Catheter Ablation With Morphologic Repetitiveness Mapping for Persistent Atrial Fibrillation

Importance

Catheter ablation for persistent atrial fibrillation (AF) has shown limited success.

Objective

To determine whether AF drivers could be accurately identified by periodicity and similarity (PRISM) mapping ablation results for persistent AF when added to pulmonary vein isolation (PVI).

Design, Setting, and Participants

This prospective randomized clinical trial was performed between June 1, 2019, and December 31, 2020, and included patients with persistent AF enrolled in 3 centers across Asia. Data were analyzed on October 1, 2022.

Intervention

Patients were assigned to the PRISM-guided approach (group 1) or the conventional approach (group 2) at a 1:1 ratio.

Main Outcomes and Measures

The primary outcome was freedom from AF or other atrial arrhythmia for longer than 30 seconds at 6 and 12 months.

Results

A total of 170 patients (mean [SD] age, 62.0 [12.3] years; 136 men [80.0%]) were enrolled (85 patients in group 1 and 85 patients in group 2). More group 1 patients achieved freedom from AF at 12 months compared with group 2 patients (60 [70.6%] vs 40 [47.1%]). Multivariate analysis indicated that the PRISM-guided approach was associated with freedom from the recurrence of atrial arrhythmia (hazard ratio, 0.53 [95% CI, 0.33-0.85]).

Conclusions and Relevance

The waveform similarity and recurrence pattern derived from high-density mapping might provide an improved guiding approach for ablation of persistent AF. Compared with the conventional procedure, this novel specific substrate ablation strategy reduced the frequency of recurrent AF and increased the likelihood of maintenance of sinus rhythm.

Trial Registration

ClinicalTrials.gov Identifier: NCT05333952.

Impact of Kawasaki disease on juvenile idiopathic arthritis in real-world patients: A population-based cohort study

Objectives

Recent research has demonstrated the commonality of several biological markers between Kawasaki disease (KD) and juvenile idiopathic arthritis (JIA), including interleukin-1β and -6. Therefore, in this cohort study, we assessed whether KD increases the risk of JIA.

Methods

This study enrolled 7009 patients with and 56 072 individuals without KD in the period 2010-2018 from Taiwan's National Health Insurance Research Database. On the basis of sex, age, and comorbidities, we executed propensity score matching at the ratio 1:8. The adjusted hazard ratio (aHR) for JIA was determined through multiple Cox regression. Stratified analysis and sensitivity tests were also employed.

Results

When adjusting for age, sex, and comorbidities, the JIA risk was noted to be 2.02-fold greater in children with KD than it was in those without (aHR: 2.02, 95% confidence interval: 1.12-3.67, p = 0.0205). The sensitivity test and subgroup analysis obtained consistent findings in the different sex and comorbidity subgroups.

Conclusion

Children's risk of JIA is higher if they have KD. Pediatricians should consider the possibility of JIA in this population. More investigations are necessary to identify the pathological mechanisms that link JIA and KD.

Implantation of monocusp valve prolongs the duration of chest tube drainage in children with tetralogy of fallot after corrective surgery

BACKGROUND

Right ventricular outflow tract obstruction relief is one of the major procedures during the total correction of tetralogy of Fallot (TOF). Pulmonary insufficiency (PI) is usually inevitable after a transannular incision with a patch repair is performed. Therefore, some surgeons advocate to place a monocusp valve within the transannular patch (TAP) in order to decrease the severity of the PI. However, the monocusp valve seemed not be very effective in some patients who underwent the complete TOF repair.

METHODS

Patients who had the classic form of TOF between January 2009 and January 2017 and underwent the corrective surgery with a TAP by the same cardiovascular surgeon were identified for further analysis. Clinical information including demographics at operation, perioperative data, and postoperative outcome were collected retrospectively and compared between the group with and without a monocusp valve.

RESULTS

A total of 24 TOF cases were included in the final analysis, and 16 (66.7%) patients received a monocusp valve placement. The patients' characteristics before and during the surgery were similar between the two groups. The median duration of chest tube drainage after the total correction in the monocusp group was longer than those without the valve (p = 0.04). There was no difference in the immediate postoperative data, including the inflammation/infection status, the duration of mechanical ventilation, and the length of ICU and hospital stay.

CONCLUSION

Implantation of a monocusp valve during the total TOF correction using a TAP did not bring benefit to improve the immediate postoperative outcomes, especially the duration of the pleural drainage. Further study with a prospective design and a larger number of cases is needed.

Distribution of triggers foci and outcomes of catheter ablation in atrial fibrillation patients in different age groups

BACKGROUND

Atrial fibrillation (AF) prevalence increases with age. Aging affects the substrate properties of the left atrium (LA) and the outcomes of catheter ablation for treating AF. We investigated the AF trigger distribution and catheter ablation outcomes in patients of different ages with AF.

METHODS

1585 patients with AF (1181 paroxysmal and 404 non- paroxysmal AF) who had undergone catheter ablation were enrolled. The patients were divided into young (20-40 year-old, n = 175), middle-aged (41-64 year-old, n = 1134), and old (≥ 65 year-old, n = 276) groups. Electrophysiological characteristics and AF trigger sites were recorded.

RESULT

The incidence of AF with only non-pulmonary vein (non-PV) foci was higher in the young group than in the other groups (8.6% vs. 3.6% vs. 3.3%, p < 0.01). Non-PV foci were more commonly located in the superior vena cava (SVC) in the young group than in the other groups (13.1% vs. 7.8% vs. 6.5%, p = 0.03). The left atrium (LA) mean voltage was higher and the incidence of very late recurrence after AF ablation was lower in the young group than in the other groups. However, the final AF recurrence rate after multiple procedures and complication rates were similar among all the groups at a mean follow-up of 5.6 years.

CONCLUSION

The young patients with AF had a higher incidence of only non-PV foci, mostly located in SVC, than the middle-aged and old patients. Our study highlights the importance of identifying the non-PV foci in catheter ablation of young patients with AF.

The application of novel segmentation software to create left atrial geometry for atrial fibrillation ablation: The implication of spatial resolution

BACKGROUND

The application of new imaging software for the reconstruction of left atrium (LA) geometry during atrial fibrillation (AF) ablation has not been well investigated.

METHODS

A total of 27 patients undergoing AF ablation using a CARTO Segmentation Module system were studied (phase I). High-density LA mapping using PentaRay was merged with computed tomography-based geometry from the auto-segmentation module. The spatial distortion between the two LA geometries was analyzed and compared using Registration Match View. The associated contact force on the two LA shells was prospectively validated in 16 AF patients (phase II).

RESULTS

Of the five LA regions, the roof area had the highest quality score between the two LA shells (1.7 ± 0.6). In addition, among the pulmonary veins (PVs), higher quality scores were observed in bilateral PV carinas (both 1.8 ± 0.1, p < 0.05) than in the anterior or posterior PV regions. Furthermore, surrounding the PV ostium, the on-surface points had a significantly higher contact force when targeting the high-density fast anatomical mapping shell than for the auto-segmentation module (right superior pulmonary vein, 20.7 ± 5.8 g vs 12.5 ± 4.4 g; right inferior pulmonary vein, 19.3 ± 6.8 g vs 11.8 ± 4.8 g; left superior pulmonary vein, 22.5 ± 7.3 g vs 11.2 ± 4.5 g; left inferior pulmonary vein, 15.7 ± 6.9 g vs 9.7 ± 4.4 g, p < 0.05 for each group).

CONCLUSION

The CARTO Segmentation Module and Registration Match View provide better anatomic accuracy and less regional distortion of the LA geometry, and this can prevent excessive contact and potential procedural complications.

Transthoracic echocardiography monitoring during ASD closure using an artificial hand system

Aim

Continuous real-time echocardiographic monitoring is essential for guidance during ASD closure. However, transthoracic echocardiography (TTE) can only be implemented intermittently during fluoroscopy. We evaluate a novel approach to provide real-time imaging during the entire procedure.

Finding

We developed a custom-made TTE monitoring apparatus using artificial hand (AH-TTE) that enables real-time TTE images during atrial septal defect (ASD) closure. Thirty-two patients underwent successful device implantation using AH-TTE monitoring without complications. The median duration for real-time AH-TTE monitoring was 22 min and the median fluoroscopy time was 7.2 min. One case of pericardial effusion and one of transient bradycardia event due to air embolism was detected. All patients had uneventful recoveries.

Conclusions

Our simple and novel monitoring technique with AH-TTE provides TEE-like monitoring and may be a new alternative method for ASD closure. It gives real-time stable TTE images and minimizes radiation exposure for the interventional team during fluoroscopy.

Extremely late recurrences (≥3 years) of atrioventricular nodal reentrant tachycardia: Electrophysiological characteristics of the index and repeat ablation procedures

BACKGROUND

Catheter ablation is an effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). However, the characteristics of extremely late (>3 years) recurrences of AVNRT after a successful initial ablation are not fully elucidated. We aimed to explore the electrophysiological characteristics of extremely late recurrences of AVNRT after a successful ablation.

METHODS

From 1991 to 2018, 3311 patients (mean age: 48.7 ± 17.4 years; men: 1328 [40.1%]) who underwent catheter ablation for AVNRT were investigated. Baseline characteristics of the patients, recurrence status, and detailed electrophysiological parameters of the index and repeat ablation procedures were obtained for analysis.

RESULTS

After a mean follow-up period of 129.5 ± 58.0 months, 65 (2.0%) patients underwent repeat ablation for recurrences of AVNRT, of whom 17 (0.5%) presented with extremely late recurrences. The incidence of transient AV block was significantly higher in patients with extremely late recurrences (5.9%) than in those without recurrences (1.9%) but lower than that in patients with recurrences within <3 years (12.5%, P < .001). In addition, among patients with extremely late recurrences of AVNRT, the atrial-His bundle interval was significantly longer (99.1 ± 23.4 vs. 76.5 ± 13.1 ms, P < .01) and the need for intravenous isoproterenol and/or atropine for the induction of AVNRT (88.2% vs. 47.1%, P = .03) was higher in the repeat ablation procedure than in the index ablation procedure.

CONCLUSION

Recurrences of AVNRT can occur 3 years after a successful initial ablation. The electrophysiological features of the index and repeat ablation procedures differed between patients with extremely late recurrences of AVNRT and those with recurrences within <3 years.

Identification of critical isthmus using coherent mapping in patients with scar-related atrial tachycardia

INTRODUCTION

Accurate identification of slow conducting regions in patients with scar-related atrial tachycardia (AT) is difficult using conventional electrogram annotation for cardiac electroanatomic mapping (EAM). Estimating delays between neighboring mapping sites is a potential option for activation map computation. We describe our initial experience with CARTO 3 Coherent Mapping (Biosense Webster Inc,) in the ablation of complex ATs.

METHODS

Twenty patients (58 ± 10 y/o, 15 males) with complex ATs were included. We created three-dimensional EAMs using CARTO 3 system with CONFIDENSE and a high-resolution mapping catheter (Biosense Webster Inc). Local activation time and coherent maps were used to aid in the identification of conduction isthmus (CI) and focal origin sites. System-defined slow or nonconducting zones and CI, defined by concealed entrainment (postpacing interval < 20 ms), CV < 0.3 m/s and local fractionated electrograms were evaluated.

RESULTS

Twenty-six complex ATs were mapped (mean: 1.3 ± 0.7 maps/pt; 4 focal, 22 isthmus-dependent). Coherent mapping was better in identifying CI/breakout sites where ablation terminated the tachycardia (96.2% vs 69.2%; P = .010) and identified significantly more CI (mean/chamber 2.0 ± 1.1 vs 1.0 ± 0.7; P < .001) with narrower width (19.8 ± 10.5 vs 43.0 ± 23.9 mm; P < .001) than conventional mapping. Ablation at origin and CI sites was successful in 25 (96.2%) with long-term recurrence in 25%.

CONCLUSIONS

Coherent mapping with conduction velocity vectors derived from adjacent mapping sites significantly improved the identification of CI sites in scar-related ATs with isthmus-dependent re-entry better than conventional mapping. It may be used in conjunction with conventional mapping strategies to facilitate recognition of slow conduction areas and critical sites that are important targets of ablation.

Clinical efficacy of open-irrigated electrode cooled with half-normal saline for initially failed radiofrequency ablation of idiopathic outflow tract ventricular arrhythmias

BACKGROUND

Acute failure of radiofrequency ablation (RFA) of ventricular arrhythmias (VAs) occur in 10%-20% of patients and is partly attributed to inadequate lesion depth acquired with standard ablation protocols. Half-normal saline (HNS)-irrigation is a promising strategy to improve the success rate of VA ablation.

OBJECTIVE

This study investigated the efficacy of HNS-irrigated ablation after a failed standard plain normal saline solution (PNSS)-irrigated ablation on idiopathic outflow tract ventricular arrhythmia (OT-VA).

METHOD

This is a prospective observational study of consecutive patients undergoing RFA of idiopathic OT-VA comparing the efficacy of additional HNS-irrigated ablation for failed standard PNSS-irrigated ablation. Acute failure was defined as persistence of spontaneous VA or persistent inducibility of the clinical VA.

RESULTS

Out of 160 OT-VA cases (51 ± 15-year-old, 62 males), 31 underwent HNS irrigation after a failed standard PNSS-irrigated ablation. The HNS group had a significantly longer procedure time (60.06 ± 43.83 vs 37.51 ± 33.40 minutes; P = .013) and higher radiation exposure (31.45 ± 20.24 vs 17.22 ± 15.25 minutes; P = .001) than the PNSS group but provided an additional acute success in 21 of 31 (67.7%) patients. Over a follow-up duration of 7.8 ± 4.6 months, 24 recurrences were identified, including 8 (25.8%) in the HNS and 16 (12.4%) in the PNSS group, with lower freedom from recurrence in the HNS group (log rank P = .009). No major complication was observed.

CONCLUSION

HNS-irrigated ablation after failed standard PNSS-irrigated ablation is safe and additionally improves acute ablation success by 67.7% for idiopathic OT-VA but with a higher rate of recurrence on follow-up. Whether the application of HNS as initial irrigant could result in better outcome requires further investigation.

Electrophysiological and clinical characteristics of catheter ablation for isolated left side atrial tachycardia over a 10-year period

AIMS

Most left atrial tachycardia (LAT) is associated with atrial fibrillation (AF). The clinical and electrophysiological characteristics and outcomes of LAT without AF have not been investigated. This study sought to determine the long-term ablation outcomes and predictors of recurrence of isolated LAT.

METHODS

This is a single-center study of consecutive patients with isolated LAT. Atrial arrhythmia recurrence was determined from follow-up records of patients who underwent LAT ablation from 2008 to 2017. Clinical and electrophysiologic characteristics associated with atrial arrhythmia recurrence were identified.

RESULTS

A total of 50 patients (53 ± 19 years, 46% male) with 59 LAT (1.16 ± 0.47 per patient) were enrolled. Over a mean follow-up of 37 ± 33 months, atrial arrhythmia recurrence occurred in 22 (44%) patients, 11 with atrial tachycardia (AT) only, five with AF only, and six with concurrent AT and AF. The incidence of pulmonary vein (PV) origins increased significantly in the repeat procedure (P = 0.036). Multivariate analysis identified left ventricular ejection fraction (LVEF) as the only predictor of any atrial arrhythmia recurrence and LAT recurrence, while smoking and identified macroreentrant LAT in the index procedure predicted AF recurrence.

CONCLUSION

This study demonstrated a higher rate of atrial arrhythmia recurrence, including AF, among patients with initially isolated LAT. A lower LVEF predicted any atrial arrhythmia and LAT recurrence, whereas smoking and index macroreentrant AT mechanism predicted long-term AF. PV ATs were frequently observed in recurrent patients irrespective of index procedure origin.

The influence of pleurodesis on the outcome of primary spontaneous pneumothorax in children

BACKGROUND

Primary spontaneous pneumothorax (PSP) has a high rate of recurrence, and pleurodesis has been shown to decrease the rate of recurrence in adult PSP. For pediatric PSP patients, there are only a few case series available and evidence on the benefits of pleurodesis is insufficient. This study aimed to analyze the outcome of pleurodesis among pediatric PSP patients via a nationwide population-based cohort in Taiwan.

METHODS

The hospitalization data from the pediatric intensive care sampling file of the National Health Insurance Research Database from January 1 to December 31, 2010, were retrieved and analyzed. Children aged 0-18 years with a discharge diagnosis of PSP (ICD-9: 512, 512.0, and 512.8) were enrolled in the study. Demographic data, management strategies, and clinical outcomes were recorded and analyzed as well.

RESULTS

A total of 1005 hospitalization cases were identified and divided into the pleurodesis (409 hospitalizations) and nonpleurodesis (596 hospitalizations) groups. In the univariate analysis, thoracoscopic surgery for PSP decreased the incidence of recurrence (hazard ratio [HR], 0.46; 95% CI, 0.32-0.67) and the need for further surgical intervention (HR, 0.29; 95% CI, 0.18-0.47); however, conventional open surgery did not. A lesser incidence of PSP recurrence (HR, 0.53; 95% CI, 0.37-0.78) and fewer subsequent surgical interventions (HR, 0.32; 95% CI, 0.20-0.52) were found in the pleurodesis group in comparison with the nonpleurodesis group. A multivariate Cox regression analysis revealed that pleurodesis was the only significant factor capable of decreasing the incidence of PSP recurrence (HR, 0.57; 95% CI, 0.38-0.86) and the need for further surgical intervention (HR, 0.40; 95% CI, 0.23-0.69).

CONCLUSION

Pleurodesis reduces the rate of recurrence and the need for further surgical intervention in pediatric PSP. It may be considered as the method of choice for the management of PSP in children.

Intermediate Pause at Daytime Is Associated With Increased Cardiovascular Risk and Mortality: An 8-Year Cohort Study

BACKGROUND

Long-term cardiovascular risk in patients with intermediate pauses remains unclear. Whether asymptomatic patients with intermediate pauses have increased future cardiovascular events remains unknown. We hypothesize that intermediate pause is associated with increased cardiovascular risk and mortality.

METHODS AND RESULTS

We retrospectively analyzed 5291 patients who have pauses of <3 seconds on 24-hour Holter monitoring. Patients with pauses of 2 to 3 seconds constitute the intermediate pause patients, who are further divided into daytime pause (8:00 am-8:00 pm), nighttime pause (8:00 pm-8:00 am), and daytime plus nighttime pause groups depending on the occurring time of the pauses. The rest of the patients (pause <2 seconds) are the no pause group. The multivariate Cox hazards regression model was used to assess the hazard ratio for mortality (primary outcome) and adverse cardiovascular events (secondary outcome). There were 4859 (91.8%) patients in no pause, 248 (4.7%) in nighttime pause, 103 (1.9%) in daytime pause, and 81 (1.5%) in daytime plus nighttime pause groups. After a follow-up of 8.8±1.7 years' follow-up, 343 (6.5%) patients died. The risk for adverse cardiovascular events, including all-cause hospitalization, cardiovascular-cause hospitalization, pacemaker implantation, new-onset atrial fibrillation/heart failure, and transient ischemic attack, were higher in daytime pause and nighttime pause patients than those in the no pause group. Daytime pause (hazard ratio, 2.35; P=0.008) and daytime plus nighttime pause (hazard ratio, 2.26; P=0.016) patients have a higher mortality rate than that in nighttime pause.

CONCLUSIONS

Patients with intermediate pause are associated with increased cardiovascular risk. Intermediate pauses occurring at daytime have a higher mortality rate than that at nighttime during long-term follow-up.

Were there enough physicians in an emergency department in the affected area after a major earthquake? An analysis of the Taiwan Chi-Chi earthquake in 1999

STUDY OBJECTIVE

The purpose of this study was to evaluate physician manpower and mobilization in an urban emergency department receiving patients after a major earthquake.

METHODS

Patient charts were reviewed. The workload of physicians was assessed semiquantitatively before and after a major earthquake. The physicians' mobilization in the postearthquake emergency response was assessed by using a confidential questionnaire.

RESULTS

In the 3 days after the earthquake, 566 patients with earthquake-related illnesses or injuries were sent to the urban ED. Three hundred one (53.2%) patients arrived within the initial 10 hours. In the initial hours, there was no significant difference between the number of patients per physician per hour before and after the earthquake. Workloads of wound treatment and advanced life support procedures were significantly higher after the earthquake compared with before the earthquake, during the first to sixth hour and second to fifth hour, respectively. Sixty-five percent of the hospital's physicians did not assist in either the ED or in any other parts of the hospital in the initial 6 hours after the earthquake.

CONCLUSION

The number of physicians in the ED was insufficient in the initial hours after the earthquake because of the sudden influx of a large number of patients. Future disaster planning must address the issue of physicians' behavior with regard to their priorities immediately after a major earthquake and include greater provision for efficient mobilization of physicians.

Giant intraluminal fibrovascular polyp of the esophagus

Giant polyps of the esophagus are relatively rare. Without previous history, the diagnosis of the disease is difficult to be made by esophagography and esophagoscopy. A case of giant intraluminal fibrovascular polyp (13x4x3.5 cm) of the esophagus is presented. The polyp was retrieved from the esophagus by a Foley's catheter and resected via the oral route.

Comparison of therapeutic efficacy of continuous ambulatory peritoneal dialysis between diabetic and non-diabetic patients: three years of experience

To evaluate the therapeutic efficacy of continuous ambulatory peritoneal dialysis (CAPD) in diabetic uremic patients and compare it with that of non-diabetics, this study presents the results obtained from CAPD usage in a 3-year period. From December 1984 through December 1987, 12 non-insulin dependent diabetic patients (3 men and 9 women aged 65.5 +/- 3.4 years and with a treatment duration of 12.8 +/- 2.7 months, M +/- SE) and 11 non-diabetics (6 men and 5 women aged 45.0 +/- 5.3 years and with a treatment duration of 9.8 +/- 1.9 months) received CAPD treatment. In most of the patients, diabetes was complicated by significant cardiovascular diseases. None of them exchanged the CAPD bag by themselves. After CAPD treatment, subjective improvements were noted in both groups of patients but were more marked in the non-diabetic group. The BUN and creatinine levels were kept in an acceptable range except that higher creatinine levels were noted in the non-diabetic patients. Serum cholesterol levels rose mildly while triglyceride levels rose markedly in the diabetic patients. Albumin levels returned to normal in the non-diabetic group but remained low in the diabetic group. All patients except for one used the traditional subcutaneous route of insulin administration and blood sugar control was poor. The electrolyte profile was improved in both groups. The BP could be controlled but medication was still necessary. After CAPD most of the non-diabetic patients returned to their previous work while the diabetic patients remained dependent.(ABSTRACT TRUNCATED AT 250 WORDS)

Complement activation by iodinated contrast media

Activation of the complement system by iodinated contrast medium (ICM) infusion was studied in 25 children with congenital heart disease who received 76% Urographin during angiocardiographic studies. Total hemolytic activity (CH50), C1q, C3, C4 and C3 activator were determined before and 2, 5, 10, 15 and 20 minutes after Urographin infusion. Results showed that CH50 decreased in 16 patients (64%), C3 in 12 patients (48%), C3 activator in 12 patients (48%), C1q in 11 patients (44%) and C4 in 11 patients (44%). No side effect was encountered in all patients. It is therefore concluded that both the classic and alternative complement pathways could be activated by ICM and no causal relationship could be found between the presence of complement activation and the occurrence of adverse reactions to ICM infusion.

Fabrication of optical waveguide taper couplers utilizing SiO(2)

The fabrication of optical waveguide couplers involving tapered layers of SiO(2) is discussed. Details of the photolithographic fabrication processing sequence are presented. This process utilizes carefully controlled etchant undercutting and has been found to be quite reproducible. It has allowed fabrication of tapers having changes in Sio(2) thickness of 1.0,microm over lengths of 55-75 microm. Results are presented which demonstrate taper transverse uniformity for distances of over 600,microm. The smoothness and gradual nature of the tapers are apparent in scanning electron microscope pictures of a taper cross section.