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Tóth P, Arnóth B, Komlósi F, Szegedi N, Salló Z, Perge P, Osztheimer I, Merkely B, Gellér L, Nagy KV. Effect of early catheter ablation of atrial fibrillation in patients with heart failure. J Cardiovasc Electrophysiol 2024; 35:1471-1479. [PMID: 38803006 DOI: 10.1111/jce.16300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/15/2024] [Accepted: 04/28/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION According to current guidelines, pulmonary vein isolation as first-line therapy should be considered for patients with atrial fibrillation (AF), however, optimal timing of the procedure is still unknown in patients with heart failure (HF). We aimed to evaluate the effect of early catheter ablation (CA) in patients with HF and left ventricular ejection fraction (LVEF) below 50%. METHODS We analyzed data from a structured registry comprising 227 patients with paroxysmal or persistent AF and HF with LVEF < 50% who underwent radiofrequency CA between 2015 and 2022. Early CA was defined as a procedure performed within 12 months of AF diagnosis. The median follow-up duration was 1748 (1176.3-2353.5) days, with a minimum follow-up of 365 days. Our endpoints were AF recurrence after a 3-months blanking period and all-cause mortality. RESULTS Among the 227 patients with a median age of 64.3 years, 97 (42.7%) experienced AF recurrence and 55 (24.2%) died during the follow-up period. The median LVEF was 40% for early CA and 38% for delayed CA (p = .053). Early CA significantly reduced AF recurrence (HR = 0.25 [0.15-0.42], p < .001), however, the timing of procedure did not affect all-cause mortality (p = .16). These findings were consistent regardless of AF subtype or the burden of comorbidities, as assessed by the CHA2DS2-VASc score. CONCLUSION The timing of CA of AF appears to be an important factor in patients with HF. Early CA reduced AF recurrence, although it does not impact all-cause mortality. We found similar results regardless of AF subtype or burden of comorbidities.
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Affiliation(s)
- Patrik Tóth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bence Arnóth
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ferenc Komlósi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Salló
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Péter Perge
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Lakshman H, Ahmed A, Coutteau S, Shah D. Uncovering the Invisible: The Role of High-density Catheters in Recognizing Fractionated Signals in Pulmonary Vein Isolation. J Innov Card Rhythm Manag 2024; 15:5889-5892. [PMID: 38948664 PMCID: PMC11210676 DOI: 10.19102/icrm.2024.15063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/05/2024] [Indexed: 07/02/2024] Open
Abstract
The HD Grid multipolar mapping catheter has emerged as an invaluable tool for greater effectiveness of pulmonary vein isolation (PVI). In the cases described here, fractionated signals seen with the HD Grid catheter at the left atrial appendage (LAA) and left superior pulmonary vein (LSPV) junction were ablated. These signals are not likely to be visualized with conventional catheters and may cause recurrences due to incomplete PVI. The directional sensitivity limitations of bipolar electrogram recordings and the unique anatomy of the LAA-LSPV ridge further contribute to the challenge of evaluating PVI. The HD Grid catheter's ability to record bipoles parallel and perpendicular to the catheter splines and its high-density mapping capabilities provide a superior means for identifying gaps in ablation and detecting the low-voltage isthmus. Furthermore, factors such as ablation quality, catheter stability, and thickness of the LAA-LSPV ridge influence the presence of fractionated signals and the success of PVI. Incorporating preprocedural imaging modalities, such as computed tomography or magnetic resonance imaging, and real-time intracardiac echocardiography could enhance the tailored approach to address these challenges. Future developments in the HD Grid technology, including the option for contact force measurement during mapping, may offer additional insights into the nature of these signals. This case series highlights the significance of using the HD Grid catheter for a detailed interrogation of the LAA-LSPV ridge, ultimately leading to more effective PVI and improved outcomes in patients with atrial fibrillation.
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Affiliation(s)
- Harini Lakshman
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, MI, USA
| | - Ammar Ahmed
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, MI, USA
| | | | - Dipak Shah
- Department of Electrophysiology, Ascension Providence Hospital, Southfield, MI, USA
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Boga M, Orbán G, Perge P, Salló Z, Tanai E, Ferencz AB, Tóth P, Komlósi F, Osztheimer I, Nagy KV, Merkely B, Gellér L, Szegedi N. Adherence to the CLOSE Protocol and Low Baseline Generator Impedance Are Independent Predictors of Durable Pulmonary Vein Isolation. J Clin Med 2024; 13:1960. [PMID: 38610727 PMCID: PMC11012634 DOI: 10.3390/jcm13071960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 03/24/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is predominantly attributed to pulmonary vein reconnection (PVR). Predictors of AF recurrence have been widely studied; however, data are scarce on procedural parameters that predict chronic PVR. We aimed to study PVR rates and predictors of PVR. Methods: We retrospectively included 100 patients who underwent repeated ablation due to AF recurrence after initial PVI with the CARTO system. PVR was determined during the repeated procedure by electrophysiological evaluation, and initial procedural characteristics predicting PVR were studied, including adherence to the CLOSE protocol, use of high power, first-pass isolation (FPI), and baseline generator impedance (BGI). Results: Thirty-eight patients underwent initial CLOSE-guided PVI, and sixty-two underwent initial non-CLOSE PVI. A repeat procedure was performed 23 ± 16 months after the initial procedure. In total, PVR was found in 192 of 373 PVs (51.5%), and all PVs were isolated in 17/100 (17%) patients. Factors associated with all PVs being isolated were adherence to the CLOSE protocol, a higher power setting, the presence of bilateral FPI, and lower BGI (88% vs. 28%, p < 0.0001; 37.5 W vs. 30 W, p = 0.0276; 88.2% vs. 40.4%, p = 0.0007; and 127.6 Ω vs. 136.6 Ω, p = 0.0027, respectively). In initial procedures with adherence to the CLOSE protocol, the FPI rate was significantly higher (73.7% vs. 25%, p < 0.0001), while there were no significant differences in terms of procedure time and left atrial dwell time (81 vs. 85 min, p = 0.83; and 60 vs. 58 min, p = 0.08, respectively). BGI ≥ 130 Ω (AUC = 0.7403, sensitivity: 77.1%, specificity: 68.8%, p = 0.0032) was associated with a significantly higher probability of PVR (OR = 6.757; p < 0.0001). In multivariable analysis, independent predictors for PVR were non-adherence to the CLOSE protocol and BGI ≥ 130 Ω. Conclusions: Our findings indicate that adherence to the CLOSE protocol and baseline generator impedance < 130 Ω during AF ablation are independent predictors of PVI durability.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, 1085 Budapest, Hungary; (M.B.); (G.O.)
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Cui J, Du X, He L, Xia SJ, Tang RB, Sang CH, Long DY, Dong JZ, Ma CS. Impact of pre-ablation left appendage flow velocities on long term recurrence of catheter ablation for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2023; 46:1412-1418. [PMID: 37736872 DOI: 10.1111/pace.14828] [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: 04/04/2023] [Revised: 07/27/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Despite undergoing a single ablation, many patients with paroxysmal atrial fibrillation (PAF) experience a gradually increasing recurrence rate. This study aims to examine the relationship between left atrial appendage emptying velocity (LAAeV) and filling velocity (LAAfV) profiles and 3-year recurrence of AF after ablation. METHODS We conducted a prospective study of 658 consecutive PAF patients who underwent their first ablation between January 2018 and December 2019. We collected the clinical and echocardiographic characteristics of the patients. LAAeV and LAAfV were obtained from a transesophageal echocardiogram (TEE) before catheter ablation. Patients were followed at regular intervals to monitor for the primary outcome of AF recurrence. RESULTS After a median follow-up period of 35.3 months (range, 10.7-36.3), 288 patients (43.8%) experienced AF recurrence after catheter ablation. Patients who experienced AF recurrence had decreased LAAeV and LAAfV (LAAeV: 56.5 ± 21.2 vs. 59.6 ± 20.7 cm/s, p = .052; LAAfV: 47.5 ± 17.9 vs. 51.7 ± 18.2, p = .003). Kaplan-Meier analysis showed that patients in the low LAAeV (<55 cm/s) group had a poorer event-free survival rate than those in the high LAAeV (≥55 cm/s) group (log-rank p = .012). Patients with LAAfV <48 cm/s had a significantly higher risk of AF recurrence than those with LAAfV ≥48 cm/s (log-rank p = .003). In the multivariable model, low LAAfV pre-ablation in TEE-guided was significantly independently associated with 3-year recurrence after single radiofrequency ablation in patients with PAF, along with LA dimension and duration of AF. CONCLUSION This study found an independent association between low LAAfV pre-ablation in TEE-guided and 3-year recurrence after single radiofrequency ablation in patients with PAF.
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Affiliation(s)
- Jing Cui
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Shi-Jun Xia
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - De-Yong Long
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Orbán G, Dohy Z, Suhai FI, Nagy AI, Salló Z, Boga M, Kiss M, Kunze K, Neji R, Botnar R, Prieto C, Gellér L, Merkely B, Vágó H, Szegedi N. Use of a new non-contrast-enhanced BOOST cardiac MR sequence before electrical cardioversion or ablation of atrial fibrillation-a pilot study. Front Cardiovasc Med 2023; 10:1177347. [PMID: 37396587 PMCID: PMC10311645 DOI: 10.3389/fcvm.2023.1177347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/24/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Left atrial appendage (LAA) thrombus is the most common source of embolization in atrial fibrillation (AF). Transesophageal echocardiography (TEE) is the gold standard method for LAA thrombus exclusion. Our pilot study aimed to compare the efficacy of a new non-contrast-enhanced cardiac magnetic resonance (CMR) sequence (BOOST) with TEE for the detection of LAA thrombus and to evaluate the usefulness of BOOST images for planning radiofrequency catheter ablation (RFCA) compared with left atrial (LA) contrast-enhanced computed tomography (CT). We also attempted to assess the patients' subjective experiences with TEE and CMR. Methods Patients with AF undergoing either electrical cardioversion or RFCA were enrolled. Participants underwent pre-procedural TEE and CMR scans to evaluate LAA thrombus status and pulmonary vein anatomy. Patient experiences with TEE and CMR were assessed using a questionnaire developed by our team. Some patients scheduled for RFCA also had pre-procedural LA contrast-enhanced CT. In such cases, the operating physician was asked to subjectively define the quality of the CT and CMR scan on a scale of 1-10 (1 = worst, 10 = best) and comment on CMR's usefulness in RFCA planning. Results Seventy-one patients were enrolled. In 94.4%, both TEE and CMR excluded, and in 1 patient, both modalities reported the presence of LAA thrombus. In 1 patient, TEE was inconclusive, but CMR excluded LAA thrombus. In 2 patients, CMR could not exclude the presence of thrombus, but in 1 of those cases, TEE was also indecisive. During TEE, 67%, during CMR, only 1.9% of patients reported pain (p < 0.0001), and 89% would prefer CMR in case of a repeat examination. The quality of the left atrial contrast-enhanced CT scans was better compared with the image quality of the CMR BOOST sequence [8 (7-9) vs. 6 (5-7), p < 0.0001]. Still, the CMR images were useful for procedural planning in 91% of cases. Conclusion The new CMR BOOST sequence provides appropriate image quality for ablation planning. The sequence might be useful for excluding larger LAA thrombi; however, its accuracy in detecting smaller thrombi is limited. Most patients preferred CMR over TEE in this indication.
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Affiliation(s)
- Gábor Orbán
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsófia Dohy
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Anikó Ilona Nagy
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Salló
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Boga
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Máté Kiss
- Siemens Healthcare Hungary, Budapest, Hungary
| | - Karl Kunze
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, United Kingdom
| | - Radhouene Neji
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, United Kingdom
| | - Rene Botnar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Escuela de Ingeniería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Prieto
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Escuela de Ingeniería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Hajnalka Vágó
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Nándor Szegedi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Papathanasiou KA, Vrachatis DA, Kazantzis D, Kossyvakis C, Giotaki SG, Deftereos G, Raisakis K, Kaoukis A, Avramides D, Lambadiari V, Siasos G, Deftereos S. Left atrial appendage morphofunctional indices could be predictive of arrhythmia recurrence post-atrial fibrillation ablation: a meta-analysis. Egypt Heart J 2023; 75:29. [PMID: 37079174 PMCID: PMC10119349 DOI: 10.1186/s43044-023-00356-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/14/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Left atrium changes are implicated in atrial fibrillation (AF) substrate and are predictive of AF outcomes. Left atrial appendage (LAA) is an integral component of left atrial structure and could be affected by atrial cardiomyopathy. We aimed to elucidate the association between LAA indices and late arrhythmia recurrence after atrial fibrillation catheter ablation (AFCA). METHODS The MEDLINE database, ClinicalTrials.gov, medRxiv and Cochrane Library were searched for studies evaluating LAA and late arrhythmia recurrence in patients undergoing AFCA. Data were pooled by meta-analysis using a random-effects model. The primary endpoint was pre-ablation difference in LAA anatomic or functional indices. RESULTS A total of 34 studies were found eligible and five LAA indices were analyzed. LAA ejection fraction and LAA emptying velocity were significantly lower in patients with AF recurrence post-ablation [SMD = - 0.66; 95% CI (- 1.01, - 0.32) and SMD = - 0.56; 95% CI (- 0.73, - 0.40) respectively] as compared to arrhythmia free controls. LAA volume and LAA orifice area were significantly higher in patients with AF recurrence post-ablation (SMD = 0.51; 95% CI 0.35-0.67, and SMD = 0.35; 95% CI 0.20-0.49, respectively) as compared to arrhythmia free controls. LAA morphology was not predictive of AF recurrence post-ablation (chicken wing morphology; OR 1.27; 95% CI 0.79-2.02). Moderate statistical heterogeneity and small case-control studies are the main limitations of our meta-analysis. CONCLUSIONS Our findings suggest that LAA ejection fraction, LAA emptying velocity, LAA orifice area and LAA volume differ between patients suffering from arrhythmia recurrence post-ablation and arrhythmia free counterparts, while LAA morphology is not predictive of AF recurrence.
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Affiliation(s)
- Konstantinos A Papathanasiou
- Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, 1 Rimini Str., Chaidari, Attiki, 12462, Athens, Greece.
| | - Dimitrios A Vrachatis
- Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, 1 Rimini Str., Chaidari, Attiki, 12462, Athens, Greece
| | - Dimitrios Kazantzis
- Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Sotiria G Giotaki
- Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, 1 Rimini Str., Chaidari, Attiki, 12462, Athens, Greece
| | - Gerasimos Deftereos
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Athens, Greece
| | - Konstantinos Raisakis
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Athens, Greece
| | - Andreas Kaoukis
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Athens, Greece
| | - Dimitrios Avramides
- Department of Cardiology, "G. Gennimatas" General Hospital of Athens, Athens, Greece
| | - Vaia Lambadiari
- Second Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, 12462, Athens, Greece
| | - Gerasimos Siasos
- 3rd Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens, Greece
| | - Spyridon Deftereos
- Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Attikon University Hospital, 1 Rimini Str., Chaidari, Attiki, 12462, Athens, Greece
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Liu Z, Mei X, Jiang H, Cui Y, Yin W, Wang K, Chen T, Zhou Y. Left Atrial Appendage Volume Predicts Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation: A Meta-Analysis. Arq Bras Cardiol 2023; 120:e20220471. [PMID: 36946857 DOI: 10.36660/abc.20220471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/16/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND The influence of left atrial appendage volume (LAAV) on the recurrence of atrial fibrillation (AF) following radiofrequency catheter ablation remains unclear. OBJECTIVES We performed a meta-analysis to assess whether LAAV is an independent predictor of AF recurrence following radiofrequency catheter ablation. METHODS The PubMed and the Cochrane Library databases were searched until March 2022 to identify publications evaluating LAAV in association with AF recurrence after radiofrequency catheter ablation. Seven studies that fulfilled the specified criteria of our analysis were found. We used the Newcastle-Ottawa Scale to evaluate the quality of the studies. The pooled effects were evaluated depending on standardized mean differences (SMDs) or hazard ratios (HRs) with 95% confidence intervals (CIs). P values < 0.05 were considered statistically significant. RESULTS A total of 1017 patients from 7 cohort studies with a mean follow-up 16.3 months were included in the meta-analysis. Data from 6 studies (943 subjects) comparing LAAV showed that the baseline LAAV was significantly higher in patients with AF recurrence compared to those without AF (SMD: -0.63; 95% CI: -0.89 to -0,37; all p values < 0.05; I2= 62.6%). Moreover, higher LAAV was independently associated with a significantly higher risk of AF recurrence after radiofrequency catheter ablation (HR: 1.10; 95% CI: 1.02 to 1.18). CONCLUSIONS The meta-analysis showed that there is a significant correlation between LAAV and AF recurrence after radiofrequency catheter ablation, and the role of LAAV in AF patients should not be ignored in clinical practice.
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Affiliation(s)
- Zhenghao Liu
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Xiaofei Mei
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Hezi Jiang
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Yujie Cui
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Weiwei Yin
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Kuangyi Wang
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Tan Chen
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
| | - Yafeng Zhou
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University , Suzhou Dushu Lake Hospital , Suzhou - China
- Institution for Hypertension of Soochow University , Suzhou - China
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Herczeg S, Simon J, Szegedi N, Karády J, Kolossváry M, Szilveszter B, Balogi B, Nagy VK, Merkely B, Széplaki G, Maurovich-Horvat P, Gellér L. High incidence of newly diagnosed obstructive coronary artery disease regardless of chest pain detected on pre-procedural cardiac computed tomography angiography in patients undergoing atrial fibrillation ablation. Coron Artery Dis 2023; 34:18-23. [PMID: 36484216 PMCID: PMC9742003 DOI: 10.1097/mca.0000000000001201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/08/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiac computed tomography (CT) is often performed before catheter ablation of atrial fibrillation to map atrial and pulmonary anatomy. Incident coronary artery disease (CAD) may also be diagnosed during cardiac CT angiography (CTA). Our aim was to assess whether coronary CTA might be able to identify a significant proportion of patients with obstructive CAD prior to their catheter ablation procedure event, even in asymptomatic patients. METHODS Consecutive patients undergoing pre-ablation coronary CTA for atrial fibrillation between 2013 and 2020 were retrospectively selected. Patients with previously diagnosed CAD were excluded. Obstructive CAD was defined as ≥50% luminal stenosis. We analyzed the relationship between obstructive CAD, any chest pain, and traditional risk factors. RESULTS Overall, 2321 patients [median age 63.0 (54.4-69.2), 1052/2321 (45.3%) female] underwent coronary CTA and 488/2321 (21.0%) were diagnosed with obstructive CAD. There was no difference regarding the rate of obstructive CAD in patients with any chest pain compared to patients without any chest pain [91/404 (22.5%) vs. 397/1917 (20.7%), P = 0.416, respectively). The following parameters were associated with obstructive CAD: age > 65 years [odds ratio (OR) = 2.51; 95% confidence interval (CI), 2.02-3.13; P < 0.001), male sex (OR = 1.59; 95% CI, 1.28-1.98; P < 0.001), hypertension (OR = 1.40; 95% CI, 1.08-1.81; P = 0.012), diabetes (OR = 1.50; 95% CI, 1.13-1.99; P = 0.006), dyslipidaemia (OR = 1.33; 95% CI, 1.07-1.66; P = 0.011) and history of smoking (OR = 1.34; 95% CI, 1.07-1.68; P = 0.011). CONCLUSIONS The high prevalence of obstructive CAD even in patients without chest pain highlights the importance of additional coronary artery diagnostics in patients undergoing left atrial CTA awaiting catheter ablation for atrial fibrillation. These patients regardless of chest pain thus may require further risk modification to decrease their potential ischemic and thromboembolic risk.
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Affiliation(s)
- Szilvia Herczeg
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Nándor Szegedi
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Júlia Karády
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Bernadett Balogi
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Vivien K Nagy
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Gábor Széplaki
- Atrial Fibrillation Institute, Mater Private Hospital, Dublin
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - László Gellér
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
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Terasawa M, Chierchia GB, Housari MA, Bala G, Cosyns B, Droogmans S, Tanaka K, Belsack D, De Mey J, Sieira J, Brugada P, de Asmundis C, Ströker E. Predictors of late pulmonary vein reconnection in patients with arrhythmia recurrence after cryoballoon ablation-per vein analysis including cardiac computed tomography-based anatomic factors. Eur Heart J Cardiovasc Imaging 2022:6958487. [PMID: 36562390 DOI: 10.1093/ehjci/jeac255] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 10/27/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS To identify predictors of individual late pulmonary vein (PV) reconnection after second-generation cryoballoon (CB2) ablation. Anatomic indicators of late pulmonary vein reconnection (LPVR) post-CB2 ablation have not yet been studied on an individual PV level, nor weighed against clinical and procedural factors. METHODS AND RESULTS Clinical, procedural, and PV anatomic data from 125 patients with a repeat procedure for arrhythmia recurrence after index CB2 ablation were analyzed. Preprocedural computed tomography (CT) evaluated 486 PVs for measurement of size; shape (ovality index); carina width; and orientation angle in frontal (superior/inferior) and transversal (anterior/posterior) plane (with horizontal line 0° as reference and upper/lower half circle as positive/negative value, respectively). Durable isolation in all PVs was demonstrated in 50/125 (40%) patients. Late reconnection rates at the different PVs were as follows: 16% left superior (LS), 12% left inferior (LI), 17% right superior (RS), and 31% right inferior (RI) PV. Multivariable analysis performed per vein showed following independent determinants predicting LPVR: ovality index [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.07-2.41, P = 0.022] and carina width (OR 0.75, CI 0.59-0.96, P = 0.024) for LSPV; carina width (OR 0.71, CI 0.53-0.95, P = 0.020) for LIPV; frontal angle (OR 0.91, CI 0.87-0.95, P < 0.001) for RIPV; and transversal angle (OR 1.15, CI 1.03-1.31, P = 0.032) for RSPV. CONCLUSION Cardiac CT-based evaluation of anatomic PV characteristics presented higher predictive value compared to clinical and procedural variables for individual LPVR after CB2 ablation. Pre-procedural identification of unfavourable PV anatomy might be important to tailor the ablation approach.
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Affiliation(s)
- Muryo Terasawa
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium.,Department of Cardiology, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku City, Tokyo 160-0023, Japan
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Maysam Al Housari
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Gezim Bala
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Steven Droogmans
- Department of Cardiology, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Kaoru Tanaka
- Department of Radiology, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Dries Belsack
- Department of Radiology, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Johan De Mey
- Department of Radiology, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
| | - Erwin Ströker
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
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Han S, Liu M, Jia R, Cen Z, Guo R, Liu G, Cui K. Left atrial appendage function and structure predictors of recurrent atrial fibrillation after catheter ablation: A meta-analysis of observational studies. Front Cardiovasc Med 2022; 9:1009494. [PMCID: PMC9632352 DOI: 10.3389/fcvm.2022.1009494] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background The results of studies evaluating the left atrial appendage (LAA) function and structure as predictors of atrial fibrillation (AF) recurrence after catheter ablation (CA) are contradictory. Therefore, we performed a meta-analysis to assess whether the LAA function and structure can predict the recurrence of AF after CA. Methods The PubMed, EMBASE, Web of Science, and Cochrane library databases were used to conduct a comprehensive literature search. Finally, 37 studies encompassing 11 LAA parameters were included in this meta-analysis. Results Compared with those in the non-recurrence group, the recurrence group had increased LAA volume (SMD 0.53, 95% CI [0.36, 0.71] p < 0.00001), LAA volume index, LAA orifice area, and LAA orifice short/long axis and decreased LAA emptying flow velocity (SMD -0.54, 95% CI [-0.68, -0.40], P < 0.00001), LAA filling flow velocity, and LAA ejection fraction, while there was no significant difference in LAA morphology or LAA depth. Conclusion Large LAA structure of pre-ablation (LAA volume, orifice area, orifice long/short axis, and volume index) and decreased LAA function of pre-ablation (LAA emptying flow velocity, filling flow velocity, ejection fraction, and LASEC) increase the odds of AF recurrence after CA. Systematic review registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42022324533].
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Affiliation(s)
- Shaojie Han
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Interventional Operating Room, Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ruikun Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhifu Cen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ran Guo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Guobin Liu
- Department of Cardiology, The First People’s Hospital of Jintang County, Chengdu, China
- *Correspondence: Guobin Liu,
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Guobin Liu,
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Gagyi RB, Szegedi N, Simon J, Wijchers S, Bhagwandien R, Kong MH, Ruppersberg P, Szili-Torok T. Left atrial anatomical variations correlate with atrial fibrillation sources near the left atrial ridge. Front Cardiovasc Med 2022; 9:928384. [PMID: 36247472 PMCID: PMC9554407 DOI: 10.3389/fcvm.2022.928384] [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: 04/25/2022] [Accepted: 08/31/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Anatomical variations and characteristics of the left atrium (LA) may have a previously undescribed effect on source locations in atrial fibrillation (AF). This is the first study aiming to investigate the relationship between anatomical characteristics of the LA and non-PV sources detected by electrographic flow (EGF) mapping in patients with persistent AF. Materials and methods We analyzed cardiac computed tomography (CT) and EGF mapping data in patients who underwent radiofrequency catheter ablation (CA). EGF mapping is a novel method based on Horn–Schunk flow estimation algorithm, used to estimate cardiac action potential flow in the atria that can detect AF sources in patients with persistent AF. By analyzing EGF maps obtained during CA procedures, we localized non-PV sources in the LA. Results Thirty patients were included in this study (mean age 62.4 ± 6.8 years). Ten patients had AF sources near the LA ridge, while twenty patients had no leading source (source activity > 26%) near the LA ridge. LA anatomical characteristics, left atrial appendage (LAA) length, and ostial diameter showed no correlation with the presence of a leading source. We documented 19 patients with abutting LAA and left superior pulmonary vein (LSPV) (distance < 2 mm), and 11 patients with non-abutting LAA–LSPV (distance > 2 mm). Three out of 19 patients presented with a leading source near ridge in the abutting LAA–LSPV group, while 7 out of 11 patients presented with a leading source near the ridge in the non-abutting LAA-LSPV group (p = 0.01). Conclusion Our data suggests that non-abutting LAA-LSPV is associated with the presence of AF sources near the LA ridge.
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Affiliation(s)
- Rita B. Gagyi
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
| | - Nándor Szegedi
- Heart and Vascular Center, The Semmelweis University Hospital, Budapest, Hungary
| | - Judit Simon
- Heart and Vascular Center, The Semmelweis University Hospital, Budapest, Hungary
| | - Sip Wijchers
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
| | - Rohit Bhagwandien
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Tamas Szili-Torok
- Department of Cardiology, Electrophysiology, Erasmus MC, Rotterdam, Netherlands
- *Correspondence: Tamas Szili-Torok,
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Chen P, Shi Y, Ju J, Pan D, Miao L, Guo X, Chen Z, Du J. Left atrial appendage flow velocity predicts recurrence of atrial fibrillation after catheter ablation: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:971848. [PMID: 36148065 PMCID: PMC9485569 DOI: 10.3389/fcvm.2022.971848] [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: 06/17/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose There is increasing evidence that left atrial appendage flow velocity (LAAFV) is linked to the recurrence of atrial fibrillation (AF) after catheter ablation (CA), suggesting the potential predictable significance of LAAFV in this setting. We performed a systematic review and meta-analysis to assess whether LAAFV is association with AF recurrence after CA. Methods Up to May 1, 2022, six databases (PubMed, EMBASE, Web of Science, Cochrane Library, Scopus, and CINAHL) were searched for literature reporting the association between LAAFV and AF recurrence after CA. All statistical analyses were carried out using STATA version 16 software. Heterogeneity was determined by the Cochrane’s Q test and I2 statistics. The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of each included study, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was adopted to evaluate the quality of evidence. Result Sixteen studies with 5,006 AF patients after CA (1,479 patients with AF recurrence, 3,527 without AF recurrence) were included in the meta-analysis. The meta-analysis of 15 studies (16 data sets) showed that patients with recurrence exhibited lower LAAFV values than those without recurrence [standardized mean difference (SMD): −0.65, 95% CI: −0.88 to −0.42, P < 0.01]. Moreover, we evaluated the association of LAAFV and the risk of AF recurrence after CA. Nine studies (11 data sets) defined LAAFV as continuous variables, and the pooled analysis suggested that for every 1 cm/s rise in LAAFV values, the risk of AF recurrence after CA decreased by 3% [Odds Ratio (OR): 0.97, 95% CI: 0.95 to 0.99, P < 0.01]. Seven studies defined LAAFV as categorical variables, and the pooled analysis showed that lower LAAFV were associated with an increased risk of AF recurrence after CA [OR: 2.28, 95% CI: 1.46 to 3.57, P < 0.01]. The subgroup analyses showed that the association between LAAFV and AF recurrence after CA was not significantly affected by the AF type and ablation procedure. The NOS indicated that included studies were moderate to high quality, while the GRADE assessment suggested a low certainty of the evidence. Conclusion Lower LAAFV may be associated with an increased risk of AF recurrence after CA. Further studies with well designed and randomized studies for LAAFV should be conducted. Systematic review registration [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022333627].
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Affiliation(s)
- Pengfei Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yujiao Shi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianqing Ju
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Lina Miao
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Xiaolin Guo
- Shanxi University of Traditional Chinese Medicine, Taiyuan, China
| | - Zhuhong Chen
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Zhuhong Chen,
| | - Jianpeng Du
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Jianpeng Du,
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Orbán G, Salló Z, Perge P, Ábrahám P, Piros K, Nagy KV, Osztheimer I, Merkely B, Gellér L, Szegedi N. Characteristics of Very High-Power, Short-Duration Radiofrequency Applications. Front Cardiovasc Med 2022; 9:941434. [PMID: 35911564 PMCID: PMC9326019 DOI: 10.3389/fcvm.2022.941434] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Pulmonary vein isolation is the cornerstone of rhythm-control therapy for atrial fibrillation (AF). The very high-power, short-duration (vHPSD) radiofrequency (RF) ablation is a novel technology that favors resistive heating while decreasing the role of conductive heating. Our study aimed to evaluate the correlations between contact force (CF), power, impedance drop (ID), and temperature; and to assess their role in lesion formation with the vHPSD technique. Methods Consecutive patients who underwent initial point-by-point RF catheter ablation for AF were enrolled in the study. The vHPSD ablation was performed applying 90 W for 4 s with an 8 ml/min irrigation rate. Results Data from 85 patients [median age 65 (59–71) years, 34% female] were collected. The median procedure time, left atrial dwelling time, and fluoroscopy time were 70 (60–90) min, 49 (42–58) min, and 7 (5–11) min, respectively. The median RF time was 312 (237-365) sec. No steam pop nor major complications occurred. A total of 6,551 vHPSD RF points were analyzed. The median of CF, maximum temperature, and ID were 14 (10–21) g, 47.6 (45.1–50.4) °C, and 8 (6–10) Ohms, respectively. CF correlated significantly with the maximum temperature (p < 0.0001). A CF of 5 g and above was associated with a significantly higher temperature compared to those lesions with a CF below 5 grams (p < 0.0001). Bilateral first-pass isolation rate was 84%. The 6-month AF-recurrence rate was 7%. Conclusion The maximum temperature and CF significantly correlate with each other during vHPSD applications. A CF ≥ 5 g leads to better tissue heating and thus might be more likely to result in good lesion formation, although this clinical study was unable to assess actual lesion sizes.
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