1
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Doll N, Weimar T, Kosior DA, Bulava A, Mokracek A, Mönnig G, Sahu J, Hunter S, Wijffels M, van Putte B, Rüb N, Nemec P, Ostrizek T, Suwalski P. Efficacy and safety of hybrid epicardial and endocardial ablation versus endocardial ablation in patients with persistent and longstanding persistent atrial fibrillation: a randomised, controlled trial. EClinicalMedicine 2023; 61:102052. [PMID: 37425372 PMCID: PMC10329123 DOI: 10.1016/j.eclinm.2023.102052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Background Endocardial catheter ablation (CA) has limited long-term benefit for persistent and longstanding persistent atrial fibrillation (PersAF/LSPAF). We hypothesized hybrid epicardial-endocardial ablation (HA) would have superior effectiveness compared to CA, including repeat (rCA), in PersAF/LSPAF. Methods CEASE-AF (NCT02695277) is a prospective, multi-center, randomized controlled trial. Nine hospitals in Poland, Czech Republic, Germany, United Kingdom, and the Netherlands enrolled eligible participants with symptomatic, drug refractory PersAF and left atrial diameter (LAD) > 4.0 cm or LSPAF. Randomization was 2:1 to HA or CA by an independent statistician and stratified by site. Treatment assignments were masked to the core rhythm monitoring laboratory. For HA, pulmonary veins (PV) and left posterior atrial wall were isolated with thoracoscopic epicardial ablation including left atrial appendage exclusion. Endocardial touch-up ablation was performed 91-180 days post-index procedure. For CA, endocardial PV isolation and optional substrate ablation were performed. rCA was permitted between days 91-180. Primary effectiveness was freedom from AF/atrial flutter/atrial tachycardia >30-s through 12-months absent class I/III anti-arrhythmic drugs except those not exceeding previously failed doses. It was assessed in the modified intention-to-treat (mITT) population who had the index procedure and follow-up data. Major complications were assessed in the ITT population who had the index procedure. Thirty-six month follow-up continues. Findings Enrollment began November 20, 2015 and ended May 22, 2020. In 154 ITT patients (102 HA; 52 CA), 75% were male, mean age was 60.7 ± 7.9 years, mean LAD was 4.7 ± 0.4 cm, and 81% had PersAF. Primary effectiveness was 71.6% (68/95) in HA versus 39.2% (20/51) in CA (absolute benefit increase: 32.4% [95% CI 14.3%-48.0%], p < 0.001). Major complications through 30-days after index procedures plus 30-days after second stage/rCA were similar (HA: 7.8% [8/102] versus CA: 5.8% [3/52], p = 0.75). Interpretation HA had superior effectiveness compared to CA/rCA in PersAF/LSPAF without significant procedural risk increase. Funding AtriCure, Inc.
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Affiliation(s)
| | - Timo Weimar
- Eberhard Karls University School of Medicine, Tuebingen, Germany
| | - Dariusz A. Kosior
- Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
- Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
| | - Alan Bulava
- Ceske Budejovice Hospital, Ceske Budejovice, Czech Republic and Faculty of Health and Social Sciences, University of South Bohemia in Ceske Budejovice, Czech Republic
| | - Ales Mokracek
- Ceske Budejovice Hospital, Ceske Budejovice, Czech Republic and Faculty of Health and Social Sciences, University of South Bohemia in Ceske Budejovice, Czech Republic
| | | | | | | | | | | | - Norman Rüb
- RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Petr Nemec
- Center of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Tomas Ostrizek
- Center of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Piotr Suwalski
- National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
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Pluymaekers NAHA, Dudink EAMP, Boersma L, Erküner Ö, Gelissen M, van Dijk V, Wijffels M, Dinh T, Vernooy K, Crijns HJ, Balt J, Luermans JGLM. External electrical cardioversion in patients with cardiac implantable electronic devices: Is it safe and is immediate device interrogation necessary? Pacing Clin Electrophysiol 2018; 41:1336-1340. [PMID: 30080928 DOI: 10.1111/pace.13467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/09/2018] [Accepted: 07/27/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Atrial tachyarrhythmias are common in patients with cardiac implantable electronic devices (CIEDs). Restoration of sinus rhythm by external electrical cardioversion (eECV) is frequently used to alleviate symptoms and to ensure optimal device function. OBJECTIVES To evaluate the safety of eECV in patients with contemporary CIEDs and to assess the need for immediate device interrogation after eECV. METHODS We conducted a retrospective observational study of 229 patients (27.9% female, age 69 ± 10 years) with a CIED (104 pacemakers, 69 implantable cardioverter defibrillators, and 56 biventricular devices) who underwent eECV between 2008 and 2016 in two centers. Data from device interrogation before eECV, immediately afterwards, and at first follow-up (FU) after eECV were collected. CIED-related complications and adverse events during and after eECV were recorded. RESULTS No significant differences between right atrial (RA) and right ventricular (RV) sensing or threshold values before eECV, immediately afterwards, or at FU were observed. A small yet significant decrease was observed in RA and RV impedance immediately after eECV (484 Ω vs 462 Ω, P < 0.001 and 536 Ω vs 514 Ω, P < 0.001, respectively). The RV impedance did not recover to the baseline value (538 Ω vs 527 Ω, P = 0.02). The impedance changes were without clinical consequences. No changes in left ventricular lead threshold or impedance values were measured. No CIED-related complications or adverse events were documented following eECV. CONCLUSION eECV in patients with contemporary CIEDs is safe. There seems to be no need for immediate device interrogation after eECV.
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Affiliation(s)
- Nikki A H A Pluymaekers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Elton A M P Dudink
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ömer Erküner
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marloes Gelissen
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Vincent van Dijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Maurits Wijffels
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Trang Dinh
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Harry J Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Jippe Balt
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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3
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Wintgens L, Klaver M, Chaldoupi S, Van Dijk V, Alipour A, Wijffels M, Balt J, Boersma L. P344Anatomy of the pulmonary veins and clinical outcome after pulmonary vein isolation in paroxysmal atrial fibrillation: a large-scaled single-centre experience. Europace 2018. [DOI: 10.1093/europace/euy015.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L Wintgens
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - M Klaver
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - S Chaldoupi
- Haga University Hospital, The Hague, Netherlands
| | - V Van Dijk
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - A Alipour
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - M Wijffels
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - J Balt
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - L Boersma
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
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4
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Wintgens L, Klaver M, Swaans M, Alipour A, Balt J, Van Dijk V, Rensing B, Wijffels M, Boersma L. P394Left atrial catheter ablation in patients with previously implanted left atrial appendage closure devices. Europace 2018. [DOI: 10.1093/europace/euy015.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L Wintgens
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - M Klaver
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - M Swaans
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - A Alipour
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - J Balt
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - V Van Dijk
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - B Rensing
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - M Wijffels
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - L Boersma
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
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5
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Pluymaekers NAHA, Dudink EAMP, Boersma L, Erkuner Ö, Gelissen M, Van Dijk V, Wijffels M, Dinh T, Vernooy K, Crijns HJGM, Balt J, Luermans JGLM. P456External electrical cardioversion in patients with cardiac implantable electronic devices: is it safe and is immediate device interrogation necessary? Europace 2018. [DOI: 10.1093/europace/euy015.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- NAHA Pluymaekers
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - EAMP Dudink
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - L Boersma
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - Ö Erkuner
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - M Gelissen
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - V Van Dijk
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - M Wijffels
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - T Dinh
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - HJGM Crijns
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
| | - J Balt
- St Antonius Hospital, Cardiology, Nieuwegein, Netherlands
| | - JGLM Luermans
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands
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6
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Van Dijk V, Fanggiday J, Wijffels M, Balt J, Daeter E, Kelder H, Boersma L. 109-05: Effects of epicardial versus transvenous left ventricular lead placement on cardiac perfusion, contractile force, and clinical performance in cardiac resynchronisation therapy; a randomized clinical trial. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i86a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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7
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Wintgens L, Chaldoupi M, Wijffels M, Balt J, Boersma L. 136-08: Adenosine-provoked dormant pulmonary vein conduction is associated with reconnection site in follow up. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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8
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Boersma LV, van der Voort P, Debruyne P, Dekker L, Simmers T, Rossenbacker T, Balt J, Wijffels M, Degreef Y. Multielectrode Pulmonary Vein Isolation Versus Single Tip Wide Area Catheter Ablation for Paroxysmal Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:e003151. [DOI: 10.1161/circep.115.003151] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 02/17/2016] [Indexed: 11/16/2022]
Abstract
Background—
Single-shot ablation techniques may facilitate safe and simple pulmonary vein isolation to treat paroxysmal atrial fibrillation. Multielectrode pulmonary vein isolation versus single tip wide area catheter ablation-paroxysmal atrial fibrillation is the first multinational, multicenter, prospective, noninferiority randomized clinical trial comparing multielectrode-phased radiofrequency ablation (MEA) to standard focal irrigated radiofrequency ablation (STA) using 3-dimensional navigation.
Methods and Results—
Patients with paroxysmal atrial fibrillation were randomized to MEA (61 patients) or STA (59 patients). Preprocedure transesophageal echocardiogram and computed tomography/magnetic resonance imaging (also 6-month postprocedure) were performed. Mean age was 57 years, 25% female sex, BMI was 28, CHA
2
DS
2
–VASc score was 0 to 1 in 82%, 8% had previous right atrial ablation, whereas all had at least 1 antiarrhythmic drug failure. The MEA group had significantly shorter mean procedure time (96±36 versus 166±46 minutes,
P
<0.001) and fluoroscopy time (23±9 versus 27±9 minutes,
P
=0.023). The total radiofrequency energy duration was 22±8 minutes for MEA versus 36±13 minutes for STA (
P
<0.001) with confirmed pulmonary vein isolation in all patients. Hospital admission was 1 day in both groups, without major adverse events either during the procedure or during 30-day follow-up. Two patients in the STA group had 1 PV with asymptomatic narrowing >50%. Freedom of atrial fibrillation for MEA and STA was 86.4% and 89.7% at 6 months, dropping to 76.3% and 81.0% at 12 months.
Conclusions—
In this multicenter, randomized clinical trial, MEA and STA had similar rates of single-procedure acute pulmonary vein isolation without serious adverse events in the first 30 days. MEA had slightly lower long-term arrhythmia freedom, but showed marked and significantly shorter procedure, fluoroscopy, and radiofrequency energy times.
Clinical Trial Registration—
URL:
www.clinicaltrials.gov
; Unique identifier: NCT01696136.
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Affiliation(s)
- Lucas V. Boersma
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Pepijn van der Voort
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Pilippe Debruyne
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Lukas Dekker
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Tim Simmers
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Tom Rossenbacker
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Jippe Balt
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Maurits Wijffels
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
| | - Yves Degreef
- From the Cardiology Department, St. Antonius Ziekenhuis, Nieuwegein, The Netherlands (L.V.B., J.B., M.W.); Cardiology Department, Catharina Ziekenhuis, Eindhoven, The Netherlands (P.v.d.V., L.D., T.S.); Cardiology Department, Imelda Ziekenhuis, Bonheiden, Belgium (P.D., T.R.); and Cardiology Department, AZ Middelheim, Antwerpen, Belgium (Y.D.)
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Proclemer A, Gasparini M, Arenal A, Lunati M, Martinez Ferrer J, Hersi A, Gulaj M, Wijffels M, Brown B, Kloppe A. Termination of arrhythmias by anti-tachycardia pacing is associated with very low healthcare utilization compared to shock therapy in patients with an implantable cardioverter defibrillator. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M, Sandoval E, Calvo N, Brugada J, Kelder J, Wijffels M, Mont L. Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST). Circulation 2012; 125:23-30. [PMID: 22082673 DOI: 10.1161/circulationaha.111.074047] [Citation(s) in RCA: 283] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become accepted therapy for antiarrhythmic drug–refractory atrial fibrillation. This study describes the first randomized clinical trial comparing their efficacy and safety during a 12-month follow-up.
Methods and Results—
One hundred twenty-four patients with antiarrhythmic drug–refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients). CA consisted of linear antral pulmonary vein isolation and optional additional lines. SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein, ganglionated plexi ablation, and left atrial appendage excision with optional additional lines. Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording. The primary end point, freedom from left atrial arrhythmia >30 seconds without antiarrhythmic drugs after 12 months, was 36.5% for CA and 65.6% for SA (
P
=0.0022). There was no difference in effect for subgroups, which was consistent at both sites. The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA (n=21 [34.4%] versus n=10 [15.9%];
P
=0.027), driven mainly by procedural complications such as pneumothorax, major bleeding, and the need for pacemaker. In the CA group, 1 patient died at 1 month of subarachnoid hemorrhage.
Conclusion—
In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA, SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up, although the procedural adverse event rate is significantly higher for SA than for CA.
Clinical Trial Registration—
URL:
http://clinicaltrials.gov
. Unique identifier: NCT00662701.
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Affiliation(s)
- Lucas V.A. Boersma
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Manuel Castella
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - WimJan van Boven
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Antonio Berruezo
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Alaaddin Yilmaz
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Mercedes Nadal
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Elena Sandoval
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Naiara Calvo
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Josep Brugada
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Johannes Kelder
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Maurits Wijffels
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
| | - Lluís Mont
- From the Departments of Cardiology (L.V.A.B., J.K., M.W.) and Cardiothoracic Surgery (W.J.v.B., A.Y.), St. Antonius Hospital, Nieuwegein, the Netherlands, and Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain (M.C., A.B., M.N., E.S., N.C., J.B., L.M.)
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11
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Boersma L, Mulder A, Jansen W, Wever E, Wijffels M. Voltage analysis after multi-electrode ablation with duty-cycled bipolar and unipolar radiofrequency energy: a case report. Europace 2009; 11:1546-8. [PMID: 19684039 PMCID: PMC2770696 DOI: 10.1093/europace/eup221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Pulmonary vein ablation with a single-tip catheter remains long and complex. We describe a typical case of a novel efficient technique with a decapolar ring catheter utilizing alternating unipolar/bipolar radiofrequency energy. Voltage analysis and electrical mapping demonstrate the potential for antrum ablation and pulmonary vein isolation.
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Affiliation(s)
- Lucas Boersma
- Cardiology Department, St Antonius Hospital Nieuwegein, 3430 EM Nieuwegein, The Netherlands.
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12
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Schwab JO, Gasparini M, Lunati M, Proclemer A, Kaup B, Santi E, Ligorio G, Klersy C, DE Sousa J, Okreglicki A, Arenal A, Wijffels M, Lemke B. Avoid delivering therapies for nonsustained fast ventricular tachyarrhythmia in patients with implantable cardioverter/defibrillator: the ADVANCE III Trial. J Cardiovasc Electrophysiol 2009; 20:663-6. [PMID: 19175450 DOI: 10.1111/j.1540-8167.2008.01415.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of this investigation is to evaluate whether a prolonged detection interval for life threatening ventricular tachyarrhythmia (VT) is able to reduce therapies (Rx) delivered by an implantable cardioverter/defibrillator (ICD). Until now, only the PREPARE trial demonstrated a reduction of ICD Rx in a cohort of primary prevention patients. METHODS AND RESULTS The ADVANCE III study is a prospective, randomized, parallel trial with 2 arms evaluating different intervals to detect (NID), i.e., 18/24 (as currently used) versus 30/40. The primary endpoint is to demonstrate a 20% reduction of ICD Rx (antitachycardia pacing or shocks) delivered to terminate spontaneous VT with a cycle length < or =320 ms in patients with Class I-IIA indication for ICD therapy, regardless of cardiac resynchronization capabilities. The worldwide investigation started in spring 2008 and is expected to be finished in 2011. CONCLUSIONS The ADVANCE III trial is the first randomized investigation evaluating the reduction of ICD Rx for fast VT due to a prolongation of NID in a general ICD patient cohort.
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Affiliation(s)
- Joerg O Schwab
- Department of Medicine-Cardiology, University of Bonn, Sigmund-Freud-Strasse 25, Bonn, Germany.
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13
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Duytschaever M, Mast F, Killian M, Blaauw Y, Wijffels M, Allessie M. Methods for determining the refractory period and excitable gap during persistent atrial fibrillation in the goat. Circulation 2001; 104:957-62. [PMID: 11514386 DOI: 10.1161/hc3401.093156] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recently, the temporal excitable gap during atrial fibrillation (AF) has been identified as a vulnerable parameter for cardioversion of AF. In this study, we evaluated 5 methods to measure the refractory period (RP(AF)) and the excitable period (EP(AF)) during persistent AF. METHODS AND RESULTS In 11 goats instrumented with 83 epicardial atrial electrodes, persistent AF (43+/-34 days) was induced with a median AF cycle length (CL) of 98+/-14 ms. To measure RP(AF), premature stimuli were applied to the center of the electrode array on the right or left atrium. The RP(AF) measured by mapping of premature stimuli was 70+/-12 ms ("gold standard"). The RP(AF) determined during entrainment of AF was 77+/-17 ms (R(2)=0.88, P<0.01). Statistical analysis of the effects of synchronized stimuli (each coupling interval x100) on the AFCL histogram yielded an RP(AF) of 70+/-13 ms (R(2)=0.94, P<0.01). A further simplification was to apply slow fixed-rate pacing (1 Hz) during AF. For each stimulus (n=250 to 500), the paced AFCL was plotted against its coupling interval, and capture was determined by statistical shortening of the AFCL (RP(AF) 71+/-17 ms, R(2)=0.84, P<0.01). The 5th percentile of the AFCL histogram as an index of RP(AF) was 77+/-12 ms (R(2)=0.90, P<0.01). CONCLUSIONS During persistent AF with an AFCL of 98+/-14 ms, the RP(AF) determined by mapping of synchronized premature stimuli (gold standard) was 70+/-12 ms, with an excitable period of 28+/-8 ms. Although the indirect methods to measure RP(AF) all correlated well with the gold standard, slow fixed-rate pacing seems to be the most attractive technique because of the ease of acquiring the data and the clear graphic result.
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Affiliation(s)
- M Duytschaever
- Department of Physiology, Maastricht University, Maastricht, the Netherlands
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14
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Power JM, Beacom GA, Alferness CA, Raman J, Wijffels M, Farish SJ, Burrell LM, Tonkin AM. Susceptibility to atrial fibrillation: a study in an ovine model of pacing-induced early heart failure. J Cardiovasc Electrophysiol 1998; 9:423-35. [PMID: 9581958 DOI: 10.1111/j.1540-8167.1998.tb00930.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The development of susceptibility to atrial fibrillation (AF) is a common consequence of many forms of cardiovascular disease, especially heart failure. In this study we used a sheep model of pacing-induced stable early heart failure to describe, quantify, and relate the level of susceptibility to AF to changes in structural and electrophysiologic parameters. METHODS AND RESULTS Epicardial electrodes were implanted on the atria and right ventricles of nine sheep. The AF threshold, atrial vulnerability period, atrial effective refractory period (ERP), and interatrial conduction time were examined during control and over a 6-week period of ventricular pacing at 190 beats/min. Left atrial (LA) area and left ventricular (LV) fractional shortening were monitored using echocardiography. There were significant increases in LA susceptibility to AF (P < 0.0003), LA area (P < 0.0002), and LA ERP400 (P < 0.0002). Rate of increase in LA area was related positively to AF susceptibility (P = 0.02) and inversely to LA ERP400 (P = 0.002). LV fractional shortening decreased to approximately 50% of control value (P < 0.00001). No changes were observed in right atrial electrophysiology. CONCLUSION In this study, susceptibility (the ability of an extrastimulus to induce AF) was rigorously measured within a predetermined format. Significant relationships were found to exist between susceptibility, certain of the observed changes in atrial electrophysiology and structure.
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Affiliation(s)
- J M Power
- Department of Medicine, University of Melbourne, Heidelberg, Australia.
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15
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Abstract
BACKGROUND After cardioversion of sustained atrial fibrillation (AF), the electrical and contractile functions of the atria are impaired, and recurrences of AF frequently occur. Whether remodeling of the structure of atrial myocardium is the basis for this problem is not known. METHODS AND RESULTS Sustained AF was induced by electrical pacing in 13 goats instrumented long-term. The goats were killed after 9 to 23 weeks, and the atrial myocardium was examined by light and electron microscopy. The changes were quantified in left and right atrial free walls, appendages, trabeculae, the interatrial septum, and the bundle of Bachmann. A substantial proportion of the atrial myocytes (up to 92%) revealed marked changes in their cellular substructures, such as loss of myofibrils, accumulation of glycogen, changes in mitochondrial shape and size, fragmentation of sarcoplasmic reticulum, and dispersion of nuclear chromatin. These changes were accompanied by an increase in size of the myocytes (up to 195%). There were virtually no signs of cellular degeneration, and the interstitial space remained unaltered. The duration of sustained AF did not significantly affect the degree of myolytic cell changes. CONCLUSIONS Sustained AF in goats leads to predominantly structural changes in the atrial myocytes similar to those seen in ventricular myocytes from chronic hibernating myocardium. These structural changes may explain the depressed contractile function of atrial myocardium after cardioversion. This goat model of AF offers a new approach to study the cascade of events leading to sustained AF and its maintenance.
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Affiliation(s)
- J Ausma
- Department of Molecular Cell Biology and Genetics, Cardiovascular Research Institute Maastricht, Maastricht University, The Netherlands
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16
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Ausma J, Wijffels M, van Eys G, Koide M, Ramaekers F, Allessie M, Borgers M. Dedifferentiation of atrial cardiomyocytes as a result of chronic atrial fibrillation. Am J Pathol 1997; 151:985-97. [PMID: 9327732 PMCID: PMC1858023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Chronic atrial fibrillation was induced in goats by electrical pacing. After 9 to 23 weeks of sustained atrial fibrillation, the morphology of the atrial structures was examined. The majority of the cardiomyocytes exhibited marked changes in their cellular substructures, with the replacement of sarcomeres by glycogen as the main characteristic. Using immuno-histochemical staining procedures, we assessed the expression and organization of contractile and cytoskeletal proteins in these cases and compared them with the expression and organization of these proteins in normal atria. Part of the atrial cardiomyocytes acquired a dedifferentiated phenotype, as deduced from the re-expression of alpha-smooth muscle actin, the disappearance of cardiotin, and the staining patterns of titin, which resembled those of embryonic cardiomyocytes. From these results we conclude that chronic atrial fibrillation induces myocardial dedifferentiation. This model of chronic atrial fibrillation in goats offers the possibility to study the time course of changes in cardiac structure during sustained atrial fibrillation and after cardioversion.
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Affiliation(s)
- J Ausma
- Department of Molecular Cell Biology and Genetics, Cardiovascular Research Institute Maastricht, Maastricht University, The Netherlands
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17
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Abstract
The presence of an excitable gap during atrial fibrillation (AF), although short and variable, may be of potential importance for the development of alternative techniques for termination of AF by rapid pacing. Also the notion that perpetuation of AF may be partly dependent on macroreentry around the natural atrial orifices, may provide a new therapeutic option for the permanent cure of AF by interrupting the anatomical circular pathways in the atria by radiofrequency ablation. In our opinion the rapidly growing understanding of the electrophysiologic mechanisms of AF certainly warrants some optimism about the possibility of cure of AF in the near future without causing too much discomfort and without carrying on unacceptable risk.
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Affiliation(s)
- M A Allessie
- Department of Physiology, Maastricht University of Limburg, The Netherlands
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18
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Abstract
In five chronically instrumented conscious dogs, we studied the antifibrillatory action of the experimental class IC drug Org 7797 ((16 alpha,17 beta)-17-methylamino-oestra-1,3,5(10)-triene-3,16-diol- (Z)-2-butenedioate). Under control conditions, paroxysms of atrial fibrillation were induced by burst pacing (50 Hz; inducibility 100%) and persisted on the average for greater than 3 min. Org 7797 (1, 2, and 3 mg/kg/h) significantly reduced both inducibility and duration of atrial fibrillation to 25 and 10%, respectively. To elucidate the electrophysiologic mechanisms of this potent antifibrillatory action, we measured the effects of Org 7797 on conduction velocity, effective refractory period (ERP), and wavelength of the atrial impulse. Org 7797 decreased atrial conduction velocity significantly by 18-25% and lengthened ERP by 18-29% (pacing 2-5 Hz). The maximal pacing frequency (Fmax) was decreased from 8.3 to 6.2 Hz. During Fmax, Org 7797 decreased the conduction velocity by 23% and lengthened ERP by 75%, resulting in a prolongation of the wave-length from 9.8 +/- 2.3 cm (control) to 13.7 +/- 2.6 cm (3 mg/kg/h; p less than 0.01). These results indicate that the antifibrillatory action of Org 7797 is based on diminution of the physiologic rate-dependent shortening of refractoriness, resulting in a prolongation of the wavelength during maximal heart rates (HRs). This electrophysiologic effect of the drug will decrease the number of multiple wavelets during fibrillation, thus increasing the statistical chance of spontaneous termination of the fibrillatory process.
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Affiliation(s)
- C Kirchhof
- Department of Physiology, University of Limburg, Maastricht, The Netherlands
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