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Hassouna S, Osmancik P. Catheter ablation for non-paroxysmal atrial fibrillation. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:1-14. [PMID: 38230517 DOI: 10.5507/bp.2023.053] [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: 08/30/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia is associated with increased morbidity and mortality. The higher mortality is due to the risk of heart failure and cardioembolic events. This in-depth review focuses on the strategies and efficacy of catheter ablation for non-paroxysmal atrial fibrillation. The main medical databases were searched for contemporary studies on catheter ablation for non-paroxysmal AF. Catheter ablation is currently proven to be the most effective treatment for AF and consists of pulmonary vein isolation as the cornerstone plus additional ablations. In terms of SR maintenance, it is less effective in non-paroxysmal AF than in paroxysmal patients. but the clinical benefit in non-paroxysmal patients is substantially higher. Since pulmonary vein isolation is ineffective, a variety of techniques have been developed, e.g. linear ablations, ablation of complex atrial fractionated electrograms, etc. Another paradox consists in the technique of catheter ablation. Despite promising results in early observation studies, further randomized studies have not confirmed the initial enthusiasm. Recently, a new approach, pulsed-field ablation, appears promising. This is an in-depth summary of current technologies and techniques for the ablation of non-paroxysmal AF. We discuss the benefits, risks and implications in the treatment of patients with non-paroxysmal AF.
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Affiliation(s)
- Sabri Hassouna
- Department of Cardiology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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2
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Li J, Cui S, Song H, Cui L, Yu H, Chu Y, Dong S. A novel stepwise catheter ablation method of the mitral isthmus for persistent atrial fibrillation: efficacy and reproducibility. BMC Cardiovasc Disord 2023; 23:466. [PMID: 37715135 PMCID: PMC10504774 DOI: 10.1186/s12872-023-03490-7] [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: 07/06/2023] [Accepted: 09/01/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Ethanol infusion of the vein of Marshall (EI-VOM) has been widely used to facilitate mitral isthmus (MI) ablation. According to the literature, the success rate of achieving a bidirectional conduction block across the MI ranges from 51 to 96%, with no standardized strategy or method available for cardiac electrophysiologists. OBJECTIVES This study aimed to introduce and evaluate a novel ablation method of MI. METHODS Consecutive patients with persistent atrial fibrillation (PeAF) that underwent catheter ablation were included. The MI ablation procedure followed a stepwise approach. In step 1, ethanol infusion of the vein of Marshall (EI-VOM) was performed. In step 2, a "V-shape" endocardial linear ablation connecting the left inferior pulmonary vein (LIPV) to mitral annulus (MA) was performed. In step 3, earliest activation sites(EASs) near the ablation line were identified using activation mapping followed by reinforced ablation. In step 4, precise epicardial ablation was performed, with the catheter introduced into the coronary sinus(CS) to target key ablation targets (KATs). RESULTS 135 patients with PeAF underwent catheter ablation with the stepwise ablation method adopted in 119 cases. Bidirectional conduction blocks were achieved in 117 patients (98.3%). The block rates of every step were 0%, 58.0%, 44.0%, and 92.9%, and the cumulative block rates for the four steps were 0%, 58.0%, 76.5%, and 98.3%, respectively. No patient experienced fatal complications. CONCLUSIONS Our novel stepwise catheter ablation method for MI yielded a high bidirectional block rate with high reproducibility.
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Affiliation(s)
- Jingchao Li
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Shihua Cui
- Dalian Medical University, Dalian, China
| | - Huihui Song
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Luqian Cui
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Haijia Yu
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Yingjie Chu
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China.
| | - Shujuan Dong
- Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China.
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3
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Risk and benefit of extrapulmonary vein ablation in atrial fibrillation. Curr Opin Cardiol 2023; 38:1-5. [PMID: 36598443 DOI: 10.1097/hco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review aims to summarize the recent development, benefit, and safety of extrapulmonary vein ablation for atrial fibrillation. RECENT FINDING Studies have shown that extrapulmonary vein ablation can help maintain normal sinus rhythm for patients with persistent atrial fibrillation. As prior strategies targeting anatomical lines and triggers are well utilized, novel techniques for substrate mapping have been rapidly developing. These strategies are well tolerated and could be chosen based on patients' conditions and physicians' experience. SUMMARY Extrapulmonary vein ablation could be safely and effectively performed for patients with atrial fibrillation. It provides further consolidation of normal sinus rhythm.
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Tsai TY, Lo LW, Cheng WH, Liu SH, Lin YJ, Chang SL, Hu YF, Chung FP, Liao JN, Tuan TC, Chao TF, Lin CY, Chang TY, Liu CM, Chheng C, Hermanto DY, An TN, Elimam AMM, Huang TC, Lee PT, Lee CH, Chen SA. 10-Year Outcomes of Patients With Non-Paroxysmal Atrial Fibrillation Undergoing Catheter Ablation. Circ J 2022; 87:84-91. [PMID: 36130901 DOI: 10.1253/circj.cj-22-0062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Radiofrequency catheter ablation (RFCA) is commonly performed in patients with non-paroxysmal atrial fibrillation (AF), but because very long-term follow-up results of RFCA are limited, we investigated the 10-year RFCA outcomes of non-paroxysmal AF.Methods and Results: We retrospectively enrolled 100 patients (89 men, mean age 53.5±8.4years) with drug-refractory symptomatic non-paroxysmal AF who underwent 3D electroanatomic-guided RFCA. Procedural characteristics at index procedures and clinical outcomes were investigated. In the index procedures, all patients had pulmonary vein isolation, 56 (56.0%), 48 (48.0%), and 32 (32.0%) underwent additional linear, complex fractionated atrial electrogram (CFAE) and non-pulmonary vein (NPV) foci ablations, respectively. After 124.1±31.7 months, 16 (16%) patients remained in sinus rhythm after just 1 procedure (3 with antiarrhythmic drugs [AAD]) and after multiple (2.1±1.3) procedures in 53 (53.0%) patients (22 with AAD). Left atrial (LA) diameter (hazard ratio HR 1.061; 95% confidence interval (CI) 1.020 to 1.103; P=0.003), presence of NPV triggers (HR 1.634; 95% CI 1.019 to 2.623; P=0.042) and undergoing CFAE ablation (HR 2.003; 95% CI 1.262 to 3.180; P=0.003) in the index procedure were independent predictors for recurrent atrial tachyarrhythmia. CONCLUSIONS The 10-year outcomes of single RFCA in non-paroxysmal AF were unsatisfactory. Enlarged LA, presence of NPV triggers, and undergoing CFAE ablation in the index procedure independently predicted single-procedure recurrence. Multiple procedures are required to achieve adequate rhythm control.
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Affiliation(s)
- Tsung-Ying Tsai
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Cardiovascular Center, Taichung Veterans General Hospital.,Faculty of Medicine, National Yang-Ming Chiao Tung University
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University
| | - Wen-Han Cheng
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Shin-Huei Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Chhay Chheng
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Dony Yugo Hermanto
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | - Ton Nukhank An
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
| | | | - Ting-Chun Huang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital
| | - Po-Tseng Lee
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital
| | - Cheng-Hung Lee
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,National Chung Hsing University
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.,Cardiovascular Center, Taichung Veterans General Hospital.,Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University.,National Chung Hsing University
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5
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Reablation in Atrial Fibrillation Recurrence and Pulmonary Vein Reconnection: Cryoballoon versus Radiofrequency as Index Ablation Procedures. J Clin Med 2022; 11:jcm11195862. [PMID: 36233729 PMCID: PMC9573280 DOI: 10.3390/jcm11195862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/17/2022] Open
Abstract
Pulmonary vein (PV) isolation is a well-established rhythm control therapy in atrial fibrillation (AF). Currently, there is no consensus on which ablation technique to use for the first procedure, cryoballoon (CB) or radiofrequency (RF). A retrospective cohort study was conducted on 1055 patients who underwent a first ablation, to assess both techniques based on the need for reablation. Patients with CB (n = 557) and RF (n = 498) ablations were clinically characterized and the need for reablation during a 30-month follow-up was used as the primary endpoint. Independent variables were analyzed to identify potential predictors. The need for reablation was significantly lower in the CB group than in the RF group (hazard ratio = 0.45 and 95% confident interval = 0.32−0.61; p < 0.001); in both paroxysmal and persistent AF, using a full-adjusted regression Cox model by age, sex, smoking, hypertension, diabetes mellitus, dyslipidemia, severe obstructive sleep apnea, dilated left atrium, persistent AF and early recurrence. RF ablation, dilated left atrium, persistent AF and early recurrence were identified as independent predictors of reablation. In addition, the CB-redo subgroup had a lower PV reconnection than the RF-redo subgroup. In conclusion, CB ablation suggests a reduction in the need for reablation and lower PV reconnection during the follow-up than RF ablation.
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6
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Theofilis P, Oikonomou E, Antonopoulos AS, Siasos G, Tsioufis K, Tousoulis D. Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives. Biomedicines 2022; 10:biomedicines10092268. [PMID: 36140368 PMCID: PMC9496262 DOI: 10.3390/biomedicines10092268] [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: 08/11/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.
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Affiliation(s)
- Panagiotis Theofilis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Alexios S. Antonopoulos
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
- Correspondence:
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7
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Charitakis E, Metelli S, Karlsson LO, Antoniadis AP, Rizas KD, Liuba I, Almroth H, Hassel Jönsson A, Schwieler J, Tsartsalis D, Sideris S, Dragioti E, Fragakis N, Chaimani A. Comparing efficacy and safety in catheter ablation strategies for atrial fibrillation: a network meta-analysis. BMC Med 2022; 20:193. [PMID: 35637488 PMCID: PMC9153169 DOI: 10.1186/s12916-022-02385-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/25/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is no consensus on the most efficient catheter ablation (CA) strategy for patients with atrial fibrillation (AF). The objective of this study was to compare the efficacy and safety of different CA strategies for AF ablation through network meta-analysis (NMA). METHODS A systematic search of PubMed, Web of Science, and CENTRAL was performed up to October 5th, 2020. Randomized controlled trials (RCT) comparing different CA approaches were included. Efficacy was defined as arrhythmia recurrence after CA and safety as any reported complication related to the procedure during a minimum follow-up time of 6 months. RESULTS In total, 67 RCTs (n = 9871) comparing 19 different CA strategies were included. The risk of recurrence was significantly decreased compared to pulmonary vein isolation (PVI) alone for PVI with renal denervation (RR: 0.60, CI: 0.38-0.94), PVI with ganglia-plexi ablation (RR: 0.62, CI: 0.41-0.94), PVI with additional ablation lines (RR: 0.8, CI: 0.68-0.95) and PVI in combination with bi-atrial modification (RR: 0.32, CI: 0.11-0.88). Strategies including PVI appeared superior to non-PVI strategies such as electrogram-based approaches. No significant differences in safety were observed. CONCLUSIONS This NMA showed that PVI in combination with additional CA strategies, such as autonomic modulation and additional lines, seem to increase the efficacy of PVI alone. These strategies can be considered in treating patients with AF, since, additionally, no differences in safety were observed. This study provides decision-makers with comprehensive and comparative evidence about the efficacy and safety of different CA strategies. SYSTEMATIC REVIEW REGISTRATION PROSPERO registry number: CRD42020169494 .
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Affiliation(s)
- Emmanouil Charitakis
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Silvia Metelli
- Research Center of Epidemiology and Statistics (CRESS-U1153), Université Paris Cité, INSERM, Paris, France
| | - Lars O Karlsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Antonios P Antoniadis
- 3rd Cardiology Department, Hippokrateion General Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Konstantinos D Rizas
- Medizinische Klinik Und Poliklinik I, LMU Klinikum, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Ioan Liuba
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Henrik Almroth
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anders Hassel Jönsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jonas Schwieler
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Skevos Sideris
- Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Elena Dragioti
- Pain and Rehabilitation Centre and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Nikolaos Fragakis
- 3rd Cardiology Department, Hippokrateion General Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Anna Chaimani
- Research Center of Epidemiology and Statistics (CRESS-U1153), Université Paris Cité, INSERM, Paris, France
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8
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Suzuki N, Kaneko S, Fujita M, Shinoda M, Kubota R, Ohashi T, Tatami Y, Suzuki J, Hori H, Adachi K, Ito R, Shirai Y, Yanagisawa S, Inden Y, Murohara T. Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis. BMC Cardiovasc Disord 2022; 22:13. [PMID: 35065605 PMCID: PMC8783511 DOI: 10.1186/s12872-022-02460-9] [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: 11/22/2021] [Accepted: 01/11/2022] [Indexed: 11/15/2022] Open
Abstract
Background The efficacy of pulmonary vein isolation (PVI) alone is not guaranteed for persistent atrial fibrillation (PeAF), and it is unclear which type of ablation approach should be applied in addition to PVI. This study aimed to compare outcomes and prognosis between empirical linear ablation and low-voltage area (LVA) ablation after PVI for PeAF. Methods We enrolled 128 patients with PeAF who were assigned to the linear ablation group (n = 64) and the LVA ablation group (n = 64) using a propensity score-matched model. After PVI and cardioversion, the patients underwent either empirical linear ablation or LVA ablation during sinus rhythm. All patients in the linear ablation group underwent both roof line and mitral valve isthmus (MVI) ablations. An electrical-guided ablation targeting LVA (< 0.5 mV) was performed in the LVA group. When there was no LVA in the LVA group, only PVI was applied. We compared the procedural outcomes and recurrence after ablation between the two groups. Results The baseline characteristics were well-balanced between the two groups. Fifty patients had LVA (22 and 28 patients in the linear and LVA groups). The roof and MVI lines were completed in 100% and 96.9% of the patients. During the mean follow-up of 279.5 ± 161.3 days, the LVA group had significantly lower recurrence than the linear group (15 patients [23%] vs. 29 patients [45%], p = 0.014). Thirty-five patients were prescribed antiarrhythmic drugs during the follow-up period (linear group, n = 17; LVA group, n = 18); amiodarone and bepridil were administered to most of the patients (15 and 17 patients, respectively). The difference in the prognosis was relevant among the patients with LVA, while this trend was not observed in those without LVA. The LVA ablation group demonstrated significantly lower radiofrequency energy and shorter procedural time compared to the linear ablation group. The recurrence of atrial flutter was more likely to occur in the linear group than in the LVA group (14 [22%] vs. 6 [9.4%], p = 0.052). Conclusion The electrophysiological-guided LVA ablation is more effective than empirical linear ablation in PeAF patients with LVA. Unnecessary empirical linear ablation might have a risk of iatrogenic gap and atrial flutter recurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02460-9.
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9
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Wu Z, Liu Y, Tong L, Dong D, Deng D, Xia L. Current progress of computational modeling for guiding clinical atrial fibrillation ablation. J Zhejiang Univ Sci B 2021; 22:805-817. [PMID: 34636185 DOI: 10.1631/jzus.b2000727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Atrial fibrillation (AF) is one of the most common arrhythmias, associated with high morbidity, mortality, and healthcare costs, and it places a significant burden on both individuals and society. Anti-arrhythmic drugs are the most commonly used strategy for treating AF. However, drug therapy faces challenges because of its limited efficacy and potential side effects. Catheter ablation is widely used as an alternative treatment for AF. Nevertheless, because the mechanism of AF is not fully understood, the recurrence rate after ablation remains high. In addition, the outcomes of ablation can vary significantly between medical institutions and patients, especially for persistent AF. Therefore, the issue of which ablation strategy is optimal is still far from settled. Computational modeling has the advantages of repeatable operation, low cost, freedom from risk, and complete control, and is a useful tool for not only predicting the results of different ablation strategies on the same model but also finding optimal personalized ablation targets for clinical reference and even guidance. This review summarizes three-dimensional computational modeling simulations of catheter ablation for AF, from the early-stage attempts such as Maze III or circumferential pulmonary vein isolation to the latest advances based on personalized substrate-guided ablation. Finally, we summarize current developments and challenges and provide our perspectives and suggestions for future directions.
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Affiliation(s)
- Zhenghong Wu
- College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou 310027, China
| | - Yunlong Liu
- School of Biomedical Engineering, Dalian University of Technology, Dalian 116024, China
| | - Lv Tong
- School of Biomedical Engineering, Dalian University of Technology, Dalian 116024, China
| | - Diandian Dong
- School of Biomedical Engineering, Dalian University of Technology, Dalian 116024, China
| | - Dongdong Deng
- School of Biomedical Engineering, Dalian University of Technology, Dalian 116024, China
| | - Ling Xia
- College of Biomedical Engineering & Instrument Science, Zhejiang University, Hangzhou 310027, China.
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10
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Inoue K, Hikoso S, Masuda M, Furukawa Y, Hirata A, Egami Y, Watanabe T, Minamiguchi H, Miyoshi M, Tanaka N, Oka T, Okada M, Kanda T, Matsuda Y, Kawasaki M, Hayashi K, Kitamura T, Dohi T, Sunaga A, Mizuno H, Nakatani D, Sakata Y. Pulmonary vein isolation alone vs. more extensive ablation with defragmentation and linear ablation of persistent atrial fibrillation: the EARNEST-PVI trial. Europace 2021; 23:565-574. [PMID: 33200213 DOI: 10.1093/europace/euaa293] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/12/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Previous studies could not demonstrate any benefit of more intensive ablation in addition to pulmonary vein isolation (PVI) including complex fractionated atrial electrogram (CFAE) and linear ablation for recurrence in the initial catheter ablation of persistent atrial fibrillation (AF). This study aimed to establish the non-inferiority of PVI alone to PVI plus these additional ablation strategies. METHODS AND RESULTS Patients with persistent AF who underwent an initial catheter ablation (n = 512, long-standing persistent AF; 128 cases) were randomly assigned in a 1:1 ratio to either PVI alone (PVI-alone group) or PVI plus CFAE and/or linear ablation (PVI-plus group). After excluding 15 cases who did not receive procedures, we analysed 249 and 248 patients, respectively. The primary endpoint was recurrence of AF, atrial flutter, and/or atrial tachycardia, and the non-inferior margin was set at a hazard ratio of 1.43. In the PVI-plus group, 85.1% of patients had linear ablation and 15.3% CFAE ablation. After 12 months, freedom from the primary endpoint occurred in 71.3% of patients in the PVI-alone group and in 78.3% in the PVI-plus group [hazard ratio = 1.56 (95% confidence interval: 1.10-2.24), non-inferior P = 0.3062]. The procedure-related complication rates were 2.0% in the PVI-alone group and 3.6% in the PVI-plus group (P = 0.199). CONCLUSION This randomized trial did not establish the non-inferiority of PVI alone to PVI plus linear ablation or CFAE ablation in patients with persistent AF, but implied that the PVI plus strategy was promising to improve the clinical efficacy (NCT03514693).
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Affiliation(s)
- Koichi Inoue
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Shungo Hikoso
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Masaharu Masuda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshio Furukawa
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Akio Hirata
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yasuyuki Egami
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
| | | | - Hitoshi Minamiguchi
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Miwa Miyoshi
- Department of Cardiovascular Medicine, Yao Municipal Hospital, Yao, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Takafumi Oka
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Masato Okada
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Takashi Kanda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasuhiro Matsuda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masato Kawasaki
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Kenichi Hayashi
- Department of Cardiology, Osaka Hospital, Japan Community Healthcare Organization, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomoharu Dohi
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Akihiro Sunaga
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Hiroya Mizuno
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Daisaku Nakatani
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Yasushi Sakata
- Cardiovascular Center, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
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11
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Marrouche NF, Greene T, Dean JM, Kholmovski EG, Boer LMD, Mansour M, Calkins H, Marchlinski F, Wilber D, Hindricks G, Mahnkopf C, Jais P, Sanders P, Brachmann J, Bax J, Dagher L, Wazni O, Akoum N. Efficacy of LGE-MRI-guided fibrosis ablation versus conventional catheter ablation of atrial fibrillation: The DECAAF II trial: Study design. J Cardiovasc Electrophysiol 2021; 32:916-924. [PMID: 33600025 DOI: 10.1111/jce.14957] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes. METHODS The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3-12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day postablation blanking period. Patients were followed for a period of 12-18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint. RESULTS AND CONCLUSION The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden.
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Affiliation(s)
- Nassir F Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tom Greene
- University of Utah, Salt Lake City, Utah, USA
| | | | | | | | - Moussa Mansour
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Francis Marchlinski
- Department of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Wilber
- Department of Cardiology, Loyola University Medical Center, Chicago, Illinois, USA
| | | | | | - Pierre Jais
- Department of Cardiology, Segalen University, Bordeaux, France
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | | | - Jereon Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Oussama Wazni
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nazem Akoum
- Department of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
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13
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5178] [Impact Index Per Article: 1726.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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14
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Waranugraha Y, Rizal A, Setiawan D, Aziz IJ. Additional complex fractionated atrial electrogram ablation does not improve the outcomes of non-paroxysmal atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials. Indian Heart J 2021; 73:63-73. [PMID: 33714411 PMCID: PMC7961253 DOI: 10.1016/j.ihj.2020.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 11/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Non-paroxysmal atrial fibrillation (AF) has a complex pathophysiological process. The standard catheter ablation approach is pulmonary vein isolation (PVI). The additional value of complex fractionated electrogram (CFAE) ablation is still unclear. We aimed to investigate the additional value of CFAE ablation for non-paroxysmal AF. METHODS We performed a systematic review and meta-analysis of randomized controlled studies up to May 2020. Articles comparing pulmonary vein isolation (PVI) plus CFAE ablation and PVI alone for AF were obtained from the electronic scientific databases. The pooled mean difference (MD) and pooled risk ratio (RR) were assessed. RESULTS A total of 8 randomized controlled trials (RCTs) including 1034 patients were involved. Following a single catheter ablation procedure, the presence of any atrial tachyarrhythmia (ATA) with or without the use of antiarrhythmic drugs (AADs) between both groups were not significantly different (RR = 1.1; 95% confidence interval [CI] = 0.97-1.24; p = 0.13). Similar results were also obtained for the presence of any ATA without the use of AADs (RR = 1.08; 95% CI = 0.96-1.22; p = 0.2). The additional CFAE ablation took longer procedure times (MD = 46.95 min; 95% CI = 38.27-55.63; p = < 0.01) and fluoroscopy times (MD = 11.69 min; 95% CI = 8.54-14.83; p = < 0.01). CONCLUSION Additional CFAE ablation failed to improve the outcomes of non-paroxysmal AF patients. It also requires a longer duration of procedure times and fluoroscopy times.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia; Brawijaya Cardiovascular Research Center, Malang, Indonesia.
| | - Ardian Rizal
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia; Brawijaya Cardiovascular Research Center, Malang, Indonesia
| | - Dion Setiawan
- Brawijaya Cardiovascular Research Center, Malang, Indonesia
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15
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Nakatani Y, Sakamoto T, Yamaguchi Y, Tsujino Y, Kataoka N, Nishida K, Mizumaki K, Kinugawa K. Left atrial posterior wall isolation affects complex fractionated atrial electrograms in persistent atrial fibrillation. J Arrhythm 2019; 35:528-534. [PMID: 31293704 PMCID: PMC6595290 DOI: 10.1002/joa3.12182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/11/2019] [Accepted: 03/25/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The impact of left atrial posterior wall isolation (LAPWI) on the complex fractionated atrial electrogram (CFAE) is unknown. METHODS CFAE mapping was performed before and after LAPWI in 46 patients with persistent atrial fibrillation (AF). RESULTS LAPWI decreased both the variable (fractionated index ≤ 120 ms; from 60 ± 4 cm2 to 50 ± 4 cm2, P < 0.001) and continuous (fractionated index ≤ 50 ms; from 4.2 ± 1.0 cm2 to 3.5 ± 0.9 cm2, P = 0.036) CFAE areas. Especially, the CFAE areas on the bottom and roof walls of the left atrium and on the posterior and bottom walls of the right atrium significantly decreased after LAPWI. The distribution of variable CFAE areas was not different between the AF-recurrence (n = 9) and AF-free (n = 37) groups before LAPWI; however, it was larger in the anterior and septal walls of the right atrium in the AF-recurrence group than in the AF-free group after LAPWI (anterior wall, 8% ± 2% vs 5% ± 1%, P = 0.048; septal wall, 23% ± 4% vs 16% ± 1%, P = 0.043). The distribution of continuous CFAE areas on the bottom wall of the right atrium was larger in the AF-recurrence group than in the AF-free group both before LAPWI (30% ± 20% vs 4% ± 2%, P = 0.008) and after LAPWI (25% ± 25% vs 3% ± 1%, P = 0.027). CONCLUSIONS LAPWI decreased the CFAE areas and affected their distribution, which contributed to AF recurrence.
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Affiliation(s)
- Yosuke Nakatani
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Tamotsu Sakamoto
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | - Yasushi Tsujino
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | - Naoya Kataoka
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
| | | | | | - Koichiro Kinugawa
- Second Department of Internal MedicineUniversity of ToyamaToyamaJapan
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16
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van der Heijden CAJ, Vroomen M, Luermans JG, Vos R, Crijns HJGM, Gelsomino S, La Meir M, Pison L, Maesen B. Hybrid versus catheter ablation in patients with persistent and longstanding persistent atrial fibrillation: a systematic review and meta-analysis†. Eur J Cardiothorac Surg 2019; 56:433-443. [DOI: 10.1093/ejcts/ezy475] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/27/2018] [Accepted: 12/06/2018] [Indexed: 02/04/2023] Open
Abstract
Summary
As the mechanisms underlying persistent atrial fibrillation (AF) are still incompletely understood, a ‘gold standard’ strategy for ablation is lacking. The results of catheter ablation, independent of the ablation strategy applied, are disappointing. Hybrid ablation, combining a thoracoscopic epicardial and transvenous endocardial approach, has shown more favourable outcomes. To date, studies comparing both techniques are lacking. Therefore, we conducted a systematic review and meta-analysis of hybrid versus catheter ablation in patients with persistent or longstanding persistent AF. A systematic literature search of studies reporting on catheter and hybrid ablation of persistent or longstanding persistent AF was performed in the PubMed database. All identified articles were screened and checked for eligibility. A meta-analysis was performed on inter-study heterogeneity and pooled correlation between baseline characteristics, primary and secondary outcomes of hybrid and catheter studies. From the 520 articles identified by the search, 34 articles could be included in the analysis. Hybrid ablation resulted in higher freedom of atrial arrhythmias in patients with persistent and longstanding-persistent AF than catheter ablation (70.7% vs 49.9%, P < 0.001). Although hybrid ablation had a slightly higher complication rate than catheter ablation, overall morbidity and mortality were low. In conclusion, hybrid ablation is more effective than catheter ablation in maintaining the sinus rhythm in patients with persistent or longstanding persistent AF. However, data directly comparing both techniques are lacking, and small, heterogenic, single-arm studies in a random-effects model prevent definite conclusions from being drawn. Therefore, larger randomized controlled trials directly comparing both techniques are needed.
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Affiliation(s)
| | - Mindy Vroomen
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Justin G Luermans
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University, Maastricht, Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mark La Meir
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
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17
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Park JW, Yu HT, Kim TH, Uhm JS, Kim JY, Joung B, Lee MH, Pak HN. Trends and Outcome of Catheter Ablation of Atrial Fibrillation Over 9 Years ― Focus on Empirical Extra-Pulmonary Vein Ablation ―. Circ J 2019; 83:304-312. [DOI: 10.1253/circj.cj-18-0928] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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18
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Pak HN. Catheter Ablation of Long-standing Persistent Atrial Fibrillation: a Reckless Challenge or a Way to Real Cure? Korean Circ J 2019; 49:134-145. [PMID: 30693681 PMCID: PMC6351275 DOI: 10.4070/kcj.2018.0418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/10/2018] [Indexed: 11/11/2022] Open
Abstract
Long-standing persistent atrial fibrillation (L-PeAF) is a category in which rhythm control is attempted while atrial fibrillation (AF) is maintained for more than 1 year. Because AF is a progressive disease and L-PeAF accompanies significant electrical and structural remodeling of atria, it is difficult to restore and maintain sinus rhythm in patients with L-PeAF. Nonetheless, the rhythm outcome is being increasingly improved by the development of sophisticated mapping devices, highly efficient catheters, and evidence-based ablation strategies, and the rational choice of patient selection criteria. This review discusses the evolution of the rhythm control outcome of L-PeAF and its future direction of development.
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Affiliation(s)
- Hui Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Korea.
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19
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Yu HT, Yang PS, Kim TH, Uhm JS, Kim JY, Joung B, Lee MH, Pak HN. Poor Rhythm Outcome of Catheter Ablation for Early-Onset Atrial Fibrillation in Women ― Mechanistic Insight ―. Circ J 2018; 82:2259-2268. [DOI: 10.1253/circj.cj-17-1358] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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20
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Almeida TP, Chu GS, Li X, Dastagir N, Tuan JH, Stafford PJ, Schlindwein FS, Ng GA. Atrial Electrogram Fractionation Distribution before and after Pulmonary Vein Isolation in Human Persistent Atrial Fibrillation-A Retrospective Multivariate Statistical Analysis. Front Physiol 2017; 8:589. [PMID: 28883795 PMCID: PMC5573839 DOI: 10.3389/fphys.2017.00589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/31/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose: Complex fractionated atrial electrograms (CFAE)-guided ablation after pulmonary vein isolation (PVI) has been used for persistent atrial fibrillation (persAF) therapy. This strategy has shown suboptimal outcomes due to, among other factors, undetected changes in the atrial tissue following PVI. In the present work, we investigate CFAE distribution before and after PVI in patients with persAF using a multivariate statistical model. Methods: 207 pairs of atrial electrograms (AEGs) were collected before and after PVI respectively, from corresponding LA regions in 18 persAF patients. Twelve attributes were measured from the AEGs, before and after PVI. Statistical models based on multivariate analysis of variance (MANOVA) and linear discriminant analysis (LDA) have been used to characterize the atrial regions and AEGs. Results: PVI significantly reduced CFAEs in the LA (70 vs. 40%; P < 0.0001). Four types of LA regions were identified, based on the AEGs characteristics: (i) fractionated before PVI that remained fractionated after PVI (31% of the collected points); (ii) fractionated that converted to normal (39%); (iii) normal prior to PVI that became fractionated (9%) and; (iv) normal that remained normal (21%). Individually, the attributes failed to distinguish these LA regions, but multivariate statistical models were effective in their discrimination (P < 0.0001). Conclusion: Our results have unveiled that there are LA regions resistant to PVI, while others are affected by it. Although, traditional methods were unable to identify these different regions, the proposed multivariate statistical model discriminated LA regions resistant to PVI from those affected by it without prior ablation information.
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Affiliation(s)
- Tiago P Almeida
- Department of Engineering, University of LeicesterLeicester, United Kingdom.,Biomedical Engineering, Center for Engineering, Modelling and Applied Social Sciences, Federal University of ABCSão Bernardo do Campo, Brazil
| | - Gavin S Chu
- Department of Cardiovascular Sciences, University of LeicesterLeicester, United Kingdom
| | - Xin Li
- Department of Engineering, University of LeicesterLeicester, United Kingdom
| | - Nawshin Dastagir
- Department of Cardiovascular Sciences, University of LeicesterLeicester, United Kingdom
| | - Jiun H Tuan
- University Hospitals of Leicester NHS TrustLeicester, United Kingdom
| | - Peter J Stafford
- University Hospitals of Leicester NHS TrustLeicester, United Kingdom
| | - Fernando S Schlindwein
- Department of Engineering, University of LeicesterLeicester, United Kingdom.,National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield HospitalLeicester, United Kingdom
| | - G André Ng
- Department of Cardiovascular Sciences, University of LeicesterLeicester, United Kingdom.,University Hospitals of Leicester NHS TrustLeicester, United Kingdom.,National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre, Glenfield HospitalLeicester, United Kingdom
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21
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Mody BP, Raza A, Jacobson J, Iwai S, Frenkel D, Rojas R, Aronow WS. Ablation of long-standing persistent atrial fibrillation. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:305. [PMID: 28856145 DOI: 10.21037/atm.2017.05.21] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the clinical setting affecting nearly 6 million people in United States and the numbers are only expected to rise as the population continues to age. Broadly it is classified into paroxysmal, persistent and longstanding persistent AF. Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Our review article emphasizes particularly on long standing persistent atrial fibrillation (LSPAF) aspect of the disease which poses a great challenge for electrophysiologists. While pulmonary vein isolation (PVI) has been established as a successful ablation strategy for paroxysmal AF, same cannot be said for LSPAF owing to its long duration, complexity of mechanisms, multiple triggers and substrate sites that are responsible for its perpetuation. The article explains different approaches currently being adopted to achieve freedom from atrial arrhythmias. These mainly include ablation techniques chiefly targeting complex fractionated atrial electrograms (CFAE), rotors, linear lesions, scars and even considering hybrid approaches in a few cases while exploring the role of delayed enhancement magnetic resonance imaging (deMRI) in the pre-procedural planning to improve the overall short and long term outcomes of catheter ablation.
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Affiliation(s)
- Behram P Mody
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Anoshia Raza
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Jason Jacobson
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Sei Iwai
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Daniel Frenkel
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Rhadames Rojas
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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