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Mumtaz M, Jabeen S, Danial A, Chaychi MTM, Zaheer MK, Mumtaz A, Mumtaz T, Herweg B. Adjunct posterior wall isolation reduces the recurrence of atrial fibrillation in patients undergoing cryoballoon ablation: A systematic review and meta-analysis. J Cardiovasc Electrophysiol 2023; 34:2043-2052. [PMID: 37526224 DOI: 10.1111/jce.16028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/03/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Recurrence rates of atrial fibrillation (AF) remain high even after complete wide area circumferential pulmonary vein isolation (PVI). In recent years adjunct posterior wall isolation (PWI) has been performed in patients with more persistent forms of AF but the benefits remain unclear. AIM The objective of this meta-analysis was to evaluate the efficacy of adjunct posterior wall isolation in reducing recurrence rates of AF using cryoballoon ablation (CBA). METHODS We searched PubMed, Google Scholar, Clinicaltrials.gov and Cochrane CENTRAL. We included studies comparing PVI to PVI + PWI in patients with either persistent or paroxysmal AF (PAF) undergoing CBA. After data extraction and quality assessment of the studies, we assessed recurrence rates of atrial tachy-arrhythmias (AF, atrial flutter, and atrial tachycardia) as well as total ablation time and procedural adverse events. Risk ratio (RR), mean difference (MD), and 95% confidence interval (CI) were calculated using Review Manager. RESULTS Concomitant PWI exhibited a substantial reduction in the risk of AF recurrence (RR: 0.51; 95% CI: 0.42-0.63, p < .00001), as well as all atrial arrhythmias (RR: 0.58; 95% CI: 0.49-0.68, p < .00001). On subgroup analysis, in patients with only PAF, adjunct PWI resulted in significant reduction in recurrence risk of AF (RR: 0.56; 95% CI: 0.41-0.76, p = .0002) as well. There was no significant difference in adverse events between both groups (RR: 0.90; 95% CI: 0.44-1.86; p = .78), whereas total ablation time was significantly increased in PVI + PWI group (MD: 21.75; 95% CI: 11.13-32.37, p < .0001). CONCLUSION Adjunct PWI when compared to PVI alone decreases recurrence rates of atrial fibrillation after CBA of patients with persistent as well as paroxysmal atrial fibrillation.
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Affiliation(s)
- Mishal Mumtaz
- Department of medicine, Quaid-e-Azam Medical College Bahawalpur, Affiliated with University of Health Sciences Lahore, Lahore, Pakistan
| | - Sidra Jabeen
- Department of medicine, Liaquat National Hospital and Medical College, Affiliated with Jinnah Sindh Medical University Karachi, Karachi, Pakistan
| | - Ahmad Danial
- Department of medicine, Quaid-e-Azam Medical College Bahawalpur, Affiliated with University of Health Sciences Lahore, Lahore, Pakistan
| | - Muhammad Tayyab Muzaffar Chaychi
- Department of medicine, Quaid-e-Azam Medical College Bahawalpur, Affiliated with University of Health Sciences Lahore, Lahore, Pakistan
| | - Muhammad Kashan Zaheer
- Department of medicine, Liaquat National Hospital and Medical College, Affiliated with Jinnah Sindh Medical University Karachi, Karachi, Pakistan
| | - Aymen Mumtaz
- Department of medicine, CMH Lahore Medical and Dental College, Affiliated with National University of Medical Sciences, Pakistan
| | - Tayebah Mumtaz
- Department of Cardiovascular, St. Elizabeth's Medical Centre, Boston, Massachusetts, USA
| | - Bengt Herweg
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Heart & Vascular Institute, Tampa General Hospital, Tampa, Florida, USA
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Masè M, Cristoforetti A, Del Greco M, Ravelli F. A Divergence-Based Approach for the Identification of Atrial Fibrillation Focal Drivers From Multipolar Mapping: A Computational Study. Front Physiol 2021; 12:749430. [PMID: 35002755 PMCID: PMC8740027 DOI: 10.3389/fphys.2021.749430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
The expanding role of catheter ablation of atrial fibrillation (AF) has stimulated the development of novel mapping strategies to guide the procedure. We introduce a novel approach to characterize wave propagation and identify AF focal drivers from multipolar mapping data. The method reconstructs continuous activation patterns in the mapping area by a radial basis function (RBF) interpolation of multisite activation time series. Velocity vector fields are analytically determined, and the vector field divergence is used as a marker of focal drivers. The method was validated in a tissue patch cellular automaton model and in an anatomically realistic left atrial (LA) model with Courtemanche-Ramirez-Nattel ionic dynamics. Divergence analysis was effective in identifying focal drivers in a complex simulated AF pattern. Localization was reliable even with consistent reduction (47%) in the number of mapping points and in the presence of activation time misdetections (noise <10% of the cycle length). Proof-of-concept application of the method to human AF mapping data showed that divergence analysis consistently detected focal activation in the pulmonary veins and LA appendage area. These results suggest the potential of divergence analysis in combination with multipolar mapping to identify AF critical sites. Further studies on large clinical datasets may help to assess the clinical feasibility and benefit of divergence analysis for the optimization of ablation treatment.
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Affiliation(s)
- Michela Masè
- Laboratory of Biophysics and Translational Cardiology, Department of Cellular, Computational and Integrative Biology – CIBIO, University of Trento, Trento, Italy
- Institute of Mountain Emergency Medicine, EURAC Research, Bolzano, Italy
| | - Alessandro Cristoforetti
- Laboratory of Biophysics and Translational Cardiology, Department of Cellular, Computational and Integrative Biology – CIBIO, University of Trento, Trento, Italy
| | - Maurizio Del Greco
- Division of Cardiology, Santa Maria del Carmine Hospital, Rovereto, Italy
| | - Flavia Ravelli
- Laboratory of Biophysics and Translational Cardiology, Department of Cellular, Computational and Integrative Biology – CIBIO, University of Trento, Trento, Italy
- CISMed – Centre for Medical Sciences, University of Trento, Trento, Italy
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Sulke N, Dulai R, Freemantle N, Sugihara C, Podd S, Eysenck W, Lewis M, Hyde J, Veasey RA, Furniss SS. Long Term outcomes of percutaneous atrial fibrillation ablation in patients with continuous monitoring. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1176-1184. [PMID: 34028066 DOI: 10.1111/pace.14282] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/09/2021] [Accepted: 05/16/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION There is limited data using continuous monitoring to assess outcomes of atrial fibrillation (AF) ablation. This study assessed long-term outcomes of AF ablation in patients with implantable cardiac devices. METHODS 207 patients (mean age 68.1 ± 9.5, 50.3% men) undergoing ablation for symptomatic AF were followed up for a mean period of 924.5 ± 636.7 days. Techniques included The Pulmonary Vein Ablation Catheter (PVAC) (59.4%), cryoablation (17.4%), point by point (14.0%) and The Novel Irrigated Multipolar Radiofrequency Ablation Catheter (nMARQ) (9.2%). RESULTS 130 (62.8%) patients had paroxysmal AF (PAF) and 77 (37.2%) persistent AF. First ablation and repeat ablation reduced AF burden significantly (relative risk 0.91, [95% CI 0.89 to 0.94]; P <0.0001 and 0.90, [95% CI, 0.86-0.94]; P <0.0001). Median AF burden in PAF patients reduced from 1.05% (interquartile range [IQR], 0.1%-8.70%) to 0.10% ([IQR], 0%-2.28%) at one year and this was maintained out to four-years. Persistent AF burden reduced from 99.9% ([IQR], 51.53%-100%) to 0.30% ([IQR], 0%-77.25%) at one year increasing to 87.3% ([IQR], 4.25%-100%) after four years. If a second ablation was required, point-by-point ablation achieved greater reduction in AF burden (relative risk, 0.77 [95% CI, 0.65-0.91]; P <0.01). CONCLUSION Ablation reduces AF burden both acutely and in the long-term. If a second ablation was required the point-by-point technique achieved greater reductions in AF burden than "single-shot" technologies. Persistent AF burden increased to near pre ablation levels by year 4 suggesting a different mechanism from PAF patients where this increase did not occur.
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Affiliation(s)
- Neil Sulke
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Eastbourne, United Kingdom
| | - Rajdip Dulai
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Eastbourne, United Kingdom
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Conn Sugihara
- Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom
| | - Steven Podd
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - William Eysenck
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Eastbourne, United Kingdom
| | - Michael Lewis
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Jonathan Hyde
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Rick A Veasey
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Eastbourne, United Kingdom
| | - Stephen S Furniss
- Cardiology Research Department, East Sussex Hospitals NHS Trust, Eastbourne District General Hospital, Eastbourne, United Kingdom
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Area Available for Atrial Fibrillation to Propagate Is an Important Determinant of Recurrence After Ablation. JACC Clin Electrophysiol 2021; 7:896-908. [PMID: 33640348 DOI: 10.1016/j.jacep.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study sought to evaluate atrial fibrillation (AF) ablation outcomes based on scar patterns and contiguous area available for AF wavefronts to propagate. BACKGROUND The relevance of ablation scar pattern acting as a barrier for electrical propagation in recurrence after catheter ablation for persistent AF is unknown. METHODS Three-month post-ablation atrial cardiac magnetic resonance was used to determine post-ablation scar. The left atrium (LA) was divided into 5 areas based on anatomical landmarks and scar patterns. The length of gaps in scar on the area boundaries was used to calculate fibrillatory areas (FAs) by adding the weighted contribution of adjacent areas. Cylindrical as well as patient-specific computational models were used to further confirm findings. RESULTS A total of 75 patients that underwent an initial ablation for AF with 2 years of follow-up were included. The average maximum FA was 7,896 ± 1,988 mm2 in patients with recurrence (n = 40) and 6,559 ± 1,784 mm2 in patients without recurrence (n = 35) (p < 0.008). After redo ablation in 19 patients with recurrence, average maximum FA was 7,807 ± 1,392 mm2 in 9 patients with recurrence and 5,030 ± 1,765 mm2 in 10 without recurrence (p < 0.007). LA volume and total scar were not significant predictors of recurrence after the first ablation. In the cylindrical model, AF self-terminated after reducing the FAs. In the patient-specific models, simulation matched the clinical outcomes with larger FAs associated with post-ablation arrhythmia recurrences. CONCLUSIONS This data provides mechanistic insights into AF recurrence, suggesting that post-ablation scar pattern dividing the atria into smaller regions is an important and better predictor than LA volume and total scar, with improved long-term outcomes in persistent AF.
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Stokes MB, Sanders P, Lau DH. Editorial commentary: Computed tomography and atrial fibrillation substrate: The knowns and unknowns. Trends Cardiovasc Med 2020; 31:467-468. [PMID: 33221490 DOI: 10.1016/j.tcm.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Michael B Stokes
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), University of Adelaide and Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
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Peigh G, Wasserlauf J, Kaplan RM, Amaral AP, Trivedi A, Chicos AB, Arora R, Kim S, Lin A, Verma N, Knight BP, Passman RS. Repeat pulmonary vein isolation with or without FIRM-guided ablation for recurrent atrial fibrillation with pulmonary vein reconnection. J Cardiovasc Electrophysiol 2020; 31:1031-1037. [PMID: 32115794 DOI: 10.1111/jce.14426] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/20/2020] [Accepted: 01/30/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Focal impulse and rotor modulation (FIRM) ablation can be used to target nonpulmonary vein (PV) sources of atrial fibrillation (AF). No published studies have compared freedom from atrial fibrillation (FFAF) after pulmonary vein reisolation (PVRI) plus FIRM to PVRI alone in patients with reconnected PVs undergoing repeat ablation. METHODS A 3:1 matched retrospective cohort study was performed on 21 patients with recurrent AF and PV reconnection who underwent PVRI plus FIRM-guided ablation and 63 patients with recurrent AF treated with PVRI alone at a single institution. All patients in the PVRI-alone cohort had cryoballoon PVRI at the time of repeat ablation without additional lesion sets for AF. Cases were matched based on the type of AF (paroxysmal vs nonparoxysmal), left atrial diameter (±4 mm), left ventricular ejection fraction (±10%), duration of AF (±18 months), and age (±5 years). The primary endpoint was FFAF after a 3-month blanking period. RESULTS Out of 53 total FIRM cases performed at Northwestern Memorial Hospital between 2015 and 2017, 21 patients had PVRI plus FIRM for recurrent AF with PV reconnection. These patients had an average of 3.3 ± 2.1 rotors (60% left atrial) ablated. Over a median follow-up time of 24.7 months (interquartile range, 13-36 months), patients in the PVRI-alone cohort demonstrated a higher rate of FFAF (n = 35; 55.6%) than patients in the PVRI plus FIRM-guided ablation cohort (n = 7; 33.3%) (logrank P = .049). CONCLUSION In patients undergoing repeat ablation for AF with PV reconnection, PVRI plus FIRM did not increase FFAF compared to PVRI alone.
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Affiliation(s)
- Graham Peigh
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jeremiah Wasserlauf
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rachel M Kaplan
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ansel P Amaral
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Amar Trivedi
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alexandru B Chicos
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rishi Arora
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Susan Kim
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Albert Lin
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nishant Verma
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Bradley P Knight
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rod S Passman
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Abstract
This review focusses on novel findings in atrial fibrillation mechanisms derived from mapping studies. Recent panoramic mapping techniques have identified 2 arrhythmic mechanisms of interest, namely, rotational (rotors) and ectopic focal activations as drivers of atrial fibrillation. Epicardial adipose tissue and fatty infiltration into the myocardium have been described as novel substrates for atrial fibrillation. There is increasing appreciation that the thin atrial walls harbor a complex 3-dimensional electrostructural substrate to contribute to atrial fibrillation sustenance. Further research is warranted to advance the field toward more targeted therapy.
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Affiliation(s)
- Dennis H Lau
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia
| | - Dominik Linz
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, University of Adelaide, Royal Adelaide Hospital, 1 Port Road, Adelaide, South Australia 5000, Australia.
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The effect of second-generation cryoablation without electrical mapping in persistent AF using continuous monitoring. J Interv Card Electrophysiol 2020; 60:175-182. [PMID: 32147799 DOI: 10.1007/s10840-020-00721-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/24/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Second-generation cryoballoon ablation is safe and effective in patients with persistent atrial fibrillation (AF). The aim of this study is to report the real long-term AF burden and freedom from AF post-cryoablation using continuous monitoring, and to assess whether intraoperative confirmation of pulmonary vein isolation using electrical mapping is necessary. METHODS A total of 33 patients (mean age 75.7 ± 5.6 years, 16 men) with persistent AF who underwent second-generation cryoablation without electrical mapping were reviewed. All patients had a cardiac implantable device and were followed up for a mean of 755 ± 170 days. RESULTS AF burden significantly decreased from 67.51% ± 34.90% to 18.28% ± 26.65% at 1-year follow-up, and this reduction was maintained at final follow-up (18.26% ± 23.70%, p < 0.001). Continuous monitoring revealed a freedom from AF rate of 33% and 24% at 1-year and full follow-up, respectively. Patients who remained in persistent AF at final follow-up had a trend towards higher pre-ablation AF burden (81.6% ± 29.7% vs 57.3% ± 36.4%, p = 0.08). CONCLUSION Second-generation cryoablation without confirming pulmonary vein isolation using electrical mapping is effective leading to significant reductions in AF burden based on continuous beat-to-beat monitoring at 1-year and long-term follow-up.
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