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Jiang Z, Huang J, Ma N, Liu H, Shen SE, Ding F, Wang Y, Tang M, Mei J. Concurrent vs Staged Hybrid Ablation for Long-Standing Persistent Atrial Fibrillation: A Propensity-Matched Cohort Study. JACC Clin Electrophysiol 2024:S2405-500X(24)00160-9. [PMID: 38573292 DOI: 10.1016/j.jacep.2024.02.017] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Long-term success rates of catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) are less than satisfactory. Further improvement of ablation methods is crucial for enhancing the treatment of LSPAF. OBJECTIVE This study sought to compare the outcomes of concurrent vs staged minimally invasive surgical-catheter hybrid ablation for LSPAF. METHODS From December 2015 to December 2021, 104 matched patients (concurrent and staged, 1:1) were included in study. In the concurrent group, both left unilateral thoracoscopic epicardial ablation (EA) and CA were performed simultaneously in one procedure. In the staged group, EA was performed at the first hospitalization. If the patients experienced atrial fibrillation (AF) recurrence, CA was performed between 3 months and 1 year after EA. RESULTS In the concurrent group, 4 patients were restored to sinus rhythm after EA, and 41 were patients restored to sinus rhythm during CA; 86.5% (45 of 52) achieved intraprocedural AF termination during concurrent hybrid ablation. In the staged group, all 52 patients underwent staged CA because of the recurrence of AF or atrial tachycardia (AT). Forty-seven (90.4%) patients achieved intraprocedural AF or AT termination during CA. Freedom from AF or AT off antiarrhythmic drugs at 2 years after hybrid ablation was 79.9% ± 5.7% in the concurrent group and 86.0% ± 4.9% in the staged group (P = 0.390). Failure of intraprocedural AF termination (HR: 14.378) was an independent risk factor for AF recurrence after hybrid ablation. CONCLUSIONS Both concurrent and staged hybrid ablation could be safely and effectively applied to treat LSPAF. Improving the intraprocedural AF termination rate predicted better outcomes.
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Affiliation(s)
- Zhaolei Jiang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Jianbing Huang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Nan Ma
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Hao Liu
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Sai-E Shen
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Fangbao Ding
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Yingman Wang
- Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China
| | - Min Tang
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China.
| | - Ju Mei
- Department of Cardiothoracic Surgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P. R. China.
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DeLurgio DB, Gill JS, Ahsan S, Kaba RA, Plasseraud KM, Halkos ME. Hybrid Convergent Procedure for the Treatment of Persistent and Long-standing Persistent Atrial Fibrillation. Arrhythm Electrophysiol Rev 2021; 10:198-204. [PMID: 34777825 PMCID: PMC8576514 DOI: 10.15420/aer.2021.24] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/08/2021] [Indexed: 01/01/2023] Open
Abstract
Recent advances have been made in AF treatment, including the role of early rhythm control and landmark clinical trials using ablation therapy. However, some treatment gaps remain, including the creation of durable lesions outside the pulmonary veins and effective treatment of longstanding persistent AF. A novel epicardial-endocardial ablation approach - the hybrid convergent procedure - was developed to combine surgical and catheter ablation techniques into a collaborative, multidisciplinary approach to managing AF. In this review, the authors discuss recently published data on hybrid convergent ablation, including results of the CONVERGE clinical trial, in the context of current challenges to treatment of persistent and long-standing persistent AF. The review also aims to provide perspective on outstanding questions and future directions in this area.
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Affiliation(s)
| | | | | | - Riyaz A Kaba
- St George's University Hospitals NHS Foundation Trust, London, UK
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Kiedrowicz RM, Wielusiński M, Wojtarowicz A, Kaźmierczak J. Atrial fibrillation risk scores to evaluate left atrial substrate based on voltage analysis in long-standing persistent type of arrhythmia. Kardiol Pol 2021; 79:525-530. [PMID: 34125925 DOI: 10.33963/kp.15902] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pre-ablation identification of left atrial (LA) low voltage areas (LVA) among long-standing persistent atrial fibrillation (LSPAF) population remains challenging. AIMS The aim of the study was to analyze the potential of selected scores originally developed to assess arrhythmia recurrences, thromboembolic complications, or progression from paroxysmal to persistent AF to predict the presence of LA-LVA in LSPAF patients. METHODS One hundred and fifty-two patients underwent pulmonary vein isolation followed by high-density-high-resolution LA voltage mapping. AF risk scores, such as APPLE, ATLAS, CAAP-AF, DR-FLASH, CHA2DS2-VASc, and HATCH were retrospectively calculated. A receiver operating characteristic curve analysis was performed to evaluate the ability of the scores to predict LVA. RESULTS Low voltage areas were detected in 52% of the patients. 28% of the patients with LVA presented severe global LVA burden, whereas 56% of the patients showed a disseminated pattern of remodeling. CAAP-AF ≥7, DR-FLASH ≥4, and CHA2DS2-VASc ≥3 predicted the presence of LVA, whereas ATLAS ≤7 indicated the absence of LVA. ATLAS ≤8, CAAP-AF ≤9, DR-FLASH ≤4, and CHA2DS2-VASc ≤3 predicted the absence of severe LVA. APPLE ≤3 and CHA2DS2-VASc ≤2 predicted the absence of a LVA disseminated pattern. Among predictive scores, ATLAS (AUC, 0.633, 95% CI, 0.543-0.723, P = 0.004), DR-FLASH (AUC, 0.696; 95% CI, 0.594-0.81; P <0.001), and CHA2DS2-VASc (AUC, 0.644; 95% CI 0.518-0.77; P = 0.025) were the best predictors for the absence of LVA, severe LVA and a disseminated pattern of LVA, respectively. CONCLUSIONS Atrial fibrillation risk stratification with specific scoring systems can unmask the presence of LA-LVA in the LSPAF population.
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Zheng Z, Yao Y, Li H, Zheng L, Liu S, Lin H, Duan F. Simultaneous hybrid maze procedure for long-standing persistent atrial fibrillation with dilated atrium. JTCVS Tech 2020; 5:34-42. [PMID: 34318103 PMCID: PMC8300042 DOI: 10.1016/j.xjtc.2020.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 12/26/2022] Open
Abstract
Background The efficacy of catheter-based or thoracoscopic ablation for treating long-standing persistent atrial fibrillation (AF) with a dilated atrium remains suboptimal. This study aimed to assess the feasibility and initial results of simultaneous hybrid ablation with a new biatrial lesion set in these patients. Methods Twenty-seven consecutive patients with long-standing persistent AF and dilated atrium underwent simultaneous hybrid ablation with a new biatrial lesion set consistent with the principle of the Cox maze procedure at our institution. Patients were followed up at 3, 6, and 12 months after the procedure and annually thereafter. Results After thoracoscopic epicardial ablation, endocardial mapping confirmed complete bilateral pulmonary vein isolation in 25 patients (96.2%). All patients were followed for a mean of 18.7 ± 8.9 months. Freedom from atrial tachyarrhythmia at 1 year after the single hybrid procedure was 64% with antiarrhythmic drugs and 60% without antiarrhythmic drugs. Freedom from atrial tachyarrhythmia at latest follow-up after the hybrid procedure and redo catheter ablation was 77.8% with antiarrhythmic drugs and 74.1% without antiarrhythmic drugs. In patients with sinus rhythm restoration, mean left atrial diameter decreased from 54.4 ± 4.3 mm to 45.2 ± 4.1 mm (P < .001), and mean right atrial diameter decreased from 59.4 ± 3.9 mm to 54.9 ± 4.4 mm (P < .001). Postoperative pleural effusion was observed in 3 patients (11.1%), and no adverse events occurred during follow-up. Conclusions In patients with long-standing persistent AF and a dilated atrium, simultaneous hybrid ablation with the new biatrial lesion set, in combination with touch-up catheter ablation when necessary, can achieve promising results. More studies are needed to confirm these findings.
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Key Words
- AAD, antiarrhythmic drug
- AF, atrial fibrillation
- AFL, atrial flutter
- CA, catheter ablation
- ECG, electrocardiography
- IVC, inferior vena cava
- LA, left atrium
- LAA, left atrial appendage
- LAD, left atrial diameter
- LSPAF, long-standing persistent atrial fibrillation
- NT-proBNP, N-terminal pro B-type natriuretic peptide
- PV, pulmonary vein
- RA, right atrium
- RAD, right atrial diameter
- SR, sinus rhythm
- SVC, superior vena cava
- dilated atrium
- hybrid ablation
- long-standing persistent atrial fibrillation
- maze
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Affiliation(s)
- Zhe Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Yao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haojie Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihui Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Arrhythmia, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Liu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hengqiang Lin
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fujian Duan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of Medical Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Poole JE, Bahnson TD, Monahan KH, Johnson G, Rostami H, Silverstein AP, Al-Khalidi HR, Rosenberg Y, Mark DB, Lee KL, Packer DL. Recurrence of Atrial Fibrillation After Catheter Ablation or Antiarrhythmic Drug Therapy in the CABANA Trial. J Am Coll Cardiol 2020; 75:3105-3118. [PMID: 32586583 PMCID: PMC8064404 DOI: 10.1016/j.jacc.2020.04.065] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/09/2020] [Accepted: 04/21/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The CABANA (Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial randomized 2,204 patients with atrial fibrillation (AF) to catheter ablation or drug therapy. Analysis by intention-to-treat showed a nonsignificant 14% relative reduction in the primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest. OBJECTIVES The purpose of this study was to assess recurrence of AF in the CABANA trial. METHODS The authors prospectively studied CABANA patients using a proprietary electrocardiogram recording monitor for symptom-activated and 24-h AF auto detection. The AF recurrence endpoint was any post-90-day blanking atrial tachyarrhythmias lasting 30 s or longer. Biannual 96-h Holter monitoring was used to assess AF burden. Patients who used the CABANA monitors and provided 90-day post-blanking recordings qualified for this analysis (n = 1,240; 56% of CABANA population). Treatment comparisons were performed using a modified intention-to-treat approach. RESULTS Median age of the 1,240 patients was 68 years, 34.4% were women, and AF was paroxysmal in 43.0%. Over 60 months of follow-up, first recurrence of any symptomatic or asymptomatic AF (hazard ratio: 0.52; 95% confidence interval: 0.45 to 0.60; p < 0.001) or first symptomatic-only AF (hazard ratio: 0.49; 95% confidence interval: 0.39 to 0.61; p < 0.001) were both significantly reduced in the catheter ablation group. Baseline Holter AF burden in both treatment groups was 48%. At 12 months, AF burden in ablation patients averaged 6.3%, and in drug-therapy patients, 14.4%. AF burden was significantly less in catheter ablation compared with drug-therapy patients across the 5-year follow-up (p < 0.001). These findings were not sensitive to the baseline pattern of AF. CONCLUSIONS Catheter ablation was effective in reducing recurrence of any AF by 48% and symptomatic AF by 51% compared with drug therapy over 5 years of follow-up. Furthermore, AF burden was also significantly reduced in catheter ablation patients, regardless of their baseline AF type. (Catheter Ablation vs Anti-arrhythmic Drug Therapy for Atrial Fibrillation Trial [CABANA]; NCT00911508).
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Affiliation(s)
- Jeanne E Poole
- University of Washington Medical Center, Seattle, Washington.
| | - Tristram D Bahnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - George Johnson
- Seattle Institute of Cardiac Research, Seattle, Washington
| | - Hoss Rostami
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Adam P Silverstein
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Kiedrowicz RM, Wielusinski M, Wojtarowicz A, Kazmierczak J. Predictors of the voltage derived left atrial fibrosis in patients with long-standing persistent atrial fibrillation. Cardiol J 2020; 29:660-669. [PMID: 32419127 PMCID: PMC9273256 DOI: 10.5603/cj.a2020.0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 04/14/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022] Open
Abstract
Background Left atrial (LA) arrhythmogenic substrate beyond the pulmonary veins (PV) seems to play a crucial role in the maintenance of atrial fibrillation (AF). The aim of this study was to evaluate the association of selected parameters with the presence and extent of voltage-defined LA fibrosis in patients with long-standing persistent AF (LSPAF) undergoing catheter ablation. Methods One hundred and sixteen consecutive patients underwent high density-high resolution voltage mapping of the LA with a multielectrode catheter following PV isolation and restoration of sinus rhythm with cardioversion. A non-invasive dataset, such as clinical variables, two- and three-dimensional echocardiography determined LA size and function and fibrillatory-wave amplitude on a standard surface electrocardiogram were obtained during AF before ablation. Results Low-voltage areas (LVA; 15 cm2 [IQR 8–31]) were detected in 56% of patients. Twenty nine percent of them presented mild, 43% moderate and 28% severe global LVA burden. In univariate analysis, age ≥ 57 years old, female sex, body surface area ≤ 1.76 m2, valvular heart disease, moderate mitral regurgitation, chronic coronary syndrome, hypothyroidism, CHA2DS2-VASc score ≥ 3 and ≥ 4 predicted the presence of LVA. In multivariate analysis only female sex, valvular heart disease and CHA2DS2-VASc ≥ 4 remained statistically significant. AF duration, LA size and function and fibrillatory-waves amplitude were neither associated with the prediction of the LVA, nor severe LVA burden. Conclusions A LSPAF diagnosis does not indicate the presence of voltage defined fibrosis in many cases. Simple non-invasive screening of the LSPAF population could predict LVA prevalence.
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Affiliation(s)
| | - Maciej Wielusinski
- Department of Cardiology, Pomeranian Medical University, Szczecin, Poland
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Hanaki Y, Machino-Ohtsuka T, Aonuma K, Komatsu Y, Machino T, Yamasaki H, Igarashi M, Sekiguchi Y, Nogami A, Ieda M. Preprocedural restoration of sinus rhythm and left atrial strain predict outcomes of catheter ablation for long-standing persistent atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:1709-1718. [PMID: 32391641 DOI: 10.1111/jce.14540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Catheter ablation (CA) for long-standing persistent atrial fibrillation (LS-AF) remains challenging. We aimed to explore whether sinus rhythm (SR) restoration and left atrium (LA) function after pretreatment with antiarrhythmic drugs (AAD's) and electrical cardioversion (ECV) predict procedural outcomes. METHODS AND RESULTS We included 100 consecutive patients with LS-AF who were treated with AAD/ECV for at least 3 months before CA. The echocardiographic LA strain during reservoir phase (LASr) was assessed after pretreatment as a marker of LA fibrosis. The recurrence was recorded for ≥1 year after the last procedure. During a 34 ± 16-month follow-up period, the single and multiple procedures and pharmaceutically assisted success rates were 40% and 71%, respectively. Patients with preprocedural SR restoration and higher LASr showed a significantly higher recurrence-free probability after the last CA (logrank P = .001 and P < .001, respectively). Failure of preprocedural SR restoration and LASr ≤8.6% were independently associated with recurrence after the last CA (hazard ratio [HR]: 3.13, 95% confidence interval [CI]: 1.42-6.91, P = .005; HR: 3.89, 95% CI: 1.65-9.17, P = .002, respectively). These parameters added incrementally to the predictive value of AF duration and LA dilatation (P = .03 and P = .002, respectively) and improved the recurrence-risk stratification (net reclassification improvement = 0.39; 95% CI = 0.13-0.65; P = .003). CONCLUSION In patients with LS-AF, the inability to restore SR and lower LASr after AAD/ECV treatment independently and incrementally predicts the recurrence after CA. These findings might be useful for determining LS-AF ablation candidates.
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Affiliation(s)
- Yuichi Hanaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuki Komatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Takeshi Machino
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Miyako Igarashi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and represents a major burden to health care systems. Atrial fibrillation is associated with a 4- to 5-fold increased risk of thromboembolic stroke. The pulmonary veins have been identified as major sources of atrial triggers for AF. This is particularly true in patients with paroxysmal AF but not always the case for those with long-standing persistent AF (LSPAF), in which other locations for ectopic beats have been well recognized. Structures with foci triggering AF include the coronary sinus, the left atrial appendage (LAA), the superior vena cava, the crista terminalis, and the ligament of Marshall. More than 30 studies reporting results on radiofrequency ablation of LSPAF have been published to date. Most of these are observational studies with very different methodologies using different strategies. As a result, there has been remarkable variation in short- and long-term success, which suggests that the optimal ablation technique for LSPAF is still to be elucidated. In this review we discuss the different approaches to LSPAF catheter ablation, starting with pulmonary vein isolation (PVI) through ablation lines in different left atrial locations, the role of complex fractionated atrial electrograms, focal impulses and rotor modulation, autonomic modulation (ganglionated plexi), alcohol ablation, and the future of epicardial mapping and ablation for this arrhythmia. A stepwise ablation approach requires several key ablation techniques, such as meticulous PVI, linear ablation at the roof and mitral isthmus, electrogram-targeted ablation with particular attention to triggers in the coronary sinus and LAA, and discretionary right atrial ablation (superior vena cava, intercaval, or cavotricuspid isthmus lines).
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Affiliation(s)
- Jorge Romero
- Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York ; Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Carola Gianni
- St. David's Medical Center, Austin, Texas ; University of Milan, Milan, Italy
| | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, Bronx, New York ; St. David's Medical Center, Austin, Texas ; University of Texas, Austin, Texas ; University of Foggia, Foggia, Italy
| | - Andrea Natale
- St. David's Medical Center, Austin, Texas ; University of Texas, Austin, Texas ; California Pacific Medical Center, San Francisco, California ; Stanford University, Palo Alto, California ; Case Western Reserve University, Cleveland, Ohio ; Scripps Clinic, San Diego, California
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Thacker EL, Jensen PN, Psaty BM, McKnight B, Longstreth WT, Dublin S, Newton KM, Smith NL, Siscovick DS, Heckbert SR. Use of statins and antihypertensive medications in relation to risk of long-standing persistent atrial fibrillation. Ann Pharmacother 2015; 49:378-86. [PMID: 25628466 DOI: 10.1177/1060028014568447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND After an initial episode of atrial fibrillation (AF), patients may develop long-standing persistent or permanent AF. OBJECTIVE We evaluated whether use of statins, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or β-blockers is associated with lower risk of long-standing persistent AF after an initial AF episode. METHODS We conducted a population-based inception cohort study of participants enrolled in Group Health, aged 30 to 84 years, with newly diagnosed AF in 2001-2004. We included only participants whose initial AF episode terminated within 6 months of onset. We ascertained the primary outcome of long-standing persistent AF from medical records, electrocardiograms, and administrative data. We determined time-varying medication use from Group Health pharmacy data. RESULTS Among 1317 participants with incident AF, 304 developed long-standing persistent AF. Our study suggests that current statin use versus never use may be associated with lower risk for long-standing persistent AF. However, the association was not statistically significant when adjusted for age, sex, cardiovascular risk factors, and current use of antiarrhythmic medication (hazard ratio [HR] = 0.77; 95% CI = 0.57, 1.03). In lagged analyses intended to reduce healthy user bias, current statin use 1 year prior versus never use 1 year prior was not associated with risk for long-standing persistent AF (HR = 0.91; 95% CI = 0.67, 1.24). ACE inhibitor, ARB, and β-blocker use were not associated with risk for long-standing persistent AF. CONCLUSIONS Current statin use may confer protection that wanes after discontinuing use. Alternatively, healthy user bias or chance may explain the association. The association of statin use with long-standing persistent AF warrants further investigation.
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Affiliation(s)
- Evan L Thacker
- University of Washington, Seattle, WA, USA Brigham Young University, Provo, UT, USA
| | | | - Bruce M Psaty
- University of Washington, Seattle, WA, USA Group Health Research Institute, Seattle, WA, USA
| | | | | | - Sascha Dublin
- University of Washington, Seattle, WA, USA Group Health Research Institute, Seattle, WA, USA
| | - Katherine M Newton
- University of Washington, Seattle, WA, USA Group Health Research Institute, Seattle, WA, USA
| | - Nicholas L Smith
- University of Washington, Seattle, WA, USA Group Health Research Institute, Seattle, WA, USA Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - David S Siscovick
- University of Washington, Seattle, WA, USA New York Academy of Medicine, New York, NY, USA
| | - Susan R Heckbert
- University of Washington, Seattle, WA, USA Group Health Research Institute, Seattle, WA, USA
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