obtained using spectral-domain OCT-A (RTVue XR Avanti with AngioVue, Optovue, Inc, Fremont, California, USA). The data of the superficial and deep vascular layers of the macula and the ONH (radial peripapillary capillary network, RPC) before and after PVI were extracted and analysed. Results: The flow density in the superficial OCT-angiogram (whole en face) and the ONH (RPC) in patients with AF was significantly lower compared to healthy controls (OCT-A superficial: study group: 48.77 (45.19; 52.12)%; control group: 53.01 (50.00; 54.25)%; p < 0.001; ONH: study group: 51.82 (48.41; 54.03)%; control group: 56.00 (54.35; 57.70)%; p < 0.001;). The flow density in the ONH (RPC) improved significantly in the study group following PVI (before: 51.82 (48.41; 54.03)%; after: 52.49 (50.34; 55.62)%; p = 0.007). Conclusions: Patients with AF showed altered ocular perfusion as measured using OCTA when compared with healthy controls. Rhythm control using PVI significantly improved ocular perfusion as measured using OCT-A. Non-contact imaging using OCTA provides novel information about the central global microperfusion of patients with AF.
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28
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Zheng J, Wang M, Tang QF, Xue F, Li KL, Dang SP, Liu XY, Zhao XX, Zhang CY, Yu ZM, Han B, Jiang TB, Yao Y, Wang RX. Atrial Fibrillation Ablation Using Robotic Magnetic Navigation Reduces the Incidence of Silent Cerebral Embolism. Front Cardiovasc Med 2021; 8:777355. [PMID: 34926624 PMCID: PMC8671737 DOI: 10.3389/fcvm.2021.777355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The incidence of silent cerebral embolisms (SCEs) has been documented after pulmonary vein isolation using different ablation technologies; however, it is unreported in patients undergoing with atrial fibrillation (AF) ablation using Robotic Magnetic Navigation (RMN). The purpose of this prospective study was to investigate the incidence, risk predictors and probable mechanisms of SCEs in patients with AF ablation and the potential impact of RMN on SCE rates. Methods and Results: We performed a prospective study of 166 patients with paroxysmal or persistent AF who underwent pulmonary vein isolation. Patients were divided into RMN group (n = 104) and manual control (MC) group (n = 62), and analyzed for their demographic, medical, echocardiographic, and risk predictors of SCEs. All patients underwent cerebral magnetic resonance imaging within 48 h before and after the ablation procedure to assess cerebral embolism. The incidence and potential risk factors of SCEs were compared between the two groups. There were 26 total cases of SCEs in this study, including 6 cases in the RMN group and 20 cases in the MC group. The incidences of SCEs in the RMN group and the MC group were 5.77 and 32.26%, respectively (X2 = 20.63 P < 0.05). Univariate logistic regression analysis demonstrated that ablation technology, CHA2DS2-VASc score, history of cerebrovascular accident/transient ischemic attack, and low ejection fraction were significantly associated with SCEs, and multivariate logistic regression analysis showed that MC ablation was the only independent risk factor of SCEs after an AF ablation procedure. Conclusions: Ablation technology, CHA2DS2-VASc score, history of cerebrovascular accident/transient ischemic attack, and low ejection fraction are associated with SCEs. However, ablation technology is the only independent risk factor of SCEs and RMN can significantly reduce the incidence of SCEs resulting from AF ablation. Clinical Trial Registration: ChiCTR2100046505.
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Affiliation(s)
- Jie Zheng
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Meng Wang
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Qun-Feng Tang
- Department of Radiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Feng Xue
- Department of Cardiology, The First Hospital Affiliated to Soochow University, Suzhou, China
| | - Ku-Lin Li
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Shi-Peng Dang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiao-Yu Liu
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiao-Xi Zhao
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Chang-Ying Zhang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Zhi-Ming Yu
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Bing Han
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, China
| | - Ting-Bo Jiang
- Department of Cardiology, The First Hospital Affiliated to Soochow University, Suzhou, China
| | - Yan Yao
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences - Peking Union Medical College, Beijing, China
| | - Ru-Xing Wang
- Department of Cardiology, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
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29
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Toso E, Gagliardi M, Peyracchia M, Angelini F, Anselmino M, Ferraris F, Giustetto C, Scaglione M, Gaita F. Long-term efficacy and impact on quality of life of atrial fibrillation catheter ablation in competitive athletes. J Sports Med Phys Fitness 2021; 62:1266-1271. [PMID: 34931787 DOI: 10.23736/s0022-4707.21.13257-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Limited data are available on the efficacy of catheter ablation (CA) for sport-associated atrial fibrillation (AF), in particular at long term follow up. Moreover, the impact of AF CA on quality of life (QoL) in this population remains unknown. We aimed to determine AF CA efficacy in athletes, to assess the impact on athletes' QoL (with SF36 score) and on training capabilities in a long term follow up (FU). METHODS A total of 1215 AF patients' candidates to CA between January 2007 and December 2012, were retrospectively screened. Athletes were defined as patients performing ≥ 5h/week of vigorous sports, achieving a total of ≥1500 h lifetime sports activity, for at least one year before AF first symptomatic episode. RESULTS Out of 1215 AF patients, 133 were considered competitive athletes and underwent to CA. Overall, 43% of our cohort showed typical or atypical atrial flutter, which required a more extensive ablation procedure. Before AF, athletes used to practice for a mean of 8.5±2.7 h/week, while after the first AF episode the mean practice duration decreased to 2.82.5 h/week. At 10-year follow up, 83% of athletes did not present any recurrent event, and training capabilities increased up to 5.6±3.6 h/week after the procedure. Moreover, intense physical activity before AF CA was related to longterm AF recurrence rates (P = 0.05). QoL scores significantly improved in each single domains (P < 0.05). CONCLUSIONS AF CA represents an effective procedure to maintain sinus rhythm in athletes, with a significant improvement in QoL.
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Affiliation(s)
- Elisabetta Toso
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy - .,Cardiology Consultant at Juventus Football Club, Turin, Italy -
| | - Marco Gagliardi
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Mattia Peyracchia
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Filippo Angelini
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Matteo Anselmino
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Federico Ferraris
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Carla Giustetto
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marco Scaglione
- Cardiology Division, Cardinal Massaia Hospital of Asti, Asti, Italy
| | - Fiorenzo Gaita
- Cardiology Division, Department of Medical Sciences, AOU Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy.,Cardiology Consultant at Juventus Football Club, Turin, Italy
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30
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Kawaji T, Morimoto T, Aizawa T, Hojo S, Kushiyama A, Yaku H, Nakatsuma K, Kaneda K, Kato M, Yokomatsu T, Miki S, Kimura T. Different Kinetics of Activated Clotting Time among Uninterrupted Oral Anticoagulants during Catheter Ablation Procedure. J Clin Pharmacol 2021; 62:792-800. [PMID: 34921561 DOI: 10.1002/jcph.2018] [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: 10/28/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022]
Abstract
Activated clotting time (ACT) kinetics under uninterrupted oral anticoagulants (OACs) has not been fully evaluated. The present study is sought to validate ACT kinetics including stability under uninterrupted use of OACs during ablation procedure in daily clinical practice. We prospectively enrolled consecutive 554 atrial fibrillation patients who underwent catheter ablation procedure under uninterrupted OACs. We evaluated ACT kinetics at an interval of 15 minutes during the procedure and periprocedural complications among five OACs (dabigatran [N = 46], rivaroxaban [N = 125], apixaban [N = 129], edoxaban [N = 184], and warfarin [N = 70]). Compared with the dabigatran group, time to achieve target ACT was significantly longer in the rivaroxaban and apixaban groups, but not in the edoxaban and warfarin groups (8.7 minutes versus 11.7 minutes, P <0.001; 13.3 minutes, P <0.001; 8.8 minutes, P = 0.64; 10.3 minutes, P = 0.19, respectively). Heparin dose to achieve target ACT was comparable except for the warfarin group. Whereas, compared with the dabigatran group, time in therapeutic range of ACT (ACT-TTR) within the first 1 hour was comparable in the rivaroxaban and apixaban group, but significantly lower in the edoxaban and warfarin groups (73.7 % versus 63.0%, P = 0.06; 67.0 %, P = 0.16; 59.2 %, P = 0.001; 58.2%, P = 0.004, respectively). In multiple regression analysis, low body weight, rivaroxaban, apixaban, and AM session had significant associations with time and heparin dose to achieve target ACT, and there were positive associations of dabigatran and apixaban with ACT-TTR within the first 1 hour. The incidence of periprocedural complications did not significantly differ among the five groups. Under uninterrupted OAC use in daily clinical practice, dabigatran showed faster achievement of target ACT and higher stability of ACT than other OACs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tetsuma Kawaji
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan.,Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takanori Aizawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shun Hojo
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | | | - Hidenori Yaku
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Kenji Nakatsuma
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Kazuhisa Kaneda
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | | | - Shinji Miki
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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The AF-FICIENT magnetic resonance imaging and endoscopy safety substudy: A visually guided radiofrequency balloon ablation catheter for pulmonary vein isolation. Heart Rhythm O2 2021; 3:15-22. [PMID: 35243431 PMCID: PMC8859808 DOI: 10.1016/j.hroo.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Early experience with a novel multielectrode saline-irrigated radiofrequency balloon (RFB) catheter with an integrated camera system found that it was safe and effective in performing single-shot pulmonary vein isolation (PVI) for atrial fibrillation. Objective The purpose of this study was to further assess potential treatment risks by looking for subclinical events. Methods The study was performed at 2 sites. Patients underwent PVI by RFB. A control group underwent conventional point-by-point radiofrequency ablation. Stroke scale questionnaire and brain magnetic resonance imaging (MRI) were performed before and after the ablation procedure, and esophageal endoscopy was performed after the procedure in RFB patients only. Results We enrolled 27 patients in the RFB group and 15 patients in the control group. The RFB and control groups were well matched [predominantly male: 62% vs 53%; CHA2DS2-VASc score: 1.9 ± 1.3 vs 1.5 ± 1.6; mean age 60 years in both groups]. All patients underwent successful ablation and completed study assessments. Clinically silent, new MRI diffusion weighted imaging cerebral lesions were observed in 8 patients (30%) in the RFB group and 1 patient (7%) in the control group, and 11 susceptibility weighted imaging lesions in the RFB group and 1 in the control group. Endoscopy showed a minor thermal injury in 1 patient in the RFB group. Conclusion An increased rate of clinically silent cerebral events was seen in the RFB group. A low rate of esophageal thermal injury was observed.
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Osawa T, Mori H, Kawai A, Kawano D, Tsutsui K, Ikeda Y, Yamaga M, Sato A, Gatate Y, Hamabe A, Tabata H, Kato R, Matsumoto K. Effects of uninterrupted dabigatran on the intensity of anticoagulation during atrial fibrillation ablation. J Arrhythm 2021; 38:58-66. [PMID: 35222751 PMCID: PMC8851590 DOI: 10.1002/joa3.12655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/25/2021] [Accepted: 11/04/2021] [Indexed: 11/09/2022] Open
Abstract
Background Uninterrupted dabigatran during atrial fibrillation (AF) ablation is now established as the standard therapy. However, there are few reports on the effects of uninterrupted dabigatran on the intensity of anticoagulation during AF ablation. Methods We retrospectively analyzed 247 consecutive patients who underwent AF ablation in our hospital from January 2017 to December 2018. Patients who took warfarin or uninterrupted direct oral anticoagulants (DOACs) except for dabigatran were excluded. 89 patients underwent ablation with uninterrupted dabigatran (uninterrupted group, male 71, mean age 59.6 ± 14.0) and 124 with interrupted DOACs (interrupted group, male 105, mean age 56.9 ± 12.9) during AF ablation. The initial ACT level, proportion of ACT levels of more than 300 s, and total amount of heparin were compared. Furthermore, the incidence of procedure complications was also evaluated. Results The initial ACT levels were significantly higher in the uninterrupted group, and the total number of ACTs of more than 300 s was significantly higher in the uninterrupted group (uninterrupted vs. interrupted; initial ACT level, 315.6 ± 59.8 vs. 264.5 ± 48.6, p < .001; total number of ACTs ≧300, n [%], 304/ 484 [62.8 %] vs. 372/745 [49.9%], p < .001). The total amount of heparin during procedure was significantly lower in the uninterrupted group (uninterrupted group vs. interrupted group; 12966 ± 4773 vs. 16371 ± 5212, p < .001). There was no significant difference in the incidence of complications between the two groups. Conclusions In the catheter ablation of AF, uninterrupted dabigatran would be useful to obtain a stable anticoagulation status during the entire procedure.
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Affiliation(s)
- Takumi Osawa
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Hitoshi Mori
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
- Department of Cardiology Saitama Medical University International Medical Center Hidaka Japan
| | - Akane Kawai
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Daisuke Kawano
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
- Department of Cardiology Saitama Medical University International Medical Center Hidaka Japan
| | - Kenta Tsutsui
- Department of Cardiology Saitama Medical University International Medical Center Hidaka Japan
| | - Yoshifumi Ikeda
- Department of Cardiology Saitama Medical University International Medical Center Hidaka Japan
| | - Mitsuki Yamaga
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Atsushi Sato
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Youdou Gatate
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Akira Hamabe
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Hirotsugu Tabata
- Department of Cardiology Japan Self Defense Forces Central Hospital Setagaya Japan
| | - Ritsushi Kato
- Department of Cardiology Saitama Medical University International Medical Center Hidaka Japan
| | - Kazuo Matsumoto
- Department of Cardiology Saitama Medical University International Medical Center Hidaka Japan
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Konishi H, Suzuki A, Hohmann S, Parker KD, Newman LK, Monahan KH, Rettmann ME, Packer DL. Comparison of Microemboli Formation Between Irrigated Catheter Tip Architecture Using a Microemboli Monitoring System. JACC Clin Electrophysiol 2021; 8:26-37. [PMID: 34454888 DOI: 10.1016/j.jacep.2021.06.012] [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: 02/23/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to compare the efficacy and safety of ablation with high and low power settings using either a flexible tip or straight SF tip irrigated catheter in the left ventricle (LV) using a peripheral microemboli monitoring system. BACKGROUND The microemboli risk of flexible and straight SF tip irrigated catheters in creating ablative lesions in the LV at variable power settings has not been adequately assessed. METHODS Six pigs underwent catheter ablation in the LV using a flexible tip or straight SF tip catheter with 2 energy settings (30 or 50 W, 30 seconds, irrigation saline 17 mL/min). RESULTS A total of 79 radiofrequency (RF) applications were assessed. High power settings via a flexible tip formed a significantly higher arterial microbubble volume in the extracorporeal circulation (P = 0.005). Notably, RF applications with a steam pop induced an exponential increase of microbubble volume with both catheters. A higher power setting induced a significantly higher number of microembolic signals on carotid artery Doppler ultrasound with a flexible tip irrigated catheter (P < 0.001). Similarly, the straight SF tip irrigated catheter tended to increase the number of microembolic signals with 50 W (P = 0.091). CONCLUSIONS RF ablation at high power settings in the LV carries a risk of microembolic events compared with lower power settings. When high power settings are used for creating ablative lesions for deep intramural foci in the LV, the risk of microembolic events induced by RF ablation should be carefully monitored.
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Affiliation(s)
- Hiroki Konishi
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Atsushi Suzuki
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Stephan Hohmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kay D Parker
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura K Newman
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristi H Monahan
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Maryam E Rettmann
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Translational Interventional Electrophysiology Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
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Lakkireddy D, Shenthar J, Garg J, Padmanabhan D, Gopinathannair R, Di Biase L, Romero J, Mohanty S, Burkhardt DJ, Al-Ahmad A, Atkins D, Bommana S, Natale A. SafeTy and Efficacy of Direct Oral Anticoagulant versus Aspirin for Reduction Of RisK of CErebrovascular Events in Patients Undergoing Ventricular Tachycardia Ablation (STROKE-VT). JACC Clin Electrophysiol 2021; 7:1493-1501. [PMID: 34393085 DOI: 10.1016/j.jacep.2021.07.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The STROKE-VT is a multicenter, randomized controlled trial that studied the differences in cerebrovascular events (CVE) between direct oral anticoagulant (DOAC) vs. ASA use post-procedurally in patients undergoing left ventricular arrhythmia (LVA) ablation [ventricular tachycardia (VT) or premature ventricular contraction (PVC)] using radiofrequency ablation (RFA). METHODS 246 patients scheduled for LVA-RFA were randomized 1:1 post-procedurally to receive DOAC or ASA. The study's primary endpoint was the incidence of stroke or TIA, or MRI detected asymptomatic cerebrovascular events (ACE) at 24 hours and 30 days follow-up. The secondary endpoints included procedure-related complications (composite of any vascular complication, pericardial complication, heart block, thromboembolic event excluding stroke or TIA) and in-hospital mortality. RESULTS There were no differences between groups regarding baseline and ablation characteristics (except the percentage of patients undergoing VT ablation, rate of amiodarone use, and total RFA time). Post-procedure cerebrovascular events (stroke and TIA) were lower in the DOAC arm versus ASA arm (0% vs. 6.5%, p<0.001 and 4.9% vs. 18%, p < 0.001; respectively). Patients in the ASA group had higher MRI detected ACE compared to the DOAC group both at 24 hours (23% vs. 12%, p = 0.03) and 30 days (18% vs. 6.5%, p = 0.006) follow-up. The acute procedure-related complication and in-hospital mortality were similar between the two groups. CONCLUSION DOAC utilization following endocardial/epicardial ablation for LVA-RFA was associated with reduced risk of transient ischemic attack or stroke, and asymptomatic MRI-detected cerebrovascular event.
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Affiliation(s)
- Dhanunjaya Lakkireddy
- Division of Cardiology, Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS.
| | - Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 9th Block Jayanagar, Bannerghatta Road, Bengaluru, India
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, CA
| | - Deepak Padmanabhan
- Department of Cardiology, Sri Jayadeva Institute of Cardiac Sciences and Research, Bengaluru, India
| | - Rakesh Gopinathannair
- Division of Cardiology, Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS
| | - Luigi Di Biase
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
| | - Jorge Romero
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
| | - David J Burkhardt
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
| | - Donita Atkins
- Division of Cardiology, Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS
| | - Sudha Bommana
- Division of Cardiology, Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX
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Incidence and risk factors of post-operative cognitive decline after ablation for atrial fibrillation. BMC Cardiovasc Disord 2021; 21:341. [PMID: 34261448 PMCID: PMC8278748 DOI: 10.1186/s12872-021-02139-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/24/2021] [Indexed: 12/05/2022] Open
Abstract
Background Catheter ablation is widely used in atrial fibrillation (AF) management. In this study, we are aimed to investigate the incidence of postprocedural cognitive decline in a larger population undergoing AF ablation under local anesthesia, and to evaluate the associated risk factors. Methods This study included 287 patients with normal cognitive functions, with 190 ablated AF patients (study group) and 97 AF patients who are awaiting ablation (practice group). We assessed the neuropsychological function of each patient for twice (study group: 24 h prior to ablation and 48 h post ablation; practice group: on the day of inclusion and 72 h later but before ablation). The reliable change index was used to analyze the neuropsychological testing scores and to identify postoperative cognitive dysfunction (POCD) at 48 h post procedure. Patients in the study group accepting a 6-month follow up were given an extra cognitive assessment. Results Among the ablated AF patients, 13.7% (26/190) had POCD at 48 h after the ablation procedure. Multivariable analysis revealed that, a minimum intraoperative activated clotting time (ACT) < 300 s (OR 3.82, 95% CI 1.48–9.96, P = 0.006) and not taking oral anticoagulants within one month prior to ablation(OR 10.35, 95% CI 3.54–30.27, P < 0.001) were significantly related to POCD at 48 h post-ablation. In 172 patients of the study group accepting a 6-month follow up, there were 23 patients with POCD at 48 h post-ablation and 149 patients without POCD. The global cognitive scores were decreased in 48 h post-operation tests (0 ± 1 vs − 0.15 ± 1.10, P < 0.001) and improved significantly at 6 months post-operation (0 ± 1 vs 0.43 ± 0.92, P < 0.001). In the 23 patients with POCD at 48 h after the procedure, global cognitive performance at 6 months was not significantly different compared with that at baseline (− 0.05 ± 1.25 vs − 0.19 ± 1.33, P = 0.32), while 13 of them had higher scores than baseline level. Conclusions Incident of POCD after ablation procedures is high in the short term. Inadequate periprocedural anticoagulation are possible risk factors. However, most POCD are reversible at 6 months, and a general improvement was observed in cognitive function at 6 months after ablation.
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Kussman BD, Imaduddin SM, Gharedaghi MH, Heldt T, LaRovere K. Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting. Anesth Analg 2021; 133:379-392. [PMID: 33764341 DOI: 10.1213/ane.0000000000005417] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.
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Affiliation(s)
- Barry D Kussman
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Syed M Imaduddin
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Mohammad Hadi Gharedaghi
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, the Institute for Medical Engineering and Science, and the Research Laboratory of Electronics, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.,Department of Neurology, Harvard Medical School, Boston, Massachusetts
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Safani M, Tobias S, Shandling AH, Redmond K, Lee MY. Comprehensive Intraprocedural Unfractionated Heparin Protocol During Catheter Ablation of Atrial Fibrillation in the Presence of Direct Oral Anticoagulants and Wide Spectrum of Body Mass Index. J Cardiovasc Pharmacol Ther 2021; 26:349-358. [PMID: 33749350 DOI: 10.1177/1074248421998492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Data on optimal dosing of unfractionated heparin (UFH) in the presence of a direct oral anticoagulant (DOAC) to achieve and maintain an activated clotting time (ACT) of ≥300 seconds during catheter ablation of atrial fibrillation (CA-AF) are limited and prevalence of obesity adds to the unpredictable response to UFH. METHODS AND RESULTS One hundred seventeen consecutive patients undergoing CA-AF were prospectively administered weight-adjusted, weight-based UFH using a pre-specified detailed protocol and retrospectively analyzed. Due to lack of distribution of UFH into muscle or adipose tissue and lower degree of vascularity in the latter compartment, each patient's ideal and actual weights were used to determine the adjusted-weight for use in all UFH doses. A UFH bolus of 200 units/kg was administered intravenously followed by an infusion of 35 units/kg/hour. The mean age was 65 years, and 85 patients (72.6%) were male. The average body mass index (BMI) was 30 (range 18-50) kg/m2. After the initial UFH bolus dose, 99 patients (84.6%) achieved ACT ≥300 sec with a mean (± SD) of 380 ± 79 sec. The mean time to reach an ACT ≥300 in all patients was 14.6 ± 12.4 minutes. Among all measured ACT values, 423 (90.8%) were ≥300 seconds. These results were consistent within all BMI categories. There were no intraprocedural thrombotic or hemorrhagic complications. Two patients (1.7%) sustained groin vascular access site hematoma without subsequent intervention and 7 patients (6%) experienced minor oozing post-procedurally. CONCLUSIONS Our comprehensive weight-adjusted, weight-based UFH protocol, during CA-AF in presence of a DOAC, rapidly achieved and maintained an effective ACT irrespective of BMI.
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Affiliation(s)
- Michael Safani
- Department of Pharmacy Services / MemorialCare Heart & Vascular Institute, Long Beach, CA, USA.,University of California, San Francisco, CA, USA
| | - Serge Tobias
- 323637MemorialCare Heart & Vascular Institute, Long Beach, CA, USA.,University of California, Irvine, CA, USA
| | - Adrian H Shandling
- 323637MemorialCare Heart & Vascular Institute, Long Beach, CA, USA.,University of California, Irvine, CA, USA
| | - Kathryn Redmond
- 323637MemorialCare Heart & Vascular Institute, Long Beach, CA, USA
| | - Mark Young Lee
- 323637MemorialCare Heart & Vascular Institute, Long Beach, CA, USA.,University of California, Irvine, CA, USA
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Hyperintense Brain Lesions in Asymptomatic Low Risk Patients with Paroxysmal Atrial Fibrillation Undergoing Radiofrequency Pulmonary Vein Isolation. J Clin Med 2021; 10:jcm10040565. [PMID: 33546182 PMCID: PMC7913160 DOI: 10.3390/jcm10040565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim was to determine the occurrence, consequences and risk factors for brain white matter hyperintensities (WMH) assessed in magnetic resonance imaging (MRI) in low-risk patients with paroxysmal atrial fibrillation (AF) undergoing radiofrequency pulmonary vein isolation (PVI-RF). METHODS 74 patients with AF (median 58.5 years (IQR 50-63), 45 male) were included. Before and after a minimum of 6 months after PVI-RF, a brain MRI and a mini-mental state examination (MMSE) were performed. RESULTS Baseline WMH lesions were found in 55 (74.3%) patients and in 48 from 62 (77.4%) patients after PVI-RF. The WMH lesions were more frequent among older patients, with a higher CHA2DS2-Vasc (C-Congestive heart failure/LV dysfunction, H-Hypertension, A-Age, D-Diabetes mellitus, S-Stroke, V-Vascular Disease, Sc-Sex category). Factors affecting the severity of the WMH were: older age, the co-existence of the PFO and coronary artery disease (CAD). After a follow-up period, the factors predisposing to brain WMH lesions occurrence (age, higher BMI and CHA2DS2-Vasc score) and to the more advanced changes (age, higher CHA2DS2-Vasc score, CAD, PFO) were obtained. CONCLUSIONS The presence and severity of cerebral microembolism are associated with age, higher CHA2DS2-Vasc score and the coexistence of PFO and CAD. PVI-RF procedure and its efficacy does not influence on MRI lesions. In this population, cerebral microembolism is not related to cognitive impairment.
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Karanian JW, Krishnasamy VP, Guidry RM, Hecht R, Woods DL, Esparza-Trujillo JA, Bakhutshvili I, Pritchard WF, Wood BJ. Monopolar Radiofrequency Energy Delivered by a Conductive Endovascular Basket or Guidewire Leads to Thermal Occlusion in a Swine Model. J Vasc Interv Radiol 2020; 31:1874-1885. [PMID: 33129433 DOI: 10.1016/j.jvir.2020.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/18/2020] [Accepted: 04/28/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To assess the feasibility of inducing vascular occlusion by application of radiofrequency (RF) energy via conductive endovascular wires or baskets. MATERIALS AND METHODS A retrievable nitinol basket and stainless steel guidewire with a platinum tip were evaluated as conductors for endovascular application of RF energy. Tissue-mimicking thermochromic gel phantoms that change color with heating were cast with 2-, 5-, and 7-mm-diameter lumens and filled with 37 oC saline. After ablation, the phantoms were sectioned, and the thermal footprints were evaluated. Six castrated male domestic swine underwent endovascular ablation using the basket in iliac arteries and guidewires in renal arteries. Post-procedural angiography was performed, and postmortem arterial segments were resected for histopathologic analysis. RESULTS In the phantom, the depth of thermal change in the 5- and 7-mm lumens averaged 6.3 and 6.0 mm along the basket, respectively, and in the 2- and 5-mm lumens, the depth of thermal change averaged 1.9 and 0.5 mm along the wire, respectively. In the swine, RF energy delivery led to angiographic occlusion at 12 of 13 sites. Thermal injury and occlusion were similar at the proximal, middle, and distal basket treatment zone, whereas injury and occlusion decreased from the proximal to the distal end of the 5-cm wire treatment zone. CONCLUSIONS Endovascular delivery of RF energy via a conductive basket in medium-sized arteries or a guidewire in small arteries led to acute angiographic and histologic occlusion. The potential to induce stasis might be useful in settings where rapid occlusion is desirable.
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Affiliation(s)
- John W Karanian
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892.
| | - Venkatesh P Krishnasamy
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - Russ M Guidry
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - Rachel Hecht
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - David L Woods
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - Juan A Esparza-Trujillo
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - Ivane Bakhutshvili
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - William F Pritchard
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
| | - Bradford J Wood
- Center for Interventional Oncology, Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, 10 Center Drive, Room 3N320C, MSC 1182, Bethesda, MD, 20892
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Nakamura K, Sasaki T, Take Y, Minami K, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Effect of preventing air intrusion on silent strokes during atrial fibrillation ablation using a mini-basket catheter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:71-81. [PMID: 33216388 DOI: 10.1111/pace.14131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Yuko Miki
- 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
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Maebashi, Japan
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Nakamura K, Sasaki T, Take Y, Minami K, Inoue M, Asahina C, Sasaki W, Kishi S, Yoshimura S, Okazaki Y, Motoda H, Niijima K, Miki Y, Goto K, Kaseno K, Yamashita E, Koyama K, Funabashi N, Naito S. Incidence and characteristics of silent cerebral embolisms after radiofrequency-based atrial fibrillation ablation: A propensity score-matched analysis between different mapping catheters and indices for guiding ablation. J Cardiovasc Electrophysiol 2020; 32:16-26. [PMID: 33141496 DOI: 10.1111/jce.14800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/24/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.
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Affiliation(s)
- Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Chisa Asahina
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Wataru Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shohei Kishi
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yoshinori Okazaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Hiroyuki Motoda
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Katsura Niijima
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yuko Miki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Koji Goto
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Kenichi Kaseno
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Eiji Yamashita
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Keiko Koyama
- Division of Radiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Nobusada Funabashi
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
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Pillarisetti J, Reddy M, Vodapally M, Annapureddy T, Molugu M, Atkins D, Bommana S, Pimentel R, Dendi R, Lakkireddy D. Comparison of peri-procedural anticoagulation with rivaroxaban and apixaban during radiofrequency ablation of atrial fibrillation. Indian Pacing Electrophysiol J 2020; 20:261-264. [PMID: 32810538 PMCID: PMC7691779 DOI: 10.1016/j.ipej.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/27/2020] [Accepted: 08/10/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Prospective studies on rivaroxaban and apixaban have shown the safety and efficacy of direct anticoagulation agents (DOAC)s used peri-procedurally during radiofrequency ablation (RFA) of atrial fibrillation (AF). Studies comparing the two agents have not been performed. METHODS Consecutive patients from a prospective registry who underwent RFA of AF between April 2012 and March 2015 and were on apixaban or rivaroxaban were studied. Clinical variables and outcomes were noted. RESULTS There were a total of 358 patients (n = 56 on apixaban and n = 302 on rivaroxaban). There were no differences in baseline characteristics between both groups. The last dose of rivaroxaban was administered the night before the procedure in 96% of patients. In patients on apixaban, 48% of patients whose procedure was in the afternoon took the medication on the morning of the procedure. TIA/CVA occurred in 2 patients (0.6%) in rivaroxaban group with none in apixaban group (p = 0.4). There was no difference in the rate of pericardial effusion between apixaban and rivaroxaban groups [1.7% vs 0.6% (p = 0.4)]. Five percent of patients in both groups had groin complications (p = 0.9). In apixaban group, all groin complications were small hematomas except one patient who had a pseudoaneurysm (1.6%). One pseudo-aneurysm, 1 fistula and 3 large hematomas were noted in patients on rivaroxaban (1.7%) with the rest being small hematomas. DOACs were restarted post procedure typically 4 h post hemostasis. CONCLUSIONS Peri-procedural uninterrupted use of apixaban and rivaroxaban during AF RFA is safe and there are no major differences between both groups.
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Affiliation(s)
| | - Madhu Reddy
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Mamatha Vodapally
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Tulasi Annapureddy
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Maruthsakhi Molugu
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Donita Atkins
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Sudharani Bommana
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Rhea Pimentel
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
| | - Raghuveer Dendi
- UT Health San Antonio, KCHRI, University of Kansas Hospital, Kansas City, KS, USA
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Parameswaran R, Al-Kaisey AM, Kalman JM. Catheter ablation for atrial fibrillation: current indications and evolving technologies. Nat Rev Cardiol 2020; 18:210-225. [PMID: 33051613 DOI: 10.1038/s41569-020-00451-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
Catheter ablation for atrial fibrillation (AF) has emerged as an important rhythm-control strategy and is by far the most common cardiac ablation procedure performed worldwide. Current guidelines recommend the procedure in symptomatic patients with paroxysmal or persistent AF who are refractory or intolerant to antiarrhythmic drugs. The procedure might also be considered as a first-line approach in selected asymptomatic patients. Data from large registries indicate that AF ablation might reduce mortality and the risk of heart failure and stroke, but evidence from randomized controlled trials is mixed. Pulmonary vein isolation using point-by-point radiofrequency or with the cryoballoon remains the cornerstone technique in AF ablation. Additional atrial ablation can be performed in patients with persistent AF, but its benefits are largely unproven. Technological advances in the past decade have focused on achieving durable vein isolation, reducing procedure duration and improving safety. Numerous exciting new technologies are in various stages of development. In this Review, we discuss the relevant data to support the recommended and evolving indications for catheter ablation of AF, describe the different ablation techniques, and highlight the latest advances in technology that aim to improve its safety and efficacy. We also discuss lifestyle modification strategies to improve ablation outcomes.
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Affiliation(s)
- Ramanathan Parameswaran
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Ahmed M Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Australia.
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Kim YG, Shim J, Boo KY, Kim DY, Lee KN, Choi JI, Kim YH. Slit-based irrigation catheters can reduce procedure-related ischemic stroke in atrial fibrillation patients undergoing radiofrequency catheter ablation. PLoS One 2020; 15:e0239339. [PMID: 33002011 PMCID: PMC7529237 DOI: 10.1371/journal.pone.0239339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022] Open
Abstract
Open irrigation ablation catheters are now the standard in radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF). Among various irrigation catheters, laser-cut slit-based irrigation system (Cool Flex and FlexAbility) has a unique design to cool the catheter tip more efficiently. We aimed to assess the safety of slit-based irrigation catheters regarding prevention of procedure-related ischemic complication in AF patients undergoing RFCA. The analysis was performed with Korea University Medicine Anam Hospital RFCA registry. Procedure-related ischemic complication was defined as ischemic stroke or transient ischemic attack (TIA) occurring within 30 days after RFCA. Patients were divided into 3 groups: non-irrigation, hole-based irrigation, and slit-based irrigation catheter groups. A total of 3,120 AF patients underwent first RFCA. Non-irrigation, non-slit-based irrigation, and slit-based irrigation catheters were used in 290, 1,539, and 1,291 patients, respectively. As compared with non-irrigation and non-slit-based irrigation catheter groups, slit-based irrigation catheter group had significantly older age, higher prevalence of non-paroxysmal AF, large left atrial size, and decreased left atrial appendage flow velocity. The CHA2DS2-VASc score was not different among the 3 groups. Procedure-related ischemic complication occurred in 17 patients (0.54%) with 16 ischemic strokes and 1 TIA event: 5/290 (1.72%), 11/1,539 (0.71%), and 1/1,291 (0.08%) events in non-irrigation, non-slit-based irrigation, and slit-based irrigation catheter groups, respectively (p = 0.001). Slit-based irrigation catheter was superior in direct comparison with non-slit-based irrigation catheter (0.71% vs. 0.08%; p = 0.009). Slit-based irrigation catheters were highly effective in preventing procedure-related ischemic complications.
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Affiliation(s)
- Yun Gi Kim
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
| | - Jaemin Shim
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Ki Yung Boo
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
| | - Do Young Kim
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
| | - Kwang-No Lee
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Arrhythmia Center, Korea University Medicine, Seoul, Republic of Korea
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El Baba M, Sabayon D, Refaat MM. Radiofrequency Catheter Ablation: How to Manage and Prevent Collateral Damage? J Innov Card Rhythm Manag 2020; 11:4234-4240. [PMID: 32983592 PMCID: PMC7510472 DOI: 10.19102/icrm.2020.110901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Radiofrequency catheter ablation has become the standard of care for the management of various arrhythmias and, in fact, the first-line therapy for many tachyarrhythmias. It entails creating scar tissue in the heart in regions where abnormal impulses form or propagate to restore normal cardiac conduction. As the heart is a complex organ and is surrounded by and related to many other anatomical structures, it is important to avoid the collateral damage that can happen from radiofrequency (RF) ablation on the endocardium as well as on the epicardium. This review explores methods for mitigating or limiting collateral damage during catheter ablation.
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Affiliation(s)
- Mohammad El Baba
- Electrophysiology Section, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Dean Sabayon
- Electrophysiology Section, Emory University Hospital, Atlanta, GA, USA
| | - Marwan M Refaat
- Department of Internal Medicine, Division of Cardiology/Electrophysiology Section, American University of Beirut Medical Center, Beirut, Lebanon.,Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine, Beirut, Lebanon
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Uninterrupted use of direct oral anticoagulants versus vitamin K antagonists for catheter ablation of atrial fibrillation with PVAC gold: incidence of silent cerebral microembolic events. J Interv Card Electrophysiol 2020; 62:39-47. [PMID: 32951115 DOI: 10.1007/s10840-020-00863-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Silent cerebral microembolic events (SCE) after duty-cycled ablation of atrial fibrillation using PVAC have been detected by cerebral magnet resonance imaging (MRI) in a substantial number of patients. The purpose of this study was to investigate if uninterrupted oral anticoagulation with non-vitamin K antagonists (NOACs) compared with vitamin K antagonists (VKA) affects the incidence of SCE after pulmonary vein isolation (PVI) using PVAC Gold. METHODS Eighty-four consecutive patients (62 ± 15 years, 58% male) undergoing a first PVI were prospectively enrolled. Of these, 42 were on VKA and 42 on uninterrupted NOAC treatment. An activated clotting time (ACT) ≥ 350 s was targeted for ablation. RESULTS Cerebral MRI the day after PVI revealed acute diffusion-weighted positive lesions in 11/42 (26%) VKA compared with 14/42 (33%) in NOAC patients (p = 0.634). No differences were found for lesion size, number of lesions/patient, and number of lesions indicating cerebral infarction (2.4% for VKA and 4.8% for NOAC patients). Seventy-five percent of NOAC patients with sporadic ACT levels < 300 s during PVI developed SCE compared with 22% of corresponding VKA patients (p = 0.030). VKA and NOAC subgroups with ACT ≥ 350 s had no reduced incidence of SCE compared with ACT 300-350 s. CONCLUSIONS A significant, but comparable, number of patients under uninterrupted anticoagulation with VKA or NOACs still experience SCE after PVAC Gold PVI. NOAC patients with sporadic subtherapeutic ACT levels during PVI are at the highest risk for SCE while permanent ACT levels ≥ 350 s did not further reduce the incidence of SCE in both groups.
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Harada M, Motoike Y, Nomura Y, Nishimura A, Koshikawa M, Murayama K, Ohno Y, Watanabe E, Ozaki Y, Izawa H. Factors associated with silent cerebral events during atrial fibrillation ablation in patients on uninterrupted oral anticoagulation. J Cardiovasc Electrophysiol 2020; 31:2889-2897. [PMID: 32786019 DOI: 10.1111/jce.14716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/29/2020] [Accepted: 08/08/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Silent cerebral events (SCEs) are related to the potential thromboembolic risk in atrial fibrillation (AF) ablation. Periprocedural uninterrupted oral anticoagulation (OAC) reportedly reduced the risk of SCEs, but the incidence still remains. METHODS AND RESULTS AF patients undergoing catheter ablation were eligible. All patients took non-vitamin K antagonist oral anticoagulants (NOACs; n = 248) or vitamin K antagonist (VKA; n = 37) for periprocedural OAC (>4 weeks) without interruption during the procedure. Brain magnetic resonance imaging was performed within 2 days after the procedure to detect SCEs. Clinical characteristics and procedure-related parameters were compared between patients with and without SCEs. SCEs were detected in 66 patients (23.1%; SCE[+]) but were not detected in 219 patients (SCE[-]). Age was higher in SCE[+] than in SCE[-] (66 ± 10 vs. 62 ± 12 years; p < .05). Persistent AF prevalence, CHADS2 /CHA2 DS2 -VASc scores, serum NT-ProBNP levels, left atrial dimension (LAD), and spontaneous echo contrast prevalence in transesophageal echocardiography significantly increased in SCE[+] versus SCE[-]. SCE[+] had lower baseline activated clotting time (ACT) before heparin injection and longer time to reach optimal ACT (>300 s) than SCE[-] (146 ± 27 vs. 156 ± 29 s and 44 ± 30 vs. 35 ± 25 min; p < .05, respectively). In multivariate analysis, age, LAD, baseline ACT, and time to reach the optimal ACT were predictors for SCEs. The average values of the ACT parameters were significantly different among NOACs/VKA. CONCLUSION Age, LAD, and intraprocedural ACT kinetics significantly affect SCEs during AF ablation. Different anticoagulants have different impacts on ACT during the procedure, which should be considered when estimating the risk of SCEs.
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Affiliation(s)
- Masahide Harada
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Yuji Motoike
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Yoshihiro Nomura
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Asuka Nishimura
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Masayuki Koshikawa
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Kazuhiro Murayama
- Joint Research Laboratory of Advanced Medical Imaging, Fujita Health University, Toyoake, Aichi, Japan
| | - Yoshiharu Ohno
- Joint Research Laboratory of Advanced Medical Imaging, Fujita Health University, Toyoake, Aichi, Japan
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University, Toyoake, Aichi, Japan
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Silent cerebral infarction after percutaneous coronary intervention of chronic total occlusions (CTO) and non-CTOs. Int J Cardiovasc Imaging 2020; 36:2107-2113. [PMID: 32681317 DOI: 10.1007/s10554-020-01939-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
Silent cerebral infarctions (SCI) determined by neuron specific enolase (NSE) elevation may develop more during chronic total occlusion (CTO) percutaneous coronary interventions (PCI) than non-CTO interventions. Our aim was to examine CTO and non-CTO PCIs for SCI development. 100 consecutive CTO and 100 non-CTO PCI patients were enrolled. SCI was detected by serum NSE measurements performed at baseline and 12 h after the interventions. New NSE elevations > 12 ng/mL after the procedure were counted as SCI. Post-procedural NSE levels were found to be significantly higher in the CTO PCI group and NSE positivity was more prevalent in the CTO PCI group (56 (56%) vs. 31 (31%), p < 0.001), but PCI of CTOs did not independently increase risk of SCI (OR: 2.39 (0.85-6.73), p: 0.10). Patients who developed SCI after PCI had the characteristics of tough PCI interventions. In the multivariate analysis, two parameters were found to be independently associated with SCI development, namely more contrast volume (OR: 1.014 (1.005-1.023), p: 0.003) and longer procedural time (OR: 1.030 (1.010-1.051), p: 0.003). It has been firstly demonstrated in the literature that CTO PCIs, by its nature, have increased rates of SCI when compared to non-CTO PCIs but presence of a CTO was not an independent predictor of SCI. Mainly, procedural characteristics of the PCIs, especially longer procedural times and more contrast consumption, observed more in CTO PCIs, have been found to be independently associated with elevations of plasma NSE levels.
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Harada M, Motoike Y, Nomura Y, Nishimura A, Koshikawa M, Murayama K, Ohno Y, Watanabe E, Izawa H, Ozaki Y. Comparison of effectiveness and safety between uninterrupted direct oral anticoagulants with and without switching to dabigatran in atrial fibrillation ablation. J Arrhythm 2020; 36:417-424. [PMID: 32528566 PMCID: PMC7280006 DOI: 10.1002/joa3.12333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/15/2020] [Accepted: 03/01/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Recent studies have demonstrated the feasibility of uninterrupted direct oral anticoagulants (DOACs) with a temporary switch to dabigatran (“dabigatran bridge”) for atrial fibrillation (AF) ablation. We compared the effectiveness and safety between uninterrupted DOACs with and without the “dabigatran bridge” in patients taking factor Xa inhibitors. Methods AF patients on factor Xa inhibitors (rivaroxaban/apixaban/edoxaban) undergoing catheter ablation were eligible (n = 348). Brain MRI was performed within 2 days after the procedure to detect silent cerebral events (SCEs). Rivaroxaban/apixaban/edoxaban were uninterruptedly used in 153 patients (Group 1); these DOACs were switched to dabigatran on the day of AF ablation in 195 patients (Group 2). After propensity score matching, the unfractionated heparin (UFH) amount and the activated clotting time (ACT) kinetics during the procedure, the SCE incidence, and the follow‐up complications (30 days, thromboembolism and major/minor bleeding) in the two groups were compared. Results Group 2 had higher initial ACT value and shorter time to optimal ACT (>300 seconds) than Group 1 (184 ± 36 s vs 145 ± 22 s, and 34 ± 29 s vs 43 ± 34 s, P < .05, respectively). Group 2 tended to require less amount of UFH to achieve optimal ACT than Group 1, but the total amount of UFH for the procedure was comparable. Group 2 had lower SCE incidence than Group 1 (16.2% vs 26.4%, P < .05). The prevalence of follow‐up complications was unchanged between the two groups. Conclusions Switching to dabigatran on the day of AF ablation decreases preclinical thromboembolic events with similar bleeding risk to uninterrupted factor Xa inhibitors.
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Affiliation(s)
- Masahide Harada
- Department of Cardiology Fujita Health University Toyoake Japan
| | - Yuji Motoike
- Department of Cardiology Fujita Health University Toyoake Japan
| | | | - Asuka Nishimura
- Department of Cardiology Fujita Health University Toyoake Japan
| | | | - Kazuhiro Murayama
- Joint Research Laboratory of Advanced Medical Imaging Fujita Health University Toyoake Japan
| | - Yoshiharu Ohno
- Joint Research Laboratory of Advanced Medical Imaging Fujita Health University Toyoake Japan
| | - Eiichi Watanabe
- Department of Cardiology Fujita Health University Toyoake Japan
| | - Hideo Izawa
- Department of Cardiology Fujita Health University Toyoake Japan
| | - Yukio Ozaki
- Department of Cardiology Fujita Health University Toyoake Japan
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A randomized comparison of two direct oral anticoagulants for patients undergoing cardiac ablation with a contemporary warfarin control arm. J Interv Card Electrophysiol 2020; 60:375-385. [PMID: 32318963 DOI: 10.1007/s10840-020-00732-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The safety and efficacy of periprocedural use of direct oral anticoagulants (DOACs) for atrial fibrillation (AF) remain unclear. We compared the incidence of asymptomatic cerebral micro-thromboembolism and hemopericardium following AF ablation among patients receiving edoxaban, rivaroxaban, and warfarin and between normal- and low-dose use of edoxaban and rivaroxaban. METHODS This prospective randomized study included 170 consecutive AF patients. Patients taking DOACs upon admission to our hospital were randomly assigned to an edoxaban group or to a rivaroxaban group. Warfarin was continued in patients receiving warfarin at admission. All patients underwent AF ablation, and cerebral MRI was performed to evaluate asymptomatic cerebral micro-thromboembolism the day after the procedure. RESULTS Sixty-one patients were assigned to edoxaban and 63 to rivaroxaban. Warfarin was continued in 46 patients. Although asymptomatic cerebral micro-thromboembolism was detected in 25 patients (16.3%), there were no significant differences among the groups. Hemopericardium occurred in 2 patients (one each in the rivaroxaban and warfarin groups). The incidence of asymptomatic cerebral micro-thromboembolism was higher in the low-dose group (9 patients, 25.7%) than in the normal-dose group (8 patients, 10.0%) for patients prescribed either edoxaban or rivaroxaban (p < 0.05). The proportion of males (88.0%, 69.5%, p < 0.05), history of prior AF ablation (64.0%, 42.2%, p < 0.05), and hypertension (68.0%, 46.1%, p < 0.05) were significantly higher in patients with cerebral thromboembolism. CONCLUSIONS The incidence of asymptomatic cerebral micro-thromboembolism and hemopericardium in AF ablation was similar among patients using edoxaban, rivaroxaban, and warfarin. However, low doses of DOACs may increase the risk of asymptomatic stroke.
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