Science.gov

Sample records for atrial flutter ablation

  1. [Catheter ablation of atrial flutter and paroxysmal atrial fibrillation].

    PubMed

    Márquez, Manlio F

    2003-01-01

    Radiofrequency catheter ablation has emerged as a curative therapy for atrial flutter based on studies demonstrating the role of the cavotricuspid isthmus. With a high rate of success and minimal complications, catheter ablation is the therapy of choice for patients with the common type of atrial flutter. Left atrial flutter, non-cavotricuspid isthmus dependent, and those associated with heart disease have a worst outcome with catheter ablation. Radiofrequency catheter ablation has also emerged as a curative therapy for paroxysmal atrial fibrillation based on studies demonstrating the role of triggering foci in the pulmonary veins for the initiation of atrial fibrillation. Catheter ablation is performed by a transseptal approach using radiofrequency energy at the ostium of each pulmonary vein. Mapping is guided by special catheters. Sequential radiofrequency applications eliminates or dissociates pulmonary vein muscle activity. Although complications exists, this is the only curative method for these patients.

  2. Is ablation of atrial flutter always safe?

    PubMed

    Brembilla-Perrot, Beatrice; Filali, Mourad Lemdersi; Zinzius, Pierre-Yves; Sellal, Jean-Marc; Beurrier, D; Schwartz, Jerome; DE Chillou, Christian; Cismaru, Gabriel; Pauriah, Mahesh

    2012-09-01

    Radiofrequency ablation of typical atrial flutter is largely used and is considered as safe. The purpose of the study was to evaluate the prevalence and the causes of severe adverse event (AE) following atrial flutter ablation. Ablation of typical flutter was performed by conventional method with an 8-mm-tip electrode catheter, a maximum power of 70 W, and a maximum target temperature of 70° for 60 seconds in 883 patients, (685 males and 198 females aged from 18 to 93 years [64 ± 11.5]; 664 had heart disease [HD]). AE occurred in 44 patients (5%). AE was life threatening in 14 patients: poorly tolerated bradycardia (transient complete atrioventricular block [AVB] or sinus bradycardia [SB] <40 beats per minute) associated with cardiac shock and acute renal failure in five patients, tamponade (n = 1), bleeding leading to death (n = 1), various AE-related deaths (n = 2), ventricular tachycardia-related death (n = 1), definitive complete AVB (n = 3), and right coronary artery occlusion-related complete AVB (n = 1). Less serious AE occurred in 30 patients: transitory major SB or second- or third-degree AVB (n = 23), bleeding (n = 4), transient ischemic attack (n = 1), and various AE (n = 2). Most of the bradycardia was related to β-blockers or other antiarrhythmic drugs used to slow atrial flutter. Factors of AE were female gender (36% vs 22%, P < 0.02) and the presence of ischemic (P < 0.03) or valvular HD (P < 0.01). AE following atrial flutter ablation occurred in 5% of patients. Most of them are avoidable by control of anticoagulants and arrest of rate-control drugs used to slow the rate of atrial flutter. ©2012, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.

  3. Late atypical atrial flutter after ablation of atrial fibrillation.

    PubMed

    Ferreira, Raquel; Primo, João; Adão, Luís; Gonzaga, Anabela; Gonçalves, Helena; Santos, Rui; Fonseca, Paulo; Santos, José; Gama, Vasco

    2016-10-01

    Cardiac surgery for structural heart disease (often involving the left atrium) and radiofrequency catheter ablation of atrial fibrillation have led to an increased incidence of regular atrial tachycardias, often presenting as atypical flutters. This type of flutter is particularly common after pulmonary vein isolation, especially after extensive atrial ablation including linear lesions and/or defragmentation. The authors describe the case of a 51-year-old man, with no relevant medical history, referred for a cardiology consultation in 2009 for paroxysmal atrial fibrillation. After failure of antiarrhythmic therapy, he underwent catheter ablation, with criteria of acute success. Three years later he again suffered palpitations and atypical atrial flutter was documented. The electrophysiology study confirmed the diagnosis of atypical left flutter and reappearance of electrical activity in the right inferior pulmonary vein. This vein was again ablated successfully and there has been no arrhythmia recurrence to date. In an era of frequent catheter ablation it is essential to understand the mechanism of this arrhythmia and to recognize such atypical flutters. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

  4. Incidence and clinical predictors of subsequent atrial fibrillation requiring additional ablation after cavotricuspid isthmus ablation for typical atrial flutter.

    PubMed

    De Bortoli, Alessandro; Shi, Li-Bin; Ohm, Ole-Jørgen; Hoff, Per Ivar; Schuster, Peter; Solheim, Eivind; Chen, Jian

    2017-06-01

    We sought to investigate the incidence of atrial fibrillation after catheter ablation for typical atrial flutter and to determine the predictors for symptomatic atrial fibrillation that required a further additional dedicated ablation procedure. 127 patients underwent elective cavotricuspid isthmus ablation with the indication of symptomatic, typical atrial flutter. The occurrence of atrial flutter, atrial fibrillation, cerebrovascular events and the need for additional ablation procedures for symptomatic atrial fibrillation was assessed during long-term follow-up. The majority of patients (70%) manifested atrial fibrillation during a follow-up period of 68 ± 24 months, and a significant proportion (42%) underwent one or multiple atrial fibrillation ablation procedures after an average of 26 months from the index procedure. Recurrence of typical atrial flutter was rare. Ten patients (8%) suffered cerebrovascular events. Earlier documentation of atrial fibrillation (OR 3.53), previous use of flecainide (OR 3.33) and left atrial diameter (OR 2.96) independently predicted occurrence of atrial fibrillation during the follow-up. A combination of pre- and intra-procedural documentation of atrial fibrillation (OR 3.81) and previous use of flecainide (OR 2.43) independently predicted additional atrial fibrillation ablation. Atrial fibrillation occurred in the majority of patients after ablation for typical atrial flutter and 42% of them required an additional dedicated ablation procedure. Pre- and intraprocedural documentation of atrial fibrillation together with previous use of flecainide independently predicted atrial fibrillation occurrence and a need for additional ablation. Anticoagulation treatment should be continued in high-risk patients in spite of clinical disappearance of atrial flutter.

  5. Electrophysiologic basis of catheter ablation in atrial flutter.

    PubMed

    Touboul, P; Saoudi, N; Atallah, G; Kirkorian, G

    1989-12-05

    A reentrant mechanism is believed to be responsible for atrial flutter. The recent development of the entrainment criteria further supports this theory, and there is a general consensus that circus movement is the underlying abnormality that supports this arrhythmia. In most clinical studies, abnormal fragmented (or double spike) electrograms, suggesting the presence of areas of localized slowing of conduction or block, have been reported. They are almost always recorded in the lower and posterior portion of the right interatrial septum, but also frequently in the high lateral portion of the right atrium. The determination of their involvement in the reentry pathway is important for designing curative procedures such as surgery or ablation. The low atrial septal area surrounding the mouth of the coronary sinus was suspected as being the critical area of slow conduction in atrial flutter. Rapid pacing at that site can yield a surface electrocardiographic pattern similar to the clinically occurring arrhythmias. Additionally, the flutter circuit can be accelerated during atrial pacing at fixed and slightly faster rates than the intrinsic tachycardia rate--the so-called entrainment phenomenon. When entrainment criteria are fulfilled, tachycardia termination being by definition ruled out, any concomitant recorded local type II block identifies an area that must be outside the circuit. Such local block may be recorded either spontaneously or during entrainment and therefore helps in identifying atrial slow conduction areas that do not belong to the reentrant path. This approach was applied to identify the optimal ablation site in 8 patients with long-standing drug resistant atrial flutter. In 7 of 8 patients, we were able to identify a fragmented potential in the low posteroseptal area during sustained atrial flutter.(ABSTRACT TRUNCATED AT 250 WORDS)

  6. Healthcare utilization and clinical outcomes after catheter ablation of atrial flutter.

    PubMed

    Dewland, Thomas A; Glidden, David V; Marcus, Gregory M

    2014-01-01

    Atrial flutter ablation is associated with a high rate of acute procedural success and symptom improvement. The relationship between ablation and other clinical outcomes has been limited to small studies primarily conducted at academic centers. We sought to determine if catheter ablation of atrial flutter is associated with reductions in healthcare utilization, atrial fibrillation, or stroke in a large, real world population. California Healthcare Cost and Utilization Project databases were used to identify patients undergoing atrial flutter ablation between 2005 and 2009. The adjusted association between atrial flutter ablation and healthcare utilization, atrial fibrillation, or stroke was investigated using Cox proportional hazards models. Among 33,004 patients with a diagnosis of atrial flutter observed for a median of 2.1 years, 2,733 (8.2%) underwent catheter ablation. Atrial flutter ablation significantly lowered the adjusted risk of inpatient hospitalization (HR 0.88, 95% CI 0.84-0.92, p<0.001), emergency department visits (HR 0.60, 95% CI 0.54-0.65, p<0.001), and overall hospital-based healthcare utilization (HR 0.94, 95% CI 0.90-0.98, p = 0.001). Atrial flutter ablation was also associated with a statistically significant 11% reduction in the adjusted hazard of atrial fibrillation (HR 0.89, 95% CI 0.81-0.97, p = 0.01). Risk of acute stroke was not significantly reduced after ablation (HR 1.09, 95% CI 0.81-1.45, p = 0.57). In a large, real world population, atrial flutter ablation was associated with significant reductions in hospital-based healthcare utilization and a reduced risk of atrial fibrillation. These findings support the early use of catheter ablation for the treatment of atrial flutter.

  7. Healthcare Utilization and Clinical Outcomes after Catheter Ablation of Atrial Flutter

    PubMed Central

    Dewland, Thomas A.; Glidden, David V.; Marcus, Gregory M.

    2014-01-01

    Atrial flutter ablation is associated with a high rate of acute procedural success and symptom improvement. The relationship between ablation and other clinical outcomes has been limited to small studies primarily conducted at academic centers. We sought to determine if catheter ablation of atrial flutter is associated with reductions in healthcare utilization, atrial fibrillation, or stroke in a large, real world population. California Healthcare Cost and Utilization Project databases were used to identify patients undergoing atrial flutter ablation between 2005 and 2009. The adjusted association between atrial flutter ablation and healthcare utilization, atrial fibrillation, or stroke was investigated using Cox proportional hazards models. Among 33,004 patients with a diagnosis of atrial flutter observed for a median of 2.1 years, 2,733 (8.2%) underwent catheter ablation. Atrial flutter ablation significantly lowered the adjusted risk of inpatient hospitalization (HR 0.88, 95% CI 0.84–0.92, p<0.001), emergency department visits (HR 0.60, 95% CI 0.54–0.65, p<0.001), and overall hospital-based healthcare utilization (HR 0.94, 95% CI 0.90–0.98, p = 0.001). Atrial flutter ablation was also associated with a statistically significant 11% reduction in the adjusted hazard of atrial fibrillation (HR 0.89, 95% CI 0.81–0.97, p = 0.01). Risk of acute stroke was not significantly reduced after ablation (HR 1.09, 95% CI 0.81–1.45, p = 0.57). In a large, real world population, atrial flutter ablation was associated with significant reductions in hospital-based healthcare utilization and a reduced risk of atrial fibrillation. These findings support the early use of catheter ablation for the treatment of atrial flutter. PMID:24983868

  8. Outcomes after ablation for typical atrial flutter (from the Loire Valley Atrial Fibrillation Project).

    PubMed

    Clementy, Nicolas; Desprets, Laurent; Pierre, Bertrand; Lallemand, Bénédicte; Simeon, Edouard; Brunet-Bernard, Anne; Babuty, Dominique; Fauchier, Laurent

    2014-11-01

    Similar predisposing factors are found in most types of atrial arrhythmias. The incidence of atrial fibrillation (AF) among patients with atrial flutter is high, suggesting similar outcomes in patients with those arrhythmias. We sought to investigate the long-term outcomes and prognostic factors of patients with AF and/or atrial flutter with contemporary management using radiofrequency ablation. In an academic institution, we retrospectively examined the clinical course of 8,962 consecutive patients admitted to our department with a diagnosis of AF and/or atrial flutter. After a median follow-up of 934 ± 1,134 days, 1,155 deaths and 715 stroke and/thromboembolic (TE) events were recorded. Patients with atrial flutter undergoing cavotricuspid isthmus ablation (n = 875, 37% with a history of AF) had a better survival rate than other patients (hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.25 to 0.49, p <0.0001). Using Cox proportional hazards model and propensity score model, after adjustment for main other confounders, ablation for atrial flutter was significantly associated with a lower risk of all-cause mortality (HR 0.55, 95% CI 0.36 to 0.84, p = 0.006) and stroke and/or TE events (HR 0.53, 95% CI 0.30 to 0.92, p = 0.02). After ablation, there was no significant difference in the risk of TE between patients with a history of AF and those with atrial flutter alone (HR 0.83, 95% CI 0.41 to 1.67, p = 0.59). In conclusion, in patients with atrial tachyarrhythmias, those with atrial flutter with contemporary management who undergo cavotricuspid isthmus radiofrequency ablation independently have a lower risk of stroke and/or TE events and death of any cause, whether a history of AF is present or not. Copyright © 2014 Elsevier Inc. All rights reserved.

  9. Restoration of Atrial Mechanical Function after Successful Radio-Frequency Catheter Ablation of Atrial Flutter

    PubMed Central

    Rhee, Kyoung-Suk; Kang, Duk-Hyun; Song, Jae-Kwan; Nam, Gi-Byoung; Choi, Kee-Joon; Kim, You-Ho

    2001-01-01

    Background: Atrial mechanical dysfunction and its recovery time course after successful radiofrequency ablation of chronic atrial flutter (AFL) has been largely unknown. We serially evaluated left atrial function by echocardiography after successful ablation of chronic atrial flutter. Methods: In 13 patients with chronic AFL, mitral E wave A wave, and the ratio of A/E velocity were measured at 1 day, 1 month, 3 months and 6–12 months after successful radiofrequency (RF) ablation. Doppler tissue imaging (DTI) technique was also used to avoid load-dependent variation in the flow velocity pattern. Results: Left atrial mechanical function, assessed by A wave velocity and the annular motion, was depressed at 1 day, but improved significantly at 1 month and maintained through 6–12 months after the ablation. Left atrial size did not change significantly. Conclusion: Left atrial mechanical function was depressed immediately after successful RF ablation of chronic AFL, but it improved significantly after 1 month and was maintained over one year. PMID:11590904

  10. Electrophysiological Mechanisms of Atrial Flutter

    PubMed Central

    Tai, Ching- Tai; Chen, Shin-Ann

    2006-01-01

    Atrial flutter (AFL) is a common arrhythmia in clinical practice. Several experimental models such as tricuspid regurgitation model, tricuspid ring model, sterile pericarditis model and atrial crush injury model have provided important information about reentrant circuit and can test the effect of antiarrhythmic drugs. Human atrial flutter has typical and atypical forms. Typical atrial flutter rotates around tricuspid annulus and uses the crista terminalis and sometimes sinus venosa as the boundary. The IVC-tricuspid isthmus is a slow conduction zone and the target of radiofrequency ablation. Atypical atrial flutter may arise from the right or left atrium. Right atrial flutter includes upper loop reentry, free wall reentry and figure of eight reentry. Left atrial flutter includes mitral annular atrial flutter, pulmonary vein-related atrial flutter and left septal atrial flutter. Radiofrequency ablation of the isthmus between the boundaries can eliminate these arrhythmias. PMID:16943903

  11. [Trans-surgical ablation of atrial flutter in patients treated with closure of atrial septal defect. Pilot project].

    PubMed

    Medeiros, A; Iturralde, P; Guevara-Valdivia, M E; Ramírez, S; Rodríguez, L; Rodríguez, I; Mendoza, C; Colín, L

    2001-01-01

    Atrial flutter is one of the most common arrhythmias in patients with atrial septal defect, after surgery 14% of patients can develop it and may be associated with high morbidity. In this study we performed prophylactic and therapeutic ablation of atrial flutter during atrial septal closure surgery drawing 4 lines; line 1, isthmus cavo-tricuspid, the area between the inferior vena cava and the tricuspid ring; line 2, the area between coronary sinus ostium and inferior vena cava; line 3, the area between tricuspid valve annulus and coronary sinus ostium; and line 4, the area between lateral atriotomy and atrial septal defect. Twenty-one patients were included, 6 (28.5%) patients had atrial flutter before surgery and 15 (71.4%) were in sinus rhythm. There were no new cases of atrial flutter, but at six months follow up 2 (33.3%) patients recidivated with atrial flutter. One patient developed high degree atrio-ventricular block and a pacemaker had to be implanted. Older age at the time of surgery and high systolic pulmonary pressure were significantly higher in those patients with atrial flutter before surgery and in patients with arrhythmias recurrence. Ablation of atrial flutter during atrial septal closure surgery can be a good option for the treatment and prevention of atrial arrhythmias, but more studies are still needed.

  12. Association of left atrial function with incident atypical atrial flutter after atrial fibrillation ablation.

    PubMed

    Gucuk Ipek, Esra; Marine, Joseph E; Habibi, Mohammadali; Chrispin, Jonathan; Lima, Joao; Rickard, Jack; Spragg, David; Zimmerman, Stefan L; Zipunnikov, Vadim; Berger, Ronald; Calkins, Hugh; Nazarian, Saman

    2016-02-01

    Symptomatic left atrial (LA) flutter (LAFL) is common after atrial fibrillation (AF) ablation. The purpose of this study was to examine the association of baseline LA function with incident LAFL after AF ablation. The source cohort included 216 patients with cardiac magnetic resonance (CMR) before initial AF ablation between 2010 and 2013. Patients who underwent cryoballoon or laser ablation, patients with AF during CMR, and those with suboptimal CMR, or missing follow-up data were excluded. Baseline LA volume and function were assessed by feature-tracking CMR analysis. The final cohort included 119 patients (mean age 58.9 ± 11 years; 76.5% men; 70.6% patients with paroxysmal AF). During a median follow-up of 421 days (interquartile range 235-751 days), 22 patients (18.5%) had incident LAFL. Baseline LA volume was similar between the 2 groups. In contrast, baseline reservoir, conduit, and contractile function of the LA were significantly impaired in patients with incident LAFL. Baseline global peak longitudinal atrial strain (PLAS) <22.65% predicted incident LAFL with 86% sensitivity and 68% specificity (C statistic 0.76). In a multivariable model adjusting for age, heart failure, and LA volume, PLAS (hazard ratio 0.9 per % increase in PLAS; P = .003) and LA linear lesions (hazard ratio 2.94; P = .020) were independently associated with incident LAFL. The coexistence of PLAS <22.65% and linear lesions was associated with 9-fold increased hazard of incident LAFL. Baseline LA function and linear lesions were independently associated with incident LAFL after AF ablation. Linear lesions should be limited to selected cases, especially in patients with impaired LA function. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  13. Identification and ablation of atypical atrial flutter. Entrainment pacing combined with electroanatomic mapping.

    PubMed

    Horlitz, M; Schley, P; Shin, D-I; Ghouzi, A; Sause, A; Wehner, M; Müller, M; Klein, R M; Bufe, A; Gülker, H

    2004-06-01

    Differentiation between typical and atypical atrial flutter solely based upon surface ECG pattern may be limited. However, successful ablation of atrial flutter depends on the exact identification of the responsible re-entrant circuit and its critical isthmus. Between August 2001 and June 2003, we performed conventional entrainment pacing within the cavotricuspid isthmus in 71 patients with sustained atrial flutter. In patients with positive entrainment we considered the arrhythmia as typical flutter and treated them with conventional ablation of the cavotricuspid isthmus. As a consequence of negative entrainment we performed 3D-electroanatomic activation mapping (CARTO trade mark ). Conventional ablation of the right atrial isthmus was successful in all patients (n = 54) with positive entrainment. We performed electroanatomic mapping in the remaining 17 patients (14 male; age 60.9 +/- 16 years) resulting in the identification of 6 cases with typical and 11 cases with atypical flutter. Therefore, entrainment pacing was able to predict the true presence of typical atrial flutter in 91.5%. Atypical flutter was right sided in 4 patients and left sided in 7 cases. Electrically silent ("low voltage") areas probably demonstrating atrial myopathy were identified in all cases with left sided and in 2 patients with right sided flutter. In these patients targets for ablation lines were located between silent areas and anatomic barriers (inferior pulmonary veins, mitral respectively tricuspid annulus, or vena cava inferior). In 1 patient, the investigation was stopped due to variable ECG pattern and atrial cycle lengths. In the remaining cases, ablation was acutely successful. One patient, after surgical closure of a ventricular septal defect, demonstrated a dual-loop intra-atrial reentry tachycardia dependent on two different isthmuses. This arrhythmia required ablation of those distinct isthmuses to be interrupted. After a mean follow-up of 8.8 +/- 3.4 months, there was one

  14. Atrial flutter and atrial fibrillation ablation - sequential or combined? A cost-benefit and risk analysis of primary prevention pulmonary vein ablation.

    PubMed

    Gula, Lorne J; Skanes, Allan C; Klein, George J; Jenkyn, Krista B; Redfearn, Damian P; Manlucu, Jaimie; Roberts, Jason D; Yee, Raymond; Tang, Anthony S L; Leong-Sit, Peter

    2016-07-01

    Recent studies have tested the hypothesis that preventive pulmonary vein isolation (PVI) at time of atrial flutter ablation in patients who have not had atrial fibrillation (AF) will reduce future incidence of AF. To model relative procedural costs, risks, and benefits of sequential versus combined ablation strategies. The decision model compares a sequential ablation strategy of atrial flutter ablation, followed by future PVI if necessary, with an initial combined flutter and preventive PVI ablation strategy. Assumptions are AF incidence 20% per year, PVI success rate 70%, PVI complication rate 4%, atrial flutter complication rate 1%, and costs $13,056 for PVI and $8,466 for atrial flutter ablation. The sequential ablation strategy is less expensive, at 1.4 vs 1.6 expected flutter ablation equivalents (FAE) ($11,852 vs $13,545) per patient, and entails less average risk, at 2% vs 4%. A combined ablation strategy is more expensive if the relative cost of PVI is more than 24.6% higher than atrial flutter ablation. A combined ablation strategy has higher total risk if PVI procedural risk is 24.6% more than atrial flutter ablation. Under base case assumptions of relative cost of PVI to flutter ablation 1.5 and relative risk 4, a sequential ablation approach has less total expected cost and less expected risk. There appears to be no compelling reason to adopt a combined ablation approach into standard practice. Nomograms are presented to allow the reader to assess which strategy is preferred according to local relative costs and risk. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  15. Racial disparities in the use of catheter ablation for atrial fibrillation and flutter.

    PubMed

    Tamariz, Leonardo; Rodriguez, Alexis; Palacio, Ana; Li, Hua; Myerburg, Robert

    2014-12-01

    Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice. Catheter ablation is an expensive but potentially curable treatment of AF. We explored differences in the use of catheter ablation for AF in the state of Florida and compared the findings to ablation for atrial flutter. We conducted a cross-sectional analysis of all ambulatory and hospital discharge procedures between 2006 and 2009 in Florida. We identified all subjects with AF and atrial flutter, using International Classification of Diseases, 9th Revision codes along with the race/ethnicity of each individual. We used logistic regression to determine the odds ratio (OR) of having a catheter ablation per disease by race and ethnicity adjusted for Charlson score, insurance status, year of the procedure, and facility location. We identified 923,590 subjects with AF and 28,714 with atrial flutter. Catheter ablations were more commonly used in atrial flutter than in AF. The adjusted OR of having catheter ablation for AF for blacks was 0.67 (95% confidence interval [CI]: 0.60-0.75, P < 0.01), and for Hispanics it was 0.83 (95% CI: 0.75-0.91, P < 0.01) when compared to whites. The adjusted OR of having an ablation for atrial flutter for blacks was 1.08 (95% CI: 0.96-1.21, P = 0.16), and for Hispanics it was 0.90 (95% CI: 0.78-1.08, P = 0.20) when compared to whites. In the state of Florida, black and Hispanic subjects with AF received less catheter ablations, whereas the same minority subjects with atrial flutter received a similar number of ablations compared to white subjects, with the same insurance and comorbidity burden. © 2014 Wiley Periodicals, Inc.

  16. P Wave Morphology in Guiding the Ablation Strategy of Focal Atrial Tachycardias and Atrial Flutter

    PubMed Central

    Lee, Justin M. S; Fynn, Simon P

    2015-01-01

    Focal atrial tachycardias arise preferentially from specific locations within the atria. Careful analysis of the P wave can provide useful information about the chamber and likely site of origin within that chamber. Macro-reentrant atrial flutter also tends to occur over a limited number of potential circuits. In this case, the ECG usually gives a guide to the chamber of origin, but unless it shows a specific morphology it is less useful in delineating the circuit involved. Nonetheless, prior knowledge of the likely chamber of origin helps to plan the ablation strategy. PMID:25308814

  17. Atrial flutter ablation in a case of diuretic resistant constrictive pericarditis.

    PubMed

    Pittaway, James F; Presern, Emma; Rathod, Vrijraj S; Rathod, Krishnaraj S; Deaner, Andrew

    2015-01-01

    We present a 66 year old gentleman with constrictive pericarditis and persistent atrial flutter. Initial management with oral loop diuretics was successful until he developed persistent atrial flutter. Once in atrial flutter the patient developed progressive signs of right heart failure resistant to high dose intravenous loop diuretics. He was referred to a tertiary electrophysiology service where he underwent successful isthmus catheter ablation and reverted to sinus rhythm. His responsiveness to diuretics improved immediately. His symptoms improved and he was discharged 48 h later on oral diuretics. He remains well one month after discharge. This is the first reported case of symptomatic improvement in a patient with constrictive pericarditis and persistent atrial flutter with targeted treatment of the dysrhythmia. This offers a possible short-term palliation option in a group of patients where definitive surgical management carries too high a risk. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

  18. Curative catheter ablation in atrial fibrillation and typical atrial flutter: systematic review and economic evaluation.

    PubMed

    Rodgers, M; McKenna, C; Palmer, S; Chambers, D; Van Hout, S; Golder, S; Pepper, C; Todd, D; Woolacott, N

    2008-11-01

    To determine the safety, clinical effectiveness and cost-effectiveness of radio frequency catheter ablation (RCFA) for the curative treatment of atrial fibrillation (AF) and typical atrial flutter. For the systematic reviews of clinical studies 25 bibliographic databases and internet sources were searched in July 2006, with subsequent update searches for controlled trials conducted in April 2007. For the review of cost-effectiveness a broad range of studies was considered, including economic evaluations conducted alongside trials, modelling studies and analyses of administrative databases. Systematic reviews of clinical studies and economic evaluations of catheter ablation for AF and typical atrial flutter were conducted. The quality of the included studies was assessed using standard methods. A decision model was developed to evaluate a strategy of RFCA compared with long-term antiarrhythmic drug (AAD) treatment alone in adults with paroxysmal AF. This was used to estimate the cost-effectiveness of RFCA in terms of cost per quality-adjusted life-year (QALY) under a range of assumptions. Decision uncertainty associated with this analysis was presented and used to inform future research priorities using the value of information analysis. A total of 4858 studies were retrieved for the review of clinical effectiveness. Of these, eight controlled studies and 53 case series of AF were included. Two controlled studies and 23 case series of typical atrial flutter were included. For atrial fibrillation, freedom from arrhythmia at 12 months in case series ranged from 28% to 85.3% with a weighted mean of 76%. Three RCTs suggested that RFCA is more effective than long-term AAD therapy in patients with drug-refractory paroxysmal AF. Single RCTs also suggested superiority of RFCA over electrical cardioversion followed by long-term AAD therapy and of RFCA plus AAD therapy over AAD maintenance therapy alone in drug-refractory patients. The available RCTs provided insufficient

  19. Ablation of typical right atrial flutter in patients with pulmonary hypertension.

    PubMed

    Luesebrink, Ulrich; Fischer, Dieter; Gezgin, Funda; Duncker, David; Koenig, Thorben; Oswald, Hanno; Klein, Gunnar; Gardiwal, Ajmal

    2012-11-01

    RF ablation for cavotricuspid isthmus (CTI) dependent flutter is an established therapy. Right atrial hypertrophy and enlargement are associated with the occurrence of cavotricuspid isthmus dependent flutter. Therefore, patients with pulmonary hypertension (PAH) are prone to atrial arrhythmias like cavotricuspid isthmus dependent flutter. However, the influence of PAH on typical atrial flutter ablation procedure has not been systematically examined. In a retrospective single-centre analysis data of patients undergoing an ablation procedure for cavotricuspid isthmus dependent flutter between January 2007 and October 2009 at Hannover Medical School, Germany were analysed. Only procedures performed by experienced electrophysiologists with an 8mm RF-ablation catheter were included. Data for 196 patients were analysed. Thirty-eight patients were identified with PAH and were compared to 158 patients without PAH for procedural ablation parameters, procedure time, ablation time, ablation points and fluoroscopy time. A bidirectional block of the CTI was achieved in all patients. Patients with severe PAH had a significantly longer procedure time (78±40 min vs. 62±29 min; p=0.033), total ablation time (20±11 min vs. 15±9 min; p=0.02) and more ablation lesions (26±16 vs. 19±12; p=0.018) as compared to patients without PAH. Cavotricuspid isthmus dependent flutter ablation in patients with PAH is associated with longer procedure duration and a greater amount of cumulative tissue ablation needed to achieve bidirectional block of the CTI compared to patients without pulmonary hypertension. Copyright © 2012 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

  20. Death and thrombo-embolic risk after ablation of atrial flutter compared with atrial fibrillation: a nationwide cohort study.

    PubMed

    Vadmann, Henrik; Gorst-Rasmussen, Anders; Hjortshøj, Søren Pihlkjær; Riahi, Sam; Lip, Gregory Y H; Larsen, Torben Bjerregaard

    2017-05-01

    The aim of this study was to investigate whether there is a similar mortality and thrombo-embolic risk, after an atrial ablation procedure, compared with an atrial fibrillation (AF) procedure. Using data from nationwide Danish health registries, we identified patients aged 18-75 years undergoing a first-time atrial flutter or an AF ablation procedure in the period 2000-13. Cox proportional hazards regression was used to calculate hazard ratios (HRs) after 5 years of follow-up, adjusting for concomitant risk factors. A total of 1096 and 2266 patients underwent an ablation for atrial flutter or AF, respectively. Age distribution was similar in the two, but atrial flutter patients had more co-morbidities. During 5 years of follow-up, we observed 38 and 36 deaths in the atrial flutter and AF groups, corresponding to an almost two-fold higher mortality rate among atrial flutter patients [crude HR 1.92, 95% confidence interval (CI) 1.22-3.03]. The higher mortality rate persisted after adjustment for age, sex, diabetes mellitus, and hypertension (adjusted HR 1.68, 95% CI 1.05-2.69). The rate of thrombo-embolic events was similar in the two groups (crude HR 1.34, 95% CI 0.71-2.56; adjusted HR 1.22, 95% CI 0.62-2.41). In this observational study, patients with atrial flutter had a significantly higher all-cause mortality rate compared with those with AF after an ablation procedure, but similar thrombo-embolic event rates. Future studies should elucidate the reason for this difference in mortality.

  1. Remote magnetic navigation for ablation of typical atrial flutter: Long-term results.

    PubMed

    Parreira, Leonor; Cavaco, Diogo; Carmo, Pedro; Reis-Santos, Katya; Quaresma, Rita; Teixeira, Tiago; Marques, Marta; Adragão, Pedro

    2014-12-01

    Remote magnetic navigation has proved to be effective in the ablation of most supraventricular and ventricular arrhythmias. Initial studies reported worse results with this system compared to conventional ablation for atrial flutter. The aim of this study was to assess the acute and long-term success of atrial flutter ablation with remote magnetic navigation and to retrospectively compare the results obtained with an 8-mm tip catheter versus an irrigated catheter. We studied 38 consecutive patients, mean age 61 ± 15 years, 28 male, who underwent ablation of typical atrial flutter with the Niobe II remote magnetic navigation system (Stereotaxis). Ablation was performed with an 8-mm tip catheter in 17 patients and with an irrigated-tip catheter in 21 patients. Acute success was defined as the presence of bidirectional isthmus block, and long-term success as absence of symptoms and atrial flutter during Holter monitoring. Bidirectional isthmus block was achieved in 37 patients (97%), and the success rate was similar in both groups. Total procedure time was not significantly different between the groups but fluoroscopy time was shorter in the irrigated tip group (13.4 ± 3.7 min vs. 6 ± 4.4 min; p<0.01). The number of applications and total radiofrequency time did not differ. There were no complications. During a follow-up of 32 ± 19 months there were two relapses, one in each group. The Niobe II remote control system for ablation of typical atrial flutter is safe and effective in both the short and long term. The 8-mm and irrigated-tip catheters showed similar safety and efficacy. Copyright © 2013 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.

  2. An Approach to Catheter Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter

    PubMed Central

    O’Neill, Mark D; Jais, Pierre; Jönsson, Anders; Takahashi, Yoshihide; Sacher, Frédéric; Hocini, Mélèze; Sanders, Prashanthan; Rostock, Thomas; Rotter, Martin; Clémenty, Jacques; Haïssaguerre, Michel

    2006-01-01

    Much of our understanding of the mechanisms of macro re-entrant atrial tachycardia comes from study of cavotricuspid isthmus (CTI) dependent atrial flutter. In the majority of cases, the diagnosis can be made from simple analysis of the surface ECG. Endocardial mapping during tachycardia allows confirmation of the macro re-entrant circuit within the right atrium while, at the same time, permitting curative catheter ablation targeting the critical isthmus of tissue located between the tricuspid annulus and the inferior vena cava. The procedure is short, safe and by demonstration of an electrophysiological endpoint - bidirectional conduction block across the CTI - is associated with an excellent outcome following ablation. It is now fair to say that catheter ablation should be considered as a first line therapy for patients with documented CTI-dependent atrial flutter. PMID:16943901

  3. Incremental pacing for the diagnosis of complete cavotricuspid isthmus block during radiofrequency ablation of atrial flutter.

    PubMed

    Bazan, Victor; Martí-Almor, Julio; Perez-Rodon, Jordi; Bruguera, Jordi; Gerstenfeld, Edward P; Callans, David J; Marchlinski, Francis E

    2010-01-01

    Complete conduction block of the cavotricuspid isthmus (CTI) reduces atrial flutter recurrences after ablation. Incremental rapid pacing may distinguish slow conduction from complete CTI conduction block. Fifty-two patients (67 +/- 9 years) undergoing 55 CTI ablation procedures were included. With ablation, double potentials (DPs) separated by an isoelectric line of > or =30 ms were obtained. Incremental atrial pacing (600-250 ms) was performed from coronary sinus (CS) and low lateral right atrium (LLRA). A <20 ms increase in the DPs distance during incremental pacing was indexed as complete CTI block. In 8 patients, an initial <20 ms DPs distance increase was noted; direct complete isthmus block was suggested and no additional ablation performed. In the remaining, the CTI line was remapped for conduction gaps and additional radiofrequency energy pulses applied. Complete block, as indexed by incremental pacing, occurred in 46 of 55 procedures, with one flutter recurrence (follow-up 8 +/- 2 months): DPs interval variation of 116 +/- 20 to 123 +/- 20 ms (CS), P = 0.21; and 122 +/- 25 to 135 +/- 35 ms (LLRA), P = 0.17. The remaining 9 patients (persistent rate-dependent DPs increase) presented 3 flutter recurrences, P = 0.01: DP distance from 127 +/- 15 to 161 +/- 18 ms (CS), P < 0.001; and 114 +/- 24 to 142 +/- 10 ms (LLRA), P = 0.007. Incremental pacing distinguishes complete CTI block from persistent conduction. Such identification, accompanied by additional ablation to achieve block, should minimize flutter recurrences after ablative therapy.

  4. Predictors of Unusual ECG Characteristics in Cavotricuspid Isthmus-Dependent Atrial Flutter Ablation

    PubMed Central

    Hoffmayer, Kurt S.; Yang, Yanfei; Joseph, Stephen; McCabe, James M; Bhave, Prashant; Hsu, Jonathan; Ng, Ramford K.; Lee, Byron K; Badhwar, Nitish; Lee, Randall J; Tseng, Zian H; Olgin, Jeffrey E; Narayan, Sanjiv M.; Marcus, Gregory M; Scheinman, Melvin M.

    2012-01-01

    Background An unusual 12 lead electrocardiographic pattern may be present in patients with cavotricuspid isthmus-dependent flutter. Objective Using baseline patient characteristics and echocardiography we sought to study predictors of unusual ECG characteristics in patients with cavotricuspid isthmus-dependent atrial flutter. Methods This was a dual center, retrospective cohort study of 147 patients undergoing electrophysiology study and ablation for cavotricuspid isthmus dependent atrial flutter. Results Among this cohort, 23 patients (16%) had unusual 12-lead ECG characteristics. Using multivariate logistic regression, we found two clinical predictors for having an unusual ECG pattern. A clockwise pattern at time of EPS was the strongest predictor of an unusual ECG pattern (odds ratio [OR] 15.3 (95% confidence interval [CI] 4.0–59.4, p<0.005). In addition, patients with decreased systolic function had a 3.5 greater odds (95% CI 1.1–11.5, p=0.037) of having an unusual ECG pattern. Conclusions Our data demonstrate that among patients suffering from cavotricuspid isthmus dependent atrial flutter who are referred for ablation, 16% will have unusual ECG patterns. Patients with clockwise atrial activation and LV dysfunction have greater odds of manifesting unusual patterns by surface electrocardiogram. PMID:21605144

  5. Voltage-guided ablation technique for cavotricuspid isthmus-dependent atrial flutter: refining the continuous line.

    PubMed

    Jacobsen, Peter K; Klein, George J; Gula, Lorne J; Krahn, Andrew D; Yee, Raymond; Leong-Sit, Peter; Mechulan, Alexis; Skanes, Allan C

    2012-06-01

    Ablation of the cavotricuspid isthmus has become first-line therapy for "isthmus-dependent" atrial flutter. The goal of ablation is to produce bidirectional cavotricuspid isthmus block. Traditionally, this has been obtained by creation of a complete ablation line across the isthmus from the ventricular end to the inferior vena cava. This article describes an alternative method used in our laboratory. There is substantial evidence that conduction across the isthmus occurs preferentially over discrete separate bundles of tissue. Consequently, voltage-guided ablation targeting only these bundles with large amplitude atrial electrograms results in a highly efficient alternate method for the interruption of conduction across the cavotricuspid isthmus. Understanding the bundle structure of conduction over the isthmus facilitates more flexible approaches to its ablation and targeting maximum voltages in our hands has resulted in reduction of ablation time and fewer recurrences.

  6. Anatomic Guidance For Ablation: Atrial Flutter, Fibrillation, and Outflow Tract Ventricular Tachycardia

    PubMed Central

    Sehar, Nandini; Mears, Jennifer; Bisco, Susan; Patel, Sandeep; Lachman, Nirusha; Asirvatham, Samuel J

    2010-01-01

    After initial documentation of excellent efficacy with radiofrequency ablation, this procedure is being performed increasingly in more complex situations and for more difficult arrhythmia. In these circumstances, an accurate knowledge of the anatomic basis for the ablation procedure will help maintain this efficacy and improve safety. In this review, we discuss the relevant anatomy for electrophysiology interventions for typical right atrial flutter, atrial fibrillation, and outflow tract ventricular tachycardia. In the pediatric population, maintaining safety is a greater challenge, and here again, knowing the neighboring and regional anatomy of the arrhythmogenic substrate for these arrhythmias may go a long way in preventing complications. PMID:20811537

  7. Does diffuse irrigation result in improved radiofrequency catheter ablation? A prospective randomized study of right atrial typical flutter ablation.

    PubMed

    Ramoul, Khaled; Wright, Matthew; Sohal, Manav; Shah, Ashok; Castro-Rodriguez, Jose; Verbeet, Thierry; Knecht, Sébastien

    2015-02-01

    Recent developments of open irrigated catheters have sought to create uniform cooling of the entire ablating electrode. The aim of this randomized study was to assess whether the diffuse irrigation of the Coolflex(®) (CF) catheter results in improved short-term procedural benefits in patients undergoing ablation of right atrial typical flutter. Sixty consecutive patients (age 62 ± 13) with typical atrial flutter were prospectively randomized to ablation of the cavotricuspid isthmus (CTI) using either a standard 3.5 mm tip ablation catheter with six distal irrigation channels (6C) (30 patients) or a 4 mm tip fully irrigated ablation catheter (CF) (30 patients). There were no significant differences seen between procedures performed with the diffusely irrigated CF catheter and the standard six-channel irrigated-tip catheter. This concerned the total procedural duration RF duration, fluoroscopic duration, the total amount of irrigation fluid, and the occurrence of steam pop. The use of a diffuse irrigation at the ablation catheter tip does neither facilitate lesion formation nor reduce the amount of irrigation during RF ablation for typical right atrial flutter using recommended flow and power settings. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

  8. The usefulness of surface 12-lead electrocardiogram to predict intra-atrial conduction block after successful atrial flutter ablation.

    PubMed

    Mairesse, Georges H; Lacroix, Dominique; Klug, Didier; Le Franc, Pierre; Kouakam, Claude; Kacet, Salem

    2003-07-01

    Intraatrial conduction block at the inferior vena cava-tricuspid annulus isthmus was shown to predict successful atrial flutter ablation. However, its demonstration requires the use of several electrode catheters. Thus, a simple approach using surface 12-lead ECG to prove the conduction block would be valuable. Twenty-two patients were prospectively studied during low septal and low lateral atrial pacing before and after successful atrial flutter ablation. Creation of the conduction block was confirmed by comparing the sequence of atrial activation using 3 multipolar catheters during atrial pacing before and after ablation. During low septal pacing, there was no significant difference before and after ablation in P-wave width, axis, or morphology. During low lateral atrial pacing, there was a significant P-wave axis rotation towards the right (from -67 +/- 27 degrees to +13 +/- 35 degrees, P <.001), and P-wave polarity in limb lead II changed from predominantly negative to predominantly positive in 21 of 22 patients. There was also an increase in P-wave width (from 136 +/- 32 to 169 +/- 36 ms, P <.001) and stimulus-to-QRS interval (from 268 +/- 61 ms to 343 +/- 95 ms, P <.001) during low lateral pacing that was not observed during low septal pacing. We conclude that creation of a conduction block in the inferior vena cava-tricuspid annulus isthmus modifies surface 12-lead ECG during low lateral atrial pacing only. We also suggest that P-wave polarity in limb lead II during low lateral pacing could be used as a noninvasive marker of unidirectional counter-clockwise conduction block during atrial flutter ablation.

  9. Catheter ablation of atypical atrial flutter: a novel 3D anatomic mapping approach to quickly localize and terminate atypical atrial flutter.

    PubMed

    Sundaram, Sri; Choe, William; Ryan Jordan, J; Mullins, Nate; Boorman, Charles; Kessler, Eric J; Nath, Sunil

    2017-09-01

    This study aims to describe a novel method of High Density Activation Sequence Mapping combined with Voltage Gradient Mapping Overlay (HD-VGM) to quickly localize and terminate atypical atrial flutter. Twenty-one patients presenting with 26 different atypical atrial flutter circuits after a previous catheter or surgical AF ablation were studied. HD-VGM was performed with a commercially available impedance-based mapping system to locate and successfully ablate the critical isthmus of each tachycardia circuit. The results were compared to 21 consecutive historical control patients who had undergone an atypical flutter ablation without HD-VGM. Twenty-six different atypical flutter circuits were evaluated. An average 3D anatomic mapping time of 12.39 ± 4.71 min was needed to collect 2996 ± 690 total points and 1016 ± 172 used mapping points. A mean of 195 ± 75 s of radiofrequency (RF) energy was needed to terminate the arrhythmias. The mean procedure time was 135 ± 46 min. With a mean follow-up 16 ± 9 months, 90% are in normal rhythm. In comparison to the control cohort, the study cohort had a shorter procedure time (135 ± 46 vs. 210 ± 41 min, p = 0.0009), fluoroscopy time (8.5 ± 3.7 vs. 17.7 ± 7.7 min, p = 0.0021), and success in termination of the arrhythmia during the procedure (100 vs. 68.2%, p = 0.0230). Ablation of atypical atrial flutter is challenging and time consuming. This case series shows that HD-VGM mapping can quickly localize and terminate an atypical flutter circuit.

  10. Simultaneous pulmonary vein cryoablation and cavotricuspid isthmus radiofrequency ablation in patients with combined atrial fibrillation and typical atrial flutter.

    PubMed

    Peyrol, Michaël; Sbragia, Pascal; Ronchard, Thibault; Cautela, Jennifer; Villacampa, Chloé; Laine, Marc; Bonello, Laurent; Thuny, Franck; Paganelli, Franck; Lévy, Samuel

    2015-01-01

    Pulmonary vein isolation (PVI) using cryoballoon (CB) technique and cavotricuspid isthmus (CTI) ablation using radiofrequency (RF) are established interventions for drug-resistant atrial fibrillation (AF) and typical atrial flutter (AFL). Twelve patients with a mean age of 62 ± 12 years underwent simultaneous delivery of RF energy at the CTI during CB applications at the PV ostia. Pulmonary vein isolation was achieved in all PVs and sustained bidirectional CTI conduction block obtained in all patients. The reported ablation protocol of combined paroxysmal AF and typical AFL did not result in prolongation of the procedure duration or in prolonged radiation exposure when compared to CB-PVI alone. No interferences between both ablation energy systems were observed. These preliminary results suggest that combined paroxysmal AF and typical AFL can be successfully and safely ablated using hybrid energy sources with simultaneous CTI ablation using RF during CB applications at the PV ostia. Copyright © 2015 Elsevier Inc. All rights reserved.

  11. Predictors of sick sinus syndrome in patients after successful radiofrequency catheter ablation of atrial flutter.

    PubMed

    Song, Changho; Jin, Moo-Nyun; Lee, Jung-Hee; Kim, In-Soo; Uhm, Jae-Sun; Pak, Hui-Nam; Lee, Moon-Hyoung; Joung, Boyoung

    2015-01-01

    The identification of sick sinus syndrome (SSS) in patients with atrial flutter (AFL) is difficult before the termination of AFL. This study investigated the patient characteristics used in predicting a high risk of SSS after AFL ablation. Out of 339 consecutive patients who had undergone radiofrequency ablation for AFL from 1991 to 2012, 27 (8%) had SSS (SSS group). We compared the clinical characteristics of patients with and without SSS (n=312, no-SSS group). The SSS group was more likely to have a lower body mass index (SSS: 22.5±3.2; no-SSS: 24.0±3.0 kg/m²; p=0.02), a history of atrial septal defects (ASD; SSS: 19%; no-SSS: 6%; p=0.01), a history of coronary artery bypass graft surgery (CABG; SSS: 11%; no-SSS: 2%; p=0.002), and a longer flutter cycle length (CL; SSS: 262.3±39.2; no-SSS: 243.0±40; p=0.02) than the no-SSS group. In multivariate analysis, a history of ASD [odds ratio (OR) 3.7, 95% confidence interval (CI) 1.2-11.4, p=0.02] and CABG (7.1, 95% CI 1.5-32.8, p=0.01) as well as longer flutter CL (1.1, 95% CI 1.0-1.2, p=0.04) were independent risk factors for SSS. A history of ASD and CABG as well as longer flutter CL increased the risk of SSS after AFL ablation. While half of the patients with SSS after AFL ablation experienced transient SSS, heart failure was associated with irreversible SSS.

  12. Pulmonary vein triggers play an important role in the initiation of atrial flutter: Initial results from the prospective randomized Atrial Fibrillation Ablation in Atrial Flutter (Triple A) trial.

    PubMed

    Schneider, Ralph; Lauschke, Joerg; Tischer, Tina; Schneider, Cindy; Voss, Wolfgang; Moehlenkamp, Felix; Glass, Aenne; Diedrich, Doreen; Bänsch, Dietmar

    2015-05-01

    The incidence of atrial fibrillation (AF) after ablation of a cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) is high. The purpose of this study was to test the hypothesis that AFL and AF may be initiated by pulmonary vein triggers. This prospective randomized trial tested the efficacy of a standalone pulmonary vein isolation (PVI) in patients with AFL but without AF. Patients with AFL but without documented AF were randomly assigned to 1 of 3 treatment groups: (1) antiarrhythmic drugs (AAD), (2) CTI ablation, or (3) circumferential PVI. The primary end-point was defined as any recurrent atrial tachyarrhythmia and the secondary end-point as recurrence of AFL. In case of tachyarrhythmia recurrence in the PVI group, a second PVI was performed to close gaps in the ablation lines. Of the 60 patients, 17 were randomized to AAD, 23 to CTI ablation, and 20 to PVI. During follow-up of 1.42 ± 0.83 years, 14 of 17 patients (82.4%) in the AAD group, 14 of 23 patients (60.9%) in the CTI group, and 2 of 20 patients (10%) in the PVI group reached the primary end-point (P <.001) after a mean of 1.4 PVI procedures per patient. AFL reoccurred in 9 patients (52.9.%) in the AAD group, in 2 patients (8.7%) in the CTI group, and after a single PVI in 3 patients (15%) in the PVI group (P = .003). After closure of gaps, 1 patient (5%) in the PVI group presented with recurrent AFL. Pulmonary vein triggers play an important role in AFL. PVI can prevent the recurrence of AFL, even without CTI ablation. Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  13. Acute myocardial infarction after radiofrequency catheter ablation of typical atrial flutter.

    PubMed

    Yune, Sehyo; Lee, Woo Joo; Hwang, Ji-won; Kim, Eun; Ha, Jung Min; Kim, June Soo

    2014-02-01

    A 53-yr-old man underwent radiofrequency ablation to treat persistent atrial flutter. After the procedure, the chest pain was getting worse, and the electrocardiogram showed ST-segment elevation in inferior leads with reciprocal changes. Immediate coronary angiography showed total occlusion with thrombi at the distal portion of the right coronary artery, which was very close to the ablation site. Intervention with thrombus aspiration and balloon dilatation was successful, and the patient recovered without any kind of sequelae. Although the exact mechanism is obscure, the most likely explanation is a thermal injury to the vascular wall that ruptured into the lumen and formed thrombus. Vasospasm and thromboembolism can also be other possibilities. This case raise the alarm to cardiologists who perform radiofrequency ablation to treat various kinds of cardiac arrhythmias, in that myocardial infarction has been rarely considered one of the complications.

  14. Radiofrequency ablation of left atrial flutter mediated with double potentials in a seemingly normally structured heart.

    PubMed

    Peng, Hui; Sun, Zhijun; Zhang, Heping; Wu, Yongquan

    2014-08-20

    Left atrial flutter (left AFL) is common in patients who undergo atrial fibrillation ablation and cardiac surgery; however, few reports describe left AFL in detail in a seemingly normally structured heart, and the mechanisms of the occurrence of such arrhythmia are still not clear. We describe left AFL in patients without prior cardiac surgery or catheter ablation and discuss the electrophysiological characteristics that may explain the preferential generation and perpetuation of such tachycardia. Eleven patients with left AFL, who had no history of cardiac surgery or interventions, underwent electrophysiological studies and 3-dimensional electroanatomic mapping studies. Echocardiography revealed a relatively mild dilation of the left atrium, mild to moderate mitral regurgitation, and a normal left ventricular ejection fraction. The electroanatomic mapping during tachycardia showed a "reentrant" activation pattern in all patients. The mean tachycardia cycle length was 266 ± 17 ms. A single-loop reentrant circuit was identified in 7 patients. A counterclockwise left atrial flutter evolved around the mitral valve annulus in 6 patients. The tachycardia rotated around the left atrial anterior wall in 1 patient. Four patients exhibited a double-loop reentrant circuit with a "figure of 8" pattern reentry. Double potentials as the critical isthmus of the circuit were identified in the left atrial anterior wall near the mitral annulus which displayed a low-voltage area matched with the left atrium-aorta contiguity. The conduction velocity was significantly slower in the double-potential recording area than in the lateral mitral annulus (0.36 ± 0.03 m/s vs 0.74 ± 0.12 m/s; P<0.05). Successful ablation around the double-potential recording site caused an interruption of the tachycardia, and remained free of recurrence during a 12-month follow-up in all patients. Left AFL in patients without a history of surgery or ablation is rarely observed in clinical practice. The

  15. Temporal pattern of conduction recurrence during radiofrequency ablation for typical atrial flutter.

    PubMed

    Stovicek, Petr; Fikar, Miroslav; Wichterle, Dan

    2006-06-01

    Conduction recurrence during radiofrequency (RF) ablation of cavotricuspid isthmus for typical atrial flutter is common. Understanding the temporal pattern of recurrences could help to predict a durable bidirectional block (BDB) and optimize the procedure. We analyzed atrial flutter ablations in 108 consecutive patients (85 males, age 63 +/- 11 years). RF energy was delivered through 8-mm tip or 4-mm cooled-tip catheter. On average, 18 +/- 11 pulses were necessary to achieve BDB. The time to recurrence of conduction after RF cessation was recorded. Early and late conduction recurrences were defined as < or =10 minutes and >10 minutes, respectively. Patients were observed for > or =30 minutes after bidirectional cavotricuspid isthmus (CTI) block was achieved. Conduction did not recur in 46 patients. In 8 cases, no block was achieved. A total of 167 conduction recurrences were recorded in the remaining 54 cases (1-10 per case). Of these, in 53 patients, recurrences were classified as early (98%) and 14 patients had late recurrences (8%). Thirteen patients had both early and late recurrences (24%). All but one late recurrence were preceded by at least one early recurrence. Absence of early recurrence had negative predictive value of 98%, while any early recurrence had positive predictive value of 26% for subsequent late conduction recovery. Incidence of isthmus conduction recurrence rapidly decayed during the waiting period. Absence of conduction recurrence within 10 minutes after first successful RF delivery was highly predictive of persistent BDB.

  16. Prospective evaluation of a simplified approach for common atrial flutter radio frequency ablation with only two catheters.

    PubMed

    Klug, D; Lacroix, D; Marquié, C; Mairesse, G; Alix, D; Dennetière, S; d'Hautefeuille, B; Zghal, N; Kacet, S

    2001-07-01

    Intra-atrial conduction block within the inferior vena cava-tricuspid annulus isthmus (IVCT) has been shown to predict successful common atrial flutter ablation. However, its demonstration requires the use of several electrode catheters and mapping of the line of block. The aim of this study was prospectively to test the feasibility of a simplified ablation procedure using only two catheters. Radio frequency (RF) ablation of common atrial flutter was performed in 30 patients with the sole use of a catheter for atrial pacing and a RF catheter. RF ablation lesions were created in the IVCT. Surface ECG criteria were used to monitor the conduction within the IVCT. The end point during low lateral atrial pacing was an increment in the interval between the pacing artefact and the peak of the R wave in surface lead II >50 ms and clockwise rotation of the P wave axis beyond -30 degrees and inferiorly. Then, the line of lesions was mapped during atrial pacing with the RF catheter. Additional RF lesions were applied if mapping disclosed a zone of residual conduction. Otherwise the procedure was stopped if mapping showed parallel double potentials all along the line. Finally, the block was reassessed with a 'Halo' catheter. Surface ECG criteria were met in 26 patients. Mapping the line of lesions showed a complete corridor of parallel double potentials in these 26 cases and in 3 of the 4 patients in whom ECG criteria were not met. Conduction evaluated with the Halo catheter showed bi-directional complete block in these 29 patients. After a follow-up of 16 +/- 4 months there was no recurrence of atrial flutter. Surface ECG criteria combined with mapping of the line of block demonstrate evidence of bi-directional IVCT block. This simplified RF ablation of common atrial flutter is feasible with a low recurrence rate.

  17. Catheter ablation of atrial fibrillation and atrial flutter in patients with diabetes mellitus: Who benefits and who does not? Data from the German ablation registry.

    PubMed

    Bogossian, Harilaos; Frommeyer, Gerrit; Brachmann, Johannes; Lewalter, Thorsten; Hoffmann, Ellen; Kuck, Karl Heinz; Andresen, Dietrich; Willems, Stephan; Spitzer, Stefan G; Deneke, Thomas; Thomas, Dierk; Hochadel, Matthias; Senges, Jochen; Eckardt, Lars; Lemke, Bernd

    2016-07-01

    Diabetes mellitus (DM) is an independent risk factor for cardiovascular disease and arrhythmias. Procedural data and complication rates in patients with DM undergoing catheter ablation for atrial arrhythmias are unknown. The German Ablation Registry has been designed as a multi-center prospective registry. Between January 2007 and January 2010 data from ablation of right atrial flutter (AFlut) and atrial fibrillation (AF) were collected from 51 German centres. Patients with DM and without DM were compared. We included 8175 patients who underwent catheter ablation of AFlut or AF. Patients with DM (n=944) were older and presented significantly more severe comorbidities. Major periprocedural complications did not significantly differ between patients with and without DM for both ablation of AFlut and AF. Kaplan-Meier survival analysis for 366days of follow-up, showed a significant increase of MACCE for DM patients as compared to controls after AFlut [6.1% vs. 3.4%(p=0.002)], but not after AF ablation [1.2% vs. 0.9%(p=0.59)]. Ablation of AFlut led to a comparable reduction of palpitations and NYHA class in both patient groups. AF ablation reduced palpitations and NYHA class in patients without DM, while patients with DM reported no improvement of NYHA class despite a reduction of palpitations. As compared to non-DM, patients with DM show no increased periprocedural risk and no increased arrhythmia recurrence after ablation of AFlut or AF. As expected patients with DM exhibit more comorbidities and an increased ongoing mortality after atrial flutter ablation presumably caused by the higher age of this group as compared to controls. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  18. Interatrial Conduction Time Can Predict New-Onset Atrial Fibrillation After Radiofrequency Ablation of Isolated, Typical Atrial Flutter.

    PubMed

    Henmi, Ryuta; Ejima, Koichiro; Shoda, Morio; Yagishita, Daigo; Hagiwara, Nobuhisa

    2016-07-16

    Many patients with successful atrial flutter (AFL) ablation will develop atrial fibrillation (AF) during follow-up. This study aimed to determine whether prolonged interatrial conduction time (IACT) is associated with risk for new-onset AF after ablation of isolated, typical AFL. Participants were 80 consecutive patients who underwent successful radiofrequency ablation of isolated, typical AFL from 2004 to 2012. Patients with any history of AF prior to AFL ablation were excluded. IACT was defined as the interval from the earliest onset of the P-wave on the ECG to the latest activation in the coronary sinus catheter during sinus rhythm measured after AFL ablation. New-onset AF was identified from 12-lead ECGs, 24-hour ambulatory monitoring, and device interrogations. During a mean follow-up of 4.1 ± 2.5 years after successful AFL ablation, 22 patients (27.5%) developed new-onset AF. Cox regression multivariate analysis demonstrated that IACT was the independent predictor of new-onset AF after AFL ablation (hazard ratio: 1.03; 95% confidence interval: 1.00-1.06; P = 0.02). IACT was accurate in predicting new-onset AF (AUC = 0.70). The optimal cut-off point of IACT for predicting new-onset AF was 120 milliseconds (sensitivity 47.6%, specificity 89.8%). Kaplan-Meier curves showed that new-onset AF after AFL ablation was significantly higher in patients with IACT ≥120 milliseconds than in patients with IACT< 120 milliseconds (P = 0.0016). Prolonged IACT predicted new-onset AF after ablation of isolated AFL. This finding may contribute to guiding decisions regarding the maintenance of anticoagulation after AFL ablation. © 2016 Wiley Periodicals, Inc.

  19. Adenosine testing in atrial flutter ablation: unmasking of dormant conduction across the cavotricuspid isthmus and risk of recurrence.

    PubMed

    Morales, Gustavo X; Macle, Laurent; Khairy, Paul; Charnigo, Richard; Davidson, Evan; Thal, Sergio; Ching, C K; Lellouche, Nicolas; Whitbeck, Matthew; Delisle, Brian; Thompson, Jenks; Di Biase, Luigi; Natale, Andrea; Nattel, Stanley; Elayi, Claude S

    2013-09-01

    Adenosine-induced hyperpolarization may identify pulmonary veins at risk of reconnection following electrical isolation for atrial fibrillation. The potential role of adenosine testing in other arrhythmic substrates, such as cavotricuspid isthmus (CTI)-dependent atrial flutter, remains unclear. We assessed whether dormant conduction across the CTI may be revealed by adenosine after ablation-induced bidirectional block, and its association with recurrent flutter. Patients undergoing catheter ablation for CTI-dependent flutter were prospectively studied. After confirming bidirectional block across the CTI by standard pacing maneuvers, adenosine (≥ 12 mg IV) was administered to assess resumption of conduction, followed by isoproterenol (ISP) bolus. Further CTI ablation was performed for persistent (but not transient) resumption of conduction. Bidirectional block across the CTI was achieved in all 81 patients (63 males), age 61.2 ± 11.0 years. The trans-CTI time increased from 71.9 ± 18.1 milliseconds preablation to 166.2 ± 26.4 milliseconds postablation. Adenosine elicited resumption of conduction across the CTI in 7 patients (8.6%), 2 of whom had transient recovery. No additional patient with dormant conduction was identified by ISP. Over a follow-up of 11.8 ± 8.0 months, atrial flutter recurred in 4 (4.9%) patients, 3/7(42.9%) with a positive adenosine challenge versus 1/74 (1.3%) with a negative response, P = 0.0016 (relative risk 31.7). Adenosine challenge following atrial flutter ablation provoked transient or persistent resumption of conduction across the CTI in almost 9% of patients and identified a subgroup at higher risk of flutter recurrence. It remains to be determined whether additional ablation guided by adenosine testing during the index procedure may further improve procedural outcomes. © 2013 Wiley Periodicals, Inc.

  20. Risk of atrial fibrillation after atrial flutter ablation: impact of AF history, gender, and antiarrhythmic drug medication.

    PubMed

    Brembilla-Perrot, Béatrice; Girerd, Nicolas; Sellal, Jean Marc; Olivier, Arnaud; Manenti, Vladimir; Villemin, Thibaut; Beurrier, Daniel; de Chillou, Christian; Louis, Pierre; Selton, Olivier; de la Chaise, Arnaud Terrier

    2014-08-01

    Atrial fibrillation (AF) and flutter (AFL) are frequently associated. We assessed the frequency and identified the predictors of AF occurrence after AFL ablation. A total of 1,121 patients referred for AFL ablation were followed for a mean duration of 2.1 ± 2.7 years. Antiarrhythmic drugs were stopped after ablation in patients with no AF prior to ablation, or continued otherwise. A total of 356 patients (31.7%) had a history of AF prior to AFL ablation. Patients with AF prior to ablation were more likely to be females (OR = 1.35, CI = 1.00-1.83, P = 0.05). After ablation, 260 (23.2%) patients experienced AF. In the multivariable model, AF prior to ablation (OR = 1.90, CI = 1.42-2.54, P < 0.001) and female gender (OR = 1.77, CI = 1.29-2.42, P < 0.001) were associated with a higher risk of AF after ablation. In patients without prior AF, class I antiarrhythmics and amiodarone prior to AFL ablation were independently associated with higher risk of AF after ablation (OR = 2.11, CI = 1.15-3.88, P = 0.02 and OR = 1.60, CI = 1.08-2.36, P = 0.02, respectively). In patients who experienced AF after ablation, 201/260 (77.3%) had a CHA2DS2-VASc ≥1. Two patients with AF prior to ablation had a stroke during the follow-up whereas none of the patients without AF prior to ablation had a stroke. AF occurrence after AFL ablation is frequent (>20%), especially in patients with a history of AF, in female patients, and in patients treated with class I antiarrythmics/amiodarone prior to AFL. Since most patients who experience AF after AFL ablation have a CHA2DS2-VASc ≥1, the decision to stop anticoagulants after ablation should be considered on an individual basis. © 2014 Wiley Periodicals, Inc.

  1. Electromagnetic versus fluoroscopic mapping of the inferior isthmus for ablation of typical atrial flutter: A prospective randomized study.

    PubMed

    Kottkamp, H; Hügl, B; Krauss, B; Wetzel, U; Fleck, A; Schuler, G; Hindricks, G

    2000-10-24

    Radiofrequency catheter ablation within the tricuspid annulus-inferior caval vein isthmus can cure typical atrial flutter. The target for ablation, nonetheless, is relatively wide, and standard ablation procedures may require significant exposure to radiation. A total of 50 patients (mean age, 58+/-11 years) with typical atrial flutter were prospectively randomized to receive isthmus ablation using conventional fluoroscopy for catheter navigation (group I, n=24) or electromagnetic mapping (group II, n=26). Complete bidirectional isthmus block was verified with double potential mapping. If complete isthmus block could not be achieved after 20 radiofrequency pulses or 25 minutes of fluoroscopy, the patients were switched to the other group. Eight patients from group I (33%) but only 1 patient from group II (4%) were switched. Overall, complete isthmus block was achieved in 47 of 50 patients (94%). The overall fluoroscopy time, including the placement of the diagnostic catheters, was 22.0+/-6.3 minutes in group I and 3.9+/-1.5 minutes in group II (P:<0.0001). The fluoroscopy time needed for isthmus mapping was 17.7+/-6.5 minutes in group I and 0.2+/-0.3 minutes in group II (P:<0.0001). Electromagnetic mapping during the induction of linear lesions for the ablation of atrial flutter permitted a highly significant reduction in exposure to fluoroscopy while maintaining high efficacy, and it allowed the time required for fluoroscopy to be reduced to levels anticipated for diagnostic electrophysiological studies.

  2. Incidence and risk factors for symptomatic heart failure after catheter ablation of atrial fibrillation and atrial flutter.

    PubMed

    Huang, Henry D; Waks, Jonathan W; Contreras-Valdes, Fernando M; Haffajee, Charles; Buxton, Alfred E; Josephson, Mark E

    2016-04-01

    To determine the incidence and risk factors for development of symptomatic heart failure (HF) following catheter ablation for atrial fibrillation (AF) and atrial flutter. We prospectively enrolled consecutive patients undergoing pulmonary vein isolation (PVI) or cavotricuspid isthmus (CTI) ablation between November 2013 and June 2014. Post-discharge symptoms were assessed via telephone follow-up and clinic visits. The primary outcome was symptomatic HF requiring treatment with new/increased diuretic dosing. Secondary outcomes were prolonged index hospitalization and readmission for HF ≤30 days. Univariate and multivariable logistic regressions were used to assess the relationship between patient/procedural characteristic and post-ablation HF. Among 111 PVI patients [median age 62.0 years; left ventricular ejection fraction (LVEF) 55%], 29 patients (26.1%) developed symptomatic HF, 6 patients (5.4%) required prolonged index hospitalization, and 8 patients (7.2%) were readmitted for HF. In univariate analyses, persistent AF [odds ratio (OR) 2.97, P = 0.02], AF at start of the procedure (OR 2.99, P = 0.01), additional ablation lines (OR 11.07, P < 0.0001), and final left atrial pressure (OR 1.10 per 1 mmHg increase, P = 0.02) were associated with HF development. Peri-procedural diuresis, net fluid balance, and LVEF were not correlated. In multivariable analyses, only additional ablation lines (ORadj 9.17, P = 0.007) were independently associated with post-ablation HF. Six patients (16.7%) developed HF after CTI ablation. A 26.1% of patients undergoing PVI and 16.7% of patients undergoing CTI ablation developed symptomatic HF when prospectively and uniformly assessed. 12.6% of patients experienced prolonged index hospitalizations or readmission for management of HF within 1 week after PVI. Improved understanding of risk factors for post-ablation HF may be critical in developing strategies to address during AF ablation. Published on behalf of the European Society of

  3. Cardiogenic Shock, Acute Severe Mitral Regurgitation and Complete Heart Block After Cavo-Tricuspid Isthmus Atrial Flutter Ablation.

    PubMed

    Aung, Thein Tun; Roberto, Edward Samuel; Kravitz, Kevin D

    2017-04-01

    Radiofrequency (RF) ablation is the first-line management of cavo-tricuspid isthmus dependent atrial flutter. It has been performed with 95% success rate. Adverse events are very rare. We report the first case of acute severe mitral regurgitation (MR) and complete heart block developed after successful atrial flutter ablation. A 62-year-old female with mild MR presented with palpitations. Surface electrocardiogram was suggestive of isthmus dependent atrial flutter. A duodecapolar mapping catheter showed an atrial flutter with cycle length of 280 ms. An 8 mm tipped Thermistor RF ablation catheter was placed at the cavo-tricuspid isthmus. RF energy was delivered as the catheter was dragged to the inferior vena cava. Temperature limit was 60 °C; the power output limit was 60 W. The patient converted to sinus rhythm with the first ablation line. Bi-directional block was recorded. Two additional ablation lines lasting 60 - 120 s were delivered. The patient started having chest pain and developed complete heart block with no escape rhythm. She became hypotensive and was immediately paced from the right ventricle. There were no signs of pericardial tamponade. Emergent bedside echo demonstrated severe MR with a retracted posteromedial mitral valve leaflet. She was 100% paced and EKG changes could not be assessed. Based on the sudden onset chest pain, hypotension, complete heart block and acute severe MR after ablation, the right coronary artery occlusion was suspected. She was immediately transferred to the catheterization laboratory. Coronary angiography revealed a total occlusion of the posterolateral branch from the right coronary artery. Balloon angioplasty and coronary artery stenting was performed. Complete heart block subsequently resolved. Subsequent bedside echocardiogram showed marked improvement of the MR. Patients with smaller body size have smaller hearts and more likely to have injury from RF current. Higher energy penetrates deeper and causes more tissue

  4. Use of adenosine to shorten the post ablation waiting period for cavotricuspid isthmus-dependent atrial flutter.

    PubMed

    Morales, Gustavo; Darrat, Yousef H; Lellouche, Nicolas; Kim, Sun Moon; Butt, Muhammad; Bidwell, Katrina; Lippert, William; Ogunbayo, Gbolahan; Hamon, David; Di Biase, Luigi; Natale, Andrea; Parrott, Kevin; Elayi, Claude S

    2017-08-01

    Dormant conduction unmasked by adenosine predicts clinical recurrences of cavotricuspid isthmus (CTI) dependent atrial flutter following catheter ablation. Conventional practice involves a waiting period of 20 to 30 minutes after achievement of a bidirectional line of block (BDB) to monitor for recovery of conduction. Assess whether abolition of dormant conduction with adenosine immediately after CTI ablation and BDB can predict the lack of CTI conduction recovery during the following 30 minutes. Consecutive patients undergoing catheter ablation for CTI-dependent atrial flutter were studied. Following the completion of CTI ablation and documentation of BDB, adenosine (≥12 mg IV) was administered immediately. In cases of dormant conduction, the CTI was ablated again until its abolition. After the achievement of BDB without dormant conduction, spontaneous CTI reconnection during the following 30 minutes and dormant conduction with adenosine at 30 minutes were evaluated. A CTI block was achieved in 171 patients. Nine patients (5.3%) had dormant conduction across the CTI immediately after ablation and BDB, and required further ablation. Two patients (1.2%) had subsequent spontaneous time-dependent reconnection within 30 minutes. Two other patients (1.2%) developed late dormant conduction with adenosine at 30 minutes. All 4 patients underwent further ablation. A negative adenosine challenge immediately after CTI ablation with bidirectional block, or after abolition of dormant conduction with further ablation, strongly predicted the absence of subsequent spontaneous reconnection within 30 minutes. Based on these results, the conventional waiting period is unnecessary in 97.6% patients without dormant conduction after CTI-dependent flutter ablation. © 2017 Wiley Periodicals, Inc.

  5. Radiofrequency ablation of coronary sinus-dependent atrial flutter guided by fractionated mid-diastolic coronary sinus potentials

    PubMed Central

    De Sisti, Antonio; Amara, Walid; Frank, Robert; Hidden-Lucet, Françoise

    2010-01-01

    Background The efficacy of radiofrequency (RF) ablation of an uncommon coronary sinus (CS)-dependent atrial flutter (AFL) was evaluated using conventional electrophysiological criteria in a highly selected subset of patients with typical and atypical AFL. Methods Fourteen patients with atrial flutter (11 males, mean age 69 ± 9 years) without previous right or left atrial RF ablation were included. Heart disease was present in eight patients. Baseline ECG suggested typical AFL in 12 patients and atypical AFL in two. Mean AFL cycle length was 324 ± 64 ms at the time of RF ablation in the CS. Lateral right atrium activation was counterclockwise (CCW) in 13 patients and clockwise in one. CS activation was CCW in all. Criteria for CS ablation included the presence of CS mid-diastolic fractionated atrial potentials (APs) associated with concealed entrainment with a postpacing interval within 20 ms. Success was defined as termination of AFL and subsequent noninducibility. Results The initial target for ablation was the cavotricuspid isthmus (CTI) in 11 patients and the CS with further CTI ablation in three. AP duration at the CS target site was 122 ± 33 ms, spanning 40 ± 12% of the AFL cycle length. CS ablation site was located 1–4 cm from the CS ostium. Ablation was successful in all patients. Mean time to AFL termination during CS ablation was 39 ± 52 s (<20 s in eight patients). No recurrence of ablated arrhythmia occurred during a follow-up of 18 ± 8 months. Conclusions The CS musculature is a critical part of some AFL circuits in patients with typical and atypical AFL. AFL can be terminated in patients with CS or CTI/CS AFL reentrant circuits by targeting CS mid-diastolic fragmented APs. PMID:20814733

  6. Risk of pacemaker implantation after uneventful successful cavotricuspid isthmus radiofrequency ablation in patients with common atrial flutter.

    PubMed

    Rodríguez-Mañero, Moisés; González-Melchor, Layla; Ballesteros, Gabriel; Raposeiras-Roubín, Sergio; García-Seara, Javier; López, Xesús Alberte Fernández; Cambeiro, Cristina González; Alcalde, Oscar; García-Bolao, Ignacio; Martínez-Sande, Luis; González-Juanatey, José Ramón

    2016-01-01

    Little is known about the risk of pacemaker implantation after common atrial flutter ablation in the long-term. We retrospectively reviewed the electrophysiology laboratory database at two Spanish University Hospitals from 1998 to 2012 to identify patients who had undergone successful ablation for cavotricuspid dependent atrial flutter. Cox regression analysis was used to examine the risk of pacemaker implantation. A total of 298 patients were considered eligible for inclusion. The mean age of the enrolled patients was 65.7±11. During 57.7±42.8 months, 30 patients (10.1%) underwent pacemaker implantation. In the stepwise multivariate models only heart rate at the time of the ablation (OR: 0.96; 95% CI: 0.93-0.98; p<0.0001) and intraventricular conduction disturbances in the baseline ECG (OR: 3.87; 95% CI: 1.54-9.70; p=0.004) were independents predictors of the need of pacemaker implantation. A heart rate of ≤65 bpm was identified as the optimal cut-off value to predict the need of pacemaker implantation in the follow-up (sensitivity: 79%, specificity: 74%) by ROC curve analyses. This is the first study of an association between the slow conducting common atrial flutter and subsequent risk of pacemaker implantation. In light of these findings, assessing it prior to ablation can be helpful for the risk stratification of sinus node disease or atrioventricular conduction disease requiring a pacemaker implantation in patients with persistent atrial flutter. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  7. Novel Strategies in the Ablation of Typical Atrial Flutter: Role of Intracardiac Echocardiography

    PubMed Central

    Bencsik, Gábor

    2015-01-01

    Radiofrequency ablation (RFA) of the cavo-tricuspid isthmus (CTI) is one of the most frequently performed procedures in electrophysiology. Despite a high success rate, ablation of the CTI can be unusually difficult in some cases. Multiple tools like angiography, 3D mapping, remote navigation and intracardiac echocardiography (ICE) have been introduced to facilitate typical flutter ablation. This review article summarizes the clinical value of different strategies and tools used for CTI ablation focusing on the importance of approaches utilizing ICE. PMID:25308811

  8. Impact of cavotricuspid isthmus morphology in CRYO versus radiofrequency ablation of typical atrial flutter.

    PubMed

    Saygi, Serkan; Bastani, Hamid; Drca, Nikola; Insulander, Per; Wredlert, Christer; Schwieler, Jonas; Jensen-Urstad, Mats

    2017-04-01

    Cryoablation (CRYO) is an alternative to radiofrequency (RF) for catheter ablation of cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). We aimed to study whether different CTI morphologies had different impacts on procedural success for CRYO and RF. This study randomized 153 patients with CTI-dependent AFL (median age 65 years; range 34-82) to RF or CRYO (78 CRYO; 75 RF). Biplane angiography (RAO 30° and LAO 60°) was done before the ablation procedure and isthmuses were classified as straight (n = 81), concave (n = 43) or pouch-like (n = 29). RF was performed with a 3.5-mm open-irrigated tip catheter and CRYO was performed with a 9 F, 8-mm tip catheter. The ablation endpoint was bidirectional block of CTI. Acute procedural success was achieved in 70/75 patients in the RF group and in 72/78 patients in the CRYO group. With regard to CRYO or RF, acute procedural success rates were similar between the three isthmus types: straight: CRYO (92%) and RF (96%); concave: CRYO (92%) and RF (94%); and pouch-like: CRYO (94%) and RF (85%). There were no significant differences regarding success rate between the different morphologies in the CRYO or the RF group. The CTI was longer in patients with acute failure compared to the patients with acute success (38 ± 7 mm versus 33 ± 6 mm, p = 0.045). The CTI morphology did not influence the acute success rate for either the CRYO or the RF ablation of CTI-dependent AFL. A longer CTI was associated with a lower success rate regardless of energy source.

  9. Efficacy comparison between cryoablation and radiofrequency ablation for patients with cavotricuspid valve isthmus dependent atrial flutter: a meta-analysis

    NASA Astrophysics Data System (ADS)

    Chen, Yi-He; Lin, Hui; Xie, Cheng-Long; Zhang, Xiao-Ting; Li, Yi-Gang

    2015-06-01

    We perform this meta-analysis to compare the efficacy and safety of cryoablation versus radiofrequency ablation for patients with cavotricuspid valve isthmus dependent atrial flutter. By searching EMBASE, MEDLINE, PubMed and Cochrane electronic databases from March 1986 to September 2014, 7 randomized clinical trials were included. Acute (risk ratio[RR]: 0.93; P = 0.14) and long-term (RR: 0.94; P = 0.08) success rate were slightly lower in cryoablation group than in radiofrequency ablation group, but the difference was not statistically significant. Additionally, the fluoroscopy time was nonsignificantly reduced (weighted mean difference[WMD]: -2.83 P = 0.29), whereas procedure time was significantly longer (WMD: 25.95; P = 0.01) in cryoablation group compared with radiofrequency ablation group. Furthermore, Pain perception during the catheter ablation was substantially less in cryoabaltion group than in radiofrequency ablation group (standardized mean difference[SMD]: -2.36 P < 0.00001). Thus, our meta-analysis demonstrated that cryoablation and radiofrequency ablation produce comparable acute and long-term success rate for patients with cavotricuspid valve isthmus dependent atrial flutter. Meanwhile, cryoablation ablation tends to reduce the fluoroscopy time and significantly reduce pain perception in cost of significantly prolonged procedure time.

  10. Efficacy comparison between cryoablation and radiofrequency ablation for patients with cavotricuspid valve isthmus dependent atrial flutter: a meta-analysis

    PubMed Central

    Chen, Yi-He; Lin, Hui; Xie, Cheng-Long; Zhang, Xiao-Ting; Li, Yi-Gang

    2015-01-01

    We perform this meta-analysis to compare the efficacy and safety of cryoablation versus radiofrequency ablation for patients with cavotricuspid valve isthmus dependent atrial flutter. By searching EMBASE, MEDLINE, PubMed and Cochrane electronic databases from March 1986 to September 2014, 7 randomized clinical trials were included. Acute (risk ratio[RR]: 0.93; P = 0.14) and long-term (RR: 0.94; P = 0.08) success rate were slightly lower in cryoablation group than in radiofrequency ablation group, but the difference was not statistically significant. Additionally, the fluoroscopy time was nonsignificantly reduced (weighted mean difference[WMD]: −2.83; P = 0.29), whereas procedure time was significantly longer (WMD: 25.95; P = 0.01) in cryoablation group compared with radiofrequency ablation group. Furthermore, Pain perception during the catheter ablation was substantially less in cryoabaltion group than in radiofrequency ablation group (standardized mean difference[SMD]: −2.36; P < 0.00001). Thus, our meta-analysis demonstrated that cryoablation and radiofrequency ablation produce comparable acute and long-term success rate for patients with cavotricuspid valve isthmus dependent atrial flutter. Meanwhile, cryoablation ablation tends to reduce the fluoroscopy time and significantly reduce pain perception in cost of significantly prolonged procedure time. PMID:26039980

  11. An optimized approach for right atrial flutter ablation: a post hoc analysis of the AURUM 8 study.

    PubMed

    Lewalter, Thorsten; Weiss, Christian; Mewis, Christian; Jung, Werner; Haverkamp, Wilhelm; Proff, Jochen; Bauer, Wolfgang

    2017-03-01

    Radiofrequency catheter ablation of typical atrial flutter can vary largely in duration from patient to patient. The purpose of this work was to determine optimal combination of ablation settings leading to the highest procedural efficacy. Our retrospective multivariate analysis comprised 448 patients undergoing atrial flutter ablation with nonirrigated 8-mm catheters at 19 clinical centers. Four procedural variables were included in the prognostic model: preset maximum temperature, preset maximum power, catheter-tip material (gold vs. platinum-iridium), and ablation technique (maximum voltage-guided vs. conventional anatomical approach). Univariate and multivariate analyses were performed using the logistic regression (for acute ablation success) and Cox constant proportional hazard models (for cumulative ablation time). Significant multivariate predictors of acute ablation success were a higher preset maximum temperature (odds 1.083 per 1 °C, P < 0.05) and gold-tip catheter (odds 2.096, P < 0.05). Predictors of cumulative ablation time were the maximum voltage-guided ablation technique (hazard ratio 1.856, P < 0.001), higher preset maximum temperature (hazard ratio 1.039 per 1 °C, P < 0.001), and gold-tip catheter (hazard ratio 1.225, P < 0.05). The combination of optimal settings (70 °C, 70 W, gold-tip catheter, maximum voltage-guided technique) increased the acute success rate from 91.7 % (for the entire study cohort) to 100 %, and reduced median cumulative ablation time from 8.3 to 4.3 min, median total procedure duration from 76 to 55 min, and median fluoroscopy time from 14 to 7 min. The combination of maximum voltage-guided gold-tip ablation at 70 °C and 70 W was associated with 100 % ablation success and minimal ablation times for nonirrigated ablation of atrial flutter.

  12. Comparison of the anterior and posterior mitral isthmus ablation lines in patients with perimitral annulus flutter or persistent atrial fibrillation.

    PubMed

    Huemer, Martin; Wutzler, Alexander; Parwani, Abdul Shokor; Attanasio, Philipp; Matsuda, Hisao; Blaschke, Florian; Boldt, Leif-Hendrik; Haverkamp, Wilhelm

    2015-11-01

    Catheter ablation of left atrial linear lesions is an effective treatment option for perimitral flutter and is often used as a substrate modification approach for persistent atrial fibrillation. The two most popular mitral isthmus lines are those of the anterior or the posterior mitral isthmus. A comparison of these two mitral isthmus ablation approaches is still pending. Patients undergoing catheter ablation either at the anterior or the posterior mitral isthmus were included. Procedural success, conduction block, procedure durations, complications, and the necessity of a coronary sinus ablation were analyzed. We investigated 80 consecutive patients, 40 (50%) with an anterior and 40 (50%) with a posterior mitral isthmus line. Twenty (25.0%) patients had perimitral annulus flutter; the remainder of the patients had persistent atrial fibrillation. Bidirectional conduction block was achieved in the same proportion in the anterior group (36; 90.0%) as it was in the posterior group (30; 75.0%) (statistically insignificant). Duration of procedure (18 ± 12 vs. 34 ± 24 min, p = 0.001), radiofrequency application (11 ± 7 vs. 18 ± 11 min, p = 0.004), and fluoroscopy (2 ± 2 vs. 8 ± 8 min, p < 0.001) values were all significantly lower in the anterior group. Only patients in the posterior line group had to be ablated via the coronary sinus 24 (60.0 %). Ablation at the anterior mitral isthmus shows the same success rate as the posterior mitral isthmus does. Catheter ablation at the anterior mitral isthmus is associated with significantly shorter procedure durations without the need of a coronary sinus ablation.

  13. [Typical atrial flutter: Diagnosis and therapy].

    PubMed

    Thomas, Dierk; Eckardt, Lars; Estner, Heidi L; Kuniss, Malte; Meyer, Christian; Neuberger, Hans-Ruprecht; Sommer, Philipp; Steven, Daniel; Voss, Frederik; Bonnemeier, Hendrik

    2016-03-01

    Typical, cavotricuspid-dependent atrial flutter is the most common atrial macroreentry tachycardia. The incidence of atrial flutter (typical and atypical forms) is age-dependent with 5/100,000 in patients less than 50 years and approximately 600/100,000 in subjects > 80 years of age. Concomitant heart failure or pulmonary disease further increases the risk of typical atrial flutter.Patients with atrial flutter may present with symptoms of palpitations, reduced exercise capacity, chest pain, or dyspnea. The risk of thromboembolism is probably similar to atrial fibrillation; therefore, the same antithrombotic prophylaxis is required in atrial flutter patients. Acutely symptomatic cases may be subjected to cardioversion or pharmacologic rate control to relieve symptoms. Catheter ablation of the cavotricuspid isthmus represents the primary choice in long-term therapy, associated with high procedural success (> 97 %) and low complication rates (0.5 %).This article represents the third part of a manuscript series designed to improve professional education in the field of cardiac electrophysiology. Mechanistic and clinical characteristics as well as management of isthmus-dependent atrial flutter are described in detail. Electrophysiological findings and catheter ablation of the arrhythmia are highlighted.

  14. Intravenous adenosine to predict conduction recurrence in cavotricuspid isthmus early after ablation of typical atrial flutter: myth or reality?

    PubMed

    Marchandise, Sébastien; Scavée, Christophe; Badot, Damien; Deceuninck, Olivier; Xhaët, Olivier; Hausman, Pierre; De Meester, Christophe; Le Polain De Waroux, Jean-Benoît

    2012-11-01

    Early recovery of conduction (ER) after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFl) occurs in approximately 10% of the patients. If not recognized, ER might lead to AFl recurrences. In this study, we hypothesized that intravenous adenosine (iADO) can be used to predict ER in the CTI immediately after RF ablation and distinguish functional block from the complete destruction of the CTI myocardium. We prospectively included 68 consecutive patients (age: 65 ± 14 years; male: 78%) referred in our centers for AFl ablation. Immediately after bidirectional isthmus block validation, a bolus of iADO was given during continuous pacing from the proximal coronary sinus. Patients with functional block revealed under iADO (iADO+) and those without (iADO-) were subsequently observed for a 30-minute waiting period (ER-) or until sustained recovery of the conduction through the CTI (ER+). Seven patients presented a persistent recovery (ER+, 10.3%, mean time to recovery: 14 ± 9 minutes). None of them presented even a transient resumption of conduction under iADO (iADO+: 0). With univariate analysis, we identified a heavy patient weight (>95 kg) as a predictor of ER (sensitivity: 71%). Adenosine does not predict early recovery in the CTI after linear ablation for atrial flutter. We found that a patient weight over 95 kg predicted early recovery of conduction through the CTI with a sensitivity of 71%. © 2012 Wiley Periodicals, Inc.

  15. Catheter ablation of atrial flutter in patients with left ventricular assist device improves symptoms of right heart failure.

    PubMed

    Hottigoudar, Rashmi U; Deam, Allen G; Birks, Emma J; McCants, Kelly C; Slaughter, Mark S; Gopinathannair, Rakesh

    2013-01-01

    Persistent atrial flutter (AFL) in left ventricular assist device (LVAD) recipients can result in loss of AV synchrony, impaired ventricular filling and right heart failure (RHF). The authors report the largest series of HeartMate II (HMII) patients who developed AFL with decompensated RHF, which successfully resolved with AFL ablation. Eight patients with HMII LVAD (mean age, 57±12 years) had medically refractory AFL, with 7 developing de novo AFL after LVAD implant (onset range, 2 days-22 months post-implant). Three patients developed recurrent syncope, 2 had inappropriate implantable cardioverter-defibrillator shocks, and 6 had new or escalating need for inotropes. All had features of decompensated RHF. Seven patients underwent electrophysiology testing where mapping confirmed typical counterclockwise AFL (mean AFL cycle length, 252±49 ms) and radiofrequency ablation of cavotricuspid isthmus restored sinus rhythm in all patients. Complete resolution of symptoms and signs of RHF with improved quality of life were noted in all. No procedural complications were noted. During a mean follow-up of 9±5 months, all patients remained free of atrial flutter. Catheter ablation of AFL in LVAD patients is safe and highly effective, resulting in immediate and significant improvement in symptoms of RHF, and should be considered first-line therapy for AFL in these patients. © 2013 Wiley Periodicals, Inc.

  16. New insights into typical atrial flutter ablation: extra-isthmus activation time on the flutter wave is predictive of extra-isthmus conduction time after isthmus block.

    PubMed

    Latcu, Decebal Gabriel; Bun, Sok-Sithikun; Arnoult, Mathieu; Ricard, Philippe; Rinaldi, Jean-Paul; Saoudi, Nadir

    2013-01-01

    Catheter ablation of typical atrial flutter (AFl) is succesful if double electrograms on the ablation line are widely separated. Nevertheless, a small interval may also be compatible with complete isthmus block. Predicting such a situation may avoid useless additionnal radiofrequency (RF) applications. We postulated that measuring the extra-isthmus activation time (EIAT) on the counterclockwise (CCW) flutter wave is correlated with the extra-isthmus conduction time after a proven block. Files of 76 patients (71 males, 71 ± 12 years) ablated for typical CCW AFl were reviewed. Ten had 2/1 conduction prohibiting reliable measurement. Three patients with proven crista terminalis shunt were also excluded. In the remaining 63 patients, EIAT was measured on the surface ECG before the first RF pulse from the beginning of the negative deflection of the F wave in lead III to the end of the positive deflection (or beginning of the plateau). After successful ablation and completion of block, right atrial (RA) CCW (during low septal pacing), and clockwise (CW) (during low lateral pacing) activation times were measured. Flutter cycle length was 247 ± 34 ms and EIAT was 142 ± 25 ms. A bidirectionnal isthmus block was obtained in all patients after an RF delivery time of 623 ± 546 s. At a pacing cycle length of 681 ± 71 ms, RA CCW and CW activation times were 147 ± 23 and 139 ± 26 ms, respectively. There was a good correlation between EIA, RA CCW (r = 0.75, p < 0.0001), and CW (r = 0.69, p = 0.0002) activation times. EIAT on the flutter wave is an easy and feasible measure. It is correlated with extra-isthmus RA conduction time after block completion. EIAT can be used as a measure to predict the post cavo-tricuspid isthmus block RA activation time.

  17. Long-term ECG monitoring using an implantable loop recorder for the detection of atrial fibrillation after cavotricuspid isthmus ablation in patients with atrial flutter.

    PubMed

    Mittal, Suneet; Pokushalov, Evgeny; Romanov, Alexander; Ferrara, Martha; Arshad, Aysha; Musat, Dan; Preminger, Mark; Sichrovsky, Tina; Steinberg, Jonathan S

    2013-11-01

    In patients with atrial flutter who undergo cavotricuspid isthmus ablation, long-term electrocardiographic (ECG) monitoring may identify new onset of atrial fibrillation (AF). To ascertain, through the use of an implantable loop recorder (ILR) with a dedicated AF detection algorithm, the incidence, duration, and burden of new AF in these patients and to develop an optimal postablation ECG monitoring strategy. We enrolled 20 patients with flutter, a CHADS2 score of 2-3, and no prior episode of AF. After cavotricuspid isthmus ablation, we implanted an ILR, which was interrogated routinely; all stored ECGs were adjudicated. During a mean follow-up of 382 ± 218 days, 3 patterns were observed. First, in 11 (55%) patients, stored ECGs confirmed AF at 62 ± 38 days after ablation. Second, in 4 (20%) patients, although the ILR suggested AF, episodes actually represented sinus rhythm with frequent premature atrial contractions and/or oversensing. Third, in 5 (25%) patients, no AF was observed. Episodes <4 hours were associated with low AF burden (<1%) or false detections. The 1-year freedom from any episode of AF >4 and >12 hours was 52% and 83%, respectively. Our data show that many (but not all) patients develop new AF within the first 4 months of flutter ablation. Since external ECG monitoring for this duration is impractical, the ILR has an important role for long-term AF surveillance. Future research should be directed toward identifying the relationship between duration/burden of AF and stroke and improving existing ILR technology. © 2013 Heart Rhythm Society. All rights reserved.

  18. Predictors of early and late left atrial tachycardia and left atrial flutter after catheter ablation of atrial fibrillation: long-term follow-up.

    PubMed

    Wójcik, Maciej; Berkowitsch, Alexander; Zaltsberg, Sergey; Hamm, Christian W; Pitschner, Heinz F; Kuniss, Malte; Neumann, Thomas

    2015-01-01

    The aim of the study was identification of the predictors of left atrial tachycardia and left atrial flutter (LATAFL) after radiofrequency catheter ablation of atrial fibrillation (CAAF). We followed 598 patients (71% male, 41% paroxysmal AF; median follow-up: 36 months) after a single step-wise CAAF procedure. The time to first documented LATAFL lasting longer than 30 s, documented in any kind of electrocardiography (ECG), was defined as an end-point. A single CAAF procedure resulted in LATAF in 58 (10%) patients. Additional lesions were performed in 275 (46%) patients. Early LATAFL recurrence (£ 3 months since the index procedure) was observed in 11 (2%) patients. Late LATAFL (> 3 months) was noted in 47 (8%) patients. The univariate predictors of LATAFL recurrence were: type of AF (p = 0.003), the size of LA (p = 0.002) and the type of procedure (p = 0.0001). The identified single independent predictors of LATAFL recurrence were enlarged LA (p = 0.001) and mul-tiple (≥ 2) additional lesions performed during the index procedure (p < 0.0001). Higher rate of LATAFL recurrence was observed in patients with non-paroxysmal AF, enlarged LA and any additional lesions performed. Two independent predictors of LATAFL recurrence after CAAF were: the enlarged LA and multiple (≥ 2) additional lesions performed during the index procedure.

  19. Initial experience in ablation of typical atrial flutter using a novel three-dimensional catheter tracking system.

    PubMed

    Sommer, Philipp; Wojdyla-Hordynska, Agnieszka; Rolf, Sascha; Gaspar, Thomas; Eitel, Charlotte; Arya, Arash; Hindricks, Gerhard; Piorkowski, Christopher

    2013-04-01

    Three-dimensional (3D) mapping has been established for clinical routine in an interventional electrophysiology (EP). Recently, a novel sensor-based 3D catheter tracking system has been introduced integrating 3D non-fluoroscopic catheter navigation into the environment of pre-recorded 2D fluoroscopy [MediGuide™ Technology (MG)]. We are reporting on the first clinical experience for ablation of typical atrial flutter. First we aimed to demonstrate safety and feasibility of this new technique. Secondly, procedural aspects such as effectiveness, procedure, and fluoroscopy time should be evaluated. Ten consecutive patients (100% male, age 68 ± 8 years) were ablated using MG technology. Two steerable diagnostic EP catheters (MediGuide Enabled Livewire™ Catheter, SJM) were used for coronary sinus cannulation and anatomical cavo-tricuspidal isthmus (CTI) reconstruction within the EnSite NavX™ System (NavX). Ablation was performed with a conventional 8 mm tip ablation catheter (IBI, SJM). In all 10 patients both sensor-equipped MG catheters could be tracked non-fluoroscopically. Successful anatomical CTI reconstruction was performed and complete isthmus block was documented after the ablation. Total procedure duration was comparable with conventional procedures (55 ± 8 min). Usage of the MG tracking system resulted in a fluoroscopy time of 2.5 ± 2 min. No adverse events occurred during the procedures. For the first clinical application of the MG technology in an interventional electrophysiology we found a stable system enabling excellent 3D orientation for spatial catheter positioning on the basis of underlying pre-recorded cine loops. Clinically, the MG technology allowed successful procedures with short fluoroscopy times, even though a sensor-equipped ablation catheter was not yet available for use in the study.

  20. Atrial Flutter, Typical and Atypical: A Review

    PubMed Central

    2017-01-01

    Clinical electrophysiology has made the traditional classification of rapid atrial rhythms into flutter and tachycardia of little clinical use. Electrophysiological studies have defined multiple mechanisms of tachycardia, both re-entrant and focal, with varying ECG morphologies and rates, authenticated by the results of catheter ablation of the focal triggers or critical isthmuses of re-entry circuits. In patients without a history of heart disease, cardiac surgery or catheter ablation, typical flutter ECG remains predictive of a right atrial re-entry circuit dependent on the inferior vena cava-tricuspid isthmus that can be very effectively treated by ablation, although late incidence of atrial fibrillation remains a problem. Secondary prevention, based on the treatment of associated atrial fibrillation risk factors, is emerging as a therapeutic option. In patients subjected to cardiac surgery or catheter ablation for the treatment of atrial fibrillation or showing atypical ECG patterns, macro-re-entrant and focal tachycardia mechanisms can be very complex and electrophysiological studies are necessary to guide ablation treatment in poorly tolerated cases. PMID:28835836

  1. Atrial Flutter, Typical and Atypical: A Review.

    PubMed

    Cosío, Francisco G

    2017-06-01

    Clinical electrophysiology has made the traditional classification of rapid atrial rhythms into flutter and tachycardia of little clinical use. Electrophysiological studies have defined multiple mechanisms of tachycardia, both re-entrant and focal, with varying ECG morphologies and rates, authenticated by the results of catheter ablation of the focal triggers or critical isthmuses of re-entry circuits. In patients without a history of heart disease, cardiac surgery or catheter ablation, typical flutter ECG remains predictive of a right atrial re-entry circuit dependent on the inferior vena cava-tricuspid isthmus that can be very effectively treated by ablation, although late incidence of atrial fibrillation remains a problem. Secondary prevention, based on the treatment of associated atrial fibrillation risk factors, is emerging as a therapeutic option. In patients subjected to cardiac surgery or catheter ablation for the treatment of atrial fibrillation or showing atypical ECG patterns, macro-re-entrant and focal tachycardia mechanisms can be very complex and electrophysiological studies are necessary to guide ablation treatment in poorly tolerated cases.

  2. [Radiofrequency ablation of type I atrial flutter: combination of electrophysiological and anatomical techniques].

    PubMed

    Rodríguez, H; Iturralde Torres, P; Cruz Cruz, F; Muñoz, M; Colín, L; Kershenovich, S; González Hermosillo, J A

    1997-01-01

    Atrial flutter type I (FLA) is one of the most common arrhythmias found in clinical practice. Reentry into the right atrium (AD) is the mechanism of this arrhythmia. The reentry mechanism has critical sites where radiofrequency (RF) can act blocking the circuit. Both, electrophysiological and anatomical approaches using RF to FLA have demonstrated a success rate above 80%. Our group combined both techniques treating 35 patients with FLA type I (22 men and 13 women), with mean age of 40.8 +/- 15 years old (range 9-70). In 21 patients (60%) this arrhythmia was associated with cardiopathy. All patients had failed to respond to different antiarrhythmic therapy. The success rate was 82.8% (29/35). When compared failure vs success we observed that patients who failed were older (51.8 vs 38.5 years old, p < 0.05), had structural cardiopathy (83.3% vs 55.1%, p = NS), had FLA type I with P waves with shorter cycle length (195 vs 254 ms, p = 0.052), had the arrhythmia chronically (129.6 vs 68.1 month, p = NS), had great left atrium diameter (41.2 vs 36.7 mm, p = 0.052) and frequently had been associated with atrial fibrillation (33.3% vs 3.4%, p = 0.02). There were no complications. Six (20.6%) patients reverted to FLA. We followed our patients during mean time 8.37 +/- 8.8 months (1-36). Our results support the notion that FLA type I can be treated with high percentage of success and low risk of complications when both RF techniques are combined. Our predictors of failure were: gender and associated atrial fibrillation (p < 0.05). We conclude that RF is the treatment of choice in every patient with FLA type I who had failed to antiarrhythmic therapy. We recommend RF as soon as FLA has been diagnosed because the probability of success is higher in such instances.

  3. Incremental pacing maneuver for atrial flutter recurrence reduction after ablation: Vallès: yield of incremental pacing after flutter ablation.

    PubMed

    Vallès, Ermengol; Bazan, Victor; Cainzos-Achirica, Miguel; Jáuregui, Miguel Eduardo; Benito, Begoña; Bruguera, Jordi; Martí-Almor, Julio

    2014-12-20

    A < 20 ms increase in the interval between cavo-tricuspid isthmus (CTI) double potentials during incremental pacing (IP) is a highly specific marker differentiating functional from complete CTI block during typical flutter (AFL) ablation. Long-term effects of IP remain unclear. We aimed to assess the impact of IP in reducing AFL recurrences after CTI ablation. One hundred and thirty-four patients (age 67 ± 13 years, 78% males) undergoing successful CTI ablation were included and divided into 2 groups: Group 1 (n = 68), in which ablation was performed before the IP maneuver was incorporated, with CTI block confirmed by at least 1 non-local and 1 local electrogram-based previously established criteria; and Group 2 (n = 66), in which IP maneuver was used to confirm complete CTI block. No intergroup differences were noted in baseline characteristics, ablation settings and fluoroscopy/radiofrequency times. Long-term AFL recurrences were observed in 14 out of 134 patients (10.4%), and were more common in Group 1 (19%, vs 1.5% among Group 2 patients, p < 0,001). Despite a longer follow-up period among the former group (1603 ± 734 vs. 964 ± 289 days, respectively), the adjusted AFL recurrence rate was still higher among Group 1 patients (4.3%/year vs. 0.6%/year, p < 0,001). Cox-regression analysis confirmed inclusion in Group 1 as the only predictor of AFL recurrences (HR = 8.2, CI 1.04-64.7, p = 0.046). The addition of the IP maneuver for the diagnosis of complete CTI block reduces AFL long-term recurrences after ablation. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  4. Acute success and short-term follow-up of catheter ablation of isthmus-dependent atrial flutter; a comparison of 8 mm tip radiofrequency and cryothermy catheters

    PubMed Central

    Janse, P.; Alings, M.; Scholten, M. F.; Mekel, J. M.; Miltenburg, M.; Jessurun, E.; Jordaens, L.

    2008-01-01

    Objectives To compare the acute success and short-term follow-up of ablation of atrial flutter using 8 mm tip radiofrequency (RF) and cryocatheters. Methods Sixty-two patients with atrial flutter were randomized to RF or cryocatheter (cryo) ablation. Right atrial angiography was performed to assess the isthmus. End point was bidirectional isthmus block on multiple criteria. A pain score was used and the analgesics were recorded. Patients were followed for at least 3 months. Results The acute success rate for RF was 83% vs 69% for cryo (NS). Procedure times were similar (mean 144 ± 48 min for RF, vs 158 ± 49 min for cryo). More applications were given with RF than with cryo (26 ± 17 vs. 18 ± 10, p < 0.05). Fluoroscopy time was longer with RF (29 ± 15 vs. 19 ± 12 min, p < 0.02). Peak CK, CK-MB and CK-MB mass were higher, also after 24 h in the cryo group. Troponin T did not differ. Repeated transient block during application (usually with cryoablation) seemed to predict failure. Cryothermy required significantly less analgesia (p < 0.01), and no use of long sheaths (p < 0.005). The isthmus tended to be longer in the failed procedures (p = 0.117). This was similar for both groups, as was the distribution of anatomic variations. Recurrences and complaints in the successful patients were similar for both groups, with a very low recurrence of atrial flutter after initial success. Conclusions In this randomized study there was no statistical difference but a trend to less favorable outcome with 8 mm tip cryocatheters compared to RF catheters for atrial flutter ablation. Cryoablation was associated with less discomfort, fewer applications, shorter fluoroscopy times and similar procedure times. The recurrence rate was very low. Cryotherapy can be considered for atrial flutter ablation under certain circumstances especially when it has been used previously in the same patient, such as in an AF ablation. PMID:18363087

  5. A new methodology for atrial flutter ablation by direct visualization of cavotricuspid conduction with voltage gradient mapping: a comparison to standard techniques.

    PubMed

    Bailin, Steven J; Johnson, William Ben; Jumrussirikul, Pitayadet; Sorentino, Denise; West, Robert

    2013-07-01

    To demonstrate that critical conduction within the cavotricuspid isthmus (CTI) can be directly visualized by voltage gradient mapping and facilitate efficient ablation compared to standard techniques. Group 1 (1 operator, n = 11) ablated based upon contact voltage measurements and voltage gradient mapping. Ablation targeted low-voltage bridges (LVBs) within the CTI. Repeat maps were obtained following ablation. Group 2 (operators 2, 3, and 4 n = 35) utilized electroanatomic navigation and ablated by the creation of linear lesions from the tricuspid valve to the inferior vena cava. Demonstration of bidirectional block (BDB) was required in both groups. LVB were associated with CTI conduction in all Group A patients. LVB ablation terminated flutter, or created BDB. Following ablation, CTI voltage connections were absent in all patients. Compared with Group B, Group A had less radiofrequency (RF) lesions to atrial flutter (AFL) termination (P = 0.001), less total RF lesions (P = 0.0001), and less total RF time (P = 0.001). Group 1 had no recurrent AFL whereas Group 2 had three recurrences. (follow-up median of 231 ± 181 days). (i) Voltage gradient mapping visualized regions of critical CTI conduction, (ii) ablation of LVB terminated AFL and resulted in BDB, (iii) repeat mapping confirmed the absence of trans-isthmus voltage, and (iv) Compared with standard ablation, voltage gradient mapping decreases total RF lesions, lesions to AFL termination, and total RF time. Use of voltage gradient mapping can facilitate successful AFL ablation.

  6. [Surface ECG characteristics of right and left atrial flutter].

    PubMed

    Rostock, Thomas; Konrad, Torsten; Sonnenschein, Sebastian; Mollnau, Hanke; Ocete, Blanca Quesada; Bock, Karsten; Spittler, Raphael; Huber, Carola; Theis, Cathrin

    2015-09-01

    Atrial tachycardia in virtually all areas of both atria has become more important in the clinical management of patients with previous complex atrial fibrillation ablation. Accurate interpretation of surface electrocardiogram (ECG) characteristics is of paramount importance to localize the origin of atrial tachycardia, particularly for planning interventional treatment. This article highlights the ECG features of different types of right and left atrial tachycardia. Typical right atrial flutter through the cavotricuspid isthmus conducts septally in a cranial direction and demonstrates sawtooth-like flutter waves which start negative in II, III and aVF and then show a steep slope upwards to the isoelectric line. The flutter rate typically ranges between 240-250 beats/min. In contrast, right atrial flutter in a clockwise rotation, flutter around the vena cava inferior or superior and around a scar (e.g. after cardiac surgery) show positive or biphasic flutter waves (lower or upper loop reentry). Left atrial flutter waves (e.g. around the mitral valve or around the pulmonary veins) are very heterogeneous and are typically positive in V1 as the left atrium is located in the posterior mediastinum. Specific knowledge of flutter wave morphology in surface ECG facilitates planning and performance of the ablation strategy.

  7. Impact of a 4q25 Genetic Variant in Atrial Flutter and the Risk of Atrial Fibrillation after Cavotricuspid Isthmus Ablation

    PubMed Central

    Aouizerat, Bradley E.; Pullinger, Clive R.; Malloy, Mary J.; Kane, John P.; Olgin, Jeffrey E.; Marcus, Gregory M.

    2013-01-01

    Background The prediction of atrial fibrillation (AF) following catheter ablation of atrial flutter (Afl) would be helpful to facilitate targeted arrhythmia monitoring and anti-coagulation strategies. A single nucleotide polymorphism, rs2200733, is strongly associated with AF. We sought to characterize the association between rs2200733 and prevalent Afl and to determine if the variant could predict AF after cavotricuspid isthmus ablation. Methods and Results We performed a genetic association study of 295 patients with Afl and/or AF and 469 controls using multivariable logistic regression. The variant was then assessed as a predictor of incident AF after cavotricuspid isthmus ablation in 87 consecutive typical Afl patients with Cox proportional hazards models. The rs2200733 rare allele was associated with an adjusted 2.06-fold increased odds of isolated Afl (95% CI: 1.13-3.76, p=0.019) and an adjusted 2.79-fold increased odds of a combined phenotype of AF and Afl (95% CI: 1.81-4.28, p<0.001). Following catheter ablation for Afl, carrier status of rs2200733 failed to predict an increased risk of AF either among all subjects (adjusted HR: 0.94; 95% CI: 0.58-1.53, p=0.806) or among those with isolated Afl (adjusted HR: 1.29; 95% CI: 0.51-3.26, p=0.585). Conclusions Our study demonstrates that Afl, whether occurring in isolation or along with AF, is associated with the rs2200733 AF risk allele. Genetic carrier status of rs2200733 failed to predict an increased risk of incident or recurrent AF following catheter ablation for Afl. These findings suggest that the causal mechanism associated with rs2200733 is germane to both AF and Afl. PMID:24237655

  8. Atrial Tachycardias Following Atrial Fibrillation Ablation

    PubMed Central

    Sághy, László; Tutuianu, Cristina; Szilágyi, Judith

    2015-01-01

    One of the most important proarrhythmic complications after left atrial (LA) ablation is regular atrial tachycardia (AT) or flutter. Those tachycardias that occur after atrial fibrillation (AF) ablation can cause even more severe symptoms than those from the original arrhythmia prior to the index ablation procedure since they are often incessant and associated with rapid ventricular response. Depending on the method and extent of LA ablation and on the electrophysiological properties of underlying LA substrate, the reported incidence of late ATs is variable. To establish the exact mechanism of these tachycardias can be difficult and controversial but correlates with the ablation technique and in the vast majority of cases the mechanism is reentry related to gaps in prior ablation lines. When tachycardias occur, conservative therapy usually is not effective, radiofrequency ablation procedure is mostly successful, but can be challenging, and requires a complex approach. PMID:25308808

  9. Impact of Impaired Renal Function on the Incidence of Atrial Fibrillation following Radiofrequency Ablation of Cavotricuspid Isthmus-Dependent Atrial Flutter

    PubMed Central

    Kwon, Chang Hee; Kim, Min Su; Roh, Jae-Hyung; Choi, Jin Hee; Jo, Uk; Lee, Woo Seok; Kim, Yoo Ri; Nam, Gi-Byoung; Choi, Kee-Joon; Kim, You-Ho

    2015-01-01

    Background and Objectives Atrial fibrillation (AF) occurs frequently after successful radiofrequency ablation (RFA) of cavotricuspid isthmus-dependent atrial flutter (CTI-AFL). Renal impairment has been implicated in the development of AF. The purpose of this study is to clarify the impact of impaired renal function on the incidence of AF after RFA of CTI-AFL. Subjects and Methods Between January 2001 and December 2013, 240 non-dialysis patients with no prior history of AF {mean age 55.9±15.2 years old; male, 192 (80.0%)} who had undergone successful CTI-AFL ablation were included in the present study. The baseline estimated glomerular filtration rate was calculated, and patients were divided into those with impaired renal function (<60 mL/min/1.73 m2) and those with preserved renal function (≥ 60 mL/min/1.73 m2). The incidence of AF was retrospectively analyzed. Results 69 (28.8%) patients experienced new onset AF during a median follow-up duration of 26 months (inter-quartile, 7-53). The incidence of AF was significantly higher in patients with impaired renal function than in those with preserved renal function {13/25 (52.0%) versus 56/215 (26.0%), log rank p=0.019}. Age, CHADS2 score, impaired renal function, and left atrial diameter were significantly associated with the incidence of AF in univariate Cox regression analysis. Multivariate analysis showed that age was the only significant predictor of AF incidence (hazard ratio, 1.024; 95% confidence interval, 1.004-1.044, p=0.020). Conclusion Patients with impaired renal function may require careful attention for the incidence of new onset AF following successful RFA of CTI-AFL. PMID:26617649

  10. Ablation for Atrial Fibrillation

    PubMed Central

    2006-01-01

    AF or atrial flutter. Seven other studies examined patients with drug-refractory, lone AF; and the remaining 7 RCTs compared ablation plus heart surgery to heart surgery alone in patients with drug-refractory AF and concomitant heart conditions. First-line Catheter Ablation for Atrial Fibrillation or Atrial Flutter Both studies concluded that catheter ablation was associated with significantly improved long-term freedom from arrhythmias and quality of life compared with medical therapy. These studies included different patient populations (those with AF in one pilot study, and those with atrial flutter in the other). Catheter ablation as first-line treatment is considered experimental at this time. Catheter Ablation Versus Medical Therapy in Patients With Drug-Refractory, Lone Atrial Fibrillation In this review, catheter ablation had success rates (freedom from arrhythmia) that ranged from 42% to 90% (median, 74%) in patients with drug-refractory, lone AF. All 3 of the RCTs comparing catheter ablation to medical therapy in patients with drug-refractory, lone AF found a significant improvement in terms of freedom from arrhythmia over a minimum of 12 months follow-up (P<.05). Ablation Plus Heart Surgery Versus Heart Surgery Alone in Patients With Atrial Fibrillation It is clear that patients with drug-refractory AF who are undergoing concomitant heart surgery (usually mitral valve repair or replacement) benefit significantly from surgical ablation, in terms of long-term freedom from AF, without substantial additional risk compared to open heart surgery alone. This group of patients represents about 1% of the patients with atrial fibrillation, thus the majority of the burden of AF lies within the patients with lone AF (i.e. those not requiring additional heart surgery). Conclusion Catheter ablation appears to be an effective treatment for patients with drug-refractory AF whose treatment alternatives are limited. Ablation technology is continually evolving with

  11. Two-dimensional echocardiographic features of the inferior right atrial isthmus: the role of vestibular thickness in catheter ablation of atrial flutter.

    PubMed

    Marcos-Alberca, Pedro; Sánchez-Quintana, Damián; Cabrera, José A; Farré, Jerónimo; Rubio, José M; de Agustín, Jose A; Almería, Carlos; Pérez-Isla, Leopoldo; Macaya, Carlos

    2014-01-01

    The aim of this study was to examine the feasibility of transthoracic two-dimensional (2D)-echocardiography in defining the cavo-tricuspid isthmus (CTI) anatomy and its value concerning the ease of catheter ablation of isthmic atrial flutter (AF). CTI analysis was accomplished in 39 cases: 16 necropsy specimens and 23 patients. Sixteen were patients with isthmus-dependent AF and seven controls with other supraventricular re-entrant tachycardias. Two-dimensional transthoracic echocardiography and a right atrium angiogram were performed before radiofrequency catheter ablation (RFCA). The measurements of the CTI with angiography were compared with those taken with echocardiography and correlation was excellent (r= 0.91; P < 0.0001). In normal patients, the dimension of the vestibular thickness was successfully compared and validated with the histological examination of the necropsy specimens: histology median 6.8 mm, range 4.4-10.5 vs. echo median 6.2 mm, range 5.4-8.7; P: NS. Vestibular thickness was greater in complex than in simple RFCA (13.6 ± 1.9 mm vs. 10.0 ± 2.3 mm; P = 0.01). When vestibular thickness ≥11.5 mm, the ablation prone to be complex (sensitivity 83.3%, specificity 80%, positive predictive value 71.4%, and negative predictive value 88.9%). Two-dimensional transthoracic echocardiography clearly depicts the inferior isthmus and, displaying the thickness of the tricuspid vestibule, it was related with complexity of the ablation procedure in isthmus-dependent AF.

  12. The benefit of tissue contact monitoring with an electrical coupling index during ablation of typical atrial flutter--a prospective randomised control trial.

    PubMed

    Jones, Michael A; Webster, David; Wong, Kelvin C K; Hayes, Christopher; Qureshi, Norman; Rajappan, Kim; Bashir, Yaver; Betts, Timothy R

    2014-12-01

    We sought to investigate the use of tissue contact monitoring by means of the electrical coupling index (ECI) in a prospective randomised control trial of patients undergoing cavotricuspid isthmus (CTI) ablation for atrial flutter. Patients with ECG-documented typical flutter undergoing their first CTI ablation were randomised to ECI™-guided or non-ECI™-guided ablation. An irrigated-tip ablation catheter was used in all cases. Consecutive 50-W, 60-s radiofrequency lesions were applied to the CTI, from the tricuspid valve to inferior vena cava, with no catheter movement permitted during radiofrequency (RF) delivery. The ablation endpoint was durable CTI block at 20 min post-ablation. Patients underwent routine clinic follow-up post-operatively. A total of 101 patients (79 male), mean age 66 (+/-11), 50 ECI-guided and 51 control cases were enrolled in the study. CTI block was achieved in all. There were no acute complications. All patients were alive at follow-up. CTI block was achieved in a single pass in 36 ECI-guided and 30 control cases (p = 0.16), and at 20 min post-ablation, re-conduction was seen in 5 and 12 cases, respectively (p = 0.07). There was no significant difference in total procedure time (62.7 ± 33 vs. 62.3 ± 33 min, p = 0.92), RF requirement (580 ± 312 vs. 574 ± 287 s, p = 0.11) or fluoroscopy time (718 ± 577 vs. 721 ± 583 s, p = 0.78). After 6 ± 4 months, recurrence of flutter had occurred in 1 (2 %) ECI vs. 8 (16 %) control cases (OR 0.13, 95 % CI 0.01-1.08, p = 0.06). ECI-guided CTI ablation demonstrated a non-statistically significant reduction in late recurrence of atrial flutter, at no cost to procedural time, radiation exposure or RF requirement.

  13. Atrial fibrillation or flutter

    MedlinePlus

    ... atrial fibrillation include: Alcohol use (especially binge drinking) Coronary artery disease Heart attack or heart bypass surgery Heart failure ... low. An ECG (a test that records the electrical activity of the heart) may show atrial fibrillation ...

  14. Maximum voltage gradient technique for optimization of ablation for typical atrial flutter with zero-fluoroscopy approach.

    PubMed

    Deutsch, Karol; Śledź, Janusz; Mazij, Mariusz; Ludwik, Bartosz; Labus, Michał; Karbarz, Dariusz; Pasicka, Bernadetta; Chrabąszcz, Michał; Śledź, Arkadiusz; Klank-Szafran, Monika; Vitali-Sendoz, Laura; Kameczura, Tomasz; Śpikowski, Jerzy; Stec, Piotr; Ujda, Marek; Stec, Sebastian

    2017-06-01

    Radiofrequency catheter ablation (RFCA) is an established effective method for the treatment of typical cavo-tricuspid isthmus (CTI)-dependent atrial flutter (AFL). The introduction of 3-dimensional electro-anatomic systems enables RFCA without fluoroscopy (No-X-Ray [NXR]). The aim of this study was to evaluate the feasibility and effectiveness of CTI RFCA during implementation of the NXR approach and the maximum voltage-guided (MVG) technique for ablation of AFL.Data were obtained from prospective standardized multicenter ablation registry. Consecutive patients with the first RFCA for CTI-dependent AFL were recruited. Two navigation approaches (NXR and fluoroscopy based as low as reasonable achievable [ALARA]) and 2 mapping and ablation techniques (MVG and pull-back technique [PBT]) were assessed. NXR + MVG (n  =  164; age: 63.7 ± 9.5; 30% women), NXR + PBT (n  =  55; age: 63.9 ± 10.7; 39% women); ALARA + MVG (n  =  36; age: 64.2 ± 9.6; 39% women); and ALARA + PBT (n  =  205; age: 64.7 ± 9.1; 30% women) were compared, respectively. All groups were simplified with a 2-catheter femoral approach using 8-mm gold tip catheters (Osypka AG, Germany or Biotronik, Germany) with 15 min of observation. The MVG technique was performed using step-by-step application by mapping the largest atrial signals within the CTI.Bidirectional block in CTI was achieved in 99% of all patients (P  =  NS, between groups). In NXR + MVG and NXR + PBT groups, the procedure time decreased (45.4 ± 17.6 and 47.2 ± 15.7 min vs. 52.6 ± 23.7 and 59.8 ± 24.0 min, P < .01) as compared to ALARA + MVG and ALARA + PBT subgroups. In NXR + MVG and NXR + PBT groups, 91% and 98% of the procedures were performed with complete elimination of fluoroscopy. The NXR approach was associated with a significant reduction in fluoroscopy exposure (from 0.2 ± 1.1 [NXR + PBT] and 0.3 ± 1.6 [NXR + MVG] to 7.7 ± 6.0 min [ALARA + MVG] and 9

  15. Maximum voltage gradient technique for optimization of ablation for typical atrial flutter with zero-fluoroscopy approach

    PubMed Central

    Deutsch, Karol; Śledź, Janusz; Mazij, Mariusz; Ludwik, Bartosz; Labus, Michał; Karbarz, Dariusz; Pasicka, Bernadetta; Chrabąszcz, Michał; Śledź, Arkadiusz; Klank-Szafran, Monika; Vitali-Sendoz, Laura; Kameczura, Tomasz; Śpikowski, Jerzy; Stec, Piotr; Ujda, Marek; Stec, Sebastian

    2017-01-01

    Abstract Radiofrequency catheter ablation (RFCA) is an established effective method for the treatment of typical cavo-tricuspid isthmus (CTI)-dependent atrial flutter (AFL). The introduction of 3-dimensional electro-anatomic systems enables RFCA without fluoroscopy (No-X-Ray [NXR]). The aim of this study was to evaluate the feasibility and effectiveness of CTI RFCA during implementation of the NXR approach and the maximum voltage-guided (MVG) technique for ablation of AFL. Data were obtained from prospective standardized multicenter ablation registry. Consecutive patients with the first RFCA for CTI-dependent AFL were recruited. Two navigation approaches (NXR and fluoroscopy based as low as reasonable achievable [ALARA]) and 2 mapping and ablation techniques (MVG and pull-back technique [PBT]) were assessed. NXR + MVG (n  =  164; age: 63.7 ± 9.5; 30% women), NXR + PBT (n  =  55; age: 63.9 ± 10.7; 39% women); ALARA + MVG (n  =  36; age: 64.2 ± 9.6; 39% women); and ALARA + PBT (n  =  205; age: 64.7 ± 9.1; 30% women) were compared, respectively. All groups were simplified with a 2-catheter femoral approach using 8-mm gold tip catheters (Osypka AG, Germany or Biotronik, Germany) with 15 min of observation. The MVG technique was performed using step-by-step application by mapping the largest atrial signals within the CTI. Bidirectional block in CTI was achieved in 99% of all patients (P  =  NS, between groups). In NXR + MVG and NXR + PBT groups, the procedure time decreased (45.4 ± 17.6 and 47.2 ± 15.7 min vs. 52.6 ± 23.7 and 59.8 ± 24.0 min, P < .01) as compared to ALARA + MVG and ALARA + PBT subgroups. In NXR + MVG and NXR + PBT groups, 91% and 98% of the procedures were performed with complete elimination of fluoroscopy. The NXR approach was associated with a significant reduction in fluoroscopy exposure (from 0.2 ± 1.1 [NXR + PBT] and 0.3 ± 1.6 [NXR + MVG] to 7.7 ± 6.0 min [ALARA

  16. High Incidence of Low Catheter-Tissue Contact Force at the Cavotricuspid Isthmus During Catheter Ablation of Atrial Flutter: Implications for Achieving Isthmus Block.

    PubMed

    Kumar, Saurabh; Morton, Joseph B; Lee, Geoffrey; Halloran, Karen; Kistler, Peter M; Kalman, Jonathan M

    2015-08-01

    Recurrent atrial flutter following cavotricuspid isthmus (CTI) ablation remains a significant problem. The prevalence of low contact force (CF) during CTI ablation using standard tools is unknown. Our aim was to characterize the prevalence of low CF applications when experienced operators performed CTI ablation using "traditional" markers of contact blinded to CF measurements. Average CF (grams, g) and force-time integral (FTI) was analyzed in 458 lesions in 17 patients undergoing CTI ablation. The isthmus was divided into the annular, mid and caval segments for region-specific analysis. Despite "good" contact using traditional markers, there was significant variability in CF within each isthmus segment (e.g., annular CTI 1-57 g). A high proportion of lesions had a CF <10 g (40%). Lowest CF was the annular (median 9 g), followed by the mid (12 g) and the caval CTI (18 g, P < 0.001). Sites of acute CTI re-connection had a lower average CF and FTI than nonreconnected sites (P < 0.05). Each 1 g increase in CF was associated with a 16% reduction in risk of recovered CTI conduction (95% confidence interval: 4-27%, P = 0.01). Use of surrogate markers of "good contact" during ablation by experienced operators in the absence of real-time CF sensing resulted in nearly half of all lesions being delivered with low CF with marked region-specific variability in CF. Low CF was implicated in longer time to achieve conduction block and increased risk of acute reconnection. These findings underscore the importance of real-time CF measurements for optimizing ablation of typical atrial flutter. © 2015 Wiley Periodicals, Inc.

  17. Three-dimensional electroanatomic entrainment map in atypical atrial flutter late after heart transplantation.

    PubMed

    Roten, Laurent; Tanner, Hildegard; Goy, Jean-Jacques; Delacrétaz, Etienne

    2010-02-01

    Atrial flutter in the donor part of orthotopic heart transplants has been reported and successfully treated by radiofrequency ablation of the cavotricuspid isthmus, but mapping and ablation of atypical flutter circuits may be challenging.(1) Entrainment mapping has been used in combination with activation mapping to define the mechanism of atypical atrial flutter. Here, we report a case where colour-coded three-dimensional (3D) entrainment mapping allowed us to accurately determine and visualize the 3D location of the reentrant circuit and to plan the ablation of a left atrial flutter without the need for activation mapping.

  18. Ablation of typical atrial flutter using a non-fluoroscopic catheter tracking system vs. conventional fluoroscopy--results from a prospective randomized study.

    PubMed

    Schoene, Katharina; Rolf, Sascha; Schloma, Denis; John, Silke; Arya, Arash; Dinov, Borislav; Richter, Sergio; Bollmann, Andreas; Hindricks, Gerhard; Sommer, Philipp

    2015-07-01

    Reduction of radiation exposure using a sensor-based non-fluoroscopic catheter tracking (NFCT) system (MediGuide™, St Jude Medical, Inc.) was recently demonstrated by retrospective comparisons. We aimed to prospectively compare the effects of using NFCT vs. standard fluoroscopy on procedural parameters in patients undergoing radiofrequency ablation of typical atrial flutter. We prospectively randomized 40 patients undergoing cavotricuspid isthmus ablation for typical atrial flutter to either NFCT (n = 20) or conventional fluoroscopy (CONV, n = 20). Procedural parameters such as fluoroscopy time, radiation dose, and procedure duration, as well as periprocedural complications were compared. There were no statistically significant differences in baseline characteristics between the two groups. Bidirectional isthmus block was achieved in all patients. Fluoroscopy time was significantly reduced in the NFCT group {0.3 [inter-quartile range (IQR) 0.2; 0.48] min} when compared with CONV [5.7 (IQR 4.2; 11.5) min] (P < 0.001). This resulted in a significant reduction in radiation dose in patients randomized to NFCT [17.4 (IQR 11; 206.6) cGy cm(2)] vs. the CONV group [418.4 (IQR 277; 812.2) cGy cm(2)] (P < 0.001). There were no significant differences in procedure duration between the NFCT group [49.5 (IQR 37; 65) min] when compared with the CONV group [33.5 (IQR 26.3; 55.5) min] (P = 0.053). No adverse events were recorded. Freedom from atrial flutter at 6 months of follow-up was 19/20 (95%) in the NFCT and 18/20 (90%) in the CONV group (n.s.). In this first prospective randomized study, by comparing NFCT with standard fluoroscopy in patients undergoing radiofrequency ablation of typical atrial flutter, NFCT significantly reduced both radiation dose and fluoroscopy time with no effects on procedural duration. These findings support the incorporation of NFCT in routine clinical use. Published on behalf of the European Society of Cardiology. All rights reserved. © The

  19. Pulmonary Vein Isolation to Reduce Future Risk of Atrial Fibrillation in Patients Undergoing Typical Flutter Ablation: Results from a Randomized Pilot Study (REDUCE AF).

    PubMed

    Mohanty, Sanghamitra; Natale, Andrea; Mohanty, Prasant; DI Biase, Luigi; Trivedi, Chintan; Santangeli, Pasquale; Bai, Rong; Burkhardt, J David; Gallinghouse, G Joseph; Horton, Rodney; Sanchez, Javier E; Hranitzky, Patrick M; Al-Ahmad, Amin; Hao, Steven; Hongo, Richard; Beheiry, Salwa; Pelargonio, Gemma; Forleo, Giovanni; Rossillo, Antonio; Themistoclakis, Sakis; Casella, Michela; Dello Russo, Antonio; Tondo, Claudio; Dixit, Sanjay

    2015-08-01

    This study examined incidence of AF following cavotricuspid isthmus (CTI) ablation alone or CTI plus prophylactic pulmonary vein isolation (PVI) in patients presenting with isolated atrial flutter (AFL) with no history of AF. We enrolled 216 patients with isolated typical atrial flutter and randomized them to CTI alone (group 1, n = 108, 61.2 ± 9.7 year, 75% male) or CTI+PVI ablation (group 2, n = 108, 62.4 ± 9.3 year, 73% male). Insertible loop recorder (ILR) was implanted in 21 and 19 patients from groups 1 and 2, respectively. Remaining patients were monitored with event recorders, ECG, 7-day Holter. Follow-up period was for 18 ± 6 months. Compared to group 1, group 2 had significantly longer procedural duration (75.9 ± 33 min vs. 161 ± 48 min [P < 0.001]) and fluoroscopy time (15.9 ± 12.3 min vs. 56.4+21 min [P < 0.001]). At the end of follow-up, 65 (60.2%) in group 1 and 77 (71.3%) in group 2 were arrhythmia free off-AAD (log-rank P = 0.044). A subgroup analysis was performed with 55 year age cut-off. In the <55 age group the CTI only population had similar success as in CTI+PVI, (21 of 24 [83.3%] vs. 19 of 22 [86.4%], respectively, log-rank P = 0.74). In the ≥55 group, having CTI+PVI showed significantly higher success compared to CTI only; 45 of 84 (53.6%) were AF/AT free in CTI only group versus 58 of 86 (67.4%) with CTI+PVI (log-rank P = 0.029). Prophylactic PVI reduced new-onset AF in patients with lone atrial flutter. © 2015 Wiley Periodicals, Inc.

  20. Atrial flutter in myotonic dystrophy type 1: Patient characteristics and clinical outcome.

    PubMed

    Wahbi, Karim; Sebag, Frederic A; Lellouche, Nicolas; Lazarus, Arnaud; Bécane, Henri-Marc; Bassez, Guillaume; Stojkovic, Tanya; Fayssoil, Abdallah; Laforêt, Pascal; Béhin, Anthony; Meune, Christophe; Eymard, Bruno; Duboc, Denis

    2016-03-01

    The prevalence and the incidence of atrial flutter in patients with myotonic dystrophy type 1 (DM1) and the most appropriate strategies for its management are unknown. We retrospectively included in the DM1 Heart Registry 929 adult patients with DM1 admitted to our Institutions between January 2000 and September 2013. We selected patients presenting with atrial flutter and analysed data relative to the occurrence of arterial thromboembolism, severe bradyarrhythmias and atrial flutter recurrences. Atrial flutter was present in 79 of the 929 patients included in our Registry, representing a 8.5% prevalence. Patients with atrial flutter were older, had a higher muscular disability rating scale score and had higher prevalence of other cardiac manifestations of DM1. Sixty patients presented with a first episode of atrial flutter, representing a 4.6% incidence. Severe bradyarrhythmias requiring permanent pacing were present in 4 patients (6.7%). Over a 53 ± 28 months mean follow-up duration, 2 patients (3.3%) had ischaemic stroke and 12 (20%) had atrial flutter recurrences. Patients who underwent radiofrequency ablation were more frequently free of atrial flutter recurrence than other patients (95 vs. 61%; HR = 0.17; P = 0.04). Atrial flutter is a common manifestation of DM1, potentially complicated by arterial thromboembolism or severe bradyarrhythmias. Radiofrequency catheter ablation is associated with a lower risk for recurrences. Copyright © 2016 Elsevier B.V. All rights reserved.

  1. Atrial flutter: more than just one of a kind.

    PubMed

    Bun, Sok-Sithikun; Latcu, Decebal Gabriel; Marchlinski, Francis; Saoudi, Nadir

    2015-09-14

    Since its first description about one century ago, our understanding of atrial flutter (AFL) circuits has considerably evolved. One AFL circuit can have variable electrocardiographic (ECG) manifestations depending on the presence of pre-existing atrial lesions, or impaired atrial substrate. Conversely, different (right sided or even left sided) atrial circuits including different mechanisms (macroreentrant, microreentrant, or focal) can present with a very similar surface ECG manifestation. The development of efficient high-resolution electroanatomical mapping systems has improved our knowledge about AFL mechanisms, as well as facilitated their curative treatment with radiofrequency catheter ablation. This article will review ECG features for typical and atypical flutters, and emphasize the limitations for circuit location from the surface ECG. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  2. Usefulness of the polarity in high-density wide range-filtered bipolar mapping to detect isthmus block during radiofrequency ablation of typical atrial flutter.

    PubMed

    Okumura, Yasuo; Watanabe, Ichiro; Yamada, Takeshi; Ohkubo, Kimie; Kawauchi, Kazunori; Ashino, Sonoko; Takagi, Yasuhiro; Sugimura, Hidezou; Hashimoto, Kenichi; Shindo, Atsushi; Saito, Satoshi

    2006-03-01

    The atrial activation sequence around the tricuspid annulus (TA) cannot always be used to establish whether complete block has been achieved across the cavotricuspid isthmus (CTI) during radiofrequency ablation (RFCA) for typical counterclockwise atrial flutter (CCW-AFL). We examined whether a change in the polarity of the atrial high-density wide range-filtered bipolar electrograms recorded near the ablation line is an accurate indicator of complete CTI block. Nineteen patients with CCW-AFL underwent RFCA. Electrograms were recorded around the TA with duodecapolar conventional (2mm x 8mm x 2mm spacing) and high-density (2-mm spacing) Halo catheters. The bipolar electrograms on the high-density Halo catheter recorded from a series of adjacent electrode pairs positioned just lateral to the ablation line were filtered at a bandpass setting of 0.05-500 Hz. The activation sequence on the conventional Halo catheter during coronary sinus pacing (CSp) and inferolateral TA pacing, and the bipolar electrograms on the high-density Halo catheter during CSp were determined before and after RFCA. The final complete CTI block was verified by the presence of widely split double electrograms > or =100 msec along the ablation line. The final complete CTI block was achieved in all the 19 patients. Before RFCA, the polarity of bipolar electrograms was predominantly negative during CCW-AFL and positive during CSp. In 18 of the 19 patients, the bipolar electrograms exhibited the CCW activation and a negative polarity during CSp only after complete CTI block. In one of those 18 patients, additional applications of RFCA changed the polarity of bipolar electrograms positive to negative although the conventional Halo electrogram activation sequence suggested complete CTI block during CSp. In seven patients, who had transverse conduction across the crista terminalis during CSp, the conventional Halo electrogram activation sequence suggested an incomplete CTI block. However, in six of those

  3. Isthmus-dependent right atrial flutter as the leading cause of atrial tachycardias after surgical atrial septal defect repair.

    PubMed

    Wasmer, Kristina; Köbe, Julia; Dechering, Dirk G; Bittner, Alex; Mönnig, Gerold; Milberg, Peter; Baumgartner, Helmut; Breithardt, Günter; Eckardt, Lars

    2013-10-03

    The purpose of this study was to evaluate clinical and electrophysiologic characteristics of AT in patients after surgical ASD repair as well as outcome after ablation. Atrial tachycardias (AT) are a common complication after surgical closure of an atrial septal defect (ASD). From a prospective ablation database we analyzed data of patients with a history of ASD repair who presented to our institution for AT ablation. We investigated ECG characteristics and the electrophysiologic mechanism of AT in this collective and analyzed follow-up data. Data of 54 patients (47.3 ± 14.5 years, 35 females) were included. In 30 patients (55.6%) ASD had been closed by direct suture, 24 patients (44.4%) had a patch for ASD repair without significant difference in terms of gender and age at the time of the procedure (p=0.234, p=0.231). In 42 patients (77.8%), electrophysiological studies were performed in AT. All patients had right atrial macro-reentrant AT. The leading mechanism was isthmus-dependent right atrial flutter in 29 patients (69.0%) with clockwise atrial activation in 41%. The mechanism of AT (typical atrial flutter (n=29), atriotomy-dependent flutter (n=7), and double loop flutter (n=5)) did not differ with regard to type of surgery. Only 70.6% of patients with proven isthmus dependent counter-clockwise atrial flutter presented with an ECG morphology typical for this mechanism. However, all clockwise typical atrial flutter patients showed the characteristic positive P-waves in the inferior leads. Of note, 83.3% of clockwise typical flutter ECGs had long isoelectric lines (mean 74.5 ms). Follow-up was complete in 45 of 54 patients. During a mean follow-up of 7.7 ± 3.7 years, 27 patients (60%) remained free of any arrhythmia, two patients had AT recurrence with different mechanisms compared to the first procedure and underwent successful ablation. Five patients (11%) developed atrial fibrillation. Isthmus dependent right atrial flutter is the leading AT mechanism in

  4. Atrial flutter following pulmonary vein isolation: what is the mechanism?

    PubMed

    Yamada, Takumi; Kay, G Neal

    2013-10-01

    A 70-year-old man with atrial flutter (AFL) following pulmonary vein (PV) isolation (PVI) underwent electrophysiologic testing. The AFL exhibited positive P waves in the inferior leads and lead V1. Left atrial activation mapping revealed 2 remote sites with early activation that were located at the antrum of the left superior PV roof and the left inferior PV bottom. A single irrigated radiofrequency ablation targeting the earliest PV activation at the left PV carina eliminated the AFL. This case demonstrated that PV carina tachycardia with multiple conduction gaps and inter-PV conduction after PVI might mimic double focal atrial tachycardias. © 2013 Wiley Periodicals, Inc.

  5. First experience of percutaneous radio-frequency ablation for atrial flutter and atrial fibrillation in a patient with HeartMate II left ventricular assist device.

    PubMed

    Maury, Philippe; Delmas, Clement; Trouillet, Charlotte; Slaughter, Mark S; Lairez, Olivier; Galinier, Michel; Roncalli, Jerome; Bertrand, David; Mathevet, Lydie; Duparc, Alexandre; Salvador, Michelle; Delay, Marc; Dambrin, Camille

    2010-10-01

    We report the first case of percutaneous radio-frequency (RF) ablation procedure in a patient implanted with a HeartMate II left ventricular assist device for refractory heart failure. This procedure was performed for poorly tolerated recurrent atrial arrhythmias. No harmful consequence happened during or after the procedure despite the potential electromagnetic interferences existing between the RF delivery and the functioning of the device.

  6. [Double tachycardia: association of an atrial flutter and a fascicular ventricular tachycardia].

    PubMed

    Monsel, F; El Hraiech, A; Amara, W

    2013-11-01

    Double tachycardia is an uncommon type of tachycardia. We report the case of a 42-year-old patient, admitted in our department for palpitations. Two types of tachycardia, narrow and wide QRS one, have been documented in the moment of palpitations. The electrophysiology study highlights an atrial flutter and a fascicular ventricular tachycardia. The patient had no recurrence of palpitations after atrial flutter ablation and medical treatment by verapamil for his ventricular tachycardia. This is the first published case combining an atrial flutter and a ventricular tachycardia.

  7. Noninvasive pacing study via pacemakers and implantable cardioverter-defibrillators for differentiating right from left atrial flutter.

    PubMed

    Burri, Haran; Zimmermann, Marc; Sunthorn, Henri; Al-Jefairi, Nora; Trentaz, Florence; Stettler, Carine; Gentil-Baron, Pascale; Shah, Dipen

    2015-06-01

    Patients with atrial flutter who are implanted with a pacemaker (PM) or implantable cardioverter-defibrillator (ICD) present with the opportunity to perform a noninvasive pacing study (NIPS) using the right atrial pacing lead to differentiate right from left atrial flutter. The purpose of this study was to study the feasibility and accuracy of NIPS to distinguish right from left atrial flutter. We enrolled consecutive patients scheduled for an electrophysiological study or ablation procedure who were in atrial flutter and who were implanted with a PM or ICD with a functional atrial lead in the right atrial appendage. Flutter tachycardia cycle lengths (TCLs) and postpacing intervals (PPIs) were measured noninvasively via the device during the procedure. A total of 48 (67%) patients were studied. Right atrial flutter was present in 32 patients (of whom 29 had typical cavotricuspid isthmus-dependent flutter) and 16 (33%) patients had left atrial flutter. A PPI-TCL interval of >100 ms was 100% specific and 81% sensitive to identify left atrial flutter, with an overall accuracy of 94% and a c statistic of 0.94 (95% confidence interval 0.87-1.00). A PPI-TCL interval of ≤100 ms had a positive predictive value of 86% for diagnosing typical flutter. NIPS via PMs and ICDs with a PPI-TCL interval of >100 ms can reliably identify left atrial flutter (although we have only validated this cutoff for leads implanted in the right atrial appendage). This simple maneuver may allow planning for left-sided access and may avoid an unnecessary invasive electrophysiological study if left atrial flutter ablation is not to be considered. Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  8. Efficacy of ablation at the anteroseptal line for the treatment of perimitral flutter.

    PubMed

    Abi-Saleh, Bernard; Skouri, Hadi; Cantillon, Daniel J; Fowler, Jeffery; Wazni, Oussama; Tchou, Patrick; Saliba, Walid

    2015-12-01

    Left atrial flutter following atrial fibrillation (AF) ablation is increasingly common and difficult to treat. We evaluated the safety and efficacy of ablation of the anteroseptal line connecting the right superior pulmonary vein (RSPV) to the anteroseptal mitral annulus (MA) for the treatment of perimitral flutter (PMF). We systematically studied patients who were previously treated with AF ablation and who presented to the electrophysiology laboratory with atrial tachyarrhythmias between January 2000 and July 2010. The diagnosis of PMF was confirmed by activation mapping and/or entrainment. After re-isolation of any recovered pulmonary vein, a linear radiofrequency (RF) ablation was performed on the line that connected the RSPV to the anteroseptal MA. In this analysis, we included only patients who were treated with an anteroseptal line for their PMF. Ablation was performed at the anteroseptal line in 27 PMF patients (63±13 years; 9 women) who had undergone prior ablation for paroxysmal (n=3) or persistent (n=24) AF, using electroanatomic activation mapping (70% CARTO, 30% NavX). The anteroseptal ablation line was effective in 22/27 (81.5%) patients in the acute-care setting. Termination of AF to sinus rhythm occurred in 15/22 (68.2%) patients, and 7/22 (31.8%) patients׳ AF converted to another right or left atrial flutter. At the 6-month follow-up, 20% of patients demonstrated recurrent left atrial tachyarrhythmia. Only one patient required repeat ablation, and the remaining patients׳ condition was controlled with antiarrhythmic medications. No major procedural complications or heart block occurred. Ablation at the left atrial anteroseptal line is safe and efficacious for the treatment of PMF. Unlike ablation at the traditional mitral isthmus line, ablation at the left atrial anteroseptal line does not require ablation in the coronary sinus.

  9. QT interval measurement and correction in patients with atrial flutter: a pilot study.

    PubMed

    Jacquemet, V; Cassani González, R; Sturmer, M; Dubé, B; Sharestan, J; Vinet, A; Mahiddine, O; Leblanc, A R; Becker, G; Kus, T; Nadeau, R

    2014-01-01

    Measurement of QT intervals during atrial flutter (AFL) is relevant to monitor the safety of drug delivery. Our aim is to compare QT and QTc intervals in AFL patients before and after catheter ablation in order to validate QT measurement during AFL. 25 patients suffering from AFL underwent catheter ablation; 9 were in sinus rhythm and 16 were in AFL at the time of the procedure. Holter ECGs were continuously recorded before, during and after the procedure. In AFL signals, flutter waves were subtracted using a previously-validated deconvolution-based method. Fridericia's QTc was computed before and after ablation after hysteresis reduction. Comparing QTc values obtained before and after ablation showed that (1) the intervention did not significantly affect QTc, and (2) the QTc during AFL was concordant with the QTc value in sinus rhythm. QTc can be reliably measured in patients with AFL using flutter wave subtraction and hysteresis reduction. Copyright © 2014 Elsevier Inc. All rights reserved.

  10. Atrial fibrillation originating from superior vena cava with atrial flutter-electrocardiogram pattern.

    PubMed

    Huang, Hung-Kai; Chang, Shih-Lin; Lin, Yenn-Jiang; Lo, Li-Wei; Hu, Yu-Feng; Chung, Fa-Po; Huang, Yen-Chang; Lin, Chung-Hsing; Chan, Chao-Shun; Chang, Hung-Yu; Lin, Chin-Yu; Chang, Yao-Ting; Huang, Ching-Hui; Chen, Shih-Ann

    2017-07-01

    Substrate property is related to the genesis and maintenance of atrial fibrillation (AF). The aim of the study was to investigate the impact of substrate property on the electrocardiogram (ECG) in patients with AF originating from the superior vena cava (SVC). Seventy-six patients with AF originating from SVC who underwent catheter ablation were included from 2004 to 2013. Of these patients, 16 had a presentation of atrial flutter (AFL)-pattern ECG during AF (group 1), and 60 patients did not (group 2). There was no significant difference in clinical characteristics between the groups. The percentage of low voltage zone (LVZ) in SVC below the level of pulmonary artery in group 1 was significantly larger than that in group 2. The polarities of the flutter wave in 12-lead ECG were compared with another 26 subjects with reverse typical AFL. The ECG morphology was characterized by negative or biphasic P waves in lead V1 in most of the patients in group 1 (62.5%), which was analogous to that in reverse typical AFL. The negative polarity of flutter waves in aVL might distinguish SVC AF with an AFL-pattern from reverse typical AFL. The ECG characteristics of AF originating from SVC can mimic atypical AFL. LVZ in the SVC may be associated with the presentation of AFL-pattern ECG. © 2017 Wiley Periodicals, Inc.

  11. Frequency and predictors of tachycardia-induced cardiomyopathy in patients with persistent atrial flutter

    PubMed Central

    Pizzale, Stephen; Lemery, Robert; Green, Martin S; Gollob, Michael H; Tang, Anthony SL; Birnie, David H

    2009-01-01

    BACKGROUND There are few data on the frequency and predictors of tachycardia-induced cardiomyopathy (TICM) in patients with persistent atrial flutter. OBJECTIVES To examine the incidence of TICM in patients undergoing ablation for persistent atrial flutter, and to examine predictors for the development of TICM. METHODS AND RESULTS One hundred eleven patients met the inclusion criteria for the present study. Twenty-eight of 111 (25%) patients had cardiomyopathy before ablation. Sixteen of 28 (57%) patients showed significant improvement in their left ventricular (LV) function postablation. LV function improved to normal in 12 of 16 (75%) patients. Nineteen of 28 (68%) cardiomyopathy patients had preablation LV function in the range in which they would be considered for an implantable cardioverter defibrillator for primary prevention of sudden cardiac death. In nine of 19 (47%) patients, the ejection fraction improved such that an implantable cardioverter defibrillator was no longer indicated. In multivariate analysis, average ventricular rate during atrial flutter was the only independent predictor of reversibility of cardiomyopathy (P=0.013). CONCLUSIONS Sixteen of 28 (57%) cardiomyopathy patients with persistent atrial flutter had significantly improved LV function postablation. In 75% of these patients, LV function improved to normal. PMID:19668781

  12. 1:1 atrial-flutter. Prevalence and clinical characteristics.

    PubMed

    Brembilla-Perrot, Béatrice; Laporte, Franck; Sellal, Jean Marc; Schwartz, Jérôme; Olivier, Arnaud; Zinzius, Pierre Yves; Manenti, Vladimir; Beurrier, Daniel; Andronache, Marius; Louis, Pierre; Selton, Olivier; de la Chaise, Arnaud Terrier; De Chillou, Christian

    2013-10-09

    Little is known about the epidemiology of 1:1 atrial flutter (AFL). Our objectives were to determine its prevalence and predisposing conditions. 1037 patients aged 16 to 93 years (mean 64±12) were consecutively referred for AFL ablation. 791 had heart disease (HD). Patients admitted with 1/1 AFL were collected. Patients were followed 3±3 years. 1:1 AFL-related tachycardiomyopathy was found in 85 patients, 59 men (69%) with a mean age of 59±12 years. The prevalence was 8%. They were compared to 952 patients, 741 men (78%, 0.04), with a mean age of 65±12 years (0.002) without 1:1 AFL. Factors favoring 1:1 AFL was the absence of HD (35 vs 23%, 0.006), the history of AF (42 vs 30.5%)(0.025) and the use of class I antiarrhythmic drugs (34 vs 13%)(p<0.0001), while use of amiodarone or beta blockers was less frequent in patients with 1:1 AFL (5, 3.5%) than in patients without 1:1 AFL (25, 15%) (p<0.0001, 0.03). The failure of ablation (9.4 vs 11%), ablation-related complications (2.3 vs 1.4%), risk of subsequent atrial fibrillation (AF) (20 vs 24%), risk of AFL recurrences (19 vs 13%) and risk of cardiac death (5 vs 6%) were similar in patients with and without 1:1 AFL. The prevalence of 1:1 AFL in patients admitted for AFL ablation was 8%. These patients were younger, had less frequent HD, had more frequent history of AF and received more frequently class I antiarrhythmic drugs than patients without 1:1 AFL. Their prognosis was similar to patients without 1:1 AFL. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  13. Response of atrial flutter to overdrive atrial pacing and intravenous disopyramide phosphate, singly and in combination.

    PubMed Central

    Camm, J; Ward, D; Spurrell, R

    1980-01-01

    Ten patients who suffered spontaneous paroxysms of atrial flutter were investigated by electrophysiological techniques. Two had overt Wolff-Parkinson-White syndrome; three Lown-Ganong-Levine syndrome; and one a concealed accessory atrioventricular connection. Atrial flutter was initiated, at study, by right atrial pacing and electrograms from the right atrium and coronary sinus were observed for at least five minutes to ensure stable flutter in both atria. Atrial flutter was terminated by 2.5 s or 5 s bursts of atrial pacing at rates 10, 50, or 100 beats/min faster than the intrinsic flutter rate in only two patients. Atrial flutter, which was reinitiated in two patients, was then treated with intravenous disopyramide phosphate, 2 mg/kg body weight, infused over five minutes. In all 10 patients the atrial rate slowed from a mean of 310 +/- 39 beats/min to 217 +/- 27 beats/min and atrial flutter terminated in one case. Though the mean ventricular rate fell from 161 +/- 52 beats/min to 156 +/- 45 beats/min the atrioventricular conduction ratio fell from 2.17 +/- 0.86 to 1.55 +/- 0.59 and four patients were left with symptomatically significant increases of ventricular rate. In seven of nine patients overdrive atrial pacing, repeated after disopryamide, resulted in the conversion of atrial flutter to sinus rhythm. In this study, overdrive atrial pacing and intravenous disopyramide, singly and in combination, terminated atrial flutter in nine of the 10 patients and it is suggested that this method may provide an effective alternative to direct current cardioversion. PMID:7426181

  14. Organized Atrial Tachycardias after Atrial Fibrillation Ablation

    PubMed Central

    Castrejón-Castrejón, Sergio; Ortega, Marta; Pérez-Silva, Armando; Doiny, David; Estrada, Alejandro; Filgueiras, David; López-Sendón, José L.; Merino, José L.

    2011-01-01

    The efficacy of catheter-based ablation techniques to treat atrial fibrillation is limited not only by recurrences of this arrhythmia but also, and not less importantly, by new-onset organized atrial tachycardias. The incidence of such tachycardias depends on the type and duration of the baseline atrial fibrillation and specially on the ablation technique which was used during the index procedure. It has been repeatedly reported that the more extensive the left atrial surface ablated, the higher the incidence of organized atrial tachycardias. The exact origin of the pathologic substrate of these trachycardias is not fully understood and may result from the interaction between preexistent regions with abnormal electrical properties and the new ones resultant from radiofrequency delivery. From a clinical point of view these atrial tachycardias tend to remit after a variable time but in some cases are responsible for significant symptoms. A precise knowledge of the most frequent types of these arrhythmias, of their mechanisms and components is necessary for a thorough electrophysiologic characterization if a new ablation procedure is required. PMID:21941669

  15. Atrial flutter: from ECG to electroanatomical 3D mapping

    PubMed Central

    PEDRINAZZI, CLAUDIO; DURIN, ORNELLA; MASCIOLI, GIOSUÈ; CURNIS, ANTONIO; RADDINO, RICCARDO; INAMA, GIUSEPPE; DEI CAS, LIVIO

    2006-01-01

    Atrial flutter is a common arrhythmia that may cause significant symptoms, including palpitations, dyspnea, chest pain and even syncope. Frequently it’s possible to diagnose atrial flutter with a 12-lead surface ECG, looking for distinctive waves in leads II, III, aVF, aVL, V1,V2. Puech and Waldo developed the first classification of atrial flutter in the 1970s. These authors divided the arrhythmia into type I and type II. Therefore, in 2001 the European Society of Cardiology and the North American Society of Pacing and Electrophysiology developed a new classification of atrial flutter, based not only on the ECG, but also on the electrophysiological mechanism. New developments in endocardial mapping, including the electroanatomical 3D mapping system, have greatly expanded our understanding of the mechanism of arrhythmias. More recently, Scheinman et al, provided an updated classification and nomenclature. The terms like common, uncommon, typical, reverse typical or atypical flutter are abandoned because they may generate confusion. The authors worked out a new terminology, which differentiates atrial flutter only on the basis of electrophysiological mechanism. PMID:21977266

  16. Atrial flutter and fibrillation in patients with pulmonary hypertension.

    PubMed

    Olsson, Karen M; Nickel, Nils P; Tongers, Jörn; Hoeper, Marius M

    2013-09-01

    Atrial flutter and fibrillation are being increasingly reported in patients with pulmonary hypertension but little is known about their clinical implications. We sought to determine the incidence and clinical impact of these arrhythmias in patients with pulmonary hypertension. In a 5-year, prospective study, we assessed the incidence of new-onset atrial flutter and fibrillation as well as risk factors, clinical consequences, management, and impact on survival in patients with pulmonary arterial hypertension (PAH, n=157) or inoperable chronic thromboembolic pulmonary hypertension (CTEPH, n=82). The cumulative 5-year incidence of new-onset atrial flutter and fibrillation was 25.1% (95% confidence interval, 13.8-35.4%). The development of these arrhythmias was frequently accompanied by clinical worsening (80%) and signs of right heart failure (30%). Stable sinus rhythm was successfully re-established in 21/24 (88%) of patients initially presenting with atrial flutter and in 16/24 (67%) of patients initially presenting with atrial fibrillation. New-onset atrial flutter and fibrillation were an independent risk factor of death (p=0.04, simple Cox regression analysis) with a higher mortality in patients with persistent atrial fibrillation when compared to patients in whom sinus rhythm was restored (estimated survival at 1, 2 and 3 years 64%, 55%, and 27% versus 97%, 80%, and 57%, respectively; p=0.01, log rank analysis). Atrial flutter and fibrillation develop in a sizable number of patients with PAH or inoperable CTEPH and often lead to clinical deterioration and right heart failure. Mortality is high when sinus rhythm cannot be restored. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  17. Left Atrial Ablation for Atrial Fibrillation

    PubMed Central

    Sternik, Leonid; Schaff, Hartzel V.; Luria, David; Glikson, Michael; Kogan, Alexander; Malachy, Ateret; First, Maya; Raanani, Ehud

    2011-01-01

    The maze procedure is the gold standard for the ablation of atrial fibrillation, and the “box lesion” around the pulmonary veins is the most important part of this procedure. We have created this lesion with a bipolar radiofrequency ablator, abandoning the usual use of this device (to achieve bilateral epicardial isolation of the pulmonary veins). From March 2004 through the end of May 2010, we performed surgical ablation of atrial fibrillation in 240 patients. Of this number, 205 underwent operation by a hybrid maze technique and the remaining 35 (our study cohort) underwent the creation of a box lesion around the pulmonary veins by means of a bipolar radiofrequency device. Ablation lines were created by connecting the left atriotomy to the amputated left atrial appendage, with 2 ablation lines made with a bipolar radiofrequency device above and below the pulmonary veins. Lesions were made along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar device. The left atrial isthmus was ablated by bipolar radiofrequency and cryoprobe. No complications were associated with the box lesion: 90% and 89% of patients were in sinus rhythm at 3 and 6 months of follow-up, respectively. By creating a box lesion around the pulmonary veins, we expect to improve transmurality by means of epicardial and endocardial ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. Isolation of the entire posterior wall of the left atrium is better electrophysiologically and renders dissection around the pulmonary veins unnecessary. PMID:21494518

  18. Electrical cardioversion for atrial fibrillation and flutter.

    PubMed

    Mead, G E; Elder, A T; Flapan, A D; Kelman, A

    2005-07-20

    Atrial fibrillation increases stroke risk and adversely affects cardiovascular haemodynamics. Electrical cardioversion may, by restoring sinus rhythm, improve cardiovascular haemodynamics, reduce the risk of stroke, and obviate the need for long-term anticoagulation. To assess the effects of electrical cardioversion of atrial fibrillation or flutter on the risk of thromboembolic events, strokes and mortality (primary outcomes), the rate of cognitive decline, quality of life, the use of anticoagulants and the risk of re-hospitalisation (secondary outcomes) in adults (>18 years). We searched the Cochrane CENTRAL Register of Controlled Trials (1967 to May 2004), MEDLINE (1966 to May 2004), Embase (1980 to May 2004), CINAHL (1982 to May 2004), proceedings of the American College of Cardiology (published in Journal of the American College of Cardiology 1983 to 2003), www.trialscentral.org, www.controlled-trials.com and reference lists of articles. We hand-searched the indexes of the Proceedings of the British Cardiac Society published in British Heart Journal (1980 to 1995) and in Heart (1995 to 2002); proceedings of the European Congress of Cardiology and meetings of the Joint Working Groups of the European Society of Cardiology (published in European Heart Journal 1983-2003); scientific sessions of the American Heart Association (published in Circulation 1990-2003). Personal contact was made with experts. Randomised controlled trial or controlled clinical trials of electrical cardioversion plus 'usual care' versus 'usual care' only, where 'usual care' included any combination of anticoagulants, antiplatelet drugs and drugs for 'rate control'. We excluded trials which used pharmacological cardioversion as the first intervention, and trials of new onset atrial fibrillation after cardiac surgery. There were no language restrictions. For dichotomous data, odds ratios were calculated; and for continuous data, the weighted mean difference was calculated. We found three

  19. Foetal atrial flutter management—the role of electrical cardioversion

    PubMed Central

    Al-Naami, Ghassan

    2012-01-01

    We report a successful electrical cardioversion of a foetal atrial flutter (AFL) immediately post delivery. We describe the diagnostic tools, assessment and the management antenatally. Then, we review the literature and discuss the debate about management. We stress the point that if the flutter wave is not progressing, the foetal heart will tolerate till term and we can try electrical cardioversion with confidence after delivery. PMID:22572503

  20. Assessing the atrial electromechanical coupling during atrial focal tachycardia, flutter, and fibrillation using electromechanical wave imaging in humans.

    PubMed

    Provost, Jean; Costet, Alexandre; Wan, Elaine; Gambhir, Alok; Whang, William; Garan, Hasan; Konofagou, Elisa E

    2015-10-01

    Minimally-invasive treatments of cardiac arrhythmias such as radio-frequency ablation are gradually gaining importance in clinical practice but still lack a noninvasive imaging modality which provides insight into the source or focus of an arrhythmia. Cardiac deformations imaged at high temporal and spatial resolution can be used to elucidate the electrical activation sequence in normal and paced human subjects non-invasively and could potentially aid to better plan and monitor ablation-based arrhythmia treatments. In this study, a novel ultrasound-based method is presented that can be used to quantitatively characterize focal and reentrant arrhythmias. Spatio-temporal maps of the full-view of the atrial and ventricular mechanics were obtained in a single heartbeat, revealing with otherwise unobtainable detail the electromechanical patterns of atrial flutter, fibrillation, and tachycardia in humans. During focal arrhythmias such as premature ventricular complex and focal atrial tachycardia, the previously developed electromechanical wave imaging methodology is hereby shown capable of identifying the location of the focal zone and the subsequent propagation of cardiac activation. During reentrant arrhythmias such as atrial flutter and fibrillation, Fourier analysis of the strains revealed highly correlated mechanical and electrical cycle lengths and propagation patterns. High frame rate ultrasound imaging of the heart can be used non-invasively and in real time, to characterize the lesser-known mechanical aspects of atrial and ventricular arrhythmias, also potentially assisting treatment planning for intraoperative and longitudinal monitoring of arrhythmias. Copyright © 2015 Elsevier Ltd. All rights reserved.

  1. Surgical Ablation of Atrial Fibrillation.

    PubMed

    Ramlawi, Basel; Abu Saleh, Walid K

    2015-01-01

    The Cox-maze procedure for the restoration of normal sinus rhythm, initially developed by Dr. James Cox, underwent several iterations over the years. The main concept consists of creating a series of transmural lesions in the right and left atria that disrupt re-entrant circuits responsible for propagating the abnormal atrial fibrillation rhythm. The left atrial appendage is excluded as a component of the Maze procedure. For the first three iterations of the Cox- maze procedure, these lesions were performed using a surgical cut-and-sew approach that ensured transmurality. The Cox-Maze IV is the most currently accepted iteration. It achieves the same lesion set of the Cox- maze III but uses alternative energy sources to create the transmural lesions, potentially in a minimally invasive approach on the beating heart. High-frequency ultrasound, microwave, and laser energy have all been used with varying success in the past. Today, bipolar radiofrequency heat or cryotherapy cooling are the most accepted sources for creating linear lesions with consistent safety and transmurality. The robust and reliable nature of these energy delivery methods has yielded a success rate reaching 90% freedom from atrial fibrillation at 12 months. Such approaches offer a significant long-term advantage over catheter-based ablation, especially in patients having longstanding, persistent atrial fibrillation with characteristics such as dilated left atrial dimensions, poor ejection fraction, and failed catheter ablation. Based on these improved results, there currently is significant interest in developing a hybrid ablation strategy that incorporates the superior transmural robust lesions of surgical ablation, the reliable stroke prevention potential of epicardial left atrial appendage exclusion, and sophisticated mapping and confirmatory catheter-based ablation technology. Such a minimally invasive hybrid strategy for ablation may lead to the development of multidisciplinary "Afib teams" to

  2. Survival after extreme left atrial hypertension and pulmonary hemorrhage in an infant supported with extracorporeal membrane oxygenation for refractory atrial flutter.

    PubMed

    Cisco, Michael J; Asija, Ritu; Dubin, Anne M; Perry, Stanton B; Hanley, Frank L; Roth, Stephen J

    2011-05-01

    We report here the survival of an infant who developed extreme left atrial hypertension and severe pulmonary hemorrhage while supported with extracorporeal membrane oxygenation for refractory atrial flutter. The patient recovered after decompression of the left heart and catheter ablation of the atrioventricular node. Lucile Packard Children's Hospital (Stanford, CA). Chart review. Recovery of lung function is possible despite systemic-level left atrial pressure resulting in pulmonary hemorrhage and complete solidification of lung parenchyma on gross inspection. Resolution of pulmonary hemorrhage despite anticoagulation while on extracorporeal membrane oxygenation can occur after relief of left atrial hypertension.

  3. Critical phase transitions during ablation of atrial fibrillation

    NASA Astrophysics Data System (ADS)

    Iravanian, Shahriar; Langberg, Jonathan J.

    2017-09-01

    Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia with significant morbidity and mortality. Pharmacological agents are not very effective in the management of AF. Therefore, ablation procedures have become the mainstay of AF management. The irregular and seemingly chaotic atrial activity in AF is caused by one or more meandering spiral waves. Previously, we have shown the presence of sudden rhythm organization during ablation of persistent AF. We hypothesize that the observed transitions from a disorganized to an organized rhythm is a critical phase transition. Here, we explore this hypothesis by simulating ablation in an anatomically-correct 3D AF model. In 722 out of 2160 simulated ablation, at least one sudden transition from AF to an organized rhythm (flutter) was noted (33%). They were marked by a sudden decrease in the cycle length entropy and increase in the mean cycle length. At the same time, the number of reentrant wavelets decreased from 2.99 ± 0.06 in AF to 1.76 ± 0.05 during flutter, and the correlation length scale increased from 13.3 ± 1.0 mm to 196.5 ± 86.6 mm (both P < 0.0001). These findings are consistent with the hypothesis that transitions from AF to an anatomical flutter behave as phase transitions in complex non-equilibrium dynamical systems with flutter acting as an absorbing state. Clinically, the facilitation of phase transition should be considered a novel mechanism of ablation and may help to design effective ablation strategies.

  4. Myocardial injury during radiofrequency and cryoablation of typical atrial flutter.

    PubMed

    Saygi, Serkan; Drca, Nikola; Insulander, Per; Schwieler, Jonas; Jensen-Urstad, Mats; Bastani, Hamid

    2016-08-01

    Cardiac enzyme elevation after radiofrequency (RF) catheter ablation of atrial flutter (AFL) is common. Some studies found that cryoablation (CRYO) of AFL, compared to RF, is associated with higher levels of troponin, a finding that may indicate CRYO causes a greater amount of myocardial injury than RF. However, other investigations found no significant differences between troponin levels after CRYO versus RF. We have in a randomized study compared the post-procedural troponin I levels in RF and CRYO and the possible relation to procedural outcome and complications. We randomized 153 patients with cavotricuspid isthmus (CTI)-dependent AFL to CRYO or RF (78 CRYO; 75 RF). RF was performed with a 3.5-mm open-irrigated-tip catheter, and CRYO was performed with an 8-mm-tip catheter. Troponin I levels were measured before and 6 h after ablation. Acute procedural success was achieved in 71/75 patients in the RF and in 72/78 patients in the CRYO. Troponin I levels were significantly elevated in both groups (baseline 0.012, 6th hour 0.35 ng/ml; p < 0.001). Troponin I levels were similar for RF and CRYO. Troponin I levels were higher in patients with acute failure compared to patients with acute success (0.48 ± 0.4 and 0.34 ± 0.16 ng/ml, p = 0.029); however, there was no difference between patients with or without late recurrence. There were no major complications in any group. RF and CRYO for CTI-dependent AFL resulted in similar amounts of procedural myocardial injury. Troponin I levels had no prognostic value for late recurrence of AFL and there were no complications related to high troponin I levels.

  5. [Antithrombotic therapy in patients with atrial flutter before planned cardioversion].

    PubMed

    М'якінькова, Людмила О; Тесленко, Юрій В; Пустовойт, Ганна Л; Ярмола, Тетяна І; Циганенко, Ірина В

    atrium flutter and fibrillation are the heart rhythm disorders that increase the risk of life-dangerous complications, e.g. cardioembolic stroke, pulmonary embolism. Recommendations for managing patients with atrial fibrillation - atrial flutter, with paroxysm duration over 48 hours, demand anticoagulant therapy. Oral anticoagulants, which are the antagonists of K vitamin (Varpharin) and the new oral anticoagulants (Rivaroxaban), are used during the per-manipulative procedure of patients with atrial flutter before restoring the sinus rhythm with transesophageal cardiac pacing. the present investigation aims to compare efficiency and safety of Varpharin and Rivaaroxaban in treatment patients with atrial flutter before planned cardioversion with transesophageal heart pacing. Varpharin (control group) - in doses equivalent for reaching the target МНВ - or Rivaroxaban (research group), 20 mg., were prescribed to 42 patients with coronary heart disease, concomitant arterial hypertension, and non-valvular paroxysm of atrial flutter with more than 48-hour duration, divided into two groups. There was held the general clinical, echocardioscopy examination. Thrombotic Risk Factor Assessment was made according to the CHA2DS2-VASc scale, Hemorrhagic Risk Factor Assessment was performed according to the HAS-BLED scale, and clinical symptoms assessment was made according to the EHRA scale. The heart rhythm was restored with the transesophageal heart pacing. the per-manipulative procedure of the patients of research group (21 days were suggested according to the guidelines) shortened, unlike the patients of control group (the period of target МНВ selection had made 30,76±0,62days), the reduction of the symptoms severity by EHRA was considered in dynamics. According to the results of transesophageal heart pacing, the heart rhythm of 15 research group patients restored, and 6 research group patients had atrial fibrillation. Among the patients of the control group, 6 had

  6. Prevalence and electrophysiological characteristics of typical atrial flutter in patients with atrial fibrillation and chronic obstructive pulmonary disease.

    PubMed

    Hayashi, Takekuni; Fukamizu, Seiji; Hojo, Rintaro; Komiyama, Kota; Tanabe, Yasuhiro; Tejima, Tamotsu; Nishizaki, Mitsuhiro; Hiraoka, Masayasu; Ako, Junya; Momomura, Shin-Ichi; Sakurada, Harumizu

    2013-12-01

    Chronic obstructive pulmonary disease (COPD) is one of the important underlying diseases of atrial fibrillation (AF). However, the prevalence and electrophysiological characteristics of typical atrial flutter (AFL) in patients with AF and COPD remain unknown. The purpose of the present study was to investigate those characteristics. We investigated 181 consecutive patients who underwent catheter ablation of AF. Twenty-eight patients were diagnosed with COPD according to the Global Initiatives for Chronic Obstructive Lung Disease (GOLD) criteria. Forty patients with no lung disease served as a control group. We analysed the electrophysiological characteristics in these groups. Typical AFL was more common in the COPD group (19/28, 68%) than in the non-COPD group (13/40, 33%; P = 0.006). The prevalence of AFL increased with the severity of COPD: 4 (50%) of 8 patients with GOLD1, 13 (72%) of 18 patients with GOLD2, and 2 (100%) of 2 patients with GOLD3. Atrial flutter cycle length and conduction time from the coronary sinus (CS) ostium to the low lateral right atrium (RA) during CS ostium pacing before and after the cavotricuspid isthmus ablation were significantly longer in the COPD group than in the non-COPD group (285 vs. 236, 71 vs. 53, 164 vs. 134 ms; P = 0.009, 0.03, 0.002, respectively). In COPD patients with AF, conduction time of RA was prolonged and typical AFL was commonly observed.

  7. Noninvasive Imaging of Human Atrial Activation during Atrial Flutter and Normal Rhythm from Body Surface Potential Maps.

    PubMed

    Zhou, Zhaoye; Jin, Qi; Yu, Long; Wu, Liqun; He, Bin

    2016-01-01

    Knowledge of atrial electrophysiological properties is crucial for clinical intervention of atrial arrhythmias and the investigation of the underlying mechanism. This study aims to evaluate the feasibility of a novel noninvasive cardiac electrical imaging technique in imaging bi-atrial activation sequences from body surface potential maps (BSPMs). The study includes 7 subjects, with 3 atrial flutter patients, and 4 healthy subjects with normal atrial activations. The subject-specific heart-torso geometries were obtained from MRI/CT images. The equivalent current densities were reconstructed from 208-channel BSPMs by solving the inverse problem using individual heart-torso geometry models. The activation times were estimated from the time instant corresponding to the highest peak in the time course of the equivalent current densities. To evaluate the performance, a total of 32 cycles of atrial flutter were analyzed. The imaged activation maps obtained from single beats were compared with the average maps and the activation maps measured from CARTO, by using correlation coefficient (CC) and relative error (RE). The cardiac electrical imaging technique is capable of imaging both focal and reentrant activations. The imaged activation maps for normal atrial activations are consistent with findings from isolated human hearts. Activation maps for isthmus-dependent counterclockwise reentry were reconstructed on three patients with typical atrial flutter. The method was capable of imaging macro counterclockwise reentrant loop in the right atrium and showed inter-atria electrical conduction through coronary sinus. The imaged activation sequences obtained from single beats showed good correlation with both the average activation maps (CC = 0.91±0.03, RE = 0.29±0.05) and the clinical endocardial findings using CARTO (CC = 0.70±0.04, RE = 0.42±0.05). The noninvasive cardiac electrical imaging technique is able to reconstruct complex atrial reentrant activations and focal

  8. Noninvasive Imaging of Human Atrial Activation during Atrial Flutter and Normal Rhythm from Body Surface Potential Maps

    PubMed Central

    Zhou, Zhaoye; Jin, Qi; Yu, Long; Wu, Liqun; He, Bin

    2016-01-01

    Background Knowledge of atrial electrophysiological properties is crucial for clinical intervention of atrial arrhythmias and the investigation of the underlying mechanism. This study aims to evaluate the feasibility of a novel noninvasive cardiac electrical imaging technique in imaging bi-atrial activation sequences from body surface potential maps (BSPMs). Methods The study includes 7 subjects, with 3 atrial flutter patients, and 4 healthy subjects with normal atrial activations. The subject-specific heart-torso geometries were obtained from MRI/CT images. The equivalent current densities were reconstructed from 208-channel BSPMs by solving the inverse problem using individual heart-torso geometry models. The activation times were estimated from the time instant corresponding to the highest peak in the time course of the equivalent current densities. To evaluate the performance, a total of 32 cycles of atrial flutter were analyzed. The imaged activation maps obtained from single beats were compared with the average maps and the activation maps measured from CARTO, by using correlation coefficient (CC) and relative error (RE). Results The cardiac electrical imaging technique is capable of imaging both focal and reentrant activations. The imaged activation maps for normal atrial activations are consistent with findings from isolated human hearts. Activation maps for isthmus-dependent counterclockwise reentry were reconstructed on three patients with typical atrial flutter. The method was capable of imaging macro counterclockwise reentrant loop in the right atrium and showed inter-atria electrical conduction through coronary sinus. The imaged activation sequences obtained from single beats showed good correlation with both the average activation maps (CC = 0.91±0.03, RE = 0.29±0.05) and the clinical endocardial findings using CARTO (CC = 0.70±0.04, RE = 0.42±0.05). Conclusions The noninvasive cardiac electrical imaging technique is able to reconstruct complex

  9. The influence of cavotricuspid isthmus length on total radiofrequency energy to cure right atrial flutter.

    PubMed

    Schernthaner, Christiana; Haidinger, Bettina; Brandt, Mathias Christoph; Kraus, Johannes; Danmayr, Franz; Hoppe, Uta C; Strohmer, Bernhard

    2016-01-01

    The complexity and success rate of right atrial flutter ablation is highly dependent on anatomical structures. The study comprised 35 consecutive patients (33-77 years old; 30 men) who underwent ablation of typical atrial flutter. The linear ablation line was measured offline as a surrogate for the cavotricuspid isthmus (CTI) length with the help of a three-dimensional mapping and navigation system (Ensite™). Biophysical parameters, such as total radiofrequency (RF) energy and time of the ablation procedure, were analysed to test the hypothesis that any of these variables show a correlation with the length of the ablation line. Bidirectional isthmus block was achieved in all cases. The isthmus length had a mean value of 32 ± 12 mm with a range of 14-57 mm. The linear regression between the CTI length and the total RF energy was not significant. There was no significant difference in energy (32.281 ± 25.587 vs. 37.136 ± 24.250 W-s, p = NS) or in the total ablation time (759 ± 646 vs. 802 ± 533 s, p = NS) between the group with short (< 29 mm; n = 17) vs. long CTI (≥ 29 mm, n = 18). When comparing different ablation technologies, total RF energy delivered with 8-mm catheter technology (group I) was significantly lower than in patients with cross over from 8-mm to cooled ablation technology (group III) (29.615 ± 12.331 vs. 62.674 ± 28.735 W-s, p = 0.01). The same was true for the comparison between cooled ablation technology (group II) and group III (19.879 ± 13.669 vs. 62.674 ± 28.735 W-s, p = 0.002). The length of the CTI as measured with help of a three-dimensional mapping system may reflect only a weak indicator for the complexity of flutter ablation procedures. The thickness of musculature and specific anatomy of the CTI seem to be the main challenges in performing a linear ablation to achieve bidirectional block.

  10. Atrial flutter after surgical maze: incidence, diagnosis, and management.

    PubMed

    Dresen, William; Mason, Pamela K

    2016-01-01

    The prevalence of atrial fibrillation is increasing and surgical ablation is becoming more common, both as a stand-alone procedure and when performed concomitantly with other cardiac surgery. Although surgical ablation is effective, with it unique challenges arise, including iatrogenic macroreentrant tachycardias that are often highly symptomatic and difficult to manage conservatively. Postsurgical ablation, localization of the arrhythmic circuit is difficult to determine using surface ECG alone because of alterations in the atrial myocardium, and multiple different pathways are often present. Most, however, localize to the left atrium, and percutaneous catheter ablation is emerging as an effective treatment modality. Patients with complex postoperative arrhythmias should be referred to a dedicated atrial fibrillation center when possible and symptomatic arrhythmias mapped and ablated. Knowledge of the previously performed surgical lesion set is of vital importance in understanding the mechanism of the arrhythmia and increasing procedural success rates. http://links.lww.com/HCO/A31.

  11. Effect of Substrate Modification in Catheter Ablation of Paroxysmal Atrial Fibrillation

    PubMed Central

    Nam, Gi-Byoung; Jin, Eun-Sun; Choi, HyungOh; Song, Hae-Geun; Kim, Sung-Hwan; Kim, Ki-Hun; Hwang, Eui-Seock; Park, Kyoung-Min; Kim, Jun; Rhee, Kyoung-Suk; Choi, Kee-Joon; Kim, You-Ho

    2012-01-01

    Catheter ablation of atrial fibrillation that targets complex fractionated electrogram sites has been widely applied in the management of persistent atrial fibrillation. The clinical outcomes of pulmonary vein isolation alone and pulmonary vein isolation plus the use of complex fractionated electrogram-guided ablation (CFEA) have not been fully compared in patients with paroxysmal atrial fibrillation. This prospective study included 70 patients with symptomatic paroxysmal atrial fibrillation that remained inducible after pulmonary vein isolation. For radio-frequency catheter ablation, patients were nonrandomly assigned to a control group (pulmonary vein isolation alone, Group 1, n=35) or a CFEA group (pulmonary vein isolation plus additional CFEA, Group 2, n=35). The times to first recurrence of atrial tachyarrhythmias were compared between the 2 groups. In Group 2, CFEA rendered atrial fibrillation noninducible in 16 patients (45.7%) and converted inducible atrial fibrillation into inducible atrial flutters in 12 patients (34.3%). Atrial fibrillation remained inducible in 7 patients (20%) after the combined ablation procedures. After a mean follow-up of 23 months, freedom from recurrence of atrial tachyarrhythmias was significantly higher in Group 2 than in Group 1 (P=0.037). In Group 1, all of the recurrent tachyarrhythmias were atrial fibrillation, whereas regular tachycardia was the major mechanism of recurrent arrhythmias in Group 2 (atrial tachycardia or atrial flutter in 5 of 6 patients and atrial fibrillation in 1 patient). We found that CFEA after pulmonary vein isolation significantly reduced recurrent atrial tachyarrhythmia and might modify the pattern of arrhythmia recurrence in patients with paroxysmal atrial fibrillation. PMID:22719147

  12. Radiofrequency ablation of atrial tachyarrhythmias in adults with tetralogy of Fallot - predictors of success and outcome.

    PubMed

    Ezzat, Vivienne A; Ryan, Matthew J; O'Leary, Justin; Ariti, Cono; Deanfield, John; Pandya, Bejal; Cullen, Shay; Walker, Fiona; Khan, Fakhar; Abrams, Dominic J; Lambiase, Pier D; Lowe, Martin D

    2017-03-01

    Adults with tetralogy of Fallot experience atrial tachyarrhythmias; however, there are a few data on the outcomes of radiofrequency ablation. We examined the characteristics, outcome, and predictors of recurrence of atrial tachyarrhythmias after radiofrequency ablation in tetralogy of Fallot patients. Methods/results Retrospective data were collected from 2004 to 2013. In total, 56 ablations were performed on 37 patients. We identified two matched controls per case: patients with tetralogy of Fallot but no radiofrequency ablation and not known to have atrial tachyarrhythmias. Acute success was 98%. Left atrial arrhythmias increased in frequency over time. The mean follow-up was 41 months; 78% were arrhythmia-free. Number of cardiac surgeries, age, and presence of atrial fibrillation were predictors of recurrence. Lone cavo-tricuspid isthmus-dependent flutter reduced the likelihood of atrial fibrillation. Right and left atria in patients with tetralogy of Fallot were larger in ablated cases than controls. NYHA class was worse in cases and improved after ablation; baseline status predicted death. Of matched non-ablated controls, a number of them had atrial fibrillation. These patients were excluded from the case-control study but analysed separately. Most of them had died during follow-up, whereas of the matched ablated cases all were alive and the majority in sinus rhythm. Patients with tetralogy of Fallot and atrial tachyarrhythmias have more dilated atria than those without atrial tachyarrhythmias. Radiofrequency ablation improves functional status. Left atrial ablation is more commonly required with repeat procedures. There is a high prevalence of atrial tachyarrhythmias, particularly atrial fibrillation, in patients with tetralogy of Fallot; early radiofrequency ablation may have a protective effect against this.

  13. Ablation of perimitral flutter: acute and long-term success of the modified anterior line.

    PubMed

    Ammar, Sonia; Luik, Armin; Hessling, Gabriele; Bruhm, Alexandra; Reents, Tilko; Semmler, Verena; Buiatti, Alessandra; Kathan, Susanne; Hofmann, Monika; Kolb, Christof; Schmitt, Claus; Deisenhofer, Isabel

    2015-03-01

    The modified anterior line (MAL) is an alternative to the mitral isthmus (MI) line for the treatment of perimitral atrial flutter (PMFL). We sought to investigate acute and long-term efficacy of this line if routinely used for PMFL. The cohort included 77 consecutive patients who underwent catheter ablation of PMFL. The anterior line was deployed between the anterolateral mitral annulus and the ostium of the left superior pulmonary vein. Perimitral atrial flutter was either the presenting arrhythmia after persistent atrial fibrillation (AF) ablation (Group 1, n = 42, 54.5%), occurring during AF ablation (Group 2, n = 25, 35%) or presenting as primary arrhythmia (Group 3, n = 8, 10%). Acute success was defined as PMFL termination during MAL deployment with demonstration of bidirectional line block. Acute success was achieved in 68 of 77 patients (88%) without difference between the three groups. In five patients an additional MI line was necessary to terminate PMFL and in four patients both lines failed to achieve termination. During follow-up (16 ± 7 months), 38 of 77 (49%) patients underwent a repeat procedure for a recurrent arrhythmia. During reablation, 13 of 38 (34%) patients were identified to have a PMFL recurrence. Persistent MAL block was demonstrated in 22 of 38 (58%) patients during the repeat ablation. The MAL is effective for acute and long-term treatment of PMFL. Maintenance of bidirectional MAL block was shown in 58% of patients during a repeat ablation. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  14. Effect of years of endurance exercise on risk of atrial fibrillation and atrial flutter.

    PubMed

    Myrstad, Marius; Nystad, Wenche; Graff-Iversen, Sidsel; Thelle, Dag S; Stigum, Hein; Aarønæs, Marit; Ranhoff, Anette H

    2014-10-15

    Emerging evidence suggests that endurance exercise increases the risk for atrial fibrillation (AF) in men, but few studies have investigated the dose-response relation between exercise and risk for atrial arrhythmias. Both exposure to exercise and reference points vary among studies, and previous studies have not differentiated between AF and atrial flutter. The aim of this study was to assess the risk for atrial arrhythmias by cumulative years of regular endurance exercise in men. To cover the range from physical inactivity to long-term endurance exercise, the study sample in this retrospective cohort study was based on 2 distinct cohorts: male participants in a long-distance cross-country ski race and men from the general population, in total 3,545 men aged ≥ 53 years. Arrhythmia diagnoses were validated by electrocardiograms during review of medical records. Regular endurance exercise was self-reported by questionnaire. A broad range of confounding factors was available for adjustment. The adjusted odds ratios per 10 years of regular endurance exercise were 1.16 (95% confidence interval 1.06 to 1.29) for AF and 1.42 (95% confidence interval 1.20 to 1.69) for atrial flutter. In stratified analyses, the associations were significant in cross-country skiers and in men from the general population. In conclusion, cumulative years of regular endurance exercise were associated with a gradually increased risk for AF and atrial flutter. Copyright © 2014 Elsevier Inc. All rights reserved.

  15. Transthoracic epicardial ablation of mitral isthmus for treatment of recurrent perimitral flutter.

    PubMed

    Berruezo, Antonio; Bisbal, Felipe; Fernández-Armenta, Juan; Calvo, Naiara; Cabrera, José Ángel; Sanchez-Quintana, Damián; Andreu, David; de Caralt, Teresa M; Brugada, Josep; Mont, Lluís

    2014-01-01

    Perimitral flutter (PMF) is a common form of left atrial tachycardia after atrial fibrillation (AF) ablation. The mitral isthmus (MI) is the standard ablation target. However, in some cases bidirectional block cannot be achieved. The purpose of this study was to describe the first experience using a transthoracic epicardial (TTE) approach to treat recurrent PMF after prior unsuccessful ablation. This is a case series of four patients with recurrence of highly symptomatic drug-refractory PMF (all male, median age 55 years, 3/4 hypertensive, 2/4 persistent AF, median AF period 24 months). Three patients presented with PMF-related tachymyocardiopathy. TTE ablation of MI was performed after a median of two prior endocardial MI and coronary sinus ablation attempts, using an open-tip 3.5-mm irrigated catheter (40 W, 45ºC). Persistent bidirectional block was assessed by activation mapping and differential pacing and was achieved in all patients. No PMF recurrence was observed after median follow-up of 18 months (range 15-22 months; two patients without antiarrhythmic drugs and two with previously ineffective amiodarone). Left ventricular function normalized in all three patients with tachycardiomyopathy. There were no complications related to TTE approach. The present study is the first to report the feasibility of a TTE approach for highly symptomatic PMF refractory to endocardial and coronary sinus MI ablation. © 2013 Heart Rhythm Society Published by Heart Rhythm Society All rights reserved.

  16. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation.

    PubMed

    Kuck, Karl-Heinz; Brugada, Josep; Fürnkranz, Alexander; Metzner, Andreas; Ouyang, Feifan; Chun, K R Julian; Elvan, Arif; Arentz, Thomas; Bestehorn, Kurt; Pocock, Stuart J; Albenque, Jean-Paul; Tondo, Claudio

    2016-06-09

    Current guidelines recommend pulmonary-vein isolation by means of catheter ablation as treatment for drug-refractory paroxysmal atrial fibrillation. Radiofrequency ablation is the most common method, and cryoballoon ablation is the second most frequently used technology. We conducted a multicenter, randomized trial to determine whether cryoballoon ablation was noninferior to radiofrequency ablation in symptomatic patients with drug-refractory paroxysmal atrial fibrillation. The primary efficacy end point in a time-to-event analysis was the first documented clinical failure (recurrence of atrial fibrillation, occurrence of atrial flutter or atrial tachycardia, use of antiarrhythmic drugs, or repeat ablation) following a 90-day period after the index ablation. The noninferiority margin was prespecified as a hazard ratio of 1.43. The primary safety end point was a composite of death, cerebrovascular events, or serious treatment-related adverse events. A total of 762 patients underwent randomization (378 assigned to cryoballoon ablation and 384 assigned to radiofrequency ablation). The mean duration of follow-up was 1.5 years. The primary efficacy end point occurred in 138 patients in the cryoballoon group and in 143 in the radiofrequency group (1-year Kaplan-Meier event rate estimates, 34.6% and 35.9%, respectively; hazard ratio, 0.96; 95% confidence interval [CI], 0.76 to 1.22; P<0.001 for noninferiority). The primary safety end point occurred in 40 patients in the cryoballoon group and in 51 patients in the radiofrequency group (1-year Kaplan-Meier event rate estimates, 10.2% and 12.8%, respectively; hazard ratio, 0.78; 95% CI, 0.52 to 1.18; P=0.24). In this randomized trial, cryoballoon ablation was noninferior to radiofrequency ablation with respect to efficacy for the treatment of patients with drug-refractory paroxysmal atrial fibrillation, and there was no significant difference between the two methods with regard to overall safety. (Funded by Medtronic; FIRE

  17. Giant primary mediastinal liposarcoma: A rare cause of atrial flutter.

    PubMed

    Arrarás-Martínez, Miguel J; Rieger-Reyes, Cristina; Panadero-Paz, Carolina; Landa-Oviedo, Hugo S; García-Tirado, Javier

    2015-11-01

    We report the case of a 68-year-old man who presented with atrial flutter and was observed radiologically to have a large mass in the posterior mediastinum. During surgical removal, spontaneous recovery of sinus rhythm occurred. There was no late recurrence of arrhythmia. The diagnosis was mediastinal liposarcoma of mixed type (extremely rare). Supraventricular arrhythmia associated with mediastinal tumors is exceptional. Surgery appears to be the only potentially curative treatment for these tumors. In cases like ours presenting with arrhythmia, surgery is considered essential for control of the arrhythmia. © The Author(s) 2015.

  18. Repeat ablation and hospitalization following cryoballoon ablation of atrial fibrillation at a single tertiary medical center

    PubMed Central

    East, Cara; Phan, Teresa; Filardo, Giovanni; Franklin, Jay; Donsky, Alan; Wheelan, Kevin R

    2017-01-01

    Cryoablation for atrial fibrillation (AF) has rapidly become a mainstream treatment for AF. In this report, 163 patients who had undergone a cryoablation procedure at one clinical center were contacted by telephone 33.1 ± 3.3 months after the procedure. All patients had received cryoablation of the pulmonary vein ostia, although concomitant procedures were performed at the same time in over 50% of the patients, including radiofrequency and/or cryoablation of other areas of the left atrium. Freedom from a repeat ablation procedure was 87%, while freedom from recurrent hospitalization for AF was 89%, as compared to previous reports of 65%. Of the 13 patients who had a repeat ablation procedure, only one was found to have a reconnection of pulmonary veins, while 4 were found to have atrial flutter. Cryoablation for AF produces a durable result in most patients out to 3 years with better outcomes than previously reported. PMID:28127119

  19. Clinical Differences between Subtypes of Atrial Fibrillation and Flutter: Cross-Sectional Registry of 407 Patients.

    PubMed

    Almeida, Eduardo Dytz; Guimarães, Raphael Boesche; Stephan, Laura Siga; Medeiros, Alexandre Kreling; Foltz, Katia; Santanna, Roberto Tofani; Pires, Leonardo Martins; Kruse, Marcelo Lapa; Lima, Gustavo Glotz de; Leiria, Tiago Luiz Luz

    2015-07-01

    Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce. To investigate the arrhythmia subtype of atrial fibrillation and flutter patients in the emergency setting and compare the clinical profile, thromboembolic risk and anticoagulants use. Cross-sectional retrospective study, with data collection from medical records of every patient treated for atrial fibrillation and flutter in the emergency department of Instituto de Cardiologia do Rio Grande do Sul during the first trimester of 2012. We included 407 patients (356 had atrial fibrillation and 51 had flutter). Patients with paroxysmal atrial fibrillation were in average 5 years younger than those with persistent atrial fibrillation. Compared to paroxysmal atrial fibrillation patients, those with persistent atrial fibrillation and flutter had larger atrial diameter (48.6 ± 7.2 vs. 47.2 ± 6.2 vs. 42.3 ± 6.4; p < 0.01) and lower left ventricular ejection fraction (66.8 ± 11 vs. 53.9 ± 17 vs. 57.4 ± 16; p < 0.01). The prevalence of stroke and heart failure was higher in persistent atrial fibrillation and flutter patients. Those with paroxysmal atrial fibrillation and flutter had higher prevalence of CHADS2 score of zero when compared to those with persistent atrial fibrillation (27.8% vs. 18% vs. 4.9%; p < 0.01). The prevalence of anticoagulation in patients with CHA2DS2-Vasc ≤ 2 was 40%. The population in our registry was similar in its comorbidities and demographic profile to those of North American and European registries. Despite the high thromboembolic risk, the use of anticoagulants was low, revealing difficulties for incorporating guideline recommendations. Public health strategies should be adopted in order to improve these rates.

  20. Clinical Differences between Subtypes of Atrial Fibrillation and Flutter: Cross-Sectional Registry of 407 Patients

    PubMed Central

    Almeida, Eduardo Dytz; Guimarães, Raphael Boesche; Stephan, Laura Siga; Medeiros, Alexandre Kreling; Foltz, Katia; Santanna, Roberto Tofani; Pires, Leonardo Martins; Kruse, Marcelo Lapa; de Lima, Gustavo Glotz; Leiria, Tiago Luiz Luz

    2015-01-01

    Introduction Atrial fibrillation and atrial flutter account for one third of hospitalizations due to arrhythmias, determining great social and economic impacts. In Brazil, data on hospital care of these patients is scarce. Objective To investigate the arrhythmia subtype of atrial fibrillation and flutter patients in the emergency setting and compare the clinical profile, thromboembolic risk and anticoagulants use. Methods Cross-sectional retrospective study, with data collection from medical records of every patient treated for atrial fibrillation and flutter in the emergency department of Instituto de Cardiologia do Rio Grande do Sul during the first trimester of 2012. Results We included 407 patients (356 had atrial fibrillation and 51 had flutter). Patients with paroxysmal atrial fibrillation were in average 5 years younger than those with persistent atrial fibrillation. Compared to paroxysmal atrial fibrillation patients, those with persistent atrial fibrillation and flutter had larger atrial diameter (48.6 ± 7.2 vs. 47.2 ± 6.2 vs. 42.3 ± 6.4; p < 0.01) and lower left ventricular ejection fraction (66.8 ± 11 vs. 53.9 ± 17 vs. 57.4 ± 16; p < 0.01). The prevalence of stroke and heart failure was higher in persistent atrial fibrillation and flutter patients. Those with paroxysmal atrial fibrillation and flutter had higher prevalence of CHADS2 score of zero when compared to those with persistent atrial fibrillation (27.8% vs. 18% vs. 4.9%; p < 0.01). The prevalence of anticoagulation in patients with CHA2DS2-Vasc ≤ 2 was 40%. Conclusions The population in our registry was similar in its comorbidities and demographic profile to those of North American and European registries. Despite the high thromboembolic risk, the use of anticoagulants was low, revealing difficulties for incorporating guideline recommendations. Public health strategies should be adopted in order to improve these rates. PMID:26016782

  1. Cavotricuspid isthmus ablation and subcutaneous monitoring device implantation in a 2-year-old baby with 2 SCN5A mutations, sinus node dysfunction, atrial flutter recurrences, and drug induced long-QT syndrome: a tricky case of pediatric overlap syndrome?

    PubMed

    De Filippo, Paolo; Ferrari, Paola; Iascone, Maria; Racheli, Marco; Senni, Michele

    2015-03-01

    We describe the case of 2-year-old baby with compound heterozygosity for paternal and maternal alleles mutation of α-subunit of the cardiac sodium channel (SCN5A), sinus node dysfunction, atrial flutter recurrences, and drug induced long-QT syndrome. In this setting, we chose at first to perform linear ablation of cavotricuspid isthmus resulting in a bidirectional isthmus block. As a second step, we decided to implant a miniaturized loop recorder that, with a minimally invasive procedure, permits us to follow the development of the disease in order to define the future strategy. After 8 months follow-up, automatic daily loop-recorder transmissions disclose the complete absence of any arrhythmia along with asymptomatic ventricular pauses due to sinus node dysfunction. Echocardiography shows normal findings, in particular no left ventricular dysfunction. © 2014 Wiley Periodicals, Inc.

  2. Association of Rate-Dependent Conduction Block Between Eccentric Coronary Sinus to Left Atrial Connections With Inducible Atrial Fibrillation and Flutter.

    PubMed

    Huang, Dong; Marine, Joseph E; Li, Jing-Bo; Zghaib, Tarek; Ipek, Esra Gucuk; Sinha, Sunil; Spragg, David D; Ashikaga, Hiroshi; Berger, Ronald D; Calkins, Hugh; Nazarian, Saman

    2017-01-01

    We sought to describe the prevalence and variability of coronary sinus (CS) and left atrial (LA) myocardium connections, their susceptibility to rate-dependent conduction block, and association with atrial fibrillation (AF) and flutter induction. The study cohort included 30 consecutive AF patients (age 63.3±10.5 years, 63% male). Multipolar catheters were positioned in the CS, high right atrium (HRA), and LA parallel to and near the CS. Trains of 10 pacing stimuli were delivered during sinus rhythm from each of the following sites: CS proximal (CSp), CS distal (CSd), LA septum (LAs), lateral LA (LAl), and HRA, at the following cycle lengths: 1000, 500, 400, 300, and 250 ms, while recording from the other catheters. With the CS 9 to 10 bipole just inside the CS ostium, CS-LA connections were observed in 100% at CS 9 to 10, 30% at CS 7 to 8, 23% at CS 5 to 6, 23% at CS 3 to 4, and 97% at CS 1 to 2. Eighteen patients (60%) had AF/atrial flutter induced. Rate-dependent conduction block of a CS-LA connection at cycle length of ≥250 ms was present in 17 (94%) of those with versus none of those without AF/atrial flutter induction (P<0.001). Rate-dependent eccentric CS-LA conduction block is associated with AF/atrial flutter induction in patients with drug-refractory AF undergoing ablation. The presence of dual muscular CS-LA connections, coupled with unidirectional block in one limb, seems to serve as a substrate for single or multiple reentry beats, and arrhythmia induction. © 2016 American Heart Association, Inc.

  3. Effect of substrate modification in catheter ablation of paroxysmal atrial fibrillation: pulmonary vein isolation alone or with complex fractionated electrogram ablation.

    PubMed

    Nam, Gi-Byoung; Jin, Eun-Sun; Choi, HyungOh; Song, Hae-Geun; Kim, Sung-Hwan; Kim, Ki-Hun; Hwang, Eui-Seock; Park, Kyoung-Min; Kim, Jun; Rhee, Kyoung-Suk; Choi, Kee-Joon; Kim, You-Ho

    2012-01-01

    Catheter ablation of atrial fibrillation that targets complex fractionated electrogram sites has been widely applied in the management of persistent atrial fibrillation. The clinical outcomes of pulmonary vein isolation alone and pulmonary vein isolation plus the use of complex fractionated electrogram-guided ablation (CFEA) have not been fully compared in patients with paroxysmal atrial fibrillation.This prospective study included 70 patients with symptomatic paroxysmal atrial fibrillation that remained inducible after pulmonary vein isolation. For radio-frequency catheter ablation, patients were nonrandomly assigned to a control group (pulmonary vein isolation alone, Group 1, n=35) or a CFEA group (pulmonary vein isolation plus additional CFEA, Group 2, n=35). The times to first recurrence of atrial tachyarrhythmias were compared between the 2 groups.In Group 2, CFEA rendered atrial fibrillation noninducible in 16 patients (45.7%) and converted inducible atrial fibrillation into inducible atrial flutters in 12 patients (34.3%). Atrial fibrillation remained inducible in 7 patients (20%) after the combined ablation procedures. After a mean follow-up of 23 months, freedom from recurrence of atrial tachyarrhythmias was significantly higher in Group 2 than in Group 1 (P=0.037). In Group 1, all of the recurrent tachyarrhythmias were atrial fibrillation, whereas regular tachycardia was the major mechanism of recurrent arrhythmias in Group 2 (atrial tachycardia or atrial flutter in 5 of 6 patients and atrial fibrillation in 1 patient).We found that CFEA after pulmonary vein isolation significantly reduced recurrent atrial tachyarrhythmia and might modify the pattern of arrhythmia recurrence in patients with paroxysmal atrial fibrillation.

  4. Ablation of Macro-Re-Entrant Atrial Arrhythmia Late after Surgical Aortic Valve Replacement.

    PubMed

    Orczykowski, Michał; Derejko, Paweł; Urbanek, Piotr; Bodalski, Robert; Kodziszewska, Katarzyna; Sierpiński, Radosław; Baranowski, Rafał; Bilińska, Maria; Szumowski, Łukasz

    2016-09-01

    Re-entrant atrial arrhythmias are common in patients after cardiac surgery. To date, however, no studies have reported the safety and efficacy of radiofrequency (RF) ablation of macro-re-entrant atrial arrhythmias in a unique, homogeneous group of patients after surgical replacement of the aortic valve and single right atriotomy. Among over 4,000 RF catheter ablations performed at the authors' center between 2008 and 2014, eight patients (seven males, one female; mean age 55.1 ± 19.9 years) after aortic valve replacement (AVR) and without history of any other cardiosurgical procedures were identified with documented macro-re-entrant atrial arrhythmia. The mechanism of macro-re-entrant arrhythmia was analyzed, as well as the safety and efficacy of RF ablation in a group of patients after AVR and single right atrial free wall atriotomy. The average time from surgery to RF catheter ablation was 11.3 ± 11.3 years (range: 4-35 years). In five patients with permanent arrhythmia, entrainment mapping proved these arrhythmias to be cavotricuspid isthmus- dependent, in three patients with paroxysmal atrial arrhythmia cavotricuspid isthmus-dependent atrial flutter was induced during the electrophysiological study. Intra-atrial re-entrant tachycardia was neither recorded nor induced in any patient. Successful ablation of cavotricuspid isthmus is defined as the termination of arrhythmia, and bidirectional block in cavotricuspid isthmus was achieved in all patients. A long-term follow up, based on a seven-day Holter monitoring, was conducted in all patients, with a mean observation time of 40.1 ± 28.6 months after the procedure. Among the patients, ablated arrhythmia (cavotricuspid isthmusdependent atrial flutter) recurred in one patient, atrial fibrillation occurred in three patients, and an atrial tachycardia in one patient. In the presented series of patients, cavotricuspid isthmus-dependent atrial flutter was shown to be the mechanism of post-cardiosurgical macro

  5. Current Hot Potatoes in Atrial Fibrillation Ablation

    PubMed Central

    Roten, Laurent; Derval, Nicolas; Pascale, Patrizio; Scherr, Daniel; Komatsu, Yuki; Shah, Ashok; Ramoul, Khaled; Denis, Arnaud; Sacher, Frédéric; Hocini, Mélèze; Haïssaguerre, Michel; Jaïs, Pierre

    2012-01-01

    Atrial fibrillation (AF) ablation has evolved to the treatment of choice for patients with drug-resistant and symptomatic AF. Pulmonary vein isolation at the ostial or antral level usually is sufficient for treatment of true paroxysmal AF. For persistent AF ablation, drivers and perpetuators outside of the pulmonary veins are responsible for AF maintenance and have to be targeted to achieve satisfying arrhythmia-free success rate. Both complex fractionated atrial electrogram (CFAE) ablation and linear ablation are added to pulmonary vein isolation for persistent AF ablation. Nevertheless, ablation failure and necessity of repeat ablations are still frequent, especially after persistent AF ablation. Pulmonary vein reconduction is the main reason for arrhythmia recurrence after paroxysmal and to a lesser extent after persistent AF ablation. Failure of persistent AF ablation mostly is a consequence of inadequate trigger ablation, substrate modification or incompletely ablated or reconducting linear lesions. In this review we will discuss these points responsible for AF recurrence after ablation and review current possibilities on how to overcome these limitations. PMID:22920482

  6. Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter.

    PubMed

    Mont, Lluís; Elosua, Roberto; Brugada, Josep

    2009-01-01

    Although the benefits of regular exercise in controlling cardiovascular risk factors have been extensively proven, little is known about the long-term cardiovascular effects of regular and extreme endurance sport practice, such as jogging, cycling, rowing, swimming, etc. Recent data from a small series suggest a relationship between regular, long-term endurance sport practice and atrial fibrillation (AF) and flutter. Reported case control studies included less than 300 athletes, with mean age between 40 and 50. Most series recruited only male patients, or more than 70% males, who had been involved in intense training for many years. Endurance sport practice increases between 2 and 10 times the probability of suffering AF, after adjusting for other risk factors. The possible mechanisms explaining the association remain speculative. Atrial ectopic beats, inflammatory changes, and atrial size have been suggested. Some of the published studies found that atrial size was larger in athletes than in controls, and this was a predictor for AF. It has also been shown that the left atrium may be enlarged in as many as 20% of competitive athletes. Other proposed mechanisms are increased vagal tone and bradycardia, affecting the atrial refractory period; however, this may facilitate rather than cause the arrhythmia. In summary, recent data suggest an association between endurance sport practice and atrial fibrillation and flutter. The underlying mechanism explaining this association is unclear, although structural atrial changes (dilatation and fibrosis) are probably present. Larger longitudinal studies and mechanistic studies are needed to further characterize the association to clarify whether a threshold limit for the intensity and duration of physical activity may prevent AF, without limiting the cardiovascular benefits of exercise.

  7. Ablation of sarcolipin results in atrial remodeling

    PubMed Central

    Xie, Lai-Hua; Shanmugam, Mayilvahanan; Park, Ji Yeon; Zhao, Zhenghang; Wen, Hairuo; Tian, Bin; Periasamy, Muthu

    2012-01-01

    Sarcolipin (SLN) is a key regulator of sarco(endo)plasmic reticulum (SR) Ca2+-ATPase (SERCA), and its expression is altered in diseased atrial myocardium. To determine the precise role of SLN in atrial Ca2+ homeostasis, we developed a SLN knockout (sln−/−) mouse model and demonstrated that ablation of SLN enhances atrial SERCA pump activity. The present study is designed to determine the long-term effects of enhanced SERCA activity on atrial remodeling in the sln−/− mice. Calcium transient measurements show an increase in atrial SR Ca2+ load and twitch Ca2+ transients. Patch-clamping experiments demonstrate activation of the forward mode of sodium/calcium exchanger, increased L-type Ca2+ channel activity, and prolongation of action potential duration at 90% repolarization in the atrial myocytes of sln−/− mice. Spontaneous Ca2+ waves, delayed afterdepolarization, and triggered activities are frequent in the atrial myocytes of sln−/− mice. Furthermore, loss of SLN in atria is associated with increased interstitial fibrosis and altered expression of genes encoding collagen and other extracellular matrix proteins. Our results also show that the sln−/− mice are susceptible to atrial arrhythmias upon aging. Together, these findings indicate that ablation of SLN results in increased SERCA activity and SR Ca2+ load, which, in turn, could cause abnormal intracellular Ca2+ handling and atrial remodeling. PMID:22496245

  8. Atrial flutter – clinical risk factors and adverse outcomes in the Framingham Heart Study

    PubMed Central

    Rahman, Faisal; Wang, Na; Yin, Xiaoyan; Ellinor, Patrick T.; Lubitz, Steven A.; LeLorier, Paul A.; McManus, David D.; Sullivan, Lisa M.; Seshadri, Sudha; Vasan, Ramachandran S.; Benjamin, Emelia J.; Magnani, Jared W.

    2015-01-01

    Background Few epidemiological cohort studies have evaluated atrial flutter (flutter) as an arrhythmia distinct from atrial fibrillation (AF). Objective To examine the clinical correlates of flutter and its associated outcomes to distinguish them from those associated with AF in the Framingham Heart Study. Methods We reviewed and adjudicated electrocardiograms previously classified as flutter or AF/flutter and another 100 electrocardiograms randomly selected from AF cases. We examined the clinical correlates of flutter by matching up to 5 AF and 5 referents to each flutter case using a nested case-referent design. We determined the 10-year outcomes associated with flutter with Cox models. Results During mean follow-up of 33.0±12.2 years, 112 participants (mean age 72±10 years, 30% women) developed flutter. In multivariable analyses, smoking (odds ratio [OR] 2.84; 95% confidence interval [CI], 1.54 to 5.23), increased PR interval (OR 1.28 per SD; 95% CI, 1.03 to 1.60), myocardial infarction (OR 2.25; 95% CI, 1.05 to 4.80) and heart failure (OR 5.22; 95% CI, 1.26 to 21.64) were associated with incident flutter. In age- and sex-adjusted models, flutter (vs. referents) was associated with 10-year increased risk of AF (hazard ratio [HR] 5.01; 95% CI, 3.14 to 7.99), myocardial infarction (HR 3.05; 95% CI, 1.42 to 6.59), heart failure (HR 4.14; 95% CI, 1.90 to 8.99), stroke (HR 2.17; 95% CI, 1.13 to 4.17), and mortality (HR 2.00; 95% CI, 1.44 to 2.79). Conclusions We identified the clinical correlates associated with flutter and observed that flutter was associated with multiple adverse outcomes. PMID:26226213

  9. Atrial flutter: Clinical risk factors and adverse outcomes in the Framingham Heart Study.

    PubMed

    Rahman, Faisal; Wang, Na; Yin, Xiaoyan; Ellinor, Patrick T; Lubitz, Steven A; LeLorier, Paul A; McManus, David D; Sullivan, Lisa M; Seshadri, Sudha; Vasan, Ramachandran S; Benjamin, Emelia J; Magnani, Jared W

    2016-01-01

    Few epidemiologic cohort studies have evaluated atrial flutter (flutter) as an arrhythmia distinct from atrial fibrillation (AF). The purpose of this study was to examine the clinical correlates of flutter and its associated outcomes to distinguish them from those associated with AF in the Framingham Heart Study. We reviewed and adjudicated electrocardiograms (ECGs) previously classified as flutter or AF/flutter and another 100 ECGs randomly selected from AF cases. We examined the clinical correlates of flutter by matching up to 5 AF and 5 referents to each flutter case using a nested case referent design. We determined the 10-year outcomes associated with flutter with Cox models. During mean follow-up of 33.0 ± 12.2 years, 112 participants (mean age 72 ± 10 years, 30% women) developed flutter. In multivariable analyses, smoking (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.54-5.23), increased PR interval (OR 1.28 per SD, 95% CI 1.03-1.60), myocardial infarction (OR 2.25, 95% CI 1.05-4.80) and heart failure (OR 5.22, 95% CI 1.26-21.64) were associated with incident flutter. In age- and sex-adjusted models, flutter (vs referents) was associated with 10-year increased risk of AF (hazard ratio [HR] 5.01, 95% CI 3.14-7.99), myocardial infarction (HR 3.05, 95% CI 1.42-6.59), heart failure (HR 4.14, 95% CI 1.90-8.99), stroke (HR 2.17, 95% CI 1.13-4.17), and mortality (HR 2.00, 95% CI 1.44-2.79). We identified the clinical correlates associated with flutter and observed that flutter was associated with multiple adverse outcomes. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  10. Anatomic approach for ganglionic plexi ablation in patients with paroxysmal atrial fibrillation.

    PubMed

    Katritsis, Demosthenes; Giazitzoglou, Eleftherios; Sougiannis, Demetrios; Goumas, Nicolaos; Paxinos, George; Camm, A John

    2008-08-01

    There is evidence that parasympathetic denervation may prevent atrial fibrillation (AF) recurrences. This study aimed at applying an anatomic approach for ablation of atrial ganglionic plexi (GPs) in patients with paroxysmal AF. Nineteen patients with symptomatic, paroxysmal AF underwent anatomically guided radiofrequency ablation at the location of the 4 main left atrial GPs and were prospectively assessed for recurrence of AF or other atrial arrhythmia. This group was compared with 19 age- and gender-matched patients who previously underwent conventional circumferential pulmonary vein ablation. All ablation procedures were uneventful. Circumferential and GP ablations were accomplished with a radiofrequency delivery time of 28 +/- 5 versus 18 +/- 3 min (p <0.001) and a fluoroscopy time of 31 +/- 5 versus 18 +/- 5 min (p <0.001), respectively. Parasympathetic reflexes during radiofrequency ablation were elicited in 4 patients (21%). Arrhythmia recurred in 7 patients (37%) with circumferential ablation and 14 patients (74%) with GP ablation, during 1-year follow-up (p for log-rank test = 0.017). In 2 patients with GP ablation, left atrial flutters were documented in addition to AF during follow-up. Patients who underwent GP ablation had an almost 2.5 times higher risk of AF recurrence compared with those who underwent circumferential ablation (hazard ratio 2.6, 95% confidence interval 1.0 to 6.6, p = 0.038). In conclusion, anatomically guided GP ablation is feasible and safe in the electrophysiology laboratory, but this approach yields inferior clinical results compared with circumferential ablation.

  11. Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation

    PubMed Central

    Vos, M; Golitsyn, S; Stangl, K; Ruda, M; Van Wijk, L; Harry, J; Perry, K; Touboul, P; Steinbeck, G; Wellens, H

    1998-01-01

    Objective—To compare the efficacy and safety of a single dose of ibutilide, a new class III antiarrhythmic drug, with that of DL-sotalol in terminating chronic atrial fibrillation or flutter in haemodynamically stable patients.
Design—Double blind, randomised study.
Setting—43 European hospitals.
Patients—308 patients (mean age 60 years, 70% men, 48% with heart disease) with sustained atrial fibrillation (n = 251) or atrial flutter (n = 57) (duration three hours to 45 days) were randomised to three groups to receive a 10 minute infusion of 1 mg ibutilide (n = 99), 2 mg ibutilide (n = 106), or 1.5 mg/kg DL-sotalol (n = 103). Infusion was discontinued at termination of the arrhythmia.
Main outcome measure—Successful conversion of atrial fibrillation or flutter, defined as termination of arrhythmia within one hour of treatment.
Results—Both drugs were more effective against atrial flutter than against atrial fibrillation. Ibutilide was superior to DL-sotalol for treating atrial flutter (70% and 56% v 19%), while the high dose of ibutilide was more effective for treating atrial fibrillation than DL-sotalol (44% v 11%) and the lower dose of ibutilide (44% v 20%, p < 0.01). The mean (SD) time to arrhythmia termination was 13 (7) minutes with 2 mg ibutilide, 19 (15) minutes with 1 mg ibutilide, and 25 (17) minutes with DL-sotalol. In all patients, the duration of arrhythmia before treatment was a predictor of arrhythmia termination, although this was less obvious in the group that received 2 mg ibutilide. This dose converted almost 48% of atrial fibrillation that was present for more than 30 days. Concomitant use of digitalis or nifedipine and prolongation of the QTc interval were not predictive of arrhythmia termination. Bradycardia (6.5%) and hypotension (3.7%) were more common side effects with DL-sotalol. Of 211 patients given ibutilide, two (0.9%) who received the higher dose developed polymorphic ventricular tachycardia

  12. [Characteristic electrocardiographic procedures of isthmic-dependent atrial flutter; influence of clinical and echocardiographic procedures].

    PubMed

    Milliez, P; Cosson, S; Courteaux, C; Obioha-Ngwu, O; Richardson, A; Josephson, M; Beaufils, P; Leenhardt, A

    2003-06-01

    The appearance of the F waves on the ECG is considered to be related to the type of circuit of the anti-clockwise flutters and the clockwise isthmic-dependant flutters. In the authors' experience, the usual ECG description of these two types of flutter is not always observed. This study was undertaken to analyse the different appearances of anti-clockwise and clockwise flutters and to try and explain the reasons for these differences. Over a 4 year period, 139 patients with an ECG of atrial flutter required electro-physiological studies and echocardiography of the 156 flutters analysed: 130 were anti-clockwise and 26 clockwise. Three types of anti-clockwise flutter were observed: type 1 with exclusively negative F waves in the inferior leads: type 2 and 3 with negative F waves in the inferior leads and a small (type 2) or large (type 3) positive terminal components. The types 2 and 3 were associated with a higher incidence of left atrial dilatation, cardiac disease and atrial fibrillation than type 1. Two types of clockwise flutter were observed: type 1 with positive notched F waves in the inferior leads with a return to the iso-electric line and type 2 with wide F waves in the inferior leads with two components, predominantly positive and negative, without return to the iso-electric line. There are different ECG appearances of anti-clockwise and clockwise flutter which seem to be correlated with structural cardiac abnormalities. The anti-clockwise flutters with a positive terminal component of the F waves in the inferior leads corresponds to a subgroup with a high probability of cardiac disease and left atrial dilatation.

  13. Discriminating atrial flutter from atrial fibrillation using a multilevel model of atrioventricular conduction.

    PubMed

    Scholz, Eberhard P; Kehrle, Florian; Vossel, Stephan; Hess, Alexander; Zitron, Edgar; Katus, Hugo A; Sager, Sebastian

    2014-05-01

    The discrimination between atrial flutter (AFlu) and atrial fibrillation (AFib) can be made difficult by an irregular ventricular response owing to complex conduction phenomena within the atrioventricular (AV) node, known as multilevel AV block. We tested the hypothesis that a mathematical algorithm might be suitable to discriminate both arrhythmias. To discriminate AFlu with irregular ventricular response from AFib based on the sequence of R-R intervals. Intracardiac recordings of 100 patients (50 patients with AFib and 50 patients with AFlu) were analyzed. On the basis of a numerical simulation of variable flutter frequencies followed by 2 levels of AV block in series, a given sequence of R-R intervals was analyzed. Although the ventricular response displays absolute irregularity in AFib, the sequences of R-R intervals follow certain rules in AFlu. We find that using a mathematical simulation of multilevel AV block, based on the R-R sequence of 16 ventricular beats, a stability of atrial activation could be predicted with a sensitivity of 84% and a specificity of 74%. When limiting the ventricular rate to 125 beats/min, discrimination could be performed with a sensitivity of even 89% and a specificity of 80%. In cases of AFlu, the atrial cycle length could be predicted with high accuracy. On the basis of the electrophysiological mechanism of multilevel AV block, we developed a computer algorithm to discriminate between AFlu and Afib. This algorithm is able to predict the stability and cycle length of atrial activation for short R-R sequences with high accuracy. Copyright © 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  14. Radiofrequency Ablation of Persistent Atrial Fibrillation

    PubMed Central

    Hussein, Ayman A.; Saliba, Walid I.; Barakat, Amr; Bassiouny, Mohammed; Chamsi-Pasha, Mohammed; Al-Bawardy, Rasha; Hakim, Ali; Tarakji, Khaldoun; Baranowski, Bryan; Cantillon, Daniel; Dresing, Thomas; Tchou, Patrick; Martin, David O.; Varma, Niraj; Bhargava, Mandeep; Callahan, Thomas; Niebauer, Mark; Kanj, Mohamed; Chung, Mina; Natale, Andrea; Lindsay, Bruce D.; Wazni, Oussama M.

    2017-01-01

    Background Various ablation strategies of persistent atrial fibrillation (PersAF) have had disappointing outcomes, despite concerted clinical and research efforts, which could reflect progressive atrial fibrillation–related atrial remodeling. Methods and Results Two-year outcomes were assessed in 1241 consecutive patients undergoing first-time ablation of PersAF (2005–2012). The time intervals between the first diagnosis of PersAF and the ablation procedures were determined. Patients had echocardiograms and measures of B-type natriuretic peptide and C-reactive protein before the procedures. The median diagnosis-to-ablation time was 3 years (25th–75th percentiles 1–6.5). With longer diagnosis-to-ablation time (based on quartiles), there was a significant increase in recurrence rates in addition to an increase in B-type natriuretic peptide levels (P=0.01), C-reactive protein levels (P<0.0001), and left atrial size (P=0.03). The arrhythmia recurrence rates over 2 years were 33.6%, 52.6%, 57.1%, and 54.6% in the first, second, third, and fourth quartiles, respectively (Pcategorical<0.0001). In Cox Proportional Hazard analyses, B-type natriuretic peptide levels, C-reactive protein levels, and left atrial size were associated with arrhythmia recurrence. The diagnosis-to-ablation time had the strongest association with the ablation outcomes which persisted in multivariable Cox analyzes (hazard ratio for recurrence per +1Log diagnosis-to-ablation time 1.27, 95% confidence interval 1.14–1.43; P<0.0001; hazard ratio fourth versus first quartile 2.44, 95% confidence interval 1.68–3.65; Pcategorical<0.0001). Conclusions In patients with PersAF undergoing ablation, the time interval between the first diagnosis of PersAF and the catheter ablation procedure had a strong association with the ablation outcomes, such as shorter diagnosis-to-ablation times were associated with better outcomes and in direct association with markers of atrial remodeling. PMID:26763227

  15. Risk of Atrial Fibrillation or Flutter Associated with Periodontitis: A Nationwide, Population-Based, Cohort Study.

    PubMed

    Chen, Der-Yuan; Lin, Ching-Heng; Chen, Yi-Ming; Chen, Hsin-Hua

    2016-01-01

    To investigate the risk of atrial fibrillation or atrial flutter in patients with periodontitis (PD) in comparison with individuals without PD. We used the 1999-2010 Taiwanese National Health Insurance Research Database to identify cases of PD in the year 2000 matching (1:1) with persons without PD during 1999-2000 according to sex and individual age as the control group. Using Cox proportional regression analysis adjusting for potential confounders, including age, sex, and comorbidities at baseline, and average annual number of ambulatory visits and dental scaling frequency during the follow-up period, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) to examine the risk of atrial fibrillation or flutter in PD patients in comparison with the control group. Subgroup analyses according to age, gender, or comorbidities were conducted to study the robustness of the association and investigate possible interaction effects. We enrolled 393,745 patients with PD and 393,745 non-PD individuals. The incidence rates of atrial fibrillation or flutter were 200 per 105 years among the PD group and 181 per 105 years in the non-PD group (incidence rate ratio, 1.10; 95% CI, 1.06-1.14). After adjusting for potential confounders, we found an increased risk of atrial fibrillation or flutter in the PD group compared with the non-PD group (HR, 1.31; 95% CI, 1.25-1.36). The greater risk of atrial fibrillation or flutter in the PD group remained significant across all disease subgroups except hyperthyroidism and sleep apnea. The present study results indicate an increased risk of atrial fibrillation or flutter in patients with PD. Lack of individual information about alcohol consumption, obesity, and tobacco use was a major limitation.

  16. Risk of Atrial Fibrillation or Flutter Associated with Periodontitis: A Nationwide, Population-Based, Cohort Study

    PubMed Central

    Chen, Yi-Ming

    2016-01-01

    Objective To investigate the risk of atrial fibrillation or atrial flutter in patients with periodontitis (PD) in comparison with individuals without PD. Methods We used the 1999–2010 Taiwanese National Health Insurance Research Database to identify cases of PD in the year 2000 matching (1:1) with persons without PD during 1999–2000 according to sex and individual age as the control group. Using Cox proportional regression analysis adjusting for potential confounders, including age, sex, and comorbidities at baseline, and average annual number of ambulatory visits and dental scaling frequency during the follow-up period, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) to examine the risk of atrial fibrillation or flutter in PD patients in comparison with the control group. Subgroup analyses according to age, gender, or comorbidities were conducted to study the robustness of the association and investigate possible interaction effects. Results We enrolled 393,745 patients with PD and 393,745 non-PD individuals. The incidence rates of atrial fibrillation or flutter were 200 per 105 years among the PD group and 181 per 105 years in the non-PD group (incidence rate ratio, 1.10; 95% CI, 1.06–1.14). After adjusting for potential confounders, we found an increased risk of atrial fibrillation or flutter in the PD group compared with the non-PD group (HR, 1.31; 95% CI, 1.25–1.36). The greater risk of atrial fibrillation or flutter in the PD group remained significant across all disease subgroups except hyperthyroidism and sleep apnea. Conclusion The present study results indicate an increased risk of atrial fibrillation or flutter in patients with PD. Lack of individual information about alcohol consumption, obesity, and tobacco use was a major limitation. PMID:27798703

  17. Lasso catheter guided ablation for paroxysmal atrial fibrillation: the first experience in Thailand.

    PubMed

    Raungratanaamporn, Ongkarn; Bhurippanyo, Kiertijai; Chotinaiwattarakul, Chunhakasem; Suksap, Suthisak; Chirapastan, Anna; Ninmaneechot, Nuntaya; Numee, Malee

    2003-05-01

    The authors used the 10-pole pulmonary vein sized loop-shaped, lasso, catheter via a transatrial septal long sheath in 10 patients who had symptomatic refractory paroxysmal atrial fibrillation (PAF) in order to map and guide for catheter ablation. The radiofrequency current was delivered at the junction between atrial tissue and the pulmonary vein which was the earliest endocardial activation time of the premature atrial contraction (PAC) initiating the PAF and at the pulmonary vein potential during sinus rhythm. Twenty two foci of PAC, 10 and 7, 4 and 1 from left and right superior and left and right inferior pulmonary veins, respectively, and 5 pulmonary vein potentials, 2 and 3 from left and right superior pulmonary veins, respectively, were ablated. After AF ablation, classical atrial flutter (AFl) could be induced in 9 patients. Isthmus line of block for AFl was performed in all patients. Two patients had atrial tachycardia at the high right atrium and also successfully ablated. The mean fluoroscopic and procedure times were 87 and 300 minutes, respectively. One patient had deep vein thrombosis which resolved after anticoagulant therapy. One patient had recurrent PAF which was successfully reablated but he still had very mild symptoms. During the mean follow-up period of 5.8 months, 9 patients remained free of symptoms. Lasso catheter is an effective tool for mapping and guiding of ablation for PAF. However, more experience and long-term follow-up are required.

  18. Comparison of safety of left atrial catheter ablation procedures for atrial arrhythmias under continuous anticoagulation with apixaban versus phenprocoumon.

    PubMed

    Kaess, Bernhard M; Ammar, Sonia; Reents, Tilko; Dillier, Roger; Lennerz, Carsten; Semmler, Verena; Grebmer, Christian; Bourier, Felix; Buiatti, Alessandra; Kolb, Christof; Deisenhofer, Isabel; Hessling, Gabriele

    2015-01-01

    Apixaban is increasingly used for stroke prevention in patients with atrial fibrillation. Data about the safety of left atrial radiofrequency ablation procedures under continuous apixaban therapy are lacking. We performed a matched-cohort study of patients undergoing left atrium ablation procedures for atrial fibrillation or left atrial flutter. For each patient on apixaban, 2 patients on phenprocoumon were matched by age, gender, and type of arrhythmia. The primary safety end point was a composite of bleeding, thromboembolic events, and death. We identified 105 consecutive patients (35 women; mean age 63 years) on apixaban and matched 210 phenprocoumon patients (70 women, mean age 64 years). The primary end point was met in 11 patients of the apixaban group and 26 patients of the phenprocoumon group (10.5% vs 12.3%, p = 0.71). Major bleeding complications occurred in 1 patient of the apixaban group and 1 patient of the phenprocoumon group (1% vs 0.5%, p >0.99). Minor bleeding complications were observed in 10 patients of the apixaban group and 25 patients of the phenprocoumon group (9.5% vs 11.9%, p = 0.61). No patient in either group experienced a thromboembolic event and no patient died. In patients on apixaban, no clinical variable was predictive for bleeding complications. Left atrial ablation procedures under continuous oral anticoagulation with apixaban are feasible and as safe as under continuous oral anticoagulation with phenprocoumon. Copyright © 2015 Elsevier Inc. All rights reserved.

  19. Possible role for cryoballoon ablation of right atrial appendage tachycardia when conventional ablation fails.

    PubMed

    Amasyali, Basri; Kilic, Ayhan

    2015-06-01

    Focal atrial tachycardia arising from the right atrial appendage usually responds well to radiofrequency ablation; however, successful ablation in this anatomic region can be challenging. Surgical excision of the right atrial appendage has sometimes been necessary to eliminate the tachycardia and prevent or reverse the resultant cardiomyopathy. We report the case of a 48-year-old man who had right atrial appendage tachycardia resistant to multiple attempts at ablation with use of conventional radiofrequency energy guided by means of a 3-dimensional mapping system. The condition led to cardiomyopathy in 3 months. The arrhythmia was successfully ablated with use of a 28-mm cryoballoon catheter that had originally been developed for catheter ablation of paroxysmal atrial fibrillation. To our knowledge, this is the first report of cryoballoon ablation without isolation of the right atrial appendage. It might also be an alternative to epicardial ablation or surgery when refractory atrial tachycardia originates from the right atrial appendage.

  20. Fourier analysis of a gated blood-pool study during atrial flutter

    SciTech Connect

    Makler, P.T. Jr.; McCarthy, D.M.; London, J.W.; Sandler, M.S.; Alavi, A.

    1983-08-01

    First-harmonic Fourier analysis of a gated blood-pool study is based on the assumption that the cardiac chambers contract once per cardiac cycle. In atrial arrhythmias this condition may not exist for the atria. We recently studied a patient with atrial flutter and 2:1 artioventricular conduction. There were predictable alterations in the first-harmonic Fourier phase and amplitude images. The observed changes from first-harmonic Fourier analysis were: (a) very low atrial amplitude values, and (b) absence of identifiable atrial regions on the phase image.

  1. Nonfluoroscopic Ablation of Atrial Fibrillation Using Cryoballoon.

    PubMed

    Razminia, Mansour; Demo, Hany; Arrieta-Garcia, Carlos; D'Silva, Oliver J; Wang, Theodore; Kehoe, Richard F

    2014-01-01

    The conventional method of cryoballoon ablation of atrial fibrillation involves the use of fluoroscopy for visual guidance. The use of fluoroscopy is accompanied by significant radiation risks to the patient and the medical staff. Herein, we report our experience in performing successful nonfluoroscopic pulmonary vein isolation using cryoballoon ablation in 5 consecutive patients with paroxysmal atrial fibrillation. Five consecutive patients with paroxysmal atrial fibrillation underwent cryoballoon ablation for pulmonary vein isolation using a nonfluoroscopic approach. Pre-procedural cardiac computed tomography or cardiac magnetic resonance imaging was not performed in any patient. A total of twenty pulmonary veins were identified and successfully isolated (100%) with the guidance of intracardiac echocardiography and 3-dimensional electroanatomic mapping. No fluoroscopy was used for the procedures. There were no major procedural adverse events. In an unselected group of patients undergoing cryoballoon ablation, a nonfluoroscopic approach is feasible and can be performed safely and effectively while eliminating the risks associated with radiation to both the patient and the medical staff.

  2. Colorectal cancer and risk of atrial fibrillation and flutter: a population-based case-control study.

    PubMed

    Erichsen, Rune; Christiansen, Christian Fynbo; Mehnert, Frank; Weiss, Noel Scott; Baron, John Anthony; Sørensen, Henrik Toft

    2012-10-01

    Colorectal cancer has recently been associated with an increased atrial fibrillation risk, but evidence is very sparse. So, we conducted a population-based case-control study in northern Denmark (population 1.7 million) during 1998-2006 to estimate the atrial fibrillation/flutter risk in colorectal cancer patients. We identified 28,333 atrial fibrillation/flutter cases and 283,260 sex-, age-, and county-matched population controls. We searched the databases for a prior colorectal cancer diagnosis, a prior cancer diagnosis other than colorectal cancer, and performance of surgery within 30 days prior to atrial fibrillation/flutter. We used conditional logistic regression to estimate the OR of atrial fibrillation/flutter in patients with colorectal cancer, cancers other than colorectal and in patient with surgery. Among cases, 0.59% (n = 168) had a colorectal cancer diagnosis within 90 days before their atrial fibrillation/flutter diagnosis, compared with 0.05% (n = 155) of controls (adjusted OR = 11.8; 95% CI 9.3-14.9). Beyond the first 90 days after a colorectal cancer diagnosis, atrial fibrillation/flutter risk was no longer increased. There was likewise an increased atrial fibrillation/flutter risk in patients diagnosed with another cancer form in the prior 90 days (OR = 7.0, 95% CI 6.3-7.8). Furthermore, the atrial fibrillation/flutter risk was elevated fivefold in patients who had undergone surgery, whether or not cancer-related. We therefore conclude that colorectal cancer patients are at increased atrial fibrillation/flutter risk exclusively in the first 90 days after cancer diagnosis, but to no greater an extent than are patients with other cancers. The performance of surgery probably plays an important role in this association.

  3. Catheter ablation of organized atrial arrhythmias in orthotopic heart transplantation.

    PubMed

    Mouhoub, Yamina; Laredo, Mikael; Varnous, Shaida; Leprince, Pascal; Waintraub, Xavier; Gandjbakhch, Estelle; Hébert, Jean-Louis; Frank, Robert; Maupain, Carole; Pavie, Alain; Hidden-Lucet, Françoise; Duthoit, Guillaume

    2017-07-21

    Organized atrial arrhythmias (OAAs) are common after orthotopic heart transplantation (OHT). Some controversies remain about their clinical presentation, relationship with atrial anastomosis and electrophysiologic features. The objectives of this retrospective study were to determine the mechanisms of OAAs after OHT and describe the outcomes of radiofrequency catheter ablation (RFCA). Thirty consecutive transplanted patients (mean age 48 ± 17 years, 86.6% male) underwent 3-dimensional electroanatomic mapping and RFCA of their OAA from 2004 to 2012 at our center. Twenty-two patients had biatrial anastomosis and 8 had bicaval anastomosis. Macro-reentry was the arrhythmia mechanism for 96% of patients. The electrophysiologic diagnoses were: cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) in 93% of patients (n = 28); perimitral AFL in 3% (n = 1); and focal atrial tachycardia (FAT) in 3% (n = 1). In 5 patients with biatrial anastomosis, a right FAT was inducible. Primary RFCA success was obtained in 93% of patients. Mean follow-up time was 39 ± 26.8 months. Electrical repermeation between recipient and donor atria, present in 20% of patients (n = 6), did not account for any of the OAAs observed. Survival without OAA relapse at 12, 24 and 60 months was 93%, 89% and 79%, respectively. CTI-dependent AFL accounted for most instances of OAA after OHT, regardless of anastomosis type. Time from transplantation to OAA was shorter with bicaval than with biatrial anastomosis. RFCA was safe and provided good long-term results. Copyright © 2017 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

  4. Pharmacological Tests in Atrial Fibrillation Ablation

    PubMed Central

    Gourraud, Jean-Baptiste; Andrade, Jason G; Macle, Laurent

    2016-01-01

    The invasive management of atrial fibrillation (AF) has been considerably changed by the identification of major sites of AF initiation and/or maintenance within the pulmonary vein antra. Percutaneous catheter ablation of these targets has become the standard of care for sustained maintenance of sinus rhythm. Long-term failure of ablation is related to an inability to create a durable transmural lesion or to identify all of the non-pulmonary vein arrhythmia triggers. Pharmacological challenges during catheter ablation have been suggested to improve outcomes in both paroxysmal and persistent AF. Herein we review the mechanism and evidence for the use of pharmacological adjuncts during the catheter ablation of AF. PMID:28116081

  5. Radiofrequency ablation for treatment of atrial fibrillation.

    PubMed

    Safaei, Nasser; Montazerghaem, Hossein; Azarfarin, Rasoul; Alizadehasl, Azin; Alikhah, Hossein

    2011-01-01

    Atrial Fibrillation (AF) is the most common cardiac arrhythmia which represents a major public health problem. The main purpose of this research is to evaluate the Radiofrequency (RF) ablation effects in the patients with chronic AF scheduled for cardiac surgery because of different heart diseases. The descriptive and prospective study was conducted on 60 patients with AF scheduled for surgery along with RF ablation. The data were collected by questionnaire and included: patients' age, sex, NYHA class, operation type, past medical history, type and cause of valvular heart disease, preoperative ECG (electrocardiogram), duration of surgery, clamping time, cardiopulmonary bypass, and RF ablation time. RF ablation was followed by the main operation. The follow up examination, ECG, and echocardiography were performed 3 and 6 months after operation. The mean age of patients was 48±10 years (18-71 years). Forty one patients had permanent AF and 19 had the persistent AF. The left ventricular ejection fraction was 48.27±9.75 percent before operation, and reached to 56.27±7.87 percent after the surgery (P<0.001). The mean NYHA class before the surgery was 2.83±0.68 which decreased to 1.34±0.46 6 months after the surgery with RF ablation (P<0.001). One patient (1.6%) died after surgery. Complete relief and freedom from AF recurrence was observed in 70% of patients in the mean follow up in 7 months after the surgery. The sinus rhythm with efficient atrial contraction was established in 100% of discharged patients. RF ablation is an effective procedure to cure atrial fibrillation in patients undergoing cardiac surgeries.

  6. Cardioversion of atrial fibrillation or atrial flutter into sinus rhythm reduces nocturnal central respiratory events and unmasks obstructive sleep apnoea.

    PubMed

    Fox, Henrik; Bitter, Thomas; Horstkotte, Dieter; Oldenburg, Olaf

    2016-05-01

    Sleep-disordered breathing (SDB), in particular obstructive sleep apnoea, is associated with an increased risk of onset or recurrence of atrial fibrillation (AF) and atrial flutter. This prospective study investigated the relationship between restoration of sinus rhythm and SDB in patients with AF or atrial flutter. 138 consecutive patients (age 67.8 ± 10.3 years, 67.4 % male) with AF (86.2 %) or atrial flutter (13.8 %) were enrolled and underwent multichannel cardiorespiratory polygraphy the night before and immediately after electrical cardioversion (CV). None of the patients was treated with ventilation therapy before or during the study. Overall prevalence of SDB [apnoea-hypopnoea index (AHI) ≥5/h] was 92 % and prevalence of moderate-to-severe SDB (AHI) ≥15/h was 64 %. Within the first night after CV, AHI decreased from 23.4 ± 16.3 to 16.3 ± 11.5/h, p < 0.001. This was due to a significant decrease in central respiratory events, with a total reduction of patients showing central sleep apnoea (n = 53 at baseline vs n = 23 immediately after CV; p < 0.001). In conclusion, SDB represents a highly prevalent comorbidity in patients with atrial arrhythmias. Through cardioversion, an immediate reduction of SDB can be detected due to a significant reduction in central respiratory events.

  7. [Atrial fibrillation ablation: application of nurse methodology].

    PubMed

    Ramos-González-Serna, Amelia; Mateos-García, M Dolores

    2011-01-01

    Ablation of pulmonary veins for treatment of atrial fibrillation involves applying radiofrequency energy wave by a catheter that causes a circumferential lesion to achieve electrical isolation and voltage drop in the interior. It is mainly applied when there is resistance to treatment and recurrence of symptoms affecting the quality of life of patients. The nurse is an important part of the multidisciplinary team who care for patients who undergo this procedure. The provision of comprehensive nursing care should include nursing procedures prior to, during, and after treatment to ensure the careful and systematic quality required. The aims of this article are: to provide specialised knowledge on the procedure of atrial fibrillation ablation, to describe the preparation of the electrophysiology laboratory, analyse nursing care and develop a standardized care plan for patients on whom this procedure is performed using the NANDA (North American Nursing Association) taxonomy and NIC (Nursing Intervention Classification).

  8. Clinical Significance of Additional Ablation of Atrial Premature Beats after Catheter Ablation for Atrial Fibrillation

    PubMed Central

    Kim, In-Soo; Yang, Pil-Sung; Kim, Tae-Hoon; Park, Junbeum; Park, Jin-Kyu; Uhm, Jae Sun; Joung, Boyoung; Lee, Moon Hyoung

    2016-01-01

    Purpose The clinical significance of post-procedural atrial premature beats immediately after catheter ablation for atrial fibrillation (AF) has not been clearly determined. We hypothesized that the provocation of immediate recurrence of atrial premature beats (IRAPB) and additional ablation improves the clinical outcome of AF ablation. Materials and Methods We enrolled 200 patients with AF (76.5% males; 57.4±11.1 years old; 64.3% paroxysmal AF) who underwent catheter ablation. Post-procedure IRAPB was defined as frequent atrial premature beats (≥6/min) under isoproterenol infusion (5 µg/min), monitored for 10 min after internal cardioversion, and we ablated mappable IRAPBs. Post-procedural IRAPB provocations were conducted in 100 patients. We compared the patients who showed IRAPB with those who did not. We also compared the IRAPB provocation group with 100 age-, sex-, and AF-type-matched patients who completed ablation without provocation (No-Test group). Results 1) Among the post-procedural IRAPB provocation group, 33% showed IRAPB and required additional ablation with a longer procedure time (p=0.001) than those without IRAPB, without increasing the complication rate. 2) During 18.0±6.6 months of follow-up, the patients who showed IRAPB had a worse clinical recurrence rate than those who did not (27.3% vs. 9.0%; p=0.016), in spite of additional IRAPB ablation. 3) However, the clinical recurrence rate was significantly lower in the IRAPB provocation group (15.0%) than in the No-Test group (28.0%; p=0.025) without lengthening of the procedure time or raising complication rate. Conclusion The presence of post-procedural IRAPB was associated with a higher recurrence rate after AF ablation. However, IRAPB provocation and additional ablation might facilitate a better clinical outcome. A further prospective randomized study is warranted. PMID:26632385

  9. Clinical Significance of Additional Ablation of Atrial Premature Beats after Catheter Ablation for Atrial Fibrillation.

    PubMed

    Kim, In Soo; Yang, Pil Sung; Kim, Tae Hoon; Park, Junbeum; Park, Jin Kyu; Uhm, Jae Sun; Joung, Boyoung; Lee, Moon Hyoung; Pak, Hui Nam

    2016-01-01

    The clinical significance of post-procedural atrial premature beats immediately after catheter ablation for atrial fibrillation (AF) has not been clearly determined. We hypothesized that the provocation of immediate recurrence of atrial premature beats (IRAPB) and additional ablation improves the clinical outcome of AF ablation. We enrolled 200 patients with AF (76.5% males; 57.4±11.1 years old; 64.3% paroxysmal AF) who underwent catheter ablation. Post-procedure IRAPB was defined as frequent atrial premature beats (≥6/min) under isoproterenol infusion (5 μg/min), monitored for 10 min after internal cardioversion, and we ablated mappable IRAPBs. Post-procedural IRAPB provocations were conducted in 100 patients. We compared the patients who showed IRAPB with those who did not. We also compared the IRAPB provocation group with 100 age-, sex-, and AF-type-matched patients who completed ablation without provocation (No-Test group). 1) Among the post-procedural IRAPB provocation group, 33% showed IRAPB and required additional ablation with a longer procedure time (p=0.001) than those without IRAPB, without increasing the complication rate. 2) During 18.0±6.6 months of follow-up, the patients who showed IRAPB had a worse clinical recurrence rate than those who did not (27.3% vs. 9.0%; p=0.016), in spite of additional IRAPB ablation. 3) However, the clinical recurrence rate was significantly lower in the IRAPB provocation group (15.0%) than in the No-Test group (28.0%; p=0.025) without lengthening of the procedure time or raising complication rate. The presence of post-procedural IRAPB was associated with a higher recurrence rate after AF ablation. However, IRAPB provocation and additional ablation might facilitate a better clinical outcome. A further prospective randomized study is warranted.

  10. Radiofrequency catheter ablation of atrial fibrillation guided by spectral mapping of atrial fibrillation nests in sinus rhythm.

    PubMed

    Mateos, José Carlos Pachón; Mateos, Enrique I Pachón; Lobo, Tasso J; Pachón, Maria Zélia C; Mateos, Juán Carlos Pachón; Pachón, Denilda Queiroz V; Vargas, Remy Nelson A; Piegas, Leopoldo S; Jatene, Adib D

    2007-09-01

    Two types of myocardia can be observed through the endocardial spectral mapping (SM) in sinus rhythm: the compact type with a smooth spectrum and the fibrillar type with a segmented spectrum (atrial fibrillation nests). During the atrial fibrillation (AF), the compact type has an organized activation and low frequency (passive), whereas the fibrillar type has a rather disorganized activation and high frequency (active/resonant), with both being activated by high-frequency sustained tachycardia--the background tachycardia (BT). To describe the treatment of AF by the ablation of the AF nests and BT. 1) Catheter ablation of the AF nests with RF [4/8 mm-60 masculine/30-40 J/30s] guided by SM in sinus rhythm, outside the pulmonary vein; 2) atrial stimulation -300 ppm; 3) Additional ablation of the AF nests if AF is induced; 4) Focal ablation if BT and/or Flutter is induced; 5) Clinical follow-up+ ECG+ Holter. A total of 50+/-18 AF nests/patient were treated. After 11.3+/-8 m, 81 patients (88%) did not present AF (28.3% with antiarrhythmic drugs). After the ablation of the AF nests, AF was not reinduced in 61 patients (71%) and BT was induced and treated in 24 patients (26%). There were two episodes of pericardial bleeding (1 treated clinically and 1 surgically), caused by sheaths that are no longer used The SM in sinus rhythm can be used in the ablation of AF nests. During the AF, the AF nests present a reactive-resonant pattern and the compact myocardium is passive, stimulated by the high frequency of the BT. After the ablation of the AF nests and the BT, it was not possible to reinduce the sustained AF. The Ablation of AF nests outside the pulmonary veins showed to be safe and highly effective in the cure and/or clinical control of the AF.

  11. Noninvasive mapping to guide atrial fibrillation ablation.

    PubMed

    Lim, Han S; Zellerhoff, Stephan; Derval, Nicolas; Denis, Arnaud; Yamashita, Seigo; Berte, Benjamin; Mahida, Saagar; Hooks, Darren; Aljefairi, Nora; Shah, Ashok J; Sacher, Frédéric; Hocini, Meleze; Jais, Pierre; Haissaguerre, Michel

    2015-03-01

    Atrial fibrillation (AF) is a dynamic rhythm. Noninvasive mapping overcomes many previous barriers to mapping such a dynamic rhythm, by providing a beat-to-beat, biatrial, panoramic view of the AF process. Catheter ablation of AF drivers guided by noninvasive mapping has yielded promising clinical results and has advanced understanding of the underlying pathophysiologic processes of this common heart rhythm disorder. Copyright © 2015 Elsevier Inc. All rights reserved.

  12. [The effectiveness and safety of d,l-sotalol in the ambulatory treatment of atrial fibrillation and flutter].

    PubMed

    Cruz Cruz, F; Iturralde Torres, P; Picos Bovio, E; Medeiros Domingo, A; Infante Vázquez, O

    1998-01-01

    Data on short and long term efficacy and safety of d,l sotalol in patients with atrial fibrillation or atrial flutter is limited. The aims of this study were to (1) assess the antiarrhythmic efficacy of d,l sotalol maintaining normal sinus rhythm in patients with refractory atrial fibrillation or flutter, (2) evaluate the efficacy of d,l sotalol in preventing recurrences of paroxysmal atrial fibrillation or flutter, (3) evaluate the control of ventricular rate in patients with paroxysmal or refractory atrial fibrillation or flutter unsuccessfully treated with other antiarrhythmic agents, (4) determine predictors of efficacy (5) assess the safety of d,l sotalol in this setting. Two hundred patients with chronic or paroxysmal atrial fibrillation or atrial flutter or both, who had failed one to six previous antiarrhythmic drug trials were treated with d,l sotalol 80 to 440 mg/day orally. Fifty four percent was female, age 47 +/- 16 years (range 7-79), follow up period 7 +/- 7 months (range 1 to 14 months), 79% of patients had the arrhythmia for more than one year. The atrial fibrillation in 37.5% of patients was chronic and paroxysmal in 23.5. The atrial flutter was chronic in 31% of patients and paroxysmal in 8%. Eighty two percent of patients was in functional class I (NYHA) and 82% had cardiac heart disease: left atrial (LA) size 44 +/- 10 mm, right atrial (RA) size 37 +/- 7 mm and left ventricular ejection fraction (LVEF) 58 +/- 8%. Total success was achieved in 58% of patients (atrial fibrillation 40% and 18% in atrial flutter), partial success in 38% (atrial fibrillation in 18% and 20% in atrial flutter) and 4% of patients failure. It was p < 0.07 when compared total success vs partial success among atrial fibrillation and atrial flutter groups. Patients with cardiac heart disease responded worst (p = 0.10) to the drug than those without it, specially if the heart was dilated. We concluded that d,l sotalol has moderate efficacy to convert and maintain normal

  13. Mapping techniques for atrial fibrillation ablation.

    PubMed

    Sra, Jasbir; Akhtar, Masood

    2007-12-01

    Atrial fibrillation (AF) is a common arrhythmia. Although significant work still needs to be done, recent advances in understanding the mechanism of AF have led to the development of elegant catheter mapping techniques for ablation of AF. These improved mapping techniques are complemented by an evolution in various imaging and navigational technologies, several of which can now be combined in a process called registration, so that the physician no longer needs to rely solely on a mental image of the anatomy of the left atrium and the pulmonary vein while attempting to ablate the region. Ongoing advances in mapping technique will increase safety and efficacy and it is likely that AF ablation will become the first-line therapy in most patients with this complicated arrhythmia.

  14. Frequency and significance of right atrial appendage thrombi in patients with persistent atrial fibrillation or atrial flutter.

    PubMed

    Cresti, Alberto; García-Fernández, Miguel Angel; Miracapillo, Gennaro; Picchi, Andrea; Cesareo, Francesca; Guerrini, Francesco; Severi, Silva

    2014-11-01

    Atrial fibrillation (AF) and atrial flutter (AFL) are strong atrial thrombosis (THR) risk factors. In recent-onset tachyarrhythmias, the incidence of left atrial appendage (LAA) THR, detected by transesophageal echocardiography (TEE), has been widely studied, ranging from 6% to 18% (AF) and 4% to 11% (AFL). On the contrary, few studies have assessed right atrial appendage (RAA) THR, and there is no information on the relation between the RAA flow characteristics and the presence of RAA THR. The aims of this study were to evaluate the incidence of RAA THR in a population of patients undergoing TEE-guided cardioversion for recent-onset atrial tachyarrhythmias and to analyze RAA Doppler flow and its relation to thrombus formation. From 1998 to 2012, patients admitted to the emergency department for persistent, non-self-terminating atrial tachyarrhythmia lasting >2 days who gave informed consent for TEE-guided cardioversion were prospectively enrolled in the study. Among 1,042 patients, complete anatomic and functional studies of the LAA and RAA were feasible in 983 (AF, n = 810 [23%]; AFL, n = 173 [5%]). The presence of RAA and LAA THR, appendage emptying velocities, and the presence of severe spontaneous echocardiographic contrast were studied. The overall incidence of atrial THR was 9.7% (96 of 983). The incidence of THR was 9.3% (91 of 983) in the LAA and 0.73% (seven of 983) in the RAA (P < .01). In the AF and AFL groups, the incidence of LAA THR was 10.3% (83 of 805), compared with 0.75% (six of 805) for RAA THR (P < .01). Among patients with AFL, the incidence of LAA THR was 6% (10 of 178), compared with 0.6% (one of 178) for RAA THR (P < .01). The mean LAA peak emptying velocity was 24 cm/sec (range, 10-32 cm/sec) in patients with LAA THR, compared with 38 cm/sec (range, 20-59 cm/sec) in those without THR; the mean RAA peak emptying velocity was 17 ± 7 cm/sec in patients with RAA THR, compared with 34 ± 13 cm/sec in those without THR (P

  15. The sawtooth EKG pattern of typical atrial flutter is not related to slow conduction velocity at the cavotricuspid isthmus.

    PubMed

    Sau, Arunashis; Sikkel, Markus B; Luther, Vishal; Wright, Ian; Guerrero, Fernando; Koa-Wing, Michael; Lefroy, David; Linton, Nicholas; Qureshi, Norman; Whinnett, Zachary; Lim, Phang Boon; Kanagaratnam, Prapa; Peters, Nicholas S; Davies, D Wyn

    2017-08-22

    We hypothesized that very high-density mapping of typical atrial flutter (AFL) would facilitate a more complete understanding of its circuit. Such very high-density mapping was performed with the Rhythmia(TM) (Boston Scientific) mapping system using its 64 electrode basket catheter. Data were acquired from 13 patients in AFL. Functional anatomy of the right atrium (RA) was readily identified during mapping including the Crista Terminalis and Eustachian ridge. The leading edge of the activation wavefront was identified without interruption and its conduction velocity (CV) was calculated. CV was not different at the cavotricuspid isthmus (CTI) compared to the remainder of the RA (1.02 vs. 1.03 m/s, P = 0.93). The sawtooth pattern of the surface electrocardiogram (EKG) flutter waves was compared to the position of the dominant wavefront. The downslope of the surface EKG flutter waves represented on average 73% ± 9% of the total flutter cycle length. During the downslope, the activation wavefront traveled significantly further than during the upslope (182 ± 21 milliseconds vs. 68 ± 29 milliseconds, P < 0.0001) with no change in CV between the two phases (0.88 vs. 0.91 m/s, P = 0.79). CV at the CTI is not slower than other RA regions during typical AFL. The gradual downslope of the sawtooth EKG  is not due to slow conduction at the CTI suggesting that success of ablation at this site relates to anatomical properties rather than the presence of a "slow isthmus." © 2017 Wiley Periodicals, Inc.

  16. Radiofrequency Ablation of Left Atrial Reentrant Tachycardias in Rheumatic Mitral Valve Disease: A Case Series.

    PubMed

    Prabhu, Mukund A; Thajudeen, Anees; Vk, Ajit Kumar; J, Tharakan; B V, Prasad Srinivas; Namboodiri, Narayanan

    2017-01-01

    Left atrial (LA) reentrant tachycardias are not uncommon in regions where rheumatic heart disease is prevalent. Some of these arrhythmias may be curable by radiofrequency ablation (RFA). However, there are limited data pertaining to this in existing literature. Three patients who had rheumatic mitral valve disease with past history of surgical-/catheter-based intervention and having no significant residual disease had symptomatic atrial flutter despite optimal medical management. An electrophysiological study confirmed an LA focal/micro-reentrant mechanism in all. There was patchy scarring of the LA, and successful RFA of these arrhythmias could be achieved. The focal nature of the scar in these patients may suggest that the rheumatic involvement of the atrium or the hemodynamic consequence of the vulvar lesion causes nonuniform insult to the atrial tissue and limited scar. At least in some patients with limited scarring, early RFA may help in the maintenance of sinus rhythm. © 2016 Wiley Periodicals, Inc.

  17. Successful treatment of atrial flutter by repeated intraperitoneal and intra-amniotic injections of amiodarone in a fetus with hydrops.

    PubMed

    Lin, Pei-Hsuan; Wu, Hsin-Hung; Tsai, Horng-Der; Hsieh, Charles Tsung-Che

    2016-06-01

    We report a case of nonimmune hydrops fetalis caused by atrial flutter, which was successfully treated by intraperitoneal and intra-amniotic injections of amiodarone. A 27-year-old woman presented at 30 weeks of pregnancy with hydrops fetalis caused by a fetal atrial flutter. As the transplacental passage of antiarrhythmic agents is impaired in hydrops fetalis, we chose direct treatment using fetal intraperitoneal and intra-amniotic injections (75-300 mg) of amiodarone. We managed to successfully convert the fetal atrial flutter to normal sinus rhythm. The woman delivered a live female baby at 33 weeks of gestation with normal sinus rhythm and neurological development. Intrauterine antiarrhythmic treatment can reduce perinatal morbidity and mortality. This report suggests that direct fetal therapy using intraperitoneal or intra-amniotic injections of amiodarone constitutes an effective treatment for atrial flutter in cases of hydrops fetalis. Copyright © 2016. Published by Elsevier B.V.

  18. Maternal antibody-associated fetal second-degree heart block and atrial flutter: case report and review.

    PubMed

    Sacks, Jeffrey H; Samai, Cyrus; Gomez, Kevin; Kanaan, Usama

    2013-01-01

    Exposure to maternal anti-Ro (SS-A) and anti-La (SS-B) antibodies is a well-described risk factor for the development of fetal atrioventricular (AV) block. The role of maternal fluorinated steroids in the treatment and prevention of antibody-mediated fetal AV block is controversial. Fetal atrial flutter has rarely been described in association with maternal antibodies. This report describes a case of fetal exposure to maternal anti-Ro antibodies with associated second-degree AV block and atrial flutter. Interestingly, the reported patient had 2:1 AV conduction during both normal atrial rates (consistent with AV node conduction disease) and episodes of flutter (consistent with physiologic AV node functionality). The fetus was treated with transplacental digoxin and dexamethasone, which resolved both rhythm disturbances. The case report is followed by a brief discussion of AV block and atrial flutter associated with maternal antibody exposure.

  19. Approaches to catheter ablation for persistent atrial fibrillation.

    PubMed

    Verma, Atul; Jiang, Chen-yang; Betts, Timothy R; Chen, Jian; Deisenhofer, Isabel; Mantovan, Roberto; Macle, Laurent; Morillo, Carlos A; Haverkamp, Wilhelm; Weerasooriya, Rukshen; Albenque, Jean-Paul; Nardi, Stefano; Menardi, Endrj; Novak, Paul; Sanders, Prashanthan

    2015-05-07

    Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation. Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation. We randomly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone (67 patients), pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity (263 patients), or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus (259 patients). The duration of follow-up was 18 months. The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure. Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures (P<0.001). After 18 months, 59% of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation, as compared with 49% of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46% of patients assigned to pulmonary-vein isolation plus linear ablation (P=0.15). There were also no significant differences among the three groups for the secondary end points, including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia. Complications included tamponade (three patients), stroke or transient ischemic attack (three patients), and atrioesophageal fistula (one patient). Among patients with persistent atrial fibrillation, we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT01203748.).

  20. Achieving Bidirectional Long Delays In Pulmonary Vein Antral Lines Prior To Bidirectional Block In Patients With Paroxysmal Atrial Fibrillation (The Bi-Bi Technique For Atrial Fibrillation Ablation).

    PubMed

    Mina Md Facc Fhrs, Adel F; L Warnecke Pa-C, Nicholas

    2016-01-01

    Background: Pulmonary Vein Antral isolation (PVAI) is currently the standard of care for both paroxysmal and persistent atrial fibrillation ablation. Reconnection to the pulmonary vein is the most common cause of recurrence of atrial fibrillation. Achieving the endpoint of bidirectional block (BDB) for cavotricuspid isthmus dependant flutter has improved our outcomes for atrial flutter ablation. With this we tried to achieve long delays in the pulmonary veins antral lines prior to complete isolation comparable to those delays found in patient with bidirectional block of atrial flutter lines. Study Objective:The objective of this paper was to evaluate feasibility and efficacy of achieving Bidirectional long delays in pulmonary vein antral lines prior to Bidirectional Block in patient with paroxysmal atrial fibrillation. Method: A retrospective analysis was performed on patients who had paroxysmal atrial fibrillation procedures at Unity Point Methodist from January 2015 to January 2016. 20 consecutive patients with paroxysmal atrial fibrillation who had AF ablation using the Bi-Bi technique were evaluated. Result: Mean age was 63, number of antiarrhythmic used prior to ablation was 1.4, mean left atrial size was 38 mm. Mean chads score was 1.3. Mean EF was 53%. Long delays in the left antral circumferential lines were achieved with mean delay of 142 milliseconds +/-100. Also long delays in the right antral circumferential lines were achieved with mean delay of 150 milliseconds +/-80. 95 % (19/20) of patients were free of any atrial arrhythmias and were off antiarrhythmic medications for AF post procedure. There was only one transient complication in one patient who developed a moderate pericardial effusion that was successfully drained with no hemodynamic changes. The only patient who had recurrence was found to have asymptomatic AF with burden on his device <1%, this patient was also found to have non PV triggers for his AF. In patients with only PV triggered AF

  1. The efficacy of pad placement for electrical cardioversion of atrial fibrillation/flutter: a systematic review.

    PubMed

    Kirkland, Scott; Stiell, Ian; AlShawabkeh, Tariq; Campbell, Sandy; Dickinson, Garth; Rowe, Brian H

    2014-07-01

    Electrical cardioversion is commonly used to treat patients with atrial fibrillation and atrial flutter to restore normal sinus rhythm. There has been considerable debate as to whether the electrode placement affects the efficacy of electrical cardioversion. The objective of this study was to examine the effectiveness of anteroposterior (A-P) versus anterolateral (A-L) electrode placement to restore normal sinus rhythm. A search of eight electronic databases, including Medline, EMBASE, CINAHL, and Cochrane was completed. Grey literature (hand-searching, Google, and SCOPUS) searching was also conducted. Studies were included if they were controlled clinical trials comparing the effectiveness of A-P versus A-L pad placement to restore normal sinus rhythm in adult patients with atrial fibrillation and flutter. Two independent reviewers judged study relevance, inclusion, and quality (e.g., risk of bias). Individual and pooled statistics were calculated as relative risks (RRs) with 95% confidence intervals (CIs) using a random-effects model, and heterogeneity (I(2) ) was reported. From 788 citations, 13 studies were included; seven involved monophasic, five involved biphasic, and one analyzed both waveform devices. The included studies tended to report cumulative success rates to restoring normal sinus rhythm after one to five sequential shocks of increasing energy; the number of shocks and energy used differed among studies. The risk of bias of the studies was "unclear." After the first shock, pad placement was not associated with an increased likelihood of restoring normal sinus rhythm (RR = 0.88; 95% CI = 0.73 to 1.06); however, heterogeneity was high (I(2) = 63%). Subgroup comparisons revealed that the A-L position was more effective (RR = 0.77; 95% CI = 0.59 to 1.00) at restoring normal sinus rhythm when using biphasic shocks (comparison p = 0.04). Overall, the pooled results failed to identify a difference between A-P and A-L pad placement in restoring normal

  2. Active Atrial Function and Atrial Scar Burden After Multiple Catheter Ablations of Persistent Atrial Fibrillation.

    PubMed

    Nührich, Jana M; Geisler, Anne C; Steven, Daniel; Hoffmann, Boris A; Schäffer, Benjamin; Lund, Gunnar; Stehning, Christian; Radunski, Ulf K; Sultan, Arian; Schwarzl, Michael; Adam, Gerhard; Willems, Stephan; Muellerleile, Kai

    2017-02-01

    Extensive and repeated substrate modification (SM) is frequently performed as an ablation strategy in persistent atrial fibrillation (persAF). The effect of these extended ablation strategies on atrial function has not been investigated sufficiently so far. The purpose was to assess atrial function by cardiac magnetic resonance (CMR) and its association with left atrial (LA) scar burden by electroanatomical voltage-mapping after multiple persAF ablation procedures. We included 16 persAF patients who had ≥2 SM procedures and a control group (CG) of 21 persAF patients without prior ablation. CMR was performed in sinus rhythm at least 4 weeks after the last cardioversion. Active left and right (RA) atrial emptying fractions (AEF) as well as peak active left atrial appendage (LAA) emptying velocities were obtained by CMR flow measurements. Furthermore, LA scar burden was quantified on electroanatomical voltage maps by the portion of points with local voltage amplitude <0.2 mV. We found median LA-AEF to be lower (13 [9-22] vs 32 [26-36] %, P < 0.001) and median LA scar burden to be higher (40 [20-68] vs nine [3-18] %, P < 0.05) in the SM group compared with the CG. Furthermore, a significant correlation was found between mean LA voltage and LA-AEF (r(2) = 0.62, P < 0.001). No significant differences were detected with respect to median RA-AEF (41 [28-48] vs 47 [35-50] %, P = 0.43) and median peak LAA emptying velocities (30 [16-40] vs 17 [13-28] cm/s, P = 0.07). Active LA function is preserved but significantly impaired and associated with ablation-related LA scar burden after multiple extensive persAF ablations. ©2016 Wiley Periodicals, Inc.

  3. Atrial fibrillation ablation using a closed irrigation radiofrequency ablation catheter.

    PubMed

    Golden, Keith; Mounsey, John Paul; Chung, Eugene; Roomiani, Pahresah; Morse, Michael Andew; Patel, Ankit; Gehi, Anil

    2012-05-01

    Catheter ablation is an effective therapy for symptomatic, medically refractory atrial fibrillation (AF). Open-irrigated radiofrequency (RF) ablation catheters produce transmural lesions at the cost of increased fluid delivery. In vivo models suggest closed-irrigated RF catheters create equivalent lesions, but clinical outcomes are limited. A cohort of 195 sequential patients with symptomatic AF underwent stepwise AF ablation (AFA) using a closed-irrigation ablation catheter. Recurrence of AF was monitored and outcomes were evaluated using Kaplan-Meier survival analysis and Cox proportional hazards models. Mean age was 59.0 years, 74.9% were male, 56.4% of patients were paroxysmal and mean duration of AF was 5.4 years. Patients had multiple comorbidities including hypertension (76.4%), tobacco abuse (42.1%), diabetes (17.4%), and obesity (mean body mass index 30.8). The median follow-up was 55.8 weeks. Overall event-free survival was 73.6% with one ablation and 77.4% after reablation (reablation rate was 8.7%). Median time to recurrence was 26.9 weeks. AF was more likely to recur in patients being treated with antiarrhythmic therapy at the time of last follow-up (recurrence rate 30.3% with antiarrhythmic drugs, 13.2% without antiarrhythmic drugs; hazard ratio [HR] 2.2, 95% confidence interval [CI] 1.1-4.4, P = 0.024) and in those with a history of AF greater than 2 years duration (HR 2.7, 95% CI 1.1-6.9, P = 0.038). Our study represents the largest cohort of patients receiving AFA with closed-irrigation ablation catheters. We demonstrate comparable outcomes to those previously reported in studies of open-irrigation ablation catheters. Given the theoretical benefits of a closed-irrigation system, a large head-to-head comparison using this catheter is warranted. ©2012, The Authors. Journal compilation ©2012 Wiley Periodicals, Inc.

  4. [Neonatal atrial flutter after the insertion of an intracardiac umbilical venous catheter].

    PubMed

    de Almeida, Marcos Moura; Tavares, Wládia Gislaynne de Sousa; Furtado, Maria Mônica Alencar Araripe; Fontenele, Maria Marcia Farias Trajano

    2016-01-01

    To describe a case of neonatal atrial flutter after the insertion of an intracardiac umbilical venous catheter, reporting the clinical presentation and reviewing the literature on this subject. A late-preterm newborn, born at 35 weeks of gestational age to a diabetic mother and large for gestational age, with respiratory distress and rule-out sepsis, required an umbilical venous access. After the insertion of the umbilical venous catheter, the patient presented with tachycardia. Chest radiography showed that the catheter was placed in the position that corresponds to the left atrium, and traction was applied. The patient persisted with tachycardia, and an electrocardiogram showed atrial flutter. As the patient was hemodynamically unstable, electric cardioversion was successfully applied. The association between atrial arrhythmias and misplaced umbilical catheters has been described in the literature, but in this case, it is noteworthy that the patient was an infant born to a diabetic mother, which consists in another risk factor for heart arrhythmias. Isolated atrial flutter is a rare tachyarrhythmia in the neonatal period and its identification is essential to establish early treatment and prevent systemic complications and even death. Copyright © 2015 Sociedade de Pediatria de São Paulo. Publicado por Elsevier Editora Ltda. All rights reserved.

  5. Atrial flutter with 1:1 conduction in undiagnosed Wolff-Parkinson-White syndrome.

    PubMed

    Nelson, Jessie G; Zhu, Dennis W

    2014-05-01

    Atrial flutter with 1:1 atrioventricular conduction via an accessory pathway is an uncommon presentation of Wolff-Parkinson-White syndrome not previously reported in the emergency medicine literature. Wolff-Parkinson-White syndrome, a form of ventricular preexcitation sometimes initially seen and diagnosed in the emergency department (ED), can present with varied tachydysrhythmias for which certain treatments are contraindicated. For instance, atrial fibrillation with preexcited conduction needs specific consideration of medication choice to avoid potential degeneration into ventricular fibrillation. We describe an adult female presenting with a very rapid, regular wide complex tachycardia successfully cardioverted in the ED followed by a normal electrocardiogram (ECG). Electrophysiology study confirmed atrial flutter with 1:1 conduction and revealed an accessory pathway consistent with Wolff-Parkinson-White syndrome, despite lack of ECG findings of preexcitation during sinus rhythm. Why should an emergency physician be aware of this? Ventricular tachycardia must be the first consideration in patients with regular wide complex tachycardia. However, clinicians should consider atrial flutter with 1:1 conduction related to an accessory pathway when treating patients with the triad of very rapid rate (>250 beats/min), wide QRS complex, and regular rhythm, especially when considering pharmacologic treatment. Emergency physicians also should be aware of electrocardiographically concealed accessory pathways, and that lack of delta waves does not rule out preexcitation syndromes such as Wolff-Parkinson-White syndrome. Copyright © 2014 Elsevier Inc. All rights reserved.

  6. Neonatal atrial flutter after insertion of an intracardiac umbilical venous catheter

    PubMed Central

    de Almeida, Marcos Moura; Tavares, Wládia Gislaynne de Sousa; Furtado, Maria Mônica Alencar Araripe; Fontenele, Maria Marcia Farias Trajano

    2016-01-01

    Abstract Objective: To describe a case of neonatal atrial flutter after the insertion of an intracardiac umbilical venous catheter, reporting the clinical presentation and reviewing the literature on this subject. Case description: A late-preterm newborn, born at 35 weeks of gestational age to a diabetic mother and large for gestational age, with respiratory distress and rule-out sepsis, required an umbilical venous access. After the insertion of the umbilical venous catheter, the patient presented with tachycardia. Chest radiography showed that the catheter was placed in the position that corresponds to the left atrium, and traction was applied. The patient persisted with tachycardia, and an electrocardiogram showed atrial flutter. As the patient was hemodynamically unstable, electric cardioversion was successfully applied. Comments: The association between atrial arrhythmias and misplaced umbilical catheters has been described in the literature, but in this case, it is noteworthy that the patient was an infant born to a diabetic mother, which consists in another risk factor for heart arrhythmias. Isolated atrial flutter is a rare tachyarrhythmia in the neonatal period and its identification is essential to establish early treatment and prevent systemic complications and even death. PMID:26525686

  7. Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison.

    PubMed

    Pokushalov, Evgeny; Romanov, Alexandr; Katritsis, Demosthenes G; Artyomenko, Sergey; Shirokova, Natalya; Karaskov, Alexandr; Mittal, Suneet; Steinberg, Jonathan S

    2013-09-01

    The optimal ablation technique for persistent and long-standing persistent atrial fibrillation (AF) is unclear. Both linear lesion (LL) and ganglionated plexus (GP) ablation have been used in addition to pulmonary vein isolation (PVI), but no direct comparison of the 2 methods exists. The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-standing persistent AF. Two hundred sixty-four consecutive patients with persistent/long-standing persistent AF were randomly assigned to 2 different ablation schemes: PVI+LL (n = 132) and PVI+GP (n = 132) ablation. Consistent sinus rhythm (SR) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device. All procedural end points were acutely achieved. At 12 months after a single procedure, 47% of the patients treated with PVI+LL were in SR compared to 54% of the patients treated with PVI+GP (P = .29). At 3 years, 34% of the patients with PVI+LL and 49% of the patients with PVI+GP maintained SR (P = .035). Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group (18% vs 6%; P = .002). After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group, the long-term overall success rate was 52% and 68%, respectively (P = .006). PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up. © 2013 Heart Rhythm Society. All rights reserved.

  8. 78 FR 11207 - Clinical Study Designs for Surgical Ablation Devices for Treatment of Atrial Fibrillation...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-02-15

    ... Treatment of Atrial Fibrillation; Guidance for Industry and Food and Drug Administration Staff; Availability... Ablation Devices for Treatment of Atrial Fibrillation.'' This guidance provides FDA's recommendations on clinical trial designs for surgical ablation devices intended for the treatment of atrial...

  9. Lessons from computer simulations of ablation of atrial fibrillation

    PubMed Central

    2016-01-01

    Abstract This paper reviews the simulations of catheter ablation in computer models of the atria, from the first attempts to the most recent anatomical models. It describes how postulated substrates of atrial fibrillation can be incorporated into mathematical models, how modelling studies can be designed to test ablation strategies, what their current trade‐offs and limitations are, and what clinically relevant lessons can be learnt from these simulations. Drawing a parallel between clinical and modelling studies, six ablation targets are considered: pulmonary vein isolation, linear ablation, ectopic foci, complex fractionated atrial electrogram, rotors and ganglionated plexi. The examples presented for each ablation target illustrate a major advantage of computer models, the ability to identify why a therapy is successful or not in a given atrial fibrillation substrate. The integration of pathophysiological data to create detailed models of arrhythmogenic substrates is expected to solidify the understanding of ablation mechanisms and to provide theoretical arguments supporting substrate‐specific ablation strategies. PMID:26846178

  10. Unanswered Questions in Complex Fractionated Atrial Electrogram Ablation.

    PubMed

    Aksu, Tolga; Guler, Tümer Erdem; Yalin, Kivanc; Oto, Ali

    2016-11-01

    Pulmonary vein isolation has been accepted as potential target for ablation of paroxysmal atrial fibrillation (AF) given that the pulmonary veins are the main source of AF triggers. However, ablation strategies for persistent AF are less well defined. Mapping and ablation of complex fractionated atrial electrograms (CFAEs) is one strategy that has been proposed as a strategy for substrate modification although there is no consensus on their definition and procedural end points. Results of clinical studies have been conflicting. In this review, we aimed to discuss yesterday, today, and tomorrow of CFAEs ablation in persistent AF ablation. © 2016 Wiley Periodicals, Inc.

  11. Effects of a novel class III antiarrhythmic agent, NIP-142, on canine atrial fibrillation and flutter.

    PubMed

    Nagasawa, Hidehiko; Fujiki, Akira; Fujikura, Naoki; Matsuda, Tomoyuki; Yamashita, Toru; Inoue, Hiroshi

    2002-02-01

    The effects of a new benzopyran derivative, NIP-142, on atrial fibrillation (AF) and flutter (AFL) and on electrophysiological variables were studied in the dog. NIP-142 (3mg/kg) was administered intravenously to pentobarbital-anesthetized beagles during vagally-induced AF and during AFL induced after placement of an intercaval crush. Isolated canine atrial tissues were studied using standard microelectrode technique. NIP-142 terminated AF in 5 of 6 dogs after an increase in fibrillation cycle length (CL) and prevented reinitiation of AF in all 6 dogs. NIP-142 terminated AFL in all 6 dogs without any appreciable change in flutter CL, and prevented reinitiation of AFL in all 6 dogs. NIP-142 prolonged atrial effective refractory periods (11+/-5%, 3+/-3%, 12+/-3%, and 10+/-5% from the baseline value at basic CLs of 150, 200, 300, and 350ms, respectively) without changes in intraatrial conduction time. The prolongation of the atrial effective refractory period was greater in the presence of vagal stimulation. NIP-142 decreased action potential phase-1 notch and increased phase-2 plateau height without making any changes in the action potential duration, although it did reverse carbachol-induced shortening of the action potential duration. In conclusion, NIP-142 is effective in treating AFL and vagally-induced AF by prolonging atrial refractoriness.

  12. Incidence, risk factors, and consequences of new-onset atrial fibrillation following epicardial ablation for ventricular tachycardia

    PubMed Central

    Mahapatra, Srijoy; LaPar, Damien J.; Bhamidipati, Castigliano M.; McDaniel, George; Kamath, Sandeep; Bunch, T. Jared; Ailawadi, Gorav

    2011-01-01

    Introduction We sought to determine the incidence, predictors, and consequences of new-onset atrial fibrillation (AF) following epicardial ventricular tachycardia (VT) ablation. Methods and results A total of 41 patients with no prior history of AF underwent epicardial VT ablation via a percutaneous subxiphoid approach. All patients were monitored continuously for 3 days following ablation and then via implantable cardiac defibrillator (ICD) or Holter monitoring. Mean age was 70.0 ± 11.3 years and mean ejection fraction was 30.3 ± 16.6%. In seven (17%) patients, the right ventricle (RV) was punctured during access with subsequent needle withdrawal without requiring surgical repair. Thirty patients (73%) were treated with amiodarone following ablation. Post-ablation, eight (19.5%) patients had documented new-onset AF within 7 days. All AF patients had clinical symptoms of pericarditis. One patient with AF was maintained on amiodarone post-procedure. Complications of AF included three patients who received inappropriate ICD shocks and one patient who developed a large, left atrial appendage clot. Acutely, all patients responded to short-term medical therapy or electrical cardioversion. At 18.0 ± 9.0 months of follow-up, no patient had recurrence of AF, and all were off antiarrhythmic drugs. One patient had typical atrial flutter requiring catheter ablation. Risk factors for AF included lack of amiodarone immediately after ablation (12.5 vs. 87.9%, P< 0.001), RV puncture (50.0 vs. 9.1%, P= 0.02), and epicardial ablation time >10 min (62.5 vs. 3.0%, P< 0.001). Conclusions Atrial fibrillation after epicardial ablation is common and can lead to ICD shocks and atrial thrombus formation. Short-term antiarrhythmic drug therapy and ICD reprogramming should be considered after epicardial VT ablation. PMID:21296778

  13. Assessment of atrial electromechanical interval using echocardiography after catheter ablation in patients with persistent atrial fibrillation

    PubMed Central

    Chen, Xiaodong; Chen, Minglong; Wang, Yingying; Yang, Bing; Ju, Weizhu; Zhang, Fengxiang; Cao, Kejiang

    2016-01-01

    Abstract We sought to investigate variation of atrial electromechanical interval after catheter ablation procedure in patients with persistent atrial fibrillation using pulse Doppler (PW) and pulse tissue Doppler imaging (PW-TDI). A total of 25 consecutive in-patients with persistent atrial fibrillation, who restored sinus rhythm after ablation procedure, were recruited in our cardiac center. Echocardiography was performed on each patient at 2 hours, 1 day, 5 days, 1 month and 3 months after the ablation therapy, and atrial electromechanical delay was measured simultaneously by PW and PW-TDI. There was no significant difference between PW and TDI in measuring atrial electromechanical delay. However, at postoperative 2 hours, peak A detection rates were mathematically but nonsignificantly greater by PW-TDI than by PW. Second, there was a significant decreasing trend in atrial electromechanical interval from postoperative 2 hours to 3 months, but only postoperative 2-hour atrial electromechanical interval was significantly greater than atrial electromechanical interval at other time. Lastly, patients without postoperative 2-hour atrial electromechanical interval had a significantly longer duration of atrial fibrillation as compared to those with postoperative 2-hour atrial electromechanical interval, by the PW or by PW-TDI, respectively. In patients with persistent atrial fibrillation, atrial electromechanical interval may decrease significantly within the first 24 hours after ablation but remain consistent later, and was significantly related to patients’ duration of atrial fibrillation. Atrial electromechanical interval, as a potential predicted factor, is recommended to be measured by either PW or TDI after 24 hours, when patients had recovered sinus rhythm by radiofrequency ablation. PMID:27924066

  14. Long-term outcome of electrical cardioversion in patients with chronic atrial flutter.

    PubMed Central

    Crijns, H. J.; Van Gelder, I. C.; Tieleman, R. G.; Brügemann, J.; De Kam, P. J.; Gosselink, A. T.; Bink-Boelkens, M. T.; Lie, K. I.

    1997-01-01

    OBJECTIVE: To determine the long-term outcome of serial electrical cardioversion therapy in patients with chronic atrial flutter. DESIGN: Prospective study, case series. SETTING: University hospital. PATIENTS: 50 consecutive patients with chronic (> 24 hours) atrial flutter without a previous relapse on antiarrhythmic drugs. INTERVENTIONS: Elective electrical cardioversion therapy, if necessary repeated, to obtain and keep patients in sinus rhythm. If the first cardioversion resulted in sinus rhythm, patients were not given antiarrhythmic drugs. Relapses were managed by repeated cardioversions then anti-arrhythmic drugs were used serially in a set sequence. MAIN OUTCOME MEASURE: Maintenance of sinus rhythm. RESULTS: Mean (SD) follow up was 3.5 (1.7) years. The first cardioversion was successful in 48 patients (96%). After a single shock and without antiarrhythmic drugs being used, 42% of the patients maintained sinus rhythm in the long-term. Only left atrial size was inversely related to the efficacy of one shock (P = 0.025). With serial cardioversion 90% of the patients were kept in sinus rhythm for 5 years. Univariate analysis showed that a long duration of arrhythmia and impaired cardiac function were both related to poor outcome. During follow up 3 patients died of progression of heart failure and another 5 died suddenly. None of these 5 patients was on antiarrhythmic drugs. CONCLUSIONS: Electrical cardioversion was an effective and safe method of converting chronic atrial flutter to sinus rhythm. To maintain sinus rhythm, more than half of the patients required multiple shocks and prophylactic antiarrhythmic drugs. Sudden death was relatively frequent in the study population; the limited data available from this study suggest that such deaths were caused by the underlying disease and not drug related proarrhythmia. PMID:9038696

  15. Biphasic versus monophasic shock for external cardioversion of atrial flutter: a prospective, randomized trial.

    PubMed

    Mortensen, Kai; Risius, Tim; Schwemer, Tjark F; Aydin, Muhammet Ali; Köster, Ralf; Klemm, Hanno U; Lutomsky, Boris; Meinertz, Thomas; Ventura, Rodolfo; Willems, Stephan

    2008-01-01

    External cardioversion is effective to terminate persistent atrial flutter. Biphasic shocks have been shown to be superior to monophasic shocks for ventricular defibrillation and atrial fibrillation cardioversion. The purpose of this trial was to compare the efficacy of rectilinear biphasic versus standard damped sine wave monophasic shocks in symptomatic patients with typical atrial flutter. 135 consecutive patients were screened, 95 (70 males, mean age 62 +/- 13 years) were included. Patients were randomly assigned to a monophasic or biphasic cardioversion protocol. Forty-seven patients randomized to the monophasic protocol received sequential shocks of 100, 150, 200, 300 and 360 J. Forty-eight patients with the biphasic protocol received 50, 75, 100, 150 or 200 J. First-shock efficacy with 50-Joule, biphasic shocks (23/48 patients, 48%) was significantly greater than with the 100-Joule, monophasic waveform (13/47 patients, 28%, p = 0.04). The cumulative second-shock efficacy with the 50- and 75-Joule, biphasic waveform (39/48 patients, 81%) was significantly greater than with the 100- and 150-Joule, monophasic waveform (25/47 patients, 53%, p < 0.05). The cumulative efficacy for the higher energy levels showed naturally no significant difference between the two groups. The amount of the mean delivered energy was significantly lower in the biphasic group (76 +/- 39 J) compared to the monophasic one (177 +/- 78 J, p < 0.05). For transthoracic cardioversion of typical atrial flutter, biphasic shocks have greater efficacy and the mean delivered current is lower than for monophasic shocks. Therefore, biphasic cardioversion with lower starting energies should be recommended. (c) 2008 S. Karger AG, Basel.

  16. Procedural Complications, Rehospitalizations, and Repeat Procedures After Catheter Ablation for Atrial Fibrillation

    PubMed Central

    Shah, Rashmee U.; Freeman, James V.; Shilane, David; Wang, Paul J.; Go, Alan S.; Hlatky, Mark A.

    2017-01-01

    Objectives The purpose of this study was to estimate rates and identify predictors of inpatient complications and 30-day readmissions, as well as repeat hospitalization rates for arrhythmia recurrence following atrial fibrillation (AF) ablation. Background AF is the most common clinically significant arrhythmia and is associated with increased morbidity and mortality. Radiofrequency or cryotherapy ablation of AF is a relatively new treatment option, and data on post-procedural outcomes in large general populations are limited. Methods Using data from the California State Inpatient Database, we identified all adult patients who underwent their first AF ablation from 2005 to 2008. We used multivariable logistic regression to identify predictors of complications and/or 30-day readmissions and Kaplan-Meier analyses to estimate rates of all-cause and arrhythmia readmissions. Results Among 4,156 patients who underwent an initial AF ablation, 5% had periprocedural complications, most commonly vascular, and 9% were readmitted within 30 days. Older age, female, prior AF hospitalizations, and less hospital experience with AF ablation were associated with higher adjusted risk of complications and/or 30-day readmissions. The rate of all-cause hospitalization was 38.5% by 1 year. The rate of readmission for recurrent AF, atrial flutter, and/or repeat ablation was 21.7% by 1 year and 29.6% by 2 years. Conclusions Periprocedural complications occurred in 1 of 20 patients undergoing AF ablation, and all-cause and arrhythmia-related rehospitalizations were common. Older age, female sex, prior AF hospitalizations, and recent hospital procedure experience were associated with a higher risk of complications and/or 30-day readmission after AF ablation. PMID:22222078

  17. Outcomes for Emergency Department Patients With Recent-Onset Atrial Fibrillation and Flutter Treated in Canadian Hospitals.

    PubMed

    Stiell, Ian G; Clement, Catherine M; Rowe, Brian H; Brison, Robert J; Wyse, D George; Birnie, David; Dorian, Paul; Lang, Eddy; Perry, Jeffrey J; Borgundvaag, Bjug; Eagles, Debra; Redfearn, Damian; Brinkhurst, Jennifer; Wells, George A

    2017-05-01

    Recent-onset atrial fibrillation and flutter are the most common arrhythmias managed in the emergency department (ED). We evaluate the management and 30-day outcomes for recent-onset atrial fibrillation and flutter patients in Canadian EDs, where cardioversion is commonly practiced. We conducted a prospective cohort study in 6 academic hospital EDs and enrolled patients who had atrial fibrillation and flutter onset within 48 hours. Patients were followed for 30 days by health records review and telephone. Adverse events included death, stroke, acute coronary syndrome, heart failure, subsequent admission, or ED electrocardioversion. We enrolled 1,091 patients with mean age 63.9 years, atrial fibrillation 84.7%, atrial flutter 15.3%, hospital admission 9.0%, and converted to sinus rhythm 80.1%. Although 10.5% of recent-onset atrial fibrillation and flutter patients had adverse events within 30 days, there were no related deaths and 1 stroke (0.1%). Adjusted odds ratios for factors associated with adverse event were hours from onset (1.03/hour; 95% confidence interval [CI] 1.01 to 1.05), history of stroke or transient ischemic attack (2.09; 95% CI 1.01 to 4.36), and pulmonary congestion on chest radiograph (7.37; 95% CI 2.40 to 22.64). Patients who left the ED in sinus rhythm were much less likely to experience an adverse event (P<.001). Although most recent-onset atrial fibrillation and flutter patients were treated aggressively in the ED, there were few 30-day serious outcomes. Physicians underprescribed oral anticoagulants. Potential risk factors for adverse events include longer duration from arrhythmia onset, previous stroke or transient ischemic attack, pulmonary congestion on chest radiograph, and not being in sinus rhythm at discharge. An ED strategy of sinus rhythm restoration and discharge in most patients is effective and safe. Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

  18. Pharmacological therapy following catheter ablation of atrial fibrillation.

    PubMed

    Rordorf, Roberto; Savastano, Simone; Gandolfi, Edoardo; Vicentini, Alessandro; Petracci, Barbara; Landolina, Maurizio

    2012-01-01

    Catheter ablation has been proven to be an effective treatment for patients with drug-resistant atrial fibrillation. Nevertheless its efficacy is limited to 60-80% of patients in different studies. Whether the use of pharmacological therapy after catheter ablation of atrial fibrillation might increase the procedural success rate is still a matter of debate. There is general agreement that antiarrhythmic drugs (AADs) are useful in the management of arrhythmias occurring in the very early period after catheter ablation (blanking period). On the contrary, limited data are available on the efficacy of AADs over a longer period. Some patients remain free of arrhythmia recurrences by the use of AADs that were ineffective before catheter ablation: whether this latter situation is to be considered a partial success of catheter ablation or a treatment failure, thus demanding a redo procedure, is still an open question. Some studies have also investigated the role of non-AADs [angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, statins and corticosteroids] in preventing atrial fibrillation recurrences after catheter ablation, reporting conflicting results. Whereas there is a general consensus on the use of anticoagulation therapy in the first phase after catheter ablation, no definite data are available on the proper long-term management of anticoagulation therapy after catheter ablation. This review focuses on the still open issue of what is the optimal pharmacological treatment of patients after catheter ablation of atrial fibrillation.

  19. Surgical ablation of atrial fibrillation during mitral-valve surgery.

    PubMed

    Gillinov, A Marc; Gelijns, Annetine C; Parides, Michael K; DeRose, Joseph J; Moskowitz, Alan J; Voisine, Pierre; Ailawadi, Gorav; Bouchard, Denis; Smith, Peter K; Mack, Michael J; Acker, Michael A; Mullen, John C; Rose, Eric A; Chang, Helena L; Puskas, John D; Couderc, Jean-Philippe; Gardner, Timothy J; Varghese, Robin; Horvath, Keith A; Bolling, Steven F; Michler, Robert E; Geller, Nancy L; Ascheim, Deborah D; Miller, Marissa A; Bagiella, Emilia; Moquete, Ellen G; Williams, Paula; Taddei-Peters, Wendy C; O'Gara, Patrick T; Blackstone, Eugene H; Argenziano, Michael

    2015-04-09

    Among patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited. We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring). More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P=0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P=0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P=0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions. The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the risk of implantation of a permanent pacemaker

  20. Surgical Ablation of Atrial Fibrillation during Mitral-Valve Surgery

    PubMed Central

    Gillinov, A. Marc; Gelijns, Annetine C.; Parides, Michael K.; DeRose, Joseph J.; Moskowitz, Alan J.; Voisine, Pierre; Ailawadi, Gorav; Bouchard, Denis; Smith, Peter K.; Mack, Michael J.; Acker, Michael A.; Mullen, John C.; Rose, Eric A.; Chang, Helena L.; Puskas, John D.; Couderc, Jean-Philippe; Gardner, Timothy J.; Varghese, Robin; Horvath, Keith A.; Bolling, Steven F.; Michler, Robert E.; Geller, Nancy L.; Ascheim, Deborah D.; Miller, Marissa A.; Bagiella, Emilia; Moquete, Ellen G.; Williams, Paula; Taddei-Peters, Wendy C.; O’Gara, Patrick T.; Blackstone, Eugene H.; Argenziano, Michael

    2015-01-01

    Background Among patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited. Methods We randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring). Results More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P = 0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P = 0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P = 0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions. Conclusions The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the

  1. Atorvastatin can ameliorate left atrial stunning induced by radiofrequency ablation for atrial fibrillation.

    PubMed

    Xie, Ruiqin; Yang, Yingtao; Cui, Wei; Yin, Hongning; Zheng, Hongmei; Zhang, Jidong; You, Ling

    2017-09-01

    The objective of this study was to study the functional changes of the left atrium after radiofrequency ablation treatment for atrial fibrillation and the therapeutic effect of atorvastatin. Fifty-eight patients undergoing radiofrequency ablation for atrial fibrillation were randomly divided into non-atorvastatin group and atorvastatin group. Patients in the atorvastatin group were treated with atorvastatin 20 mg p.o. per night in addition to the conventional treatment of atrial fibrillation; patients in the non-atorvastatin group received conventional treatment of atrial fibrillation only. Echocardiography was performed before radiofrequency ablation operation and 1 week, 2 weeks, 3 weeks, and 4 weeks after operation. Two-dimensional ultrasound speckle tracking imaging system was used to measure the structural indexes of the left atrium. Results indicated that there was no significant change for indexes representing the structural status of the left atrium within a month after radiofrequency ablation (P > 0.05); however, there were significant changes for indexes representing the functional status of the left atrium. There were also significant changes in indexes reflecting left atrial strain status: the S and SRs of atorvastatin group were higher than those of non-atorvastatin group (P < 0.05). In summary, atorvastatin could improve left atrial function and shorten the duration of atrial stunning after radiofrequency ablation of atrial fibrillation.

  2. Management of Atrio-Esophageal Fistula Following Left Atrial Ablation

    PubMed Central

    Yousuf, Tariq; Keshmiri, Hesam; Bulwa, Zachary; Kramer, Jason; Sharjeel Arshad, Hafiz Muhammad; Issa, Rasha; Woznicka, Daniel; Gordon, Paul; Abi-Mansour, Pierre

    2016-01-01

    Currently, no guidelines have been established for the treatment of atrio-esophageal fistula (AEF) secondary to left atrial ablation therapy. After comprehensive literature review, we aim to make suggestions on the management of this complex complication and also present a case series. We performed a review of the existing literature on AEF in the setting of atrial ablation. Using keywords atrial fibrillation, atrial ablation, fistula formation, atrio-esophageal fistula, complications, interventions, and prognosis, a search was made using the medical databases PUBMED and MEDLINE for reports in English from 2000 to April 2015. A statistical analysis was performed to compare the three different intervention arms: medical management, stent placement and surgical intervention. The results of our systematic review confirm the high mortality rate associated with AEF following left atrial ablation and the necessity to diagnose atrio-esophageal injury in a timely manner. The mortality rates of this complication are 96% with medical management alone, 100% with stent placement, and 33 % with surgical intervention. Atrio-esophageal injury and subsequent AEF is an infrequent but potentially fatal complication of atrial ablation. Early, prompt, and definitive surgical intervention is the treatment of choice. PMID:28197267

  3. Steerable sheath technology in the ablation of atrial fibrillation.

    PubMed

    Joseph, Jubin; Wong, Kelvin C K; Ginks, Matthew R; Bashir, Yaver; Betts, Timothy R; Rajappan, Kim

    2013-12-01

    Steerable sheaths have been shown to reduce procedure time in the catheter ablation of atrial fibrillation (AF), where catheter positioning and stability is typically challenging. This review critically addresses and highlights the recent developments in design of sheaths used to manipulate the ablation catheter and how these developments may impact on the ablation procedure itself, in particular the likelihood of first-time success. Patents relating to steerable sheaths are reviewed and discussed to gauge potential future developments in this area.

  4. Thermal distribution of microwave antenna for atrial fibrillation catheter ablation.

    PubMed

    Zhang, Huijuan; Nan, Qun; Liu, Youjun

    2013-09-01

    The aim of this study is to investigate the effects of ablation parameters on thermal distribution during microwave atrial fibrillation catheter ablation, such as ablation time, ablation power, blood condition and antenna placement, and give proper ablative parameters to realise transmural ablation. In this paper, simplified 3D antenna-myocardium-blood finite element method models were built to simulate the endocardial ablation operation. Thermal distribution was obtained based on the coupled electromagnetic-thermal analysis. Under different antenna placement conditions and different microwave power inputs within 60 s, the lesion dimensions (maximum depth, maximum width) of the ablation zones were analysed. The ablation width and depth increased with the ablation time. The increase rate significantly slowed down after 10 s. The maximum temperature was located in 1 mm under the antenna tip when perpendicular to the endocardium, while 1.5 mm away from the antenna axis and 26 mm along the antenna (with antenna length about 30 mm) in the myocardium when parallel to the endocardium. The maximum temperature in the ablated area decreased and the effective ablation area (with the temperature raised to 50°C) shifted deeper into the myocardium due to the blood cooling. The research validated that the microwave antenna can provide continuous long and linear lesions for the treatment of atrial fibrillation. The dimensions of the created lesion widths were all larger than those of the depths. It is easy for the microwave antenna to produce transmural lesions for an atrial wall thickness of 2-6 mm by adjusting the applied power and ablation time.

  5. Statin Use and Risk of Atrial Fibrillation or Flutter: A Population-based Case-Control Study.

    PubMed

    Veronese, Giacomo; Montomoli, Jonathan; Schmidt, Morten; Horváth-Puhó, Erzsébet; Sørensen, Henrik Toft

    2015-01-01

    The pleiotropic effects of statins have been suggested to prevent atrial fibrillation onset. We conducted a population-based case-control study using medical databases from Northern Denmark (population: 1.8 million) to examine the association between statin use and atrial fibrillation or flutter. We identified 51,374 patients with atrial fibrillation or flutter between 1999 and 2010 and 513,670 matched population controls. We collected data on statin prescriptions redeemed within 90 days (current users) or longer (former users) before the diagnosis date of atrial fibrillation or flutter. We stratified statin users by duration of exposure, determined by the number of days between first and last redeemed prescription before the diagnosis date (<365, 365-1094, and ≥1095 days). We used conditional logistic regression to compute odds ratios (ORs) and 95% confidence intervals (CIs), controlling for potential confounders. We defined people without previous statin use as never users (reference). A total of 7360 (14.3%) cases and 55,699 (10.8%) controls were current statin users. Among current users (adjusted OR: 0.96, 95% CI, 0.93-0.99), the preventive effect of statins on atrial fibrillation or flutter was related to duration of use: adjusted ORs decreased from 1.35 (95% CI, 1.28-1.42) for users who were prescribed statins for <365 days to 0.85 (95% CI, 0.81-0.89) for users who were prescribed statins for ≥1095 days compared with never users. For former users (adjusted OR: 0.94, 95% CI. 0.90-0.98), the ORs did not change with varying lengths of exposure. In conclusion, long-term statin use may reduce the risk of atrial fibrillation or flutter compared with never use.

  6. Emergency Department Management of Atrial Fibrillation and Flutter and Patient Quality of Life at One Month Postvisit.

    PubMed

    Ballard, Dustin W; Reed, Mary E; Singh, Nimmie; Rauchwerger, Adina S; Hamity, Courtnee A; Warton, E Margaret; Chettipally, Uli K; Mark, Dustin G; Vinson, David R

    2015-12-01

    We identify characteristics of patients with atrial fibrillation or flutter associated with favorable assessments of emergency department (ED) effectiveness and 30-day quality of life. As part of a prospective observational study of ED management and short-term outcomes of patients with nonvalvular atrial fibrillation or flutter, we adapted a disease-specific quality-of-life instrument. By telephone, we administered the Atrial Fibrillation Effect on Quality-of-life survey to patients 30 days after an ED visit in which they were treated for newly diagnosed or recent-onset atrial fibrillation or flutter and discharged home. We also asked respondents to rate the effectiveness of ED treatment. Using data prospectively collected in the ED and extracted from electronic health records, we recorded rhythm management (cardioversion attempts and type) and patient and ED treatment characteristics. Using multivariable regression, we examined the association between these characteristics and patient-reported effectiveness of ED treatment ("very effective" or not) and any atrial fibrillation or flutter quality-of-life effect. Six hundred fifty-two eligible ED patients (response rate 89%) treated between May 2011 and November 2012 completed follow-up. Of these patients, 454 (69.6%) reported that their ED treatment was "very effective" and 113 (17.3%) reported no quality-of-life influence. In multivariable analyses, there was an association between ED electrocardioversion and perceived ED effectiveness (P<.05) but none between treatment strategy and 30-day atrial fibrillation or flutter quality-of-life score. Respondents who were younger, women, and had worse pre-ED self-reported health (P<.05) were more likely to report a quality-of-life effect. In this observational study, ED rhythm management strategy was associated with greater perceived effectiveness of the ED visit but not with a difference in 30-day quality-of-life score. Copyright © 2015 American College of Emergency

  7. Radiofrequency and microwave energy sources in surgical ablation of atrial fibrillation: a comparative analysis.

    PubMed

    Topkara, Veli K; Williams, Mathew R; Barili, Fabio; Bastos, Renata; Liu, Judy F; Liberman, Elyse A; Russo, Mark J; Oz, Mehmet C; Argenziano, Michael

    2006-01-01

    Due to its complexity and risk of bleeding, the Maze III procedure has been largely replaced by surgical ablation for atrial fibrillation (AF) using alternative energy sources. Radiofrequency (RF) and microwave (MW) are the most commonly used energy forms. In this study, we sought to compare these energy modalities in terms of clinical outcomes. Two hundred five patients underwent surgical ablation of AF, from October 1999 to May 2004 at our institution via an endocardial approach. Patients were categorized into 2 groups: RF and MW. Baseline characteristics, operative details, and clinical outcomes were compared between the 2 groups. Rhythm success was defined as freedom from AF and atrial flutter as determined by postoperative electrocardiograms. One hundred twenty patients (58.5%) were ablated using RF, whereas 85 (41.5%) were ablated with MW. Most of the patients had persistent AF in both the RF and MW groups (85.7% versus 80.0%, respectively; P = .363). Intraoperative left atrial size was 6.4 +/- 1.7 cm for the RF group and 6.4 +/- 1.7 cm for the MW group (P = .820). Postoperative rhythm success at 6 and 12 months was 72.4% versus 71.4% (P +/- .611) and 75.0% versus 66.7% (P = .909) for the RF and MW groups, respectively. Hospital length of stay was comparable for both groups (15.4 +/- 14.0 versus 13.3 +/- 13.9 days; P = .307). Postoperative survival at 6 months, 1 year, and 3 years was 90.4%, 89.5%, and 86.1% for RF patients compared to 87.9%, 86.5%, and 84.4% for MW patients, respectively (log rank P = .490). RF and MW energy forms yield comparable postoperative rhythm success, hospital length of stay, and postoperative survival. Both sources are rapid, safe, and effective alternatives to "cut and sew" techniques for surgical treatment of AF.

  8. Atrial conduction delay predicts atrial fibrillation in paroxysmal supraventricular tachycardia patients after radiofrequency catheter ablation.

    PubMed

    Xu, Zhen-Xing; Zhong, Jing-Quan; Zhang, Wei; Yue, Xin; Rong, Bing; Zhu, Qing; Zheng, Zhaotong; Zhang, Yun

    2014-06-01

    This study aimed to assess whether intra- and inter-atrial conduction delay could predict atrial fibrillation (AF) for paroxysmal supraventricular tachycardia (PSVT) patients after successful treatment by radiofrequency catheter ablation (RFCA). Echocardiography examination was performed on 524 consecutive PSVT patients (15 patients were excluded). Left atrial dimension, right atrial diameter and intra- and inter-atrial conduction delay were measured before ablation. Patients were divided into group A (n = 32): occurrence of AF after the ablation and group B (n = 477): remained in sinus rhythm during follow-up. Receiver operating characteristic (ROC) curve analysis was performed to estimate the predictive value of intra- and inter-atrial conduction delay. Both intra- and inter-atrial conduction delay were higher in group A than in group B (4.79 ± 0.30 msec vs. 4.56 ± 0.32 msec; 21.98 ± 1.32 msec vs. 20.01 ± 1.33; p < 0.05). Binary logistic regression analysis showed that intra- and inter-atrial conduction were significant influential factors for the occurrence of AF (odds ratio [OR] = 13.577, 95% confidence interval [CI], 3.469-48.914; OR = 2.569, 95% CI, 1.909-3.459, p < 0.05). The ROC cure analysis revealed that intra-atrial conduction delay ≥ 4.45 msec and inter-atrial conduction delay ≥ 20.65 were the most optimal cut-off value for predicting AF in PSVT patients after RFCA. In conclusion, this is the first study to show that the intra- and inter-atrial conduction delay could effectively predict AF in post-ablation PSVT patients.

  9. Rotor mapping and ablation to treat atrial fibrillation.

    PubMed

    Zaman, Junaid A B; Peters, Nicholas S; Narayan, Sanjiv M

    2015-01-01

    Rotors have long been postulated to drive atrial fibrillation, but evidence has been limited to animal models. This changed recently with the demonstration using focal impulse and rotor modulation (FIRM) mapping that rotors act as human atrial fibrillation sources. This mechanistic approach to diagnosing the causes of atrial fibrillation in individual patients has been supported by substantially improved outcomes from FIRM-guided ablation, resulting in increased attention to rotors as therapeutic targets. In this review, we outline the pathophysiology of rotors in animal and in-silico studies of fibrillation, and how this motivated FIRM mapping in humans. We highlight the characteristics of rotors in human atrial fibrillation, now validated by several techniques, with discussion on similar and discrepant findings between techniques. The interventional approaches to eliminate atrial fibrillation rotors are explained and the ablation results in latest studies using FIRM are discussed. We propose that mapping localized sources for human atrial fibrillation, specifically rotors, is moving the field towards a unifying hypothesis that explains several otherwise contradictory observations in atrial fibrillation management. We conclude by suggesting areas of potential research that may reveal more about these critical sites and how these may lead to better and novel treatments for atrial fibrillation.

  10. Troponin utilization in patients presenting with atrial fibrillation/flutter to the emergency department: retrospective chart review

    PubMed Central

    2011-01-01

    Background There are few recommendations about the use of cardiac markers in the investigation and management of atrial fibrillation/flutter. Currently, it is unknown how many patients with atrial fibrillation/flutter undergo troponin testing, and how positive troponin results are managed in the emergency department. We sought to look at the emergency department troponin utilization patterns. Methods We performed a retrospective chart review of patients with atrial fibrillation/flutter presenting to the emergency department at three centers. Outcome measures included the rates of troponins ordered by emergency doctors, number of positive troponins, and those with positive troponins treated as acute coronary syndrome (ACS) by consulting services. Results Four hundred fifty-one charts were reviewed. A total of 388 (86%) of the patients had troponins ordered, 13.7% had positive results, and 4.9% were treated for ACS. Conclusions Troponin tests are ordered in a high percentage of patients with atrial fibrillation/flutter presenting to emergency departments. Five percent of our total patient cohort was diagnosed as having acute coronary syndrome by consulting services. PMID:21651774

  11. Left atrium segmentation for atrial fibrillation ablation

    NASA Astrophysics Data System (ADS)

    Karim, R.; Mohiaddin, R.; Rueckert, D.

    2008-03-01

    Segmentation of the left atrium is vital for pre-operative assessment of its anatomy in radio-frequency catheter ablation (RFCA) surgery. RFCA is commonly used for treating atrial fibrillation. In this paper we present an semi-automatic approach for segmenting the left atrium and the pulmonary veins from MR angiography (MRA) data sets. We also present an automatic approach for further subdividing the segmented atrium into the atrium body and the pulmonary veins. The segmentation algorithm is based on the notion that in MRA the atrium becomes connected to surrounding structures via partial volume affected voxels and narrow vessels, the atrium can be separated if these regions are characterized and identified. The blood pool, obtained by subtracting the pre- and post-contrast scans, is first segmented using a region-growing approach. The segmented blood pool is then subdivided into disjoint subdivisions based on its Euclidean distance transform. These subdivisions are then merged automatically starting from a seed point and stopping at points where the atrium leaks into a neighbouring structure. The resulting merged subdivisions produce the segmented atrium. Measuring the size of the pulmonary vein ostium is vital for selecting the optimal Lasso catheter diameter. We present a second technique for automatically identifying the atrium body from segmented left atrium images. The separating surface between the atrium body and the pulmonary veins gives the ostia locations and can play an important role in measuring their diameters. The technique relies on evolving interfaces modelled using level sets. Results have been presented on 20 patient MRA datasets.

  12. Surgical Ablation of Atrial Fibrillation Using Energy Sources.

    PubMed

    Brick, Alexandre Visconti; Braile, Domingo Marcolino

    2015-01-01

    Surgical ablation, concomitant with other operations, is an option for treatment in patients with chronic atrial fibrillation. The aim of this study is to present a literature review on surgical ablation of atrial fibrillation in patients undergoing cardiac surgery, considering energy sources and return to sinus rhythm. A comprehensive survey was performed in the literature on surgical ablation of atrial fibrillation considering energy sources, sample size, study type, outcome (early and late), and return to sinus rhythm. Analyzing studies with immediate results (n=5), the percentage of return to sinus rhythm ranged from 73% to 96%, while those with long-term results (n=20) (from 12 months on) ranged from 62% to 97.7%. In both of them, there was subsequent clinical improvement of patients who underwent ablation, regardless of the energy source used. Surgical ablation of atrial fibrillation is essential for the treatment of this arrhythmia. With current technology, it may be minimally invasive, making it mandatory to perform a procedure in an attempt to revert to sinus rhythm in patients requiring heart surgery.

  13. Surgical Ablation of Atrial Fibrillation Using Energy Sources

    PubMed Central

    Brick, Alexandre Visconti; Braile, Domingo Marcolino

    2015-01-01

    Surgical ablation, concomitant with other operations, is an option for treatment in patients with chronic atrial fibrillation. The aim of this study is to present a literature review on surgical ablation of atrial fibrillation in patients undergoing cardiac surgery, considering energy sources and return to sinus rhythm. A comprehensive survey was performed in the literature on surgical ablation of atrial fibrillation considering energy sources, sample size, study type, outcome (early and late), and return to sinus rhythm. Analyzing studies with immediate results (n=5), the percentage of return to sinus rhythm ranged from 73% to 96%, while those with long-term results (n=20) (from 12 months on) ranged from 62% to 97.7%. In both of them, there was subsequent clinical improvement of patients who underwent ablation, regardless of the energy source used. Surgical ablation of atrial fibrillation is essential for the treatment of this arrhythmia. With current technology, it may be minimally invasive, making it mandatory to perform a procedure in an attempt to revert to sinus rhythm in patients requiring heart surgery. PMID:26934404

  14. Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study.

    PubMed

    Cresti, Alberto; García-Fernández, Miguel Angel; De Sensi, Francesco; Miracapillo, Gennaro; Picchi, Andrea; Scalese, Marco; Severi, Silva

    2016-03-01

    Prevalence of left appendage thrombosis ranges from 6 to 18% in persistent atrial fibrillation (AF). Few and low sample size studies have assessed left and right atrial thrombosis in persistent atrial flutter (AFL) and a wide variety of frequencies, from 1 to 21%, has been reported. The aim of this study was to evaluate the prevalence of atrial appendage thrombosis in a large population of patients undergoing transoesophageal echocardiography (TEE)-guided cardioversion (CV) for recent AFL onset and compare it with AF. From 1999 to September 2014, we collected data of 1081 patients to CV: 877 affected by AF (81.1%) and 204 by AFL (18.9%). The presence of auricular thrombosis was evaluated by TEE in AF or AFL persisting for more than 48 h. The presence of appendage thrombosis, Doppler emptying velocities, and severe spontaneous echo contrast (SEC) was studied. The overall prevalence of atrial thrombosis was 9.62% (104/1081). Frequency of atrial thrombosis in AFL patients was 6.4% (13/204) vs. 10.5% among AF (92/877), P = 0.074. Comparing the two appendages, frequency of left atrial appendage thrombosis was in AFL 5.9% (12/204) vs. 9.9% (87/877) in the AF group, P = 0.07. Right atrial appendage thrombosis was present in 0.5% (1/204) in the AFL group vs. 0.8% (7/877) in the AF group, P = 0.64. Moderate to severe SEC (3+/4+) was present in 28% of AFL patients (57/204) vs. 35% of AF patients (307/877), P = 0.05. Auricular thrombosis is not an infrequent finding in AFL before CV. Our study suggests the use of TEE screening in AFL, as well as in AF, when patients arrive to clinical attention after more than 48 h from arrhythmia onset. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  15. Detection of paroxysmal atrial fibrillation or flutter in patients with acute ischemic stroke or transient ischemic attack by Holter monitoring.

    PubMed

    Thakkar, Sandeep; Bagarhatta, Rajeev

    2014-01-01

    Paroxysmal atrial fibrillation and flutter are strong risk factors for stroke. Due to high recurrence rate of ischemic events and given the benefit of oral anticoagulation over antiplatelet drugs, it is important to identify this arrhythmia. Unfortunately, paroxysmal AF or flutter is asymptomatic in majority and therefore, difficult to detect. Consecutive patients presenting with symptoms of acute ischemic stroke or transient ischemic attack were included. All patients free of AF or flutter on presentation underwent 24 h Holter monitoring within 7 days of admission. Overall, fifty two (52) patients (mean age 59.51 ± 13.45 years) with acute stroke (80.8%) and TIA (19.8%) underwent 24 h Holter monitoring. Paroxysmal AF was detected in 3 cases (5.8%), all 3 patients had acute stroke and were older than age 60 years. Type of stroke was the only factor which was associated with greater risk of having paroxysmal AF or flutter, AF accounted for 50% cases (2 out of 4) of clinically suspected cardio embolic stroke. Screening consecutive patients with ischemic stroke with routine Holter monitoring will identify new atrial fibrillation/flutter in approximately one in 17 patients. Older age and type of stroke are strongly associated with increased risk. By carefully selecting the patients, the detection rates could be further increased. Copyright © 2014 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

  16. [Contribution of atrial activation to the segment of the typical atrial flutter wave: an electro-anatomic insight into the electrocardiogram morphology].

    PubMed

    Wang, Jun; Chen, Minglong; Yang, Bing; Ju, Weizhu; Zhang, Fengxiang; Yang, Gang; Li, Mingfang; Cao, Kejiang

    2015-07-01

    To investigate how the intra-cardiac activation was translates into the characterized flutter wave in patients with cavatricuspid isthmus-dependent counter-clockwise atrial flutter (CTI-AFL). A total of 15 hospitalized CTI-AFL patients (mean age: (60 ± 14) years old, 1 female) from October 2012 to February 2014 were enrolled in the study. The activation map was re-constructed during AFL rhythm for left atrium and right atrium using 3-dimensional mapping system. The flutter wave in surface electrocardiogram was analyzed in combination with the intra-cardiac activation. The mean left ventricular ejection fraction was (60.8 ± 6.6)%, and the left atrial diameter was (39.0 ± 3.4) mm. The mean tachycardia cycle length was (220 ± 24) ms. The activation map was completed in all cases. In inferior leads, the flutter wave was divided into three parts: slowly downward part, sharp downward part and the terminal positive part. The three parts corresponded to the fixed activation part of the macro-reentry. The distinctive flutter wave of CTI-AFL was determined by the unique macro-reentry activation in the right atrium. The activation of left atrium contributes to the downward part of the wave.

  17. Factors affecting the development of atrial fibrillation and atrial flutter (AF/AFL) following autologous hematopoietic SCT (auto-HSCT).

    PubMed

    Steuter, J A; Villanueva, M L H; Loberiza, F R; Armitage, J O; Bociek, R G; Ganti, A K; Tarantolo, S R; Vose, J M; Easley, A; Bierman, P J

    2013-07-01

    The use of autologous hematopoietic SCT (auto-HSCT) has expanded to include older patients. Increasing age is a well-appreciated risk factor for the development of atrial fibrillation and/or atrial flutter (AF/AFL) in the general population. As more elderly patients undergo auto-HSCT, the risk of developing AF/AFL post transplant may also increase. However, few data evaluating other risk factors for the development of AF/AFL following auto-HSCT exist. Therefore, we performed a retrospective study to determine the incidence of AF/AFL following auto-HSCT and to determine the risk factors associated with the development of AF/AFL. Patients who developed AF/AFL were compared with a group of patients who received auto-HSCT within the same time period (April 1999 to May 2005) and were within 5 years of age. Of the 516 patients who underwent auto-HSCT at the University of Nebraska Medical Center 44 (8.5%) developed AF/AFL at a median time of 4 days (range, days 1-9) following auto-HSCT. In multivariate analysis, risk factors for developing AF/AFL were older age, odds ratio and 95% CI of 1.14 (1.07-1.21), elevated serum creatinine level, 2.69 (1.00-7.22), history of previous arrhythmia, 9.33 (3.01-28.99), and history of previous mediastinal irradiation, 11.12 (1.33-92.96).

  18. Management of refractory atrial fibrillation post surgical ablation

    PubMed Central

    Altman, Robert K.; Proietti, Riccardo; Barrett, Conor D.; Paoletti Perini, Alessandro; Santangeli, Pasquale; Danik, Stephan B.; Di Biase, Luigi

    2014-01-01

    Over the past two decades, invasive techniques to treat atrial fibrillation (AF) including catheter-based and surgical procedures have evolved along with our understanding of the pathophysiology of this arrhythmia. Surgical treatment of AF may be performed on patients undergoing cardiac surgery for other reasons (concomitant surgical ablation) or as a stand-alone procedure. Advances in technology and technique have made surgical intervention for AF more widespread. Despite improvements in outcome of both catheter-based and surgical treatment for AF, recurrence of atrial arrhythmias following initial invasive therapy may occur.Atrial arrhythmias may occur early or late in the post-operative course after surgical ablation. Early arrhythmias are generally treated with prompt electrical cardioversion with or without antiarrhythmic therapy and do not necessarily represent treatment failure. The mechanism of persistent or late occurring atrial arrhythmias is complex, and these arrhythmias may be resistant to antiarrhythmic drug therapy. The characterization and management of recurrent atrial arrhythmias following surgical ablation of AF are discussed below. PMID:24516805

  19. Mechanisms and clinical significance of early recurrences of atrial arrhythmias after catheter ablation for atrial fibrillation

    PubMed Central

    Liang, Jackson J; Dixit, Sanjay; Santangeli, Pasquale

    2016-01-01

    Early recurrence of atrial arrhythmias (ERAA) after ablation is common and strongly predicts late recurrences and ablation failure. However, since arrhythmia may eventually resolve in up to half of patients with ERAA, guidelines do not recommend immediate reintervention for ERAA episodes occurring during a 3-mo post-ablation blanking period. Certain clinical demographic, electrophysiologic, procedural, and ERAA-related characteristics may predict a higher likelihood of long-term ablation failure. In this review, we aim to discuss potential mechanisms of ERAA, and to summarize the clinical significance, prognostic implications, and treatment options for ERAA. PMID:27957250

  20. Ablating atrial fibrillation: A translational science perspective for clinicians.

    PubMed

    Weiss, James N; Qu, Zhilin; Shivkumar, Kalyanam

    2016-09-01

    Although considerable progress has been made in developing ablation approaches to cure atrial fibrillation (AF), outcomes are still suboptimal, especially for persistent and long-lasting persistent AF. In this topical review, we review the arrhythmia mechanisms, both reentrant and nonreentrant, that are potentially relevant to human AF at various stages/settings. We describe arrhythmia mapping techniques used to distinguish between the different mechanisms, with a particular focus on the detection of rotors. We discuss which arrhythmia mechanisms are likely to respond to ablation, and the challenges and prospects for improving upon current ablation strategies to achieve better outcomes.

  1. Microwave Ablation in Mitral Valve Surgery for Atrial Fibrillation (MAMA).

    PubMed

    Jönsson, Anders; Lehto, Mika; Ahn, Henrik; Hermansson, Ulf; Linde, Peter; Ahlsson, Anders; Koistinen, Juhani; Savola, Jukka; Raatikainen, Pekka; Lepojärvi, Martti; Sahlman, Antero; Werkkala, Kalervo; Toivonen, Lauri; Walfridsson, Håkan

    2012-01-01

    Objective: Microwave ablation in conjunction with open heart surgery is effective in restoring sinus rhythm (SR) in patients with atrial fibrillation (AF). In patients assigned for isolated mitral valve surgery no prospective randomized trial has reported its efficacy. Methods: 70 patients with longlasting AF where included from 5 different centres. They were randomly assigned to mitral valve surgery and atrial microwave ablation or mitral valve surgery alone. Results: Out of 70 randomized, 66 and 64 patients were available for evaluation at 6 and 12 months. At 12 months SR was restored and preserved in 71.0 % in the ablation group vs 36.4 % in the control group (P=0.006), corresponding figures at 6 months was 62.5 % vs 26.5 % (P=0.003). The 30-day mortality rate was 1.4 %, with one death in the ablation group vs zero deaths in the control group. At 12 months the mortality rate was 7,1 % (Ablation n=3 vs Control n=2). No significant differences existed between the groups with regard to the overall rate of serious adverse events (SAE) during the perioperative period or at the end of the study. 16 % of patients randomized to ablation were on antiarrhytmic drugs compared to 6 % in the control group after 1 year (p=0.22). Conclusion: Microwave ablation of left and right atrium in conjunction with mitral valve surgery is safe and effectively restores sinus rhythm in patients with longlasting AF as compared to mitral valve surgery alone.

  2. Left atrial function and scar after catheter ablation of atrial fibrillation.

    PubMed

    Wylie, John V; Peters, Dana C; Essebag, Vidal; Manning, Warren J; Josephson, Mark E; Hauser, Thomas H

    2008-05-01

    Catheter ablation of atrial fibrillation (AF) involves extensive radiofrequency ablation (RFA) of the left atrium (LA) around the pulmonary veins. The effect of this therapy on LA function is not fully characterized. The purpose of this study was to determine whether catheter ablation of AF is associated with a change in LA function. LA and right atrial (RA) systolic function was assessed in 33 consecutive patients with paroxysmal or persistent AF referred for ablation using cardiovascular magnetic resonance (CMR) imaging. Steady-state free precession ECG cine CMR imaging was performed before and after (mean 48 days) AF ablation. All patients underwent circumferential pulmonary vein isolation using an 8-mm tip RFA catheter. High spatial resolution late gadolinium enhancement CMR images of LA scar were obtained in 16 patients. Maximum LA volume decreased by 15% (P <.001), and LA ejection fraction decreased by 14% (P <.001) after AF ablation. Maximum RA volume decreased by 13% (P = .018), but RA ejection fraction increased by 5% (P = .008). Mean LA scar volume was 8.1 +/- 3.7 mL. A linear correlation was observed between change in LA ejection fraction and scar volume (r = -0.75, P <.001). Catheter ablation of AF is associated with decreased LA size and reduced atrial systolic function. This change strongly correlates with the volume of LA scar. This finding may have implications for postprocedural thromboembolic risk and for procedures involving more extensive RFA.

  3. Atrial Flutter

    MedlinePlus

    ... AHA Get with the Guidelines-AFIB IAC Cardiac Electrophysiology Accreditation Science & Research Heart Rhythm Journal Heart Rhythm ... AHA Get with the Guidelines-AFIB IAC Cardiac Electrophysiology Accreditation Science & Research less Heart Rhythm Journal Heart ...

  4. Radiofrequency ablation of atrial fibrillation during concomitant cardiac surgery.

    PubMed

    Pinho-Gomes, Ana C; Amorim, Mário J; Oliveira, Sílvia M; Azevedo, Luís; Almeida, Jorge; Monteiro, Vítor; Maciel, Maria Júlia; Pinho, Paulo; Leite-Moreira, Adelino F

    2014-01-01

    We present the experience of our centre with radiofrequency ablation of atrial fibrillation concomitantly with cardiac surgery Methods: 170 patients underwent atrial fibrillation ablation with uni/bipolar-radiofrequency. They were followed for 3-months and then as appropriate for the cardiac disease. In 2013, patients still alive underwent rhythm monitoring with ECG and 24-hour tape if in sinus rhythm Mean age was 65 years old and 42% of the patients were male. Paroxysmal AF was rare (7%). Most patients had preserved ejection fraction and dilated left atria (diameter 53.2±7.5 mm). The most common indication for cardiac surgery was valve disease. More than 75% of the patients underwent prophylactic closure of the left atrial appendage. Pulmonary vein isolation was performed in all patients, followed by other left atrial ablation lines. Overall, surgical complications were rare, being the most frequent pacemaker implantation (15%). Median length of stay was 9 days (p25-p75:7-14). At discharge, 69% of the patients were in sinus rhythm, being 90% on anticoagulation and 69% on amiodarone. In-hospital mortality was less than 3% (5 patients), none of them related to the ablation procedure. At 3 months, 50% of the patients were in sinus rhythm, being 92% on anticoagulation and 75% on antiarrhythmic drugs. Direct current cardioversion was successful in 8 of 12 patients. In the multivariate analysis, being in sinus rhythm at discharge was the single independent predictor of maintaining sinus rhythm at 3 months. In 2013 (469 patients-year), 40% of the patients were in sinus rhythm, being 80% on anticoagulation and 45% on antiarrhythmic drugs. Concurrent atrial fibrillation ablation with radiofrequency achieves satisfactory and stable recovery of sinu rhythm without adding significant operative risk and post-operative complications.

  5. [Catheter ablation for paroxysmal atrial fibrillation: new generation cryoballoon or contact force sensing radiofrequency ablation?].

    PubMed

    Nagy, Zsófia; Kis, Zsuzsanna; Som, Zoltán; Földesi, Csaba; Kardos, Attila

    2016-05-29

    Contact force sensing radiofrequency ablation and the new generation cryoballoon ablation are prevalent techniques for the treatment of paroxysmal atrial fibrillation. The authors aimed to compare the procedural and 1-year outcome of patients after radiofrequency and cryoballoon ablation. 96 patients with paroxysmal atrial fibrillation (radiofrequency ablation: 58, cryoballoon: 38 patients; 65 men and 31 women aged 28-70 years) were enrolled. At postprocedural 1, 3, 6 and 12 months ECG, Holter monitoring and telephone interviews were performed. Procedure and fluorosocopy time were: radiofrequency ablation, 118.5 ± 15 min and 15.8 ± 6 min; cryoballoon, 73.5 ± 16 min (p<0.05) and 13.8 ± 4.,1 min (p = 0.09), respectively. One year later freedom from atrial fibrillation was achieved in 76.5% of patients who underwent radiofrequency ablation and in 81% of patients treated with cryoballoon. Temporary phrenic nerve palsy occurred in two patients and pericardial tamponade developed in one patient. In this single center study freedom from paroxysmal atrial fibrillation was similar in the two groups with significant shorter procedure time in the cryoballoon group.

  6. CHADS(2) and CHA(2)DS (2)-VASc score of patients with atrial fibrillation or flutter and newly detected left atrial thrombus.

    PubMed

    Wasmer, Kristina; Köbe, Julia; Dechering, Dirk; Milberg, Peter; Pott, Christian; Vogler, Julia; Stypmann, Jörg; Waltenberger, Johannes; Mönnig, Gerold; Breithardt, Günter; Eckardt, Lars

    2013-02-01

    The risk of developing a stroke or systemic embolus due to a left atrial (LA) thrombus in patients with atrial fibrillation (AF) and/or atrial flutter (AFL) is estimated by the CHADS(2) score and more recently the CHA(2)DS(2)-VASc score. We aimed to further characterize AF/AFL patients who were found to have a LA thrombus on a transesophageal echocardiogram (TEE). Of 3,165 TEE between 2005 and 2011 for a broad spectrum of indications, we detected 65 AF patients with LA thrombus (2 %). There were 40 men and 25 women, mean age was 65 ± 13 years (range 36-88 years). Mean CHADS(2) score was 1.8 ± 1.1 and mean CHA(2)DS(2)-VASc score was 3.0 ± 1.6. 11 patients (17 %) had a CHADS(2) score of 0, 12 patients (18 %) of 1, 28 patients (43 %) of 2 and 12 patients (18 %) of 3. Hypertension was the most frequent risk factor (72 %), followed by congestive heart failure (32 %), diabetes (23 %) and age ≥75 years (23 %). Mean difference between CHADS(2) and CHA(2)DS(2)-VASc was 1.25 ± 0.91. Of the 11 patients (17 %) with a LA thrombus despite a CHADS(2) score of 0, five had a CHA(2)DS(2)-VASc score of 0, four a CHA(2)DS(2)-VASc score of 1 and two a CHA(2)DS(2)-VASc score of 2. In an unselected TEE population with newly detected LA thrombus about one-third of patients fell into the low-risk group when classified based on the CHADS(2) score, while a much lower population fell in the same low-risk group when classified according to the CHA(2)DS(2)-VASc score. However, this does not prove clinical superiority of the CHA(2)DS(2)-VASc score over the established CHADS(2) score. Whether our observation has clinical implications (e.g. TEE prior to LA ablation irrespective of CHADS(2) score), or argues for use of the CHA(2)DS(2)-VASc score needs to be evaluated in prospective studies.

  7. Epicardial Adipose Tissue Thickness and Ablation Outcome of Atrial Fibrillation

    PubMed Central

    Tsao, Hsuan-Ming; Lin, Yenn-Jiang; Yun, Chun-Ho; Lai, Yau-Huei; Chang, Shih-Lin; Lo, Li-Wei; Hu, Yu-Feng; Tuan, Ta-Chuan; Chang, Hung-Yu; Kuo, Jen-Yuan; Yeh, Hung-I; Wu, Tsu-Juey; Hsieh, Ming-Hsiung; Yu, Wen-Chung; Chen, Shih-Ann

    2013-01-01

    Objectives Epicardial fat was closely related to atrial fibrillation (AF). Transthoracic echocardiography (TTE) has been proposed to be a convenient imaging tool in assessing epicardial adipose tissue (EAT). The goal of the present study was to investigate whether the EAT thickness measured on TTE was a useful parameter in predicting procedural outcomes of AF ablations. Methods and Results A total of 227 paroxysmal AF (PAF) and 56 non-paroxysmal AF (non-PAF) patients receiving catheter ablations from 2008-2010 were enrolled. Echocardiography-derived regional EAT thickness from parasternal long-axis view was quantified for each patient. Free of recurrence was defined as the absence of atrial arrhythmias without using antiarrhythmic agents after ablations. The mean EAT thickness of the study population was 6.1 ± 0.8 mm. Non-PAF patients had a thicker EAT than that of PAF patients (7.0 ± 0.7 mm versus 5.9 ± 0.7 mm, p value <0.001). During the follow-up of 16 ± 9 months, there were 95 patients (33.6%) suffering from recurrences of atrial arrhythmias. Non-PAF, chads2 score, left atrial diameter and EAT thickness were independent predictors of recurrence after catheter ablations. At a cutoff value of 6 mm for PAF and 6.9 mm for non-PAF, the measurement of EAT thickness could help us to identify patients at risk of recurrences. Conclusions EAT thickness may serve as a useful parameter in predicting recurrences after AF ablations. Compared to other imaging modalities, TTE can be an alternative choice with less cost and time in assessing the effects of EAT on ablation outcomes. PMID:24066158

  8. Spontaneous left atrial reentry tachycardias : radiofrequency ablation and outcome.

    PubMed

    Schneider, R; Schneider, C; Bänsch, D

    2015-02-01

    Spontaneous left atrial reentry tachycardias (LART) in patients without previous cardiac surgical or catheter ablation are rare. Several therapeutic concepts of catheter ablation have been suggested: linear lesions (LL), circumferential pulmonary vein isolation (PVI), and both (LL + PVI). In all, 28 consecutive symptomatic patients with 51 LARTs presented to our institution for catheter ablation. Electroanatomical mapping was performed on 25 patients. Three patients were ablated conventionally during LART; 25 patients (89.3 %) had extensive low-voltage areas in the left atrium (atrial myopathy). One of the following ablation strategies was applied: first, LL (n = 8), second, PVI + LL (n = 11), and third PVI alone (n = 9). Fourteen patients (50 %) had a recurrent arrhythmia during a mean follow-up of 12.2 ± 11.1 months. Six patients presented with a recurrent LART (21.4 %), 4 with LART and atrial fibrillation (Afib) (14.3 %), and 4 with Afib (14.3 %). The recurrence rate of any arrhythmia (LART and Afib) was 37.5 % in the LL group, 44.4 % in the PVI group, and 63.6 % in the PVI + LL group (ns); the recurrence rate of LARTs was 12.5 % in the LL group, 22.2 % in the PVI group, and 63.6 % in the PVI + LL group (p < 0.05). Atrial tachyarrhythmia recurrence after ablation of spontaneous LART in mid-term is considerable. Stable LARTs are effectively treated by LL. PVI alone may be an acceptable alternative, especially in patients with unstable LARTs and Afib. However, the risk of recurrent LARTs after a more extensive strategy with PVI and LL is considerable, probably due to proarrhythmic effects of long linear lesions.

  9. Staged hybrid ablation for persistent and longstanding persistent atrial fibrillation effectively restores sinus rhythm in long-term observation

    PubMed Central

    Filipiak, Krzysztof; Kowalski, Oskar; Buchta, Piotr; Niklewski, Tomasz; Nadziakiewicz, Pawel; Koba, Rafał; Gąsior, Mariusz; Kalarus, Zbigniew; Zembala, Marian

    2016-01-01

    Introduction Hybrid ablation (HABL) of atrial fibrillation combining endoscopic, minimally invasive, closed chest epicardial ablation with endocardial CARTO-guided accuracy was introduced to overcome the limitations of current therapeutic options for patients with persistent (PSAF) and longstanding persistent atrial fibrillation (LSPAF). The purpose of this study was to evaluate the procedural safety and feasibility as well as effectiveness of HABL in patients with PSAF and LSPAF 1 year after the procedure. Material and methods The study is a single-center, prospective clinical registry. From 07/2009 to 12.2014, 90 patients with PSAF (n = 39) and LSPAF (n = 51), at the mean age of 54.8 ±9.8, in mean EHRA class 2.6, underwent HABL. 64.4% of patients had a history of prior cardioversion or catheter ablation. Thirteen patients had LVEF less than 35%. Mean AF duration was 4.5 ±3.7 years. Patients were scheduled for 3-, 6- and 12-month follow-up with 7-day Holter monitoring. Results At 6 months after the procedure 78% (54/69) of patients were in SR. At 12 months after the procedure 86% (59/69) were in SR and 62.3% (43/69) in SR and off class I/III antiarrhythmic drugs (AADs). Only 1% (1/69) of patients required a repeat ablation for atrial flutter. A significant decrease in LA dimension and an increase in LVEF were noted. Conclusions A combination of epicardial and endocardial RF ablation should be considered as a treatment option for patients with persistent and long-standing persistent atrial fibrillation as it is safe and effective in restoring sinus rhythm. PMID:28144262

  10. Automated planning of ablation targets in atrial fibrillation treatment

    NASA Astrophysics Data System (ADS)

    Keustermans, Johannes; De Buck, Stijn; Heidbüchel, Hein; Suetens, Paul

    2011-03-01

    Catheter based radio-frequency ablation is used as an invasive treatment of atrial fibrillation. This procedure is often guided by the use of 3D anatomical models obtained from CT, MRI or rotational angiography. During the intervention the operator accurately guides the catheter to prespecified target ablation lines. The planning stage, however, can be time consuming and operator dependent which is suboptimal both from a cost and health perspective. Therefore, we present a novel statistical model-based algorithm for locating ablation targets from 3D rotational angiography images. Based on a training data set of 20 patients, consisting of 3D rotational angiography images with 30 manually indicated ablation points, a statistical local appearance and shape model is built. The local appearance model is based on local image descriptors to capture the intensity patterns around each ablation point. The local shape model is constructed by embedding the ablation points in an undirected graph and imposing that each ablation point only interacts with its neighbors. Identifying the ablation points on a new 3D rotational angiography image is performed by proposing a set of possible candidate locations for each ablation point, as such, converting the problem into a labeling problem. The algorithm is validated using a leave-one-out-approach on the training data set, by computing the distance between the ablation lines obtained by the algorithm and the manually identified ablation points. The distance error is equal to 3.8+/-2.9 mm. As ablation lesion size is around 5-7 mm, automated planning of ablation targets by the presented approach is sufficiently accurate.

  11. Recurrent spontaneous clinical perimitral atrial tachycardia in the context of atrial fibrillation ablation.

    PubMed

    Miyazaki, Shinsuke; Shah, Ashok J; Hocini, Mélèze; Haïssaguerre, Michel; Jaïs, Pierre

    2015-01-01

    Recurrent perimitral atrial tachycardia (AT) is a challenging arrhythmia and is frequently encountered in the context of atrial fibrillation (AF) ablation. The purpose of this study was to investigate the clinical characteristics and the procedural and clinical outcomes in patients with recurrent perimitral atrial tachycardia (PMAT) after AF ablation. Among 520 consecutive ablation procedures for recurrent AT/AF after AF ablation, 40 procedures (patients) were performed for clinically recurrent PMAT 12.1 ± 13.6 months after the last procedure (total 2.2 ± 1.3 procedures). Previously, mitral isthmus (MI) linear ablation was performed in 26 of 40 procedures, including 13 procedures with complete block and 13 with 159.0 ± 23.0 ms of conduction delay without block. As a reference group, conduction delay was evaluated in 55 patients with incomplete MI block and absence of spontaneous PMAT during the follow-up period. Recurrent PMATs were terminated by MI linear ablation in 26 of 40 patients. Bidirectional block across the MI and anterior line joining the mitral annulus and left atrial roof was achieved in 33 (82.5%) and 2 (5%) patients, respectively. At mean follow-up of 26.7 ± 14.5 months, 2 patients (5%) underwent reablation for spontaneously recurrent PMAT. At 12 months after the ablation procedure for PMAT, 73.5% of the patients were free from AT/AF. Conduction delay >149 ms predicted the occurrence of spontaneous PMAT with 80.0% sensitivity and 87.3% specificity. PMAT can recur even after successful bidirectional MI linear block. Substantial conduction delay without block across the MI from a previous procedure(s) could predispose to recurrent PMAT. Although most clinical PMATs can be successfully treated by catheter ablation, very late recurrence is possible. Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  12. Trends in inflammatory biomarkers during atrial fibrillation ablation across different catheter ablation strategies.

    PubMed

    Schmidt, Martin; Marschang, Harald; Clifford, Sarah; Harald, Rittger; Guido, Ritscher; Oliver, Turschner; Johannes, Brachmann; Daccarett, Marcos

    2012-06-28

    Chest pain after atrial fibrillation (AF) ablations is a common complaint with a wide differential diagnosis including coronary events. Elevation of troponins (Trop I) has been shown with radio-frequency (RF) ablation for atrial fibrillation. New devices including cryoballoon and multipolar ablation catheters have been introduced as alternative methods. We aim to compare cardiac injury following AF ablations according to different ablation technologies. In consecutive patients undergoing AF ablations with RF ablation, cryoballoon or multipolar ablation catheter (PVAC), Trop I, creatine kinase (CK) and CRP were analyzed immediately prior to and 24h following completion of ablation. Coronary events and symptoms and serial ECGs post procedure were evaluated. A total of 243 patients were included, 18.5% of them females. The mean age was 63 ± 11 years old. Baseline Trop I, CK and CRP levels were within normal range in all patients. After RF ablation Trop I, CK and CRP levels were elevated in 100%, 20% and 91% of patients respectively (Trop I 3.55 pg/ml [range: 0.60-24.01 pg/ml], CK 147 U/l [range: 56-380 U/l] and CRP 2.15 mg/dl [range: 0.28-20.98 mg/dl]). All post-procedure Trop I levels were above the range of myocardial infarction (>0.15 ng/ml). After cryoballoon ablation, Trop I and CK levels were significantly higher than after RF or PVAC ablation (p<0.001). No ischemic ECG changes were documented. Trop I elevations are not specific for ischemia in the setting of chest pain after AF ablation. Cryoballoon ablation resulted in a higher amount of cardiac injury. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

  13. Atrial Tachycardias after Atrial Fibrillation Ablation Manifest Different Waveform Characteristics: Implications for Characterizing Tachycardias

    PubMed Central

    Biviano, Angelo B.; Ciaccio, Edward J.; Fleitman, Jessica; Knotts, Robert; Lawrence, John; Haynes, Norrisa; Cyrille, Nicole; Hickey, Kathleen; Iyer, Vivek; Wan, Elaine; Whang, William; Garan, Hasan

    2015-01-01

    INTRODUCTON Atrial fibrillation (AF) ablation patients often manifest atrial tachycardias (AT) with atypical ECG morphologies that preclude accurate localization and mechanism. Diagnostic maneuvers used to define ATs during electrophysiology studies can be limited by tachycardia termination or transformation. Additional methods of characterizing post-AF ablation ATs are required. METHODS AND RESULTS We evaluated the utility of noninvasive ECG signal analytics in post-ablation AF patients for the following features: 1) Localization of ATs (i.e., right versus left atrium), and 2) Identification of common left AT mechanisms (i.e., focal vs. macroreentrant). Atrial waveforms from the surface ECG were used to analyze: 1) Spectral organization, including dominant amplitude (DA) and mean spectral profile (MP), and 2) Temporospatial variability, using temporospatial correlation coefficients. We studied 94 ATs in 71 patients who had undergone prior pulmonary vein isolation for AF and returned for a second ablation: 1) right atrial cavotricuspid-isthmus dependent (CTI) ATs (n=21); 2) left atrial macroreentrant ATs (n=41) and focal ATs (n=32). Right CTI ATs manifested higher DAs and lower MPs than left ATs, indicative of greater stability and less complexity in the frequency spectrum. Left macroreentrant ATs possessed higher temporospatial organization than left focal ATs. CONCLUSIONS Noninvasively recorded atrial waveform signal analyses show that right ATs possess more stable activation properties than left ATs, and left macroreentrant ATs manifest higher temporospatial organization than left focal ATs. Further prospective analyses evaluating the role these novel ECG-derived tools can play to help localize and identify mechanisms of common ATs in AF ablation patients are warranted. PMID:26228873

  14. Ablation of long-standing persistent atrial fibrillation

    PubMed Central

    Mody, Behram P.; Raza, Anoshia; Jacobson, Jason; Iwai, Sei; Frenkel, Daniel; Rojas, Rhadames

    2017-01-01

    Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the clinical setting affecting nearly 6 million people in United States and the numbers are only expected to rise as the population continues to age. Broadly it is classified into paroxysmal, persistent and longstanding persistent AF. Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Our review article emphasizes particularly on long standing persistent atrial fibrillation (LSPAF) aspect of the disease which poses a great challenge for electrophysiologists. While pulmonary vein isolation (PVI) has been established as a successful ablation strategy for paroxysmal AF, same cannot be said for LSPAF owing to its long duration, complexity of mechanisms, multiple triggers and substrate sites that are responsible for its perpetuation. The article explains different approaches currently being adopted to achieve freedom from atrial arrhythmias. These mainly include ablation techniques chiefly targeting complex fractionated atrial electrograms (CFAE), rotors, linear lesions, scars and even considering hybrid approaches in a few cases while exploring the role of delayed enhancement magnetic resonance imaging (deMRI) in the pre-procedural planning to improve the overall short and long term outcomes of catheter ablation. PMID:28856145

  15. Cost analysis of radiofrequency catheter ablation for atrial fibrillation.

    PubMed

    Gorenek, Bulent; Kudaiberdieva, Gulmira

    2013-09-10

    Atrial fibrillation is the most common arrhythmia associated with increased mortality and morbidity. Its management requires high healthcare expenditures; 52%-70% of expenses for AF care are constituted by hospitalization costs. The current management strategies of pharmacological rhythm control and pharmacological or invasive rate control show no difference in impact on major outcomes in patients with AF. Radiofrequency catheter ablation (RFA) has been shown to reduce the risk of AF recurrence, improve quality of life and reduce hospitalization rate as compared to pharmacological rhythm control and rate control strategies. This review summarizes current knowledge on cost and cost-effectiveness analysis of RFA for patients with atrial fibrillation.

  16. Ablation for atrial fibrillation: are cures really achieved?

    PubMed

    Pacifico, Antonio; Henry, Philip D

    2004-06-02

    During the past 10 years numerous studies on the treatment of paroxysmal atrial fibrillation (AF) by right and left atrial ablation procedures have been published. The results of studies based on follow-up periods of a few months have been repeatedly interpreted as providing evidence for curative therapy. However, insufficient focus on the variability of the natural history of paroxysmal AF, the inadequate detection of silent arrhythmic events, the eclectic post-interventional use of antiarrhythmic drugs, and the lack of appropriate control groups make the reports unconvincing. Randomized controlled trials are needed to confirm postulated long-term cure rates for AF.

  17. Vagal denervation in atrial fibrillation ablation: A comprehensive review.

    PubMed

    Aksu, Tolga; Güler, Tümer Erdem; Mutluer, Ferit Onur; Oto, Mehmet Ali

    2017-08-01

    Although pulmonary vein isolation is accepted as an established interventional treatment in paroxysmal atrial fibrillation (AF), alternative modalities are being investigated because of the high recurrence rates of nonparoxysmal forms. One of the alternative ablation approaches is ablation or modification of vagal ganglionated plexi (VGP). The technique has not only been used in vagally mediated AF but also investigated in paroxysmal and nonparoxysmal AF. Clinical studies demonstrate significant discrepancy related with detection of VGP sites or ablation targets and definition of procedurel end-points, so far. In this review, we aimed to discuss the current data on the role of VGP in the pathogenesis of AF and potential therapeutic implications of ablation of these ganglia.

  18. Usefulness of ablation of complex fractionated atrial electrograms using nifekalant in persistent atrial fibrillation.

    PubMed

    Kumagai, Koichiro; Toyama, Hideko

    2013-01-01

    Additional ablation of complex fractionated atrial electrograms (CFAE) after pulmonary vein isolation (PVI) has been shown to improve the success of ablation of persistent atrial fibrillation (AF). However, extensive ablation is often necessary to eliminate all CFAE or to terminate AF. We assessed the usefulness of the administration of an antiarrhythmic drug (AAD) before CFAE ablation. One-hundred and ten patients with persistent AF first underwent PVI, roof and floor linear ablation (box isolation). One hundred patients who remained in AF after box isolation were then randomized to either receive (AAD group, n=50) or not receive (no-AAD group, n=50) intravenous nifekalant (0.3mg/kg) followed by a CFAE ablation. In the AAD group, nifekalant terminated AF in 19 (38%) patients and ablation of localized CFAE was performed in 31 patients who remained in AF after nifekalant, and terminated AF in 11 (35%) patients. In the no-AAD group, ablation of CFAE terminated AF in 13 (26%) patients. The AAD group had a significantly lesser number of radio frequency applications at CFAE sites (18 ± 12 versus 36 ± 10, p<0.0001) and shorter procedure time (162 ± 34 versus 197 ± 29 min, p<0.0001) compared with the no-AAD group. However, there was no significant difference in success rate at 12 months after a single ablation procedure between the two groups (AAD group, 74% versus no-AAD group, 76%). An approach to ablation using nifekalant may be useful in localizing areas of CFAE, reducing the number of applications at CFAE sites and procedure time. Ablation of only CFAE localized with nifekalant may be sufficient for clinical outcome. Copyright © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

  19. Percutaneous epicardial ablation of incessant atrial tachycardia originating from the left atrial appendage

    PubMed Central

    Ban, Ji-Eun; Park, Tae Young

    2016-01-01

    A 38-year-old woman presented with antiarrhythmic drug-refractory atrial tachycardia (AT). Holter recording demonstrated incessant episodes of AT followed by a long sinus pause. Electrophysiologic study revealed that the earliest endocardial activation was observed at the neck of the left atrial appendage (LAA). After unsuccessful endocardial ablation, epicardial access via a percutaneous subxiphoid approach demonstrated that the earliest epicardial atrial activation was observed on the opposite site to the endocardial LAA neck suggestive of ligament of Marshall (LOM) muscle sleeve as regarding the epicardial sharp potentials under guidance of a circular mapping catheter. Application of radiofrequency (RF) energy at this site terminated the tachycardia. After tachycardia ablation, the sinus pause also resolved. PMID:28066659

  20. Incremental His-to-coronary sinus maneuver: a nonlocal electrogram-based technique to assess complete cavotricuspid isthmus block during typical flutter ablation.

    PubMed

    Vallès, Ermengol; Bazán, Victor; Benito, Begoña; Jáuregui, Miguel Eduardo; Bruguera, Jordi; Guijo, Miguel Angel; Altaba, Carmen; Martí-Almor, Julio

    2013-08-01

    Achievement of complete cavotricuspid isthmus (CTI) conduction block reduces typical atrial flutter recurrences after ablation. The lack of increase in the His-to-coronary sinus ostium atrial interval during incremental pacing (IP) from the low lateral right atrium may distinguish slow conduction from complete CTI conduction block. Sixty-six consecutive patients (age, 65±13 years; 18% female) were prospectively included. A <10 ms increase in the His-to-coronary sinus ostium atrial timing during low lateral right atrium IP at cycle length of 600 ms through 300 ms was compared with the previously reported IP maneuver for the confirmation of complete CTI block. On the basis of the IP maneuver, complete CTI block (phase 2) was achieved in 59 patients, in 13 of whom an intermediate phase of functional CTI block (phase 1) was observed. In the remaining 7 patients, the IP maneuver did not allow for assessment of complete CTI block because of the presence of inconclusive potentials in the CTI ablation line. As compared with the IP maneuver, the incremental His-to-coronary sinus ostium maneuver was consistent with functional CTI block during phase 1 in all cases and conclusive of complete CTI block in 98% of cases during phase 2. The incremental His-to-coronary sinus ostium maneuver is analogous to the IP maneuver in distinguishing complete CTI block from persistent CTI conduction. This maneuver may provide confirmation of CTI block in those patients in whom assessment of local electrogram-based criteria is not feasible because of inconclusive potentials in the CTI ablation line.

  1. The role of digitalis pharmacokinetics in converting atrial fibrillation and flutter to regular sinus rhythm.

    PubMed

    Jelliffe, Roger W

    2014-05-01

    This report examined the role of digitalis pharmacokinetics in helping to guide therapy with digitalis glycosides with regard to converting atrial fibrillation (AF) or flutter to regular sinus rhythm (RSR). Pharmacokinetic models of digitoxin and digoxin, containing a peripheral non-serum effect compartment, were used to analyze outcomes in a non-systematic literature review of five clinical studies, using the computed concentrations of digitoxin and digoxin in the effect compartment of these models in an analysis of their outcomes. Four cases treated by the author were similarly examined. Three literature studies showed results no different from placebo. Dosage regimens achieved ≤11 ng/g in the model's peripheral compartment. However, two other studies achieved significant conversion to RSR. Their peripheral concentrations were 9-14 ng/g. In the four patients treated by the author, three converted using classical clinical titration with incremental doses, plus therapeutic drug monitoring and pharmacokinetic guidance from the models for maintenance dosage. They converted at peripheral concentrations of 9-18 ng/g, similar to the two studies above. No toxicity was seen. Successful maintenance was achieved, using the models and their pharmacokinetic guidance, by giving somewhat larger than average recommended dosage regimens in order to maintain peripheral concentrations present at conversion. The fourth patient did not convert, but only reached peripheral concentrations of 6-7 ng/g, similar to the studies in which conversion was no better than placebo. Pharmacokinetic analysis and guidance play a highly significant role in converting AF to RSR. To the author's knowledge, this has not been specifically described before. In my experience, conversion of AF or flutter to RSR does not occur until peripheral concentrations of 9-18 ng/g are reached. Results in the four cases correlated well with the literature findings. More work is needed to further evaluate these

  2. The Role of Digitalis Pharmacokinetics in Converting Atrial Fibrillation and Flutter to Sinus Rhythm

    PubMed Central

    Jelliffe, Roger

    2014-01-01

    This report examined the role of digitalis pharmacokinetics in helping to guide therapy with digitalis glycosides with regard to converting atrial fibrillation (AF) or flutter to regular sinus rhythm (RSR). Pharmacokinetic models of digitoxin and digoxin, containing a peripheral nonserum effect compartment, were used to analyze outcomes in a nonsystematic literature review of five clinical studies, using the computed concentrations of digitoxin and digoxin in the effect compartment of these models in an analysis of their outcomes. Four cases treated by the author were similarly examined. Three literature studies showed results no different from placebo. Dosage regimens achieved ≤ 11 ng/gm in the model’s peripheral compartment. However, two other studies achieved significant conversion to RSR. Their peripheral concentrations were 9 to14 ng/gm. In addition, four patients were treated by the author. Three converted using classical clinical titration with incremental doses, plus therapeutic drug monitoring and pharmacokinetic guidance from the models for maintenance dosage. They converted at peripheral concentrations of 9 to 18 ng/gm, similar to the two studies above. No toxicity was seen. Successful maintenance was achieved, using the models and their pharmacokinetic guidance, by giving somewhat larger than average recommended dosage regimens in order to maintain peripheral concentrations present at conversion. The fourth patient did not convert, but only reached peripheral concentrations of 6–7 ng/gm, similar to the studies in which conversion was no better than placebo. Pharmacokinetic analysis and guidance play a highly significant role in converting AF to RSR. To the author’s knowledge, this has not been specifically described before. In my experience, conversion of AF or flutter to RSR does not occur until peripheral concentrations of 9 –18 ng/gm are reached. Results in the four cases correlated well with the literature findings. More work is needed to

  3. Continuation of statin therapy and a decreased risk of atrial fibrillation/flutter in patients with and without chronic kidney disease.

    PubMed

    Chang, Chia-Hsuin; Lee, Yen-Chieh; Tsai, Chia-Ti; Chang, Sheng-Nan; Chung, Yu-Heng; Lin, Min-Shung; Lin, Jou-Wei; Lai, Mei-Shu

    2014-01-01

    To contain cost, Taiwan's previous National Health Insurance Reimbursement Policy requested that physicians discontinue their patients' statin therapy once the serum cholesterol had reached appropriate levels. This allowed us to evaluate the association between statin continuation and the occurrence of atrial fibrillation/flutter and whether it was modified by chronic kidney disease (CKD) status. Patients who initiated statin therapy between January 1, 2001 and December 31, 2009 were identified from a random sample of one million subjects in the Taiwan National Health Insurance Research Database. The outcome was atrial fibrillation/flutter. A proportional hazard regression model with time-varying statin use was applied to estimate the hazard ratios (HR) and 95% confidence intervals (CIs) for atrial fibrillation/flutter according to current statin use versus treatment discontinuation, adjusted for baseline disease risk scores and time-varying covariates. A total of 6767 CKD and 63,678 non-CKD patients initiating statin therapy were included and followed for an average of 4.0 years. A total of 1118 participants experienced new-onset atrial fibrillation/flutter. The incidence of atrial fibrillation/flutter was approximately 2 fold higher in the CKD patients. Continuation of statin therapy was associated with a 22% (adjusted hazard ratio 0.78; 95% CI: 0.65-0.93) and 57% (adjusted HR 0.43; 95% CI: 0.27-0.68) decrease in atrial fibrillation/flutter hazard as compared with discontinuation in non-CKD and CKD patients, respectively. Continuation of statin therapy was associated with a decreased risk of atrial fibrillation/flutter among CKD and non-CKD patients. However, further randomized studies are still needed to assess the association. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  4. Atrial flutter with spontaneous 1:1 atrioventricular conduction in adults: an uncommon but frequently missed cause for syncope/presyncope.

    PubMed

    Turitto, Gioia; Akhrass, Philippe; Leonardi, Marino; Saponieri, Cesare; Sette, Antonella; El-Sherif, Nabil

    2009-01-01

    To compare patients with atrial flutter (AFl) and 1:1 atrioventricular conduction (AVC) with patients with AFl and higher AVC. The characteristics of 19 patients with AFl and 1:1 AVC (group A) were compared with those of 116 consecutive patients with AFl and 2:1 AVC or higher degree AV block (group B). Age, gender, and left ventricular function were similar in the two groups. In group A versus group B, more patients had no structural heart disease (42% vs 17%, P < 0.05) and syncope/presyncope (90% vs 12%, P < 0.05). The AFl cycle length (CL) in group A was longer than in group B (265 +/- 24 ms vs 241 +/- 26 ms, P < 0.01). The transition from AFl with 1:1 to 2:1 AVC or vice versa was associated with small but definite changes in AFl CL, which showed larger variations in response to sympathetic stimulation. In group A patients who were studied off drugs, the atrial-His interval was not different from group B, but maximal atrial pacing rate with 1:1 AVC was faster. In group A, five patients were misdiagnosed as ventricular tachyarrhythmias, and three with a defibrillator received inappropriate shocks. Four patients had ablation of AVC and six had ablation of AFl circuit. The main difference between groups A and B may be an inherent capacity of the AV node for faster conduction, especially in response to increased sympathetic tone. The latter affects not only AVC but also the AFl CL. One should be aware of the different presentations of AFl with 1:1 AVC to avoid misdiagnosis/mismanagement and to consider the diagnosis in patients with narrow or wide QRS tachycardia and rates above 220/min.

  5. Catheter ablation in patients with persistent atrial fibrillation

    PubMed Central

    Kirchhof, Paulus; Calkins, Hugh

    2017-01-01

    Catheter ablation is increasingly offered to patients who suffer from symptoms due to atrial fibrillation (AF), based on a growing body of evidence illustrating its efficacy compared with antiarrhythmic drug therapy. Approximately one-third of AF ablation procedures are currently performed in patients with persistent or long-standing persistent AF. Here, we review the available information to guide catheter ablation in these more chronic forms of AF. We identify the following principles: Our clinical ability to discriminate paroxysmal and persistent AF is limited. Pulmonary vein isolation is a reasonable and effective first approach for catheter ablation of persistent AF. Other ablation strategies are being developed and need to be properly evaluated in controlled, multicentre trials. Treatment of concomitant conditions promoting recurrent AF by life style interventions and medical therapy should be a routine adjunct to catheter ablation of persistent AF. Early rhythm control therapy has a biological rationale and trials evaluating its value are underway. There is a clear need to generate more evidence for the best approach to ablation of persistent AF beyond pulmonary vein isolation in the form of adequately powered controlled multi-centre trials. PMID:27389907

  6. Factors influencing immediate and long-term outcome of electrical cardioversion of persistent atrial fibrillation and flutter

    PubMed Central

    Tabery, S.; Bouwels, L.; Uijen, G.J.H.; Uppelschoten, A.; Verheugt, F.W.A.

    2001-01-01

    Background To investigate which factors influence the immediate and long-term outcome of elective electrical cardioversion for persistent (>48h) atrial fibrillation or flutter. Methods In 255 patients, 435 electrical cardioversions were performed. Relevant clinical, electrocardiographic and echocardiographic factors were registered at each cardioversion. Each factor was tested separately in relation to immediate success and the outcome at six months and one year after cardioversion. Results In 70% of the patients, sinus rhythm was restored immediately after electrical cardioversion. After six months only 20% of the patients were still in sinus rhythm, and one year after cardioversion this figure had dropped to 14%. Sotalol used during electrical cardioversion resulted in the highest immediate success. Furthermore, atrial flutter, two or fewer electrical shocks and shocks ≤200 Joules resulted in the highest immediate success rate, whilst hypertensive heart disease resulted in the lowest immediate success rate. However, only shocks ≤200 Joules and a first cardioversion promoted the persistence of sinus rhythm after six months. A normal electrocardiogram, two or more cardioversions in the past and the use of a beta-blocking drug other than sotalol during cardioversion increased the chance of recurrence within six months. The duration of the arrhythmia >one month to 200 Joules and more than two cardioversions in the past were associated with a high number of recurrences one year later. With multivariate analysis we found that atrial flutter, low energy levels, low number of shocks and a long QTc-interval influence the immediate success positively. However, no factor influenced the persistence of sinus rhythm at six months and one year. Conclusion In patients with persistent atrial fibrillation or flutter, only about

  7. Catheter ablation of atrial fibrillation without the use of fluoroscopy.

    PubMed

    Reddy, Vivek Y; Morales, Gustavo; Ahmed, Humera; Neuzil, Petr; Dukkipati, Srinivas; Kim, Steve; Clemens, Janet; D'Avila, Andre

    2010-11-01

    In performing catheter ablation of paroxysmal atrial fibrillation (PAF), the advent of electroanatomical mapping (EAM) has significantly reduced fluoroscopy time. Recent advances in the ability of EAM systems to simultaneously visualize multiple catheters have allowed some operators to perform certain procedures, such as catheter ablation of supraventricular tachycardias, with zero fluoroscopy use. The purpose of this study was to evaluate the feasibility and safety of pulmonary vein (PV) isolation with zero fluoroscopy use, using a combination of three-dimensional EAM and intracardiac echocardiography (ICE). Using the NavX EAM system, the right atrial (RA) and coronary sinus (CS) geometries were created without fluoroscopy. Fluoroless transseptal puncture was performed under ICE guidance. Using a deflectable sheath and a multipolar catheter, the left atrial (LA) and PV anatomies were rendered and, in select cases, integrated with a three-dimensional computed tomography (CT) image. Irrigated radiofrequency ablation was performed to encircle each pair of ipsilateral PVs. This series included 20 consecutive PAF patients. RA/CS mapping required 5.5 ± 2.6 minutes. In all patients, single (n = 18) or dual (n = 2) transseptal access was successfully achieved. The LA-PV anatomy was rendered using either a circular (14 patients) or penta-array (six patients) catheter in 22 ± 10 minutes; CT image integration was used in 11 patients. Using 49 ± 18 ablation lesions/patient, electrical isolation was achieved in 38/39 ipsilateral PV isolating lesion sets (97%). The procedure time was 244 ± 75 minutes. There were no complications. Completely fluoroless catheter ablation of paroxysmal AF is safely feasible using a combination of ICE and EAM. Copyright © 2010 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  8. MRI evaluation of RF ablation scarring for atrial fibrillation treatment

    NASA Astrophysics Data System (ADS)

    Ishihara, Yuri; Nazafat, Reza; Wylie, John V.; Linguraru, Marius G.; Josephson, Mark E.; Howe, Robert D.; Manning, Warren J.; Peters, Dana C.

    2007-03-01

    This study presents a multi-modality image registration method that evaluates left atrial scarring after radiofrequency (RF) ablation for pulmonary vein (PV) isolation. Our group has recently developed a delayed enhancement magnetic resonance imaging (DE-MRI) method with the potential to visualize and monitor non-invasively post-ablation scarring in the left atrium and the PV ostia. We wished to compare the 3D configuration of scarring in the DE-MRI image and the ablation points recorded by electroanatomical mapping (EAM) system, hypothesizing that scarring detected by DE-MRI overlaps with ablation points recorded by the EAM system used in the procedure. Methods and Results: Three data sets, DE-MRI images and pulmonary vein MR angiography (PV-MRA) images, and EAM data (CARTO-XP, Biosense-Webster, Inc., Diamond Bar, CA) from a patient who underwent PV ablation, were used for the multi-modal image registration. Contrast-enhanced MR imaging was performed 38 days after the ablation procedure. PV-MRA and DE-MRI were fused by intensity-based rigid registration. Scar tissue was extracted from the DE-MRI images using multiple threshold values. EAM data was further fused with segmented PV-MRA by the iterative closest point algorithm (ICP). After registration, the distance from PV-MRA to the scar was 2.6 +/- 2.1 mm, and from ablation points to the surface of the scar was 2.5 +/- 2.3 mm. The fused image demonstrates the 3D relationship between the PV ostia, the scar and the EAM recording of ablation points. Conclusion: Multimodal data fusion indicated that the scar tissue lesion after PV isolation showed good overlap with the ablation points.

  9. Safety and Efficacy of Dronedarone in the Treatment of Atrial Fibrillation/Flutter

    PubMed Central

    Naccarelli, Gerald V.; Wolbrette, Deborah L.; Levin, Vadim; Samii, Soraya; Banchs, Javier E.; Penny-Peterson, Erica; Gonzalez, Mario D.

    2011-01-01

    Dronedarone is an amiodarone analog but differs structurally from amiodarone in that the iodine moiety was removed and a methane-sulfonyl group was added. These modifications reduced thyroid and other end-organ adverse effects and makes dronedarone less lipophilic, shortening its half-life. Dronedarone has been shown to prevent atrial fibrillation/flutter (AF/AFl) recurrences in several multi-center trials. In addition to its rhythm control properties, dronedarone has rate control properties and slows the ventricular response during AF. Dronedarone is approved in Europe for rhythm and rate control indications. In patients with decompensated heart failure, dronedarone treatment increased mortality and cardiovascular hospitalizations. However, when dronedarone was used in elderly high risk AF/AFl patients excluding such high risk heart failure, cardiovascular hospitalizations were significantly reduced and the drug was approved in the USA for this indication in 2009 by the Food and Drug Administration. Updated guidelines suggest dronedarone as a front-line antiarrhythmic in many patients with AF/Fl but caution that the drug should not be used in patients with advanced heart failure. In addition, the recent results of the PALLAS trial suggest that dronedarone should not be used in the long-term treatment of patients with permanent AF. PMID:22084608

  10. Low left atrial appendage flow velocity predicts recurrence of atrial fibrillation after catheter ablation of persistent atrial fibrillation.

    PubMed

    Kanda, Takashi; Masuda, Masaharu; Sunaga, Akihiro; Fujita, Masashi; Iida, Osamu; Okamoto, Shin; Ishihara, Takayuki; Watanabe, Tetsuya; Takahara, Mitsuyoshi; Sakata, Yasushi; Uematsu, Masaaki

    2015-11-01

    Recurrence after catheter ablation of persistent atrial fibrillation (AF) remains an unsolved issue. This study aimed to explore the association between the left atrial appendage peak flow velocity (LAAV) and AF recurrence after ablation in persistent AF patients. Fifty-three consecutive patients who underwent an initial catheter ablation of persistent AF were enrolled [age, 65±10 years; male, 42 (79%)]. The LAAV was obtained by transesophageal echocardiography before ablation. All the patients underwent pulmonary vein isolation and were followed up for 12 months. The LAAV and other clinical factors (AF duration, CHA2DS2VASc score, left atrial diameter, left atrial volume, and left ventricular ejection fraction) were tested using a Cox proportional hazards regression analysis as predictors of AF recurrence during the 1-year follow-up. AF recurrence occurred in 16 (30%) patients. The patients with AF recurrences had lower LAAVs (23.3±7.2cm/s vs. 33.3±15.1cm/s, p=0.002) than those without AF recurrence. In the multivariable analysis, a low LAAV independently predicted AF recurrence (hazard ratio, 3.04; 95% confidence interval, 1.05-8.79; p=0.040). A Kaplan-Meier analysis also demonstrated a lower survival rate free from AF recurrence in the low LAAV group than in the high LAAV group (p=0.030). A low LAAV was associated with AF recurrence after the initial catheter ablation of persistent AF. Copyright © 2015. Published by Elsevier Ltd.

  11. Pacemaker implantation after catheter ablation for atrial fibrillation.

    PubMed

    Deshmukh, Abhishek J; Yao, Xiaoxi; Schilz, Stephanie; Van Houten, Holly; Sangaralingham, Lindsey R; Asirvatham, Samuel J; Friedman, Paul A; Packer, Douglas L; Noseworthy, Peter A

    2016-01-01

    Sinus node dysfunction requiring pacemaker implantation is commonly associated with atrial fibrillation (AF), but may not be clinically apparent until restoration of sinus rhythm with ablation or cardioversion. We sought to determine frequency, time course, and predictors for pacemaker implantation after catheter ablation, and to compare the overall rates to a matched cardioversion cohort. We conducted a retrospective analysis using a large US commercial insurance database and identified 12,158 AF patients who underwent catheter ablation between January 1, 2005 and December 31, 2012. Over an average of 2.4 years of follow-up, 5.6 % of the patients underwent pacemaker implantation. Using the Cox proportional hazards models, we found that risk of risks of pacemaker implantation was associated with older age (50-64 and ≥65 versus <50 years), female gender, higher CHADS2 score (≥2 and 1 versus 0), higher Charlson index (≥2 versus 0-1), certain baseline comorbidities (conduction disorder, coronary atherosclerosis, and congestive heart failure), and the year of ablation. There was no significant difference in the risk of pacemaker implantation between ablation patients and propensity score (PS)-matched cardioversion groups (3.5 versus. 4.1 % at 1 year and 8.8 versus 8.3 % at 5 years). Overall, pacemaker implantation occurs in about 1/28 patients within 1 year of catheter ablation. The overall implantation rate decreased between 2005 and 2012. Furthermore, the risk after ablation is similar to cardioversion, suggesting that patients require pacing due to a common underlying electrophysiologic substrate, rather than the ablation itself.

  12. Predictive value of various Doppler-derived parameters of atrial conduction time for successful atrial fibrillation ablation

    PubMed Central

    Valtuille, Lucas; Choy, Jonathan B; Becher, Harald

    2015-01-01

    Various Doppler-derived parameters of left atrial electrical remodeling have been demonstrated to predict recurrence of atrial fibrillation (AF) after AF ablation. The aim of this study was to compare three Doppler-derived measures of atrial conduction time in patients undergoing AF ablation, and to investigate their predictive value for successful procedure. In 32 prospectively enrolled patients undergoing the first AF ablation, atrial conduction time was estimated by measuring the time delay between the onset of P-wave on the surface ECG to the peak of the a′-wave on the pulsed-wave Doppler and color-coded tissue Doppler imaging of the left atrial lateral wall, and to the peak of the A-wave on the pulsed-wave Doppler of the mitral inflow. There was a significant difference in the baseline atrial conduction time measured by different echocardiographic techniques. Most (88%) patients had normal or only mildly dilated left atrium. At 6 months, 12 patients (38%) had recurrent AF/atrial tachycardia. The duration of history of AF was the only predictor of AF/atrial tachycardia recurrence following the first AF ablation (P=0.024; OR 1.023, CI 1.003–1.044). A combination of normal left atrial volume and history of paroxysmal AF of ≤48 months was associated with the best outcome. Predictive value of the Doppler derived parameters of atrial conduction time may be reduced in the early stages of left atrial remodeling. Future studies may determine which echocardiographic parameter correlates best with the extent of left atrial remodeling and is most predictive of successful AF ablation. PMID:26795694

  13. Predictive value of various Doppler-derived parameters of atrial conduction time for successful atrial fibrillation ablation.

    PubMed

    Shanks, Miriam; Valtuille, Lucas; Choy, Jonathan B; Becher, Harald

    2015-12-01

    Various Doppler-derived parameters of left atrial electrical remodeling have been demonstrated to predict recurrence of atrial fibrillation (AF) after AF ablation. The aim of this study was to compare three Doppler-derived measures of atrial conduction time in patients undergoing AF ablation, and to investigate their predictive value for successful procedure. In 32 prospectively enrolled patients undergoing the first AF ablation, atrial conduction time was estimated by measuring the time delay between the onset of P-wave on the surface ECG to the peak of the a'-wave on the pulsed-wave Doppler and color-coded tissue Doppler imaging of the left atrial lateral wall, and to the peak of the A-wave on the pulsed-wave Doppler of the mitral inflow. There was a significant difference in the baseline atrial conduction time measured by different echocardiographic techniques. Most (88%) patients had normal or only mildly dilated left atrium. At 6 months, 12 patients (38%) had recurrent AF/atrial tachycardia. The duration of history of AF was the only predictor of AF/atrial tachycardia recurrence following the first AF ablation (P=0.024; OR 1.023, CI 1.003-1.044). A combination of normal left atrial volume and history of paroxysmal AF of ≤48 months was associated with the best outcome. Predictive value of the Doppler derived parameters of atrial conduction time may be reduced in the early stages of left atrial remodeling. Future studies may determine which echocardiographic parameter correlates best with the extent of left atrial remodeling and is most predictive of successful AF ablation.

  14. Ablation of atrial fibrillation using novel 4-dimensional catheter tracking within autoregistered left atrial angiograms.

    PubMed

    Rolf, Sascha; Sommer, Philipp; Gaspar, Thomas; John, Silke; Arya, Arash; Hindricks, Gerhard; Piorkowski, Christopher

    2012-08-01

    We describe a novel fluoroscopy coregistered, 4-dimensional catheter tracking technology (MediGuide Technology [MGT]) used for treatment of patients with atrial fibrillation. The aim of the study was to investigate (1) the feasibility of nonfluoroscopic catheter manipulation within dynamic left atrial chamber models; (2) the integration of the technology into an established electroanatomical mapping system; and (3) potential clinical impact. Forty-nine patients received atrial fibrillation ablation using MGT-enabled NavX-EnSite. Matched patients ablated with a conventional NavX-EnSite system served as a control group. MGT was used for the deployment of diagnostic catheters within preacquired cine loops, for nonfluoroscopic chamber mapping within dynamic angiograms, and for 4-dimensional tagging of anatomical landmarks. Integration with the electroanatomical mapping system allowed correction of field distortions and a reference tool to detect and correct map shifts. Catheter ablation was done without MGT because the ablation catheter was not MGT enabled. MGT worked safely and stably in all 49 patients. Catheter deployment within the preacquired cine loops was successfully performed in 45 of 49 (92%) patients. Catheter tracking within dynamic left atrial angiograms allowed nearly nonfluoroscopic creation of NavX-EnSite geometries with subsequent computed tomography model registration in all 49 patients. Overall, MGT significantly reduced total procedural fluoroscopy time (median [quartiles]) from 31 minutes (25, 43 minutes) to 16 minutes (10, 23 minutes) and irradiation dose from 14 453±7403 to 7363±5827 cGy*cm(2) (mean±SD), respectively (P<0.001). MGT is a tracking technology that allows 4-dimensional visualization of dedicated catheters within moving chamber models. Integration of the MGT with an established electroanatomical mapping system provided algorithms to facilitate mapping in the electroanatomical mapping system environment. As a first measurable

  15. Atrial Fibrillation Ablation Guided by a Novel Nonfluoroscopic Navigation System.

    PubMed

    Ballesteros, Gabriel; Ramos, Pablo; Neglia, Renzo; Menéndez, Diego; García-Bolao, Ignacio

    2017-09-01

    Rhythmia is a new nonfluoroscopic navigation system that is able to create high-density electroanatomic maps. The aim of this study was to describe the acute outcomes of atrial fibrillation (AF) ablation guided by this system, to analyze the volume provided by its electroanatomic map, and to describe its ability to locate pulmonary vein (PV) reconnection gaps in redo procedures. This observational study included 62 patients who underwent AF ablation with Rhythmia compared with a retrospective cohort who underwent AF ablation with a conventional nonfluoroscopic navigation system (Ensite Velocity). The number of surface electrograms per map was significantly higher in Rhythmia procedures (12 125 ± 2826 vs 133 ± 21 with Velocity; P < .001), with no significant differences in the total procedure time. The Orion catheter was placed for mapping in 99.5% of PV (95.61% in the control group with a conventional circular mapping catheter; P = .04). There were no significant differences in the percentage of PV isolation between the 2 groups. In redo procedures, an ablation gap could be identified on the activation map in 67% of the reconnected PV (40% in the control group; P = .042). The measured left atrial volume was lower than that calculated by computed tomography (109.3 v 15.2 and 129.9 ± 13.2 mL, respectively; P < .001). There were no significant differences in the number of complications. The Rhythmia system is effective for AF ablation procedures, with procedure times and safety profiles similar to conventional nonfluoroscopic navigation systems. In redo procedures, it appears to be more effective in identifying reconnected PV conduction gaps. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

  16. Thoracic vein ablation terminates chronic atrial fibrillation in dogs.

    PubMed

    Park, Angela M; Chou, Chung-Chuan; Drury, Paul C; Okuyama, Yuji; Peter, Anish; Hamabe, Akira; Miyauchi, Yasushi; Kass, Robert M; Karagueuzian, Hrayr S; Fishbein, Michael C; Lin, Shien-Fong; Chen, Peng-Sheng

    2004-06-01

    The thoracic vein hypothesis of chronic atrial fibrillation (AF) posits that rapid, repetitive activations from muscle sleeves within thoracic veins underlie the mechanism of sustained AF. If this is so, thoracic vein ablation should terminate sustained AF and prevent its reinduction. Six female mongrel dogs underwent chronic pulmonary vein (PV) pacing at 20 Hz to induce sustained (>48 h) AF. Bipolar electrodes were used to record from the atria and thoracic veins, including the vein of Marshall, four PVs, and the superior vena cava. Radio frequency (RF) application was applied around the PVs and superior vena cava and along the vein of Marshall until electrical activity was eliminated. Computerized mapping (1,792 electrodes, 1 mm resolution) was also performed. Sustained AF was induced in 30.6 +/- 6.5 days, and ablation was done 17.3 +/- 8.5 days afterward. Before ablation, the PVs had shorter activation cycle lengths than the atria, and rapid, repetitive activations were observed in the PVs. All dogs converted to sinus rhythm during (n = 4 dogs) or within 90 min of completion of RF ablation. Rapid atrial pacing afterward induced only nonsustained (<60 s) AF in all dogs. Average AF cycle lengths after reinduction were significantly (P = 0.01) longer (183 +/- 31.5 ms) than baseline (106 +/- 16.2 ms). There were no activation cycle length gradients after RF application. We conclude that thoracic vein ablation converts canine sustained AF into sinus rhythm and prevents the reinduction of sustained AF. These findings suggest that thoracic veins are important in the maintenance of AF in dogs.

  17. A systematic review of surgical ablation versus catheter ablation for atrial fibrillation

    PubMed Central

    Kearney, Katherine; Stephenson, Rowan; Phan, Kevin; Chan, Wei Yen; Huang, Min Yin

    2014-01-01

    Background Atrial fibrillation (AF) is an increasingly prevalent condition in the ageing population, with significantly associated morbidity and mortality. Surgical and catheter ablative strategies both aim to reduce mortality and morbidity through freedom from AF. This review consolidates all currently available comparative data to evaluate these two interventions. Methods A systematic search was conducted across MEDLINE, PubMed, Embase, Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews from January 2000 until August 2013. All studies were critically appraised and only those directly comparing surgical and catheter ablation were included. Results Seven studies were deemed suitable for analysis according to the inclusion criteria. Freedom from AF was significantly higher in the surgical ablation group versus the catheter ablation group at 6-month, 12-month and study endpoint follow-up periods. Subgroup analysis demonstrated similar trends, with higher freedom from AF in the surgical ablation group for paroxysmal AF patients. The incidence of pacemaker implantation was higher, while no difference in stroke or cardiac tamponade was demonstrated for the surgical versus catheter ablation groups. Conclusions Current evidence suggests that epicardial ablative strategies are associated with higher freedom from AF, higher pacemaker implantation rates and comparable neurological complications and cardiac tamponade incidence to catheter ablative treatment. Other complications and risks were poorly reported, which warrants further randomized controlled trials (RCTs) of adequate power and follow-up duration. PMID:24516794

  18. Curative ablation for atrial fibrillation: a systematic review.

    PubMed

    Gjesdal, Knut; Vist, Gunn E; Bugge, Einar; Rossvoll, Ole; Johansen, Marit; Norderhaug, Inger; Ohm, Ole-J

    2008-02-01

    To perform a systematic review of randomized controlled trials (RCTs) on catheter ablation for atrial fibrillation (AF). Radiofrequency catheter (RF)-ablation around pulmonary vein ostia and in left atrium may reduce or prevent recurrence of AF, as documented in observational studies and registry reports; however, few RCTs are available. Using relevant search phrases, Cochrane Library, MEDLINE and EMBASE were searched for RCTs, last time in May 2007. Titles and abstracts were screened. When entry criteria were fulfilled, full-text papers were read and graded according to quality and relevance. One thousand and ninety four abstracts were evaluated, and five RCTs included (578 randomized patients). The studies had moderate quality and relevance, but the results were consistent: ablation is better than drug treatment in preventing AF recurrence; the relative risk (95% CI)) one year after ablation ranged from 0.20 (0.08-0.51) to 0.62 (0.39-0.99). Results from observational and registry studies are confirmed: RF-ablation reduces recurrence rate of AF, and can be done with few serious complications. Limitations are few patients>70 years, and only one year follow-up.

  19. Surgical ablation for atrial fibrillation: techniques, indications, and results

    PubMed Central

    Lawrance, Christopher P.; Henn, Matthew C.; Damiano, Ralph J.

    2015-01-01

    Purpose of review The aim of this review is to focus specifically on the indications, evolution of technique, and results of surgical ablation for atrial fibrillation. Recent findings With the introduction of the Cox-Maze IV procedure utilizing bipolar radiofrequency ablation and cryoablation, long-term studies have demonstrated a significant decrease in aortic cross-clamp times and major complications with a comparable rate of restoration of sinus rhythm. New hybrid approaches utilizing both catheter-based ablation and minimally invasive surgical approaches have been developed, but have not been standardized. Early studies have demonstrated reasonable success rates of hybrid procedures, with advantages that include confirmation of conduction block, decreased surgical morbidity, and possibly reduced morbidity. However, hybrid approaches have the disadvantage of significantly increased operative times. Summary The Cox-Maze IV is currently the gold standard for surgical treatment of atrial fibrillation. New hybrid approaches have potential advantages with promising early results, but a standard lesion set, improvement in operative times, and long-term results still need to be evaluated. PMID:25389650

  20. [Atrial fibrillation and regular tachycardia in two young patients--are both treated with atrial fibrillation ablation?].

    PubMed

    von Bodman, G; Brömsen, J; Kopf, C; Füller, M; Block, M

    2014-04-17

    Two young patients with documented episodes of symptomatic paroxysmal atrial fibrillation have been referred for pulmonary vein isolation. Both patients had a history of concomitant regular tachycardia. in both cases pulmonaryvein isolation has not been performed but in each patient a supraventricular tachycardia (right focal atrial tachycardia/atrioventricular reentry tachycardia) could be induced and ablated instead. Concomitant supraventricular tachycardia acting as a trigger arrhythmia is frequent in young patients with atrial fibrillation without underlying cardiacdisease. In these patients a concomitant supra-ventricular tachycardia should beexcluded by electrophysiological study or ablated before pulmonary vein isolation or initiating an antiarrhythmic drug therapy. In most cases ablation of supraventricular tachycardia is safe and successful whereas the risks of ablative therapy of atrial fibrillation can not be neglected and success is moderate.

  1. Circus movement atrial flutter in the canine sterile pericarditis model. Activation patterns during initiation, termination, and sustained reentry in vivo.

    PubMed

    Schoels, W; Gough, W B; Restivo, M; el-Sherif, N

    1990-07-01

    The mechanisms of single-loop reentry in a syncytium without anatomically predetermined pathways have not been shown. Using a "jacket electrode" with 111 bipolar electrodes in a nylon matrix, we mapped in situ the atrial epicardial surface during atrial flutter in dogs with sterile pericarditis. Of 21 episodes of reentrant atrial flutter, only four showed double-loop ("figure-eight") reentry, whereas in 17 episodes a single loop was present. During initiation of single-loop reentry, an arc of functional block extended to the atrioventricular (AV) ring. This forced activation to proceed as a single wave around the free end of the arc, before breaking through the arc close to the AV ring. Activation continued as one loop around an arc close to the AV ring (in eight episodes) or around a combined functional and anatomic obstacle (in nine episodes) when the arc joined an atrial vessel. A zone of slow conduction was consistently bordered by the arc of block and the AV ring or by the anatomic obstacle and the AV ring. Spontaneous termination occurred when conduction failed in this area and the arc rejoined the AV ring. High-density recordings (2 mm) along the arc of block showed double potentials separated by an isoelectric interval, interpreted as local activation and electrotonus due to activation on the opposite side of the arc. Histologically, a diffuse inflammatory reaction involved 50-80% of the atrial wall. A transitional layer of myocardial bundles with preserved cross striation, but separated by edema and inflammatory cells, was enclosed between an epicardial layer of fragmented myocytes and an endocardial layer of grossly intact myocardium. There were no distinctive features at sites of functional conduction block or slowed conduction. In conclusion, single-loop reentry is the common pattern during atrial flutter in this model. Its induction depends on an interaction of the AV ring, a functional arc of block, and a zone of slow conduction. The location of the

  2. Ablation Technology for the Surgical Treatment of Atrial Fibrillation

    PubMed Central

    Melby, Spencer J.; Schuessler, Richard B.; Damiano, Ralph J.

    2014-01-01

    The Cox maze procedure for the surgical treatment of atrial fibrillation has been simplified from its original cut-and-sew technique. Various energy sources now exist which create linear lines of ablation that can be used to replace the original incisions, greatly facilitating the surgical approach. This review article describes the anatomy of the atria that must be considered in choosing a successful energy source. Furthermore the device characteristics, safety profile, mechanism of tissue injury, and ability to create transmural lesions of the various energy sources that have been used in the Cox maze procedure, along with the strengths and weaknesses of each device is discussed. PMID:23995989

  3. The epidemiology and management of recent-onset atrial fibrillation and flutter presenting to the Emergency Department.

    PubMed

    Hamilton, Ailsa; Clark, Donna; Gray, Alasdair; Cragg, Aidan; Grubb, Neill

    2015-06-01

    Atrial fibrillation (AF) and flutter are common tachyarrhythmias seen in the Emergency Department (ED). The management of recent-onset AF remains poorly defined. Two management strategies have been proposed: rhythm control versus rate control. The aims of this study were to investigate the epidemiology and management of recent-onset AF presenting to one large tertiary ED. Retrospective analysis of ED records was carried out using the ED PAS database to identify eligible patients presenting between 1 July 2009 and 30 June 2011 with onset of AF in the previous 7 days. Patients were included for analysis if it was their first presentation, first diagnosis or a paroxysm of atrial fibrillation. A total of 494 patients (625 presentations) were analysed. AF (n=564; 90.2%) and flutter (n=61; 9.8%) were the presenting rhythms. In all, 374 (53.8%) presentations were paroxysmal atrial fibrillation. For patients with AF, rhythm control was attempted in 171 (55.0%) patients presenting less than 48 h after symptom onset. Pharmacotherapy was the approach in 105 (31.4%) patients, compared with direct current cardioversion (n=45; 26.3%). Twenty-one patients received both. Flecainide (n=85) and amiodarone (n=33) were the main first-line pharmacotherapies, restoring sinus rhythm in 81.3 and 81.4% of patients, respectively. The overall efficacy of direct current cardioversion in restoring sinus rhythm was similar (78.8%). Eighty-one patients presented more than 48 h after symptom onset. Of those patients managed in the ED (n=38; 71.7%) were managed with rate control. The majority of patients with atrial flutter presented less than 48 h after symptom onset (n=48; 78.7%). Sixteen of these patients were managed with rhythm control strategies in the ED. The epidemiology of recent-onset AF in this series is comparable with previous publications. Rhythm control was only attempted in approximately half of all eligible patients. There was no single-favoured management strategy. Our

  4. Sex Differences in Outcomes After Discharge from the Emergency Department for Atrial Fibrillation/Flutter.

    PubMed

    Rosychuk, Rhonda J; Holroyd, Brian R; Zhang, Xuechen; Rowe, Brian H; Graham, Michelle M

    2017-06-01

    Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to emergency departments (EDs). We examined sex differences in outcomes for patients with AFF discharged from the ED in Alberta, Canada. ED presentations for AFF during 1999-2011 that ended in discharge were extracted from administrative databases for all Alberta residents (age ≥ 35 years). Multivariable models determined the effect of sex on the time to ED return for AFF, the first follow-up visit with a physician, the first follow-up visit with a specialist (cardiologist or internal medicine physician), and death. There were 21,062 patients/ED presentations (47.5% women). About 10% returned to the ED for AFF after discharge; the time to return was similar for both sexes (P = 0.39). Time to a first physician visit was shorter (unadjusted hazard ratio [uHR] = 1.10) and time to a specialist follow-up visit was longer (uHR = 0.93) for women than for men. Interactions between sex and age, socioeconomic groups, and comorbidities were identified that changed the effect of sex on time to follow-up. More women died by 30 (1.3% vs 0.9%; P = 0.009) and 90 (2.9% vs 2.4%, P = 0.02) days. The time between ED discharge and death was shorter for women in 1 socioeconomic group (P = 0.008) and for those with peripheral vascular disease (P = 0.02) or diabetes (P = 0.03). We identified sex differences for time to return to the ED, follow-up visit, and death (most importantly, increased mortality rates among women at 30 and 90 days), and time to death remained significant after adjustment for other demographic and health-related variables. Our findings have important potential implications for physicians in the emergency setting. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  5. Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X-TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF).

    PubMed

    Lip, Gregory Y H; Hammerstingl, Christoph; Marin, Francisco; Cappato, Riccardo; Meng, Isabelle Ling; Kirsch, Bodo; Morandi, Eolo; van Eickels, Martin; Cohen, Ariel

    2015-04-01

    There are still many unresolved issues concerning patient outcomes and prognostic factors in patients with atrial fibrillation (AF) and left atrial/left atrial appendage (LA/LAA) thrombi. Rivaroxaban (Xarelto®), a potent and highly selective oral, direct factor Xa inhibitor, is a new therapeutic option in this setting. The planned study program will consist of a prospective interventional study (X-TRA) and a retrospective observational registry (CLOT-AF). The primary objective of the X-TRA study is to explore the efficacy of rivaroxaban in the treatment of LA/LAA thrombi in patients with nonvalvular AF or atrial flutter, scheduled to undergo cardioversion or AF ablation, in whom an LA/LAA thrombus has been found on transesophageal echocardiography (TEE) before the procedure. The primary end point is the complete LA/LAA thrombus resolution rate at 6 weeks of end of treatment confirmed by TEE. The secondary objectives are to describe categories of thrombus outcome in patients (resolved, reduced, unchanged, larger, or new) confirmed on TEE at the end of treatment (after 6 weeks of treatment), incidence of the composite of stroke and noncentral nervous system systemic embolism at the end of treatment and during follow-up, and incidence of all bleeding at the end of treatment and during follow-up. The objective of the CLOT-AF registry is to provide retrospective thrombus-related patient outcome data after standard-of-care anticoagulant treatment in patients with nonvalvular AF or atrial flutter, who have TEE-documented LA/LAA thrombi. The data will be used as a reference for the prospective X-TRA study. In conclusion, X-TRA and CLOT-AF will provide some answers to the many unresolved issues concerning patient outcomes and prognostic factors in patients with AF and LAA thrombi. Results from this study program would provide the first prospective interventional study (X-TRA) and a large international retrospective observational registry (CLOT-AF) on the prevalence and

  6. Analysis of Bipolar Radiofrequency Ablation in Treatment of Atrial Fibrillation Associated with Rheumatic Heart Disease

    PubMed Central

    Li, Yang; Wu, Zhong

    2016-01-01

    Background Among patients with rheumatic heart disease (RHD), 45% to 60% present with atrial fibrillation (AF), which is associated with increased rates of thromboembolism, heart failure, and even death. The bipolar radiofrequency ablation (BRFA) combining with mitral valve procedure has been adopted in patients of AF associated with RHD, but evaluations about its effectiveness are still limited. Methods A total of 87 patients with RHD and long persistent AF who had accepted mitral valve replacement concomitant with BRFA were studied. Clinical data were collected to analyze the midterm results of BRFA and evaluate its efficiency. Univariate and multivariate analyses were used to identify the independent factors associated with late AF recurrence. Results Sixty-six (75.9%) patients maintained sinus rhythm after a mean follow-up of 13.4 ± 5.2 months. Late AF recurrence had been detected in 21 (24.1%) patients, 11 (12.6%) patients were confirmed to be AF, 8 (9.2%) patients were atrial flutter and 2 (2.3%) patients were junctional rhythm. In Multivariate logistic regression analysis, body mass index (BMI) (OR = 1.756, 95% CI = 1.289–2.391, p = 0.000) and early AF recurrence (OR = 5.479, 95% CI = 1.189–25.254, p = 0.029) were independent predictors of late AF recurrence. In addition, left ventricular ejection fraction (LVEF) and New York Heart Association class showed a greater improvement in patients who maintained sinus rhythm than those who experienced late AF recurrence. Conclusion BRFA is an effective technique for the treatment of long persistent AF associated with RHD during mitral valve replacement. The BMI and early AF recurrence are independent predictors for late AF recurrence. Patients with long-term restoration of sinus rhythm experienced a greater improvement of left ventricular function after BRFA. PMID:26960188

  7. Characteristics and Outcomes of Atrial Tachycardia Originating from the Sinus Venosus during Catheter Ablation of Atrial Fibrillation

    PubMed Central

    Park, Yae Min; Kook, Hyungdon; Kim, Woohyeon; Lee, Son Ki; Choi, Jong-Il; Lim, Hong Euy; Park, Sang Weon

    2013-01-01

    Background and Objectives The sinus venosus (SV) is not a well known source of atrial tachycardia (AT), but it can harbor AT during catheter ablation of atrial fibrillation (AF). Subjects and Methods A total of 1223 patients who underwent catheter ablation for AF were reviewed. Electrophysiological and electrocardiographic characteristics and outcomes after catheter ablation of AT originating from the SV were investigated. Results Ten patients (0.82%) demonstrated AT from the SV (7 males, 53.9±16.0 years, 6 persistent) during ablation of AF. The mean cycle length was 281±73 ms. After pulmonary vein isolation and left atrial ablation, AF converted to AT from the SV during right atrial ablation in 2 patients, by rapid atrial pacing after AF termination in 7 patients, and during isoproterenol infusion in 1 patient. Positive P-waves in inferior leads were shown in most patients (90%). The activation sequence of AT was from proximal to distal in the superior vena cava and high to low in the right atrium, which was similar to that of AT from crista terminalis. Fragmented double potentials were recorded during sinus, and a second discrete potential preceded the onset of P wave by 80±37 ms during AT. Using 4.4±2.7 radiofrequency focal applications, ATs were terminated and became no longer inducible in all. After ablation procedure, two patients showed transient right phrenic nerve palsy. After 19.9±14.8 months, all but 1 patient were free of atrial tachyarrhythmia without complications. Conclusion The AT which develops during AF ablation is rarely originated from SV, and its electrophysiologic characteristics may be helpful in guiding effective focal ablation. PMID:23407327

  8. Effect of left atrial appendage excision on procedure outcome in patients with persistent atrial fibrillation undergoing surgical ablation.

    PubMed

    Romanov, Alexander; Pokushalov, Evgeny; Elesin, Dmitry; Bogachev-Prokophiev, Alexander; Ponomarev, Dmitry; Losik, Denis; Bayramova, Sevda; Strelnikov, Artem; Shabanov, Vitaliy; Pidanov, Oleg; Kropotkin, Evgeny; Ivanickii, Eduard; Karaskov, Alexander; Steinberg, Jonathan S

    2016-09-01

    Catheter ablation is less successful for treatment of persistent atrial fibrillation (PersAF) than for paroxysmal atrial fibrillation. Some studies suggest that left atrial appendage (LAA) isolation in addition to pulmonary vein isolation (PVI) is required to maximize the benefits for PersAF after ablation. The purpose of this study was to compare the efficacy and safety of 2 surgical ablation approaches for PersAF via video-assisted thoracoscopy: PVI + box lesion and PVI + box lesion + LAA excision. We randomly assigned 176 patients with PersAF to video-assisted thoracoscopic surgical ablation with PVI + box lesion (88 patients) or PVI + box lesion + LAA excision (88 patients). The primary endpoint was freedom from any documented atrial arrhythmia lasting >30 seconds after a single ablation procedure without antiarrhythmic drug (AAD). After 18 months of follow-up, 61 of 86 patients (70.9%) assigned to PVI + box lesion were free from recurrent atrial fibrillation compared to 64 of 87 patients (73.6%) assigned to PVI + box lesion + LAA excision after a single ablation procedure without AAD (P = .73). Freedom from any atrial arrhythmia after a single procedure with or without AAD was also nonsignificant (70.9% vs 74.7%, respectively). There were no significant differences between groups with regard to adverse events, including death, transient ischemic attack, stroke, pneumothorax, and hydrothorax. Among patients with PersAF, no reduction in the rate of recurrent atrial fibrillation was found when LAA excision was performed in addition to PVI and box lesion during surgical ablation. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  9. Functional mitral regurgitation: predictor for atrial substrate remodeling and poor ablation outcome in paroxysmal atrial fibrillation

    PubMed Central

    Qiao, Yu; Wu, Lingmin; Hou, Bingbo; Sun, Wei; Zheng, Lihui; Ding, Ligang; Chen, Gang; Zhang, Shu; Yao, Yan

    2016-01-01

    Abstract Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. We sought to investigate the association between FMR and atrial substrate remodeling as well as the ablation outcome in paroxysmal AF (PAF) patients. We retrospectively analyzed a prospectively enrolled cohort of 132 patients (age 55.1 ± 9.6 years, 75.8% male) with symptomatic PAF who underwent initial ablation in our institute. Functional mitral regurgitation was defined as regurgitation jet area to left atrium (LA) area ratio ≥ 0.1 without any primary valvular disease. Voltage mapping of LA was performed under sinus rhythm. Low voltage zones (LVZs) were semi-quantitatively estimated and presented as low voltage index. Follow-up for AF recurrence ≥ 12 months was performed. In total, 40 patients (29.6%) were detected with FMR, who were older than the non-FMR patients (P = 0.007) and had larger LA diameters (P = 0.02). Left atrium LVZs were observed in 64.9% of patients with FMR versus 22.1% patients without FMR (P < 0.001). Functional mitral regurgitation independently predicted the presence of LVZs (OR 7.286; 95% CI 3.023–17.562; P < 0.001). During a mean follow-up of 22.9 ± 6.5 months, 38 patients (28.8%) experienced AF recurrence. The recurrence rate was 60.0% and 19.5% in FMR and non-FMR cohort, respectively (log rank P < 0.001). Multivariate analysis showed that FMR was an independent predictor for AF recurrence (HR 2.291; 95% CI 1.062–4.942; P = 0.03). Functional mitral regurgitation was strongly associated with atrial substrate remodeling. Furthermore, patients with FMR have substantial risk for AF recurrence post ablation. PMID:27472715

  10. Personalization of atrial anatomy and electrophysiology as a basis for clinical modeling of radio-frequency ablation of atrial fibrillation.

    PubMed

    Krueger, Martin W; Seemann, Gunnar; Rhode, Kawal; Keller, D U J; Schilling, Christopher; Arujuna, Aruna; Gill, Jaswinder; O'Neill, Mark D; Razavi, Reza; Dössel, Olaf

    2013-01-01

    Multiscale cardiac modeling has made great advances over the last decade. Highly detailed atrial models were created and used for the investigation of initiation and perpetuation of atrial fibrillation. The next challenge is the use of personalized atrial models in clinical practice. In this study, a framework of simple and robust tools is presented, which enables the generation and validation of patient-specific anatomical and electrophysiological atrial models. Introduction of rule-based atrial fiber orientation produced a realistic excitation sequence and a better correlation to the measured electrocardiograms. Personalization of the global conduction velocity lead to a precise match of the measured P-wave duration. The use of a virtual cohort of nine patient and volunteer models averaged out possible model-specific errors. Intra-atrial excitation conduction was personalized manually from left atrial local activation time maps. Inclusion of LE-MRI data into the simulations revealed possible gaps in ablation lesions. A fast marching level set approach to compute atrial depolarization was extended to incorporate anisotropy and conduction velocity heterogeneities and reproduced the monodomain solution. The presented chain of tools is an important step towards the use of atrial models for the patient-specific AF diagnosis and ablation therapy planing.

  11. Very long-term outcome of catheter ablation of post-incisional atrial tachycardia: Role of incisional and non-incisional scar.

    PubMed

    Zhou, Gong-Bu; Hu, Ji-Qiang; Guo, Xiao-Gang; Liu, Xu; Yang, Jian-du; Sun, Qi; Ma, Jian; Ouyang, Fei-Fan; Zhang, Shu

    2016-02-15

    The arrhythmogenicity of right atrial (RA) incisional scar after cardiac surgery could result in atrial tachycardia (AT). Radiofrequency catheter ablation is effective in the treatment of such tachycardia. However, data regarding long-term outcomes are limited. A total of 105 patients with prior RA incision who underwent radiofrequency catheter ablation of AT were included. In the first procedure, electroanatomic mapping (EAM) revealed a total of 139 ATs in 105 patients, including 88 cavotricuspid isthmus dependent atrial flutters (IDAFs), 5 mitral annulus reentrant tachycardias (MARTs), 44 intra-atrial reentrant tachycardias (IARTs) and 2 focal ATs (FATs). AT was successfully eliminated in 101 (96.1%) patients. During a mean follow-up period of 90 ± 36 months, recurrent AT was observed in 23 patients and 21 underwent a second ablation. A total of 23 ATs were identified in redo procedures including 4 IDAFs, 2 MARTs, 12 IARTs and 5 FATs. The time to recurrence was significantly different among various AT types. Acute success was achieved in 20 of 23 redo procedures. Taking a total of 21 patients presenting atrial fibrillation during follow-up into account, 85 patients (81.9%) were in sinus rhythm. No complications except for a case of RA compartmentation occurred. RA incisional scar played an essential role in promoting both IDAF and IART, while non-incisional scar contributed to a substantial rate of late recurrent AT in forms of both macroreentry and small reentry. Catheter ablation using EAM system resulted in a high success rate during long-term follow-up. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

  12. Novel Computational Analysis of Left Atrial Anatomy Improves Prediction of Atrial Fibrillation Recurrence after Ablation.

    PubMed

    Varela, Marta; Bisbal, Felipe; Zacur, Ernesto; Berruezo, Antonio; Aslanidi, Oleg V; Mont, Lluis; Lamata, Pablo

    2017-01-01

    The left atrium (LA) can change in size and shape due to atrial fibrillation (AF)-induced remodeling. These alterations can be linked to poorer outcomes of AF ablation. In this study, we propose a novel comprehensive computational analysis of LA anatomy to identify what features of LA shape can optimally predict post-ablation AF recurrence. To this end, we construct smooth 3D geometrical models from the segmentation of the LA blood pool captured in pre-procedural MR images. We first apply this methodology to characterize the LA anatomy of 144 AF patients and build a statistical shape model that includes the most salient variations in shape across this cohort. We then perform a discriminant analysis to optimally distinguish between recurrent and non-recurrent patients. From this analysis, we propose a new shape metric called vertical asymmetry, which measures the imbalance of size along the anterior to posterior direction between the superior and inferior left atrial hemispheres. Vertical asymmetry was found, in combination with LA sphericity, to be the best predictor of post-ablation recurrence at both 12 and 24 months (area under the ROC curve: 0.71 and 0.68, respectively) outperforming other shape markers and any of their combinations. We also found that model-derived shape metrics, such as the anterior-posterior radius, were better predictors than equivalent metrics taken directly from MRI or echocardiography, suggesting that the proposed approach leads to a reduction of the impact of data artifacts and noise. This novel methodology contributes to an improved characterization of LA organ remodeling and the reported findings have the potential to improve patient selection and risk stratification for catheter ablations in AF.

  13. Novel Computational Analysis of Left Atrial Anatomy Improves Prediction of Atrial Fibrillation Recurrence after Ablation

    PubMed Central

    Varela, Marta; Bisbal, Felipe; Zacur, Ernesto; Berruezo, Antonio; Aslanidi, Oleg V.; Mont, Lluis; Lamata, Pablo

    2017-01-01

    The left atrium (LA) can change in size and shape due to atrial fibrillation (AF)-induced remodeling. These alterations can be linked to poorer outcomes of AF ablation. In this study, we propose a novel comprehensive computational analysis of LA anatomy to identify what features of LA shape can optimally predict post-ablation AF recurrence. To this end, we construct smooth 3D geometrical models from the segmentation of the LA blood pool captured in pre-procedural MR images. We first apply this methodology to characterize the LA anatomy of 144 AF patients and build a statistical shape model that includes the most salient variations in shape across this cohort. We then perform a discriminant analysis to optimally distinguish between recurrent and non-recurrent patients. From this analysis, we propose a new shape metric called vertical asymmetry, which measures the imbalance of size along the anterior to posterior direction between the superior and inferior left atrial hemispheres. Vertical asymmetry was found, in combination with LA sphericity, to be the best predictor of post-ablation recurrence at both 12 and 24 months (area under the ROC curve: 0.71 and 0.68, respectively) outperforming other shape markers and any of their combinations. We also found that model-derived shape metrics, such as the anterior-posterior radius, were better predictors than equivalent metrics taken directly from MRI or echocardiography, suggesting that the proposed approach leads to a reduction of the impact of data artifacts and noise. This novel methodology contributes to an improved characterization of LA organ remodeling and the reported findings have the potential to improve patient selection and risk stratification for catheter ablations in AF. PMID:28261103

  14. The safety and efficacy of trans-baffle puncture to enable catheter ablation of atrial tachycardias following the Mustard procedure: a single centre experience and literature review.

    PubMed

    Jones, David G; Jarman, Julian W E; Lyne, Jonathan C; Markides, Vias; Gatzoulis, Michael A; Wong, Tom

    2013-09-30

    Targets for catheter ablation of atrial tachyarrhythmias (AT) in post-Mustard procedure patients are often located in the pulmonary venous atrium (PVA). Traditional access to this chamber is retrograde via the aorta. However trans-baffle puncture may be a key determinant of successful ablation in many cases. All AT ablations performed in patients late after Mustard and Senning operations by a single operator from 2007 to 2012 were reviewed. Nine procedures were identified. In total, 12 ATs were treated, seven persistent, the remainder induced, consisting of counterclockwise cavotricuspid isthmus dependent flutter (5), macroreentrant with isthmus in the systemic venous atrium (SVA) (2), macroreentrant with isthmus in the PVA (1), focal from the PVA (3), and focal from the SVA (1). Ablation within the PVA was required in all procedures to treat AT. Retrograde access in one patient was impossible due to the presence of a Bjork-Shiley tricuspid valve replacement; retrograde access in another two patients was attempted but catheter manipulation was ineffective and AT could not be mapped and ablated. Trans-baffle puncture was performed with transoesophageal echocardiographic guidance in all cases without complications and resulted in successful ablation of AT. Access to the pulmonary venous atrium is essential for successful ablation of AT in many Mustard patients. Trans-baffle puncture remains a relevant technique to modern practice and can be performed safely and effectively. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

  15. An Update on the Energy Sources and Catheter Technology for the Ablation of Atrial Fibrillation.

    PubMed

    Arora, Pawan K; Hansen, James C; Price, Adam D; Koblish, Josef; Avitall, Boaz

    2010-01-01

    The ablation of atrial fibrillation (AF) is an area of intense research in cardiac electrophysiology. In this review, we discuss the development of catheter-based interventions for AF ablation. We outline the pathophysiologic and anatomic bases for ablative lesion sets and the evolution of various catheter designs for the delivery of radiofrequency (RF), cryothermal, and other ablative energy sources. The strengths and weaknesses of various specialized RF catheters and alternative energy systems are delineated, with respect to efficacy and patient safety.

  16. Novel P Wave Indices to Predict Atrial Fibrillation Recurrence After Radiofrequency Ablation for Paroxysmal Atrial Fibrillation

    PubMed Central

    Hu, Xiaoliang; Jiang, Jingzhou; Ma, Yuedong; Tang, Anli

    2016-01-01

    Background Circumferential pulmonary vein isolation (CPVI) is a widely used treatment for paroxysmal atrial fibrillation (AF). Several P wave duration (PWD) parameters have been suggested to predict post-ablation recurrence, but their use remains controversial. This study aimed to identify novel P wave indices that predict post-ablation AF recurrence. Material/Methods We selected 171 consecutive patients undergoing CPVI for paroxysmal AF. Electrocardiography (ECG) recordings were obtained at the beginning and the end of ablation. PWD was measured in all 12 leads. The PWD variation was calculated by subtracting the pre-ablation PWD from the post-ablation PWD. Results PWD was significantly shortened in leads II, III, aVF, and V1 after ablation. During a mean follow-up of 19.96±4.32 months, AF recurrence occurred in 32 (18.7%) patients. No significant differences in baseline characteristics or pre- or post-ablation PWD were observed between the AF recurrence and non-recurrence groups. Patients with AF recurrence exhibited a smaller PWD variation in leads II (1.21(−0.56, 2.40) vs. −5.77(−9.10, −4.06) ms, P<0.001), III (−5.92(−9.87, 3.27) vs. −9.44(−11.89, −5.57) ms, P=0.001) and V1 (−4.43(−6.64, −3.13) vs. −6.33(−8.19,−4.59) ms, P=0.003). Multivariable logistic regression analysis demonstrated that smaller PWD variations in lead II and III were independent risk factors for AF recurrence. PWD variation ≥−2.21 ms in lead II displayed the highest combined sensitivity and specificity (85.29% and 83.94%, respectively) for predicting post-ablation AF recurrence. A PWD variation ≥0 ms displayed the best practical value in predicting AF recurrence. Conclusions PWD variation in lead II is an effective predictor of post-ablation AF recurrence. PMID:27450644

  17. Digoxin versus placebo, no intervention, or other medical interventions for atrial fibrillation and atrial flutter: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis.

    PubMed

    Sethi, Naqash J; Safi, Sanam; Feinberg, Joshua; Nielsen, Emil E; Gluud, Christian; Jakobsen, Janus C

    2017-04-05

    Atrial fibrillation is the most common arrhythmia of the heart with a prevalence of approximately 2% in the western world. Atrial flutter, another arrhythmia, occurs less often with an incidence of approximately 200,000 new patients per year in the USA. Patients with atrial fibrillation and atrial flutter have an increased risk of death and morbidities. In the management of atrial fibrillation and atrial flutter, it is often necessary to use medical interventions to lower the heart rate. Lowering the heart rate may theoretically prevent the development of heart failure and tachycardia-mediated cardiomyopathy. The evidence on the benefits and harms of digoxin compared with placebo or with other medical interventions is unclear. This protocol for a systematic review aims at identifying the beneficial and harmful effects of digoxin compared with placebo, no intervention, or with other medical interventions for atrial fibrillation and atrial flutter. This protocol for a systematic review was conducted following the recommendations of Cochrane and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials comparing digoxin with placebo, no intervention, or with other medical interventions. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed and classified as either at high risk of bias or low risk of bias, and our primary conclusions will be based on trials with low risk of bias. We will perform our meta-analyses of the extracted data using Review Manager 5.3 and Trial Sequential Analysis ver. 0.9.5.5 beta. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table based on GRADE assessments of the quality of the evidence. The results of this systematic review have the potential to benefit

  18. The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: a protocol for a systematic review with meta-analysis and Trial Sequential Analysis.

    PubMed

    Sethi, Naqash J; Safi, Sanam; Nielsen, Emil E; Feinberg, Joshua; Gluud, Christian; Jakobsen, Janus C

    2017-03-06

    Atrial fibrillation is the most common arrhythmia of the heart with a prevalence of approximately 2% in the western world. Atrial flutter, another arrhythmia, occurs less often with an incidence of approximately 200,000 new patients per year in the USA. Patients with atrial fibrillation and atrial flutter have an increased risk of death and morbidities. The management of atrial fibrillation and atrial flutter is often based on interventions aiming at either a rhythm control strategy or a rate control strategy. The evidence on the comparable effects of these strategies is unclear. This protocol for a systematic review aims at identifying the best overall treatment strategy for atrial fibrillation and atrial flutter. This protocol for a systematic review was performed following the recommendations of the Cochrane Collaboration and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials assessing the effects of any rhythm control strategy versus any rate control strategy. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed and classified as either high risk of bias or low risk of bias, and our conclusions will be based on trials with low risk of bias. The analyses of the extracted data will be performed using Review Manager 5 and Trial Sequential Analysis. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table and use GRADE assessment to assess the quality of the evidence. The results of this systematic review have the potential to benefit thousands of patients worldwide as well as healthcare systems and healthcare economy. PROSPERO CRD42016051433.

  19. [Patient selection for catheter ablation of atrial fibrillation].

    PubMed

    Márquez, Manlio F

    2007-01-01

    The present report describes the program of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) in patients referred to the AF Clinic of the National Institute of Cardiology. Specific inclusion criteria are required for RFCA of AF. If the patient fulfills it, then an electrophysiological study is performed. A transseptal approach and special mapping catheters are used to detect abnormal electrical activity (AEA). Pulmonary vein isolation is performed at the ostium/ antrum of those veins with AEA if the patient had paroxysmal AF. Global pulmonary vein isolation with some additional lines guided by electroanatomical mapping is performed in the case of chronic AF. Postoperative follow-up includes consultation, ECG and Holter monitoring at 1, 3, 6 and 12-month. RFCA is a useful and relatively safe procedure for the treatment of AF and the only one with curative potential.

  20. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study).

    PubMed

    Mont, Lluís; Bisbal, Felipe; Hernández-Madrid, Antonio; Pérez-Castellano, Nicasio; Viñolas, Xavier; Arenal, Angel; Arribas, Fernando; Fernández-Lozano, Ignacio; Bodegas, Andrés; Cobos, Albert; Matía, Roberto; Pérez-Villacastín, Julián; Guerra, José M; Ávila, Pablo; López-Gil, María; Castro, Victor; Arana, José Ignacio; Brugada, Josep

    2014-02-01

    Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0-43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213).

  1. Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study)

    PubMed Central

    Mont, Lluís; Bisbal, Felipe; Hernández-Madrid, Antonio; Pérez-Castellano, Nicasio; Viñolas, Xavier; Arenal, Angel; Arribas, Fernando; Fernández-Lozano, Ignacio; Bodegas, Andrés; Cobos, Albert; Matía, Roberto; Pérez-Villacastín, Julián; Guerra, José M.; Ávila, Pablo; López-Gil, María; Castro, Victor; Arana, José Ignacio; Brugada, Josep

    2014-01-01

    Background Catheter ablation (CA) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation (AF) when compared with antiarrhythmic drug therapy (ADT). No randomized studies have compared the two strategies in persistent AF. The present randomized trial aimed to compare the effectiveness of CA vs. ADT in treating persistent AF. Methods and results Patients with persistent AF were randomly assigned to CA or ADT (excluding patients with long-standing persistent AF). Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting >24 h that occurred after a 3-month blanking period. Secondary endpoints were any atrial tachyarrhythmia lasting >30 s, hospitalization, and electrical cardioversion. In total, 146 patients were included (aged 55 ± 9 years, 77% male). The ADT group received class Ic (43.8%) or class III drugs (56.3%). In an intention-to-treat analysis, 69 of 98 patients (70.4%) in the CA group and 21 of 48 patients (43.7%) in the ADT group were free of the primary endpoint (P = 0.002), implying an absolute risk difference of 26.6% (95% CI 10.0–43.3) in favour of CA. The proportion of patients free of any recurrence (>30 s) was higher in the CA group than in the ADT group (60.2 vs. 29.2%; P < 0.001) and cardioversion was less frequent (34.7 vs. 50%, respectively; P = 0.018). Conclusion Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up. Clinical Trial Registration Information NCT00863213 (http://clinicaltrials.gov/ct2/show/NCT00863213). PMID:24135832

  2. Towards patient-specific modelling of lesion formation during radiofrequency catheter ablation for atrial fibrillation

    PubMed Central

    Soor, Navjeevan; Morgan, Ross; Varela, Marta; Aslanidi, Oleg V.

    2017-01-01

    Radiofrequency catheter ablation procedures are a first-line method of clinical treatment for atrial fibrillation. However, they suffer from suboptimal success rates and are also prone to potentially serious adverse effects. These limitations can be at least partially attributed to the inter- and intra- patient variations in atrial wall thickness, and could be mitigated by patient-specific approaches to the procedure. In this study, a modelling approach to optimising ablation procedures in subject-specific 3D atrial geometries was applied. The approach enabled the evaluation of optimal ablation times to create lesions for a given wall thickness measured from MRI. A nonliner relationship was revealed between the thickness and catheter contact time required for fully transmural lesions. Hence, our approach based on MRI reconstruction of the atrial wall combined with subject-specific modelling of ablation can provide useful information for improving clinical procedures.

  3. Randomized comparison between pulmonary vein antral isolation versus complex fractionated electrogram ablation for paroxysmal atrial fibrillation.

    PubMed

    Chen, Minglong; Yang, Bing; Chen, Hongwu; Ju, Weizhu; Zhang, Fengxiang; Tse, Hung-Fat; Cao, Kejiang

    2011-09-01

    Circumferential pulmonary vein antral isolation (PVAI) and atrial complex fractionated electrograms (CFEs) are both ablative techniques for the treatment of paroxysmal atrial fibrillation (PAF). However, data on the comparative value of these 2 ablation strategies are very limited. We randomized 118 patients with drug-refractory PAF to receive PVAI ablation (n = 60) or CFE ablation (n = 58). For CFE group, spontaneous/induced AF was mapped using validated, automated software to guide ablation until all CFE areas were eliminated. For PVAI group, all 4 pulmonary vein antra were electrically isolated as confirmed by circular mapping catheter. Patients with spontaneous/inducible AF after the initial ablation procedure were crossed over to the other arms. After initial ablation procedure, AF persisted/inducible in 24/59 patients (41%), and 34/58 patients (59%) assigned to PVAI and CFE ablation, respectively (P = 0.05). Then 58 patients underwent PVAI + CFE ablation. After 22.6 ± 6.4 months, PVAI ablation group was more likely than CFE ablation group to achieve control of any AF/atrial tachycardia (AT) off drugs (43/60, 72% vs 33/58, 57%, P = 0.075) and lower recurrence rate of AT (11.9% vs 34.5%, P = 0.004). Patients who received CFE ablation alone (38%) had significantly lower overall success rate to achieve control of AF/AT off drugs compared with patients who received PVAI ablation (77%, P = 0.002) alone or PVAI + CFE ablation (69%, P = 0.008) due to higher recurrence rate of AT (50% vs 6% vs 13%, P < 0.01). CFE ablation in PAF patients was associated with higher occurrence rate of postprocedure AT compared with PVAI ablation, whereby making it less likely to be a sole ablation strategy for PAF patients.  © 2011 Wiley Periodicals, Inc.

  4. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department.

    PubMed

    Fromm, Christian; Suau, Salvador J; Cohen, Victor; Likourezos, Antonios; Jellinek-Cohen, Samantha; Rose, Jonathan; Marshall, John

    2015-08-01

    Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are both commonly used to treat atrial fibrillation/flutter (AFF) in the emergency department (ED). However, there is considerable regional variability in emergency physician practice patterns and debate among physicians as to which agent is more effective. To date, only one small prospective, randomized trial has compared the effectiveness of diltiazem and metoprolol for rate control of AFF in the ED and concluded no difference in effectiveness between the two agents. Our aim was to compare the effectiveness of diltiazem with metoprolol for rate control of AFF in the ED. A convenience sample of adult patients presenting with rapid atrial fibrillation or flutter was randomly assigned to receive either diltiazem or metoprolol. The study team monitored each subject's systolic and diastolic blood pressures and heart rates for 30 min. In the first 5 min, 50.0% of the diltiazem group and 10.7% of the metoprolol group reached the target heart rate (HR) of <100 beats per minute (bpm) (p < 0.005). By 30 min, 95.8% of the diltiazem group and 46.4% of the metoprolol group reached the target HR < 100 bpm (p < 0.0001). Mean decrease in HR for the diltiazem group was more rapid and substantial than that of the metoprolol group. From a safety perspective, there was no difference between the groups with respect to hypotension (systolic blood pressure < 90 mm Hg) and bradycardia (HR < 60 bpm). Diltiazem was more effective in achieving rate control in ED patients with AFF and did so with no increased incidence of adverse effects. Copyright © 2015 Elsevier Inc. All rights reserved.

  5. Plowing the atrium and growing thrombi: two cases of large atrial thrombi following ablative and surgical procedure for atrial fibrillation.

    PubMed

    Carasso, Shemy; Kuperstein, Rafael; Konen, Eli; Glikson, Michael; Feinberg, Micha S

    2006-10-01

    We present two patients with a large left atrial (LA) thrombus following invasive treatment for atrial fibrillation and inadequate anticoagulation. Case 1: A 30-year-old woman, with a one-year history of symptomatic paroxysmal atrial fibrillation resistant to medical therapy, underwent catheter ablation for atrial fibrillation. Three days after the procedure the patient presented with dizziness, fatigue, rapid atrial fibrillation with a sub-therapeutic INR. Transesophageal echocardiography (TEE) revealed a large LA thrombus. Case 2: A 59-year-old male, with severe mitral regurgitation and chronic atrial fibrillation, underwent mitral valve repair and Cox-Maze procedure. Three months later, while asymptomatic, a follow-up transthoracic echocardiography a large posterior LA thrombus was imaged. His INR was also sub-therapeutic. Both patients were treated by enhancing anticoagulation and close echocardiographic follow-up. So far both patients have remained asymptomatic two months following discharge. Large LA thrombi detected by transthoracic echocardiography are a rare complication of the Cox-Maze procedure and radio-frequency ablation for atrial fibrillation, which may occur even in patients with restored normal sinus rhythm receiving inadequate anticoagulation therapy.

  6. Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm.

    PubMed

    Scheuermeyer, Frank X; Pourvali, Reza; Rowe, Brian H; Grafstein, Eric; Heslop, Claire; MacPhee, Jan; McGrath, Lorraine; Ward, John; Heilbron, Brett; Christenson, Jim

    2015-05-01

    Although the management and outcomes of emergency department (ED) patients with atrial fibrillation or flutter have been explored, such studies have typically excluded patients with acute underlying medical illnesses. We seek to describe the ED treatment and outcomes of these complex patients with atrial fibrillation or flutter. This retrospective descriptive cohort study used an ECG database from 2 urban EDs to identify consecutive ED patients with an ECG demonstrating atrial fibrillation or flutter from January 1, 2009, to December 31, 2009. We categorized patients with atrial fibrillation or flutter as "complex" according to prespecified criteria and then grouped them as being managed with rate or rhythm control attempts, or not. The primary outcome was safety of rate or rhythm control, measured by whether patients had a predefined adverse event or not. The secondary outcome was the success of rate or rhythm control, defined as rate control decreasing the pulse rate by 20 beats/min and successful rhythm control, both within 4 hours of treatment initiation. Descriptive statistics were used to compare the 2 groups. Four hundred sixteen complex patients with atrial fibrillation or flutter were identified. Patients managed with rate or rhythm control were similar in all baseline characteristics and illness distribution to patients who were not managed in this manner. The 135 patients with attempted rate control (105) or rhythm control (30) had 55 adverse events (40.7%; 95% confidence interval [CI] 32.5% to 49.5%), whereas the 281 patients not managed with rate or rhythm control had 20 adverse events (7.1%; 95% CI 4.5% to 10.9%), for a risk difference of 33.6% (95% CI 24.3% to 42.5%) and a relative risk of 5.7 (95% CI 3.6 to 9.1). Twenty of 105 patients (19.1%; 95% CI 12.3% to 28.1%) were successfully rate controlled, whereas 4 of 30 (13.3%; 95% CI 4.4% to 31.6%) were successfully rhythm controlled. In ED patients with complex atrial fibrillation or flutter, attempts

  7. Repeat left atrial catheter ablation: cardiac magnetic resonance prediction of endocardial voltage and gaps in ablation lesion sets.

    PubMed

    Harrison, James L; Sohns, Christian; Linton, Nick W; Karim, Rashed; Williams, Steven E; Rhode, Kawal S; Gill, Jaswinder; Cooklin, Michael; Rinaldi, C Aldo; Wright, Matthew; Schaeffter, Tobias; Razavi, Reza S; O'Neill, Mark D

    2015-04-01

    Studies have reported an inverse relationship between late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) signal intensity and left atrial (LA) endocardial voltage after LA ablation. However, there is controversy regarding the reproducibility of atrial LGE CMR and its ability to identify gaps in ablation lesions. Using systematic and objective techniques, this study examines the correlation between atrial CMR and endocardial voltage. Twenty patients who had previous ablation for atrial fibrillation and represented with paroxysmal atrial fibrillation or atrial tachycardia underwent preablation LGE CMR. During the ablation procedure, high-density point-by-point Carto voltage maps were acquired. Three-dimensional CMR reconstructions were registered with the Carto anatomies to allow comparison of voltage and LGE signal intensity. Signal intensities around the left and right pulmonary vein antra and along the LA roof and mitral lines on the CMR-segmented LA shells were extracted to examine differences between electrically isolated and reconnected lesions. There were a total of 6767 data points across the 20 patients. Only 119 (1.8%) of the points were ≤ 0.05 mV. There was only a weak inverse correlation between either unipolar (r = -0.18) or bipolar (r = -0.17) voltage and LGE CMR signal intensities with low voltage occurring across a large range of signal intensities. Signal intensities were not statistically different for electrically isolated and reconnected lesions. This study demonstrates that there is only a weak point-by-point relationship between LGE CMR and endocardial voltage in patients undergoing repeat LA ablation. Using an objective method of assessing gaps in ablation lesions, LGE CMR is unable to reliably predict sites of electrical conduction. © 2015 American Heart Association, Inc.

  8. Atrial Electrogram Discordance During Baseline versus Re-Induced Atrial Fibrillation: Potential Ramifications For Ablation Procedures

    PubMed Central

    Biviano, Angelo B.; Ciaccio, Edward J.; Knotts, Robert; Lawrence, John; Iyer, Vivek; Whang, William; Garan, Hasan

    2015-01-01

    Background There are scant data comparing the electrogram (EGM) signal characteristics of AF in the baseline versus electrically induced states during ablation procedures. Objective The purpose of this study was to use novel intracardiac signal analysis techniques to gain insights into the effects of catheter ablation and AF re-induction on AF EGMs in patients with persistent AF. Methods We collected left atrial EGMs in patients undergoing first ablation for persistent AF at three time intervals: i) AF at baseline; ii) AF after pulmonary vein isolation (PVI) and; iii) AF after post-PVI cardioversion and subsequent re-induction. We analyzed the following two EGM spectral characteristics: 1a) dominant frequency (DF) and 1b) spectral complexity; and the following two EGM morphologic characteristics: 2a) morphology variation, and 2b) pattern repetitiveness. Results There were no differences in AF dominant frequency, dominant amplitude, spectral complexity, or metrics of EGM morphology or repetitiveness at baseline versus after PVI. However, dominant frequency, dominant amplitude, and spectral complexity differed significantly after DC cardioversion and re-induction of AF. Conclusions The frequency, spectral complexity and local EGM morphologies of AF do not significantly change over the course of a pulmonary vein isolation procedure in patients with persistent AF. However, re-induction of AF after DC cardioversion results in different DF and spectral complexity, consistent with a change in the characteristics of the perpetuating source(s) of the newly induced AF. These data suggest that AF properties can vary significantly between baseline versus re-induced AF, with potential clinical ramifications for outcomes of catheter ablation procedures. PMID:25818256

  9. Catheter ablation for atrial fibrillation: results from the first European Snapshot Survey on Procedural Routines for Atrial Fibrillation Ablation (ESS-PRAFA) Part II.

    PubMed

    Chen, Jian; Dagres, Nikolaos; Hocini, Melece; Fauchier, Laurent; Bongiorni, Maria Grazia; Defaye, Pascal; Hernandez-Madrid, Antonio; Estner, Heidi; Sciaraffia, Elena; Blomström-Lundqvist, Carina

    2015-11-01

    The European Snapshot Survey on Procedural Routines in Atrial Fibrillation Ablation (ESS-PRAFA) is a prospective, multicentre snapshot survey collecting patient-based data on current clinical practices during atrial fibrillation (AF) ablation. The participating centres were asked to prospectively enrol consecutive patients during a 6-week period (from September to October 2014). A web-based case report form was employed to collect information of patients and data of procedures. A total of 455 eligible consecutive patients from 13 countries were enrolled (mean age 59 ± 10.8 years, 28.8% women). Distinct strategies and endpoints were collected for AF ablation procedures. Pulmonary vein isolation (PVI) was performed in 96.7% and served as the endpoint in 91.3% of procedures. A total of 52 (11.5%) patients underwent ablation as first-line therapy. The cryoballoon technique was employed in 31.4% of procedures. Procedure, ablation, and fluoroscopy times differed among various types of AF ablation. Divergences in patient selection and complications were observed among low-, medium-, and high-volume centres. Adverse events were observed in 4.6% of AF ablation procedures. In conclusion, PVI was still the main strategy for AF ablation. Procedure-related complications seemed not to have declined. The centre volume played an important role in patient selection, strategy choice, and had impact on the rate of periprocedural complication.

  10. Isoproterenol infusion increases level of consciousness during catheter ablation of atrial fibrillation.

    PubMed

    O'Neill, Daniel K; Aizer, Anthony; Linton, Patrick; Bloom, Marc; Rose, Emily; Chinitz, Larry

    2012-08-01

    The objective of this study was to determine the effects of isoproterenol infusion on level of consciousness during ablation using total intravenous anesthesia. Seven patients undergoing total intravenous anesthesia for atrial fibrillation ablation were monitored for level of consciousness using bispectral EEG levels (BIS). Isoproterenol infusion was performed after the ablation during anesthesia. BIS levels prior to, during, and post-isoproterenol infusion were recorded and correlated to isoproterenol infusion doses. In all patients, BIS levels significantly increased during isoproterenol infusion (median BIS prior to infusion, 46; during infusion, 64 (p < 0.02)). With a subsequent increase in anesthetic medication, BIS levels could again be reduced. Isoproterenol infusion alters consciousness level during total intravenous anesthesia for atrial fibrillation ablation. BIS monitoring is a novel way to modulate anesthesia during ablation to potentially optimize patient comfort and ablation success.

  11. Ablation for Persistent Atrial Fibrillation-Is There a Role for More Than PVI?

    PubMed

    Lappe, Jason M; Cutler, Michael J; Day, John D; Bunch, T Jared

    2016-03-01

    Persistent atrial fibrillation (AF) is a prevalent condition that can be difficult to treat medically, and an ablation strategy is often sought. Currently, the cornerstone of AF ablation strategies is pulmonary vein isolation (PVI). Unfortunately, the single procedure success rates are limited, particularly when long-term outcomes (>1 year) are considered. As a result, the most recent consensus statement recommends that in patients with persistent AF a more extensive ablation be considered. Many additive procedural approaches to PVI have been investigated. These include electrical compartmentalization of the atria with linear lesions (LLs), ablation of complex fractionated atrial electrograms (CFAEs), ablation of the dominant frequency (DF) signals, and focal impulse and rotor modulation (FIRM) ablation. Each of these approaches has demonstrated degrees of additive success when performed with a PVI in patients with persistent AF. This review provides an in-depth discussion of these techniques, their successes in treating persistent AF, and their shortcomings.

  12. Paroxysmal atrial fibrillation ablation: Achieving permanent pulmonary vein isolation by point-by-point radiofrequency lesions

    PubMed Central

    Pedrote, Alonso; Acosta, Juan; Jáuregui-Garrido, Beatriz; Frutos-López, Manuel; Arana-Rueda, Eduardo

    2017-01-01

    Pulmonary vein isolation by point-by-point radiofrequency catheter ablation constitutes the cornerstone of catheter ablation strategies for the treatment of atrial fibrillation. However, despite advances in pulmonary vein isolation ablation strategies, long-term success rates after ablation remain suboptimal, which highlights the need to develop techniques to achieve more durable lesions. Strategies proposed to improve the durability of pulmonary vein isolation can be divided into two groups: Those addressed to improving the quality of the lesion and those that optimize the detection of acute PV reconnection during the ablation procedure. This manuscript reviews the role and potential benefits of these techniques according to current clinical evidence. PMID:28400919

  13. Ablation of Persistent Atrial Fibrillation Targeting Low-Voltage Areas With Selective Activation Characteristics.

    PubMed

    Jadidi, Amir S; Lehrmann, Heiko; Keyl, Cornelius; Sorrel, Jérémie; Markstein, Viktor; Minners, Jan; Park, Chan-Il; Denis, Arnaud; Jaïs, Pierre; Hocini, Mélèze; Potocnik, Clemens; Allgeier, Juergen; Hochholzer, Willibald; Herrera-Sidloky, Claudia; Kim, Steve; Omri, Youssef El; Neumann, Franz-Josef; Weber, Reinhold; Haïssaguerre, Michel; Arentz, Thomas

    2016-03-01

    Complex-fractionated atrial electrograms and atrial fibrosis are associated with maintenance of persistent atrial fibrillation (AF). We hypothesized that pulmonary vein isolation (PVI) plus ablation of selective atrial low-voltage sites may be more successful than PVI only. A total of 85 consecutive patients with persistent AF underwent high-density atrial voltage mapping, PVI, and ablation at low-voltage areas (LVA < 0.5 mV in AF) associated with electric activity lasting > 70% of AF cycle length on a single electrode (fractionated activity) or multiple electrodes around the circumferential mapping catheter (rotational activity) or discrete rapid local activity (group I). The procedural end point was AF termination. Arrhythmia freedom was compared with a control group (66 patients) undergoing PVI only (group II). PVI alone was performed in 23 of 85 (27%) patients of group I with low amount (< 10% of left atrial surface area) of atrial low voltage. Selective atrial ablation in addition to PVI was performed in 62 patients with termination of AF in 45 (73%) after 11 ± 9 minutes radiofrequency delivery. AF-termination sites colocalized within LVA in 80% and at border zones in 20%. Single-procedural arrhythmia freedom at 13 months median follow-up was achieved in 59 of 85 (69%) patients in group I, which was significantly higher than the matched control group (31/66 [47%], P < 0.001). There was no significant difference in the success rate of patients in group I with a low amount of low voltage undergoing PVI only and patients requiring PVI+selective low-voltage ablation (P = 0.42). Ablation of sites with distinct activation characteristics within/at borderzones of LVA in addition to PVI is more effective than conventional PVI-only strategy for persistent AF. PVI only seems to be sufficient to treat patients with left atrial low voltage < 10%. © 2016 American Heart Association, Inc.

  14. Is Cryoballoon Ablation Preferable to Radiofrequency Ablation for Treatment of Atrial Fibrillation by Pulmonary Vein Isolation? A Meta-Analysis

    PubMed Central

    Xu, Junxia; Huang, Yingqun; Cai, Hongbin; Qi, Yue; Jia, Nan; Shen, Weifeng; Lin, Jinxiu; Peng, Feng; Niu, Wenquan

    2014-01-01

    Objective Currently radiofrequency and cryoballoon ablations are the two standard ablation systems used for catheter ablation of atrial fibrillation; however, there is no universal consensus on which ablation is the optimal choice. We therefore sought to undertake a meta-analysis with special emphases on comparing the efficacy and safety between cryoballoon and radiofrequency ablations by synthesizing published clinical trials. Methods and Results Articles were identified by searching the MEDLINE and EMBASE databases before September 2013, by reviewing the bibliographies of eligible reports, and by consulting with experts in this field. Data were extracted independently and in duplicate. There were respectively 469 and 635 patients referred for cryoballoon and radiofrequency ablations from 14 qualified clinical trials. Overall analyses indicated that cryoballoon ablation significantly reduced fluoroscopic time and total procedure time by a weighted mean of 14.13 (95% confidence interval [95% CI]: 2.82 to 25.45; P = 0.014) minutes and 29.65 (95% CI: 8.54 to 50.77; P = 0.006) minutes compared with radiofrequency ablation, respectively, whereas ablation time in cryoballoon ablation was nonsignificantly elongated by a weighted mean of 11.66 (95% CI: −10.71 to 34.04; P = 0.307) minutes. Patients referred for cryoballoon ablation had a high yet nonsignificant success rate of catheter ablation compared with cryoballoon ablation (odds ratio; 95% CI; P: 1.34; 0.53 to 3.36; 0.538), and cryoballoon ablation was also found to be associated with the relatively low risk of having recurrent atrial fibrillation (0.75; 0.3 to 1.88; 0.538) and major complications (0.46; 0.11 to 1.83; 0.269). There was strong evidence of heterogeneity and low probability of publication bias. Conclusion Our findings demonstrate greater improvement in fluoroscopic time and total procedure duration for atrial fibrillation patients referred for cryoballoon ablation than those for

  15. Box lesion in the open left atrium for surgical ablation of atrial fibrillation.

    PubMed

    Sternik, Leonid; Kogan, Alexander; Luria, David; Glikson, Michael; Malachy, Ateret; Levin, Shany; Raanani, Ehud

    2014-03-01

    Cut-and-sew maze with a box lesion around the pulmonary veins is currently the criterion standard procedure for surgical ablation of atrial fibrillation. Recently, we changed our technique from standard bilateral epicardial pulmonary vein isolation with interconnecting lesions to a box lesion procedure with a bipolar radiofrequency ablation device. Our study describes this technique. Between March 2009 and June 2012, we performed 90 ablations by the box technique with a bipolar radiofrequency device. Fifty-five patients (61%) had persistent atrial fibrillation, and 21 (23%) had long-standing persistent atrial fibrillation. The left atriotomy was performed along the interatrial septum and the left atrial appendage amputated. The box was made by connecting the left atriotomy to the base of the amputated appendage with lines along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar radiofrequency ablation device. The left atrial isthmus was ablated by cryoprobe. There were no ablation-related complications. The box was easy to perform, with no dissection around the pulmonary veins. At 6-month, 1-year, and 2-year follow-ups, 80 (94%), 69 (93%), and 47 (91%) patients, respectively, were in sinus rhythm. Freedoms from antiarrhythmic medications in patients in sinus rhythm at 6 months, 1 year, and 2 years were 78%, 88%, and 85%, respectively. The box lesion provided excellent freedom from atrial fibrillation and may improve transmurality through ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. With the box lesion, dissection around the pulmonary veins is unnecessary. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

  16. Virtual ablation for atrial fibrillation in personalized in-silico three-dimensional left atrial modeling: comparison with clinical catheter ablation.

    PubMed

    Hwang, Minki; Kwon, Soon-Sung; Wi, Jin; Park, Mijin; Lee, Hyun-Seung; Park, Jin-Seo; Lee, Young-Seon; Shim, Eun Bo; Pak, Hui-Nam

    2014-09-01

    Although catheter ablation is an effective rhythm control strategy for atrial fibrillation (AF), empirically-based ablation has a substantial recurrence rate. The purposes of this study were to develop a computational platform for patient-specific virtual AF ablation and to compare the anti-fibrillatory effects of 5 different virtual ablation protocols with empirically chosen clinical ablations. We included 20 patients with AF (65% male, 60.1 ± 10.5 years old, 80% persistent AF [PeAF]) who had undergone empirically-based catheter ablation: circumferential pulmonary vein isolation (CPVI) for paroxysmal AF (PAF) and additional posterior box lesion (L1) and anterior line (L2) for PeAF. Using patient-specific three-dimensional left atrial (LA) geometry, we generated a finite element model and tested the AF termination rate after 5 different virtual ablations: CPVI alone, CPVI + L1, CPVI + L1,2, CPVI with complex fractionated atrial electrogram (CFAE) ablation, and CFAE ablation alone. 1. Virtual CPVI + L1,2 ablation showed the highest AF termination rate in overall patients (55%) and PeAF patients (n = 16, 62.5%). 2. The virtual AF maintenance duration was shortest in the case of virtual CPVI + L1,2 ablation in overall patients (2.19 ± 1.28 vs. 2.91 ± 1.04 s, p = 0.009) and in patients with PeAF (2.05 ± 1.23 vs. 2.93 ± 10.2 s, p = 0.004) compared with other protocols. Virtual AF ablation using personalized in-silico model of LA is feasible. Virtual ablation with CPVI + L1,2 shows the highest antifibrillatory effect, concordant with the empirical ablation protocol in patients with PeAF. Copyright © 2014 Elsevier Ltd. All rights reserved.

  17. Ablation of Complex Fractionated Atrial Electrograms for Atrial Fibrillation Rhythm Control: A Systematic Review and Meta-analysis.

    PubMed

    Fadahunsi, Opeyemi; Talabi, Taiwo; Olowoyeye, Abiola; Iluyomade, Anthony; Shogbesan, Oluwaseun; Donato, Anthony

    2016-06-01

    Pulmonary vein isolation (PVI) has become an increasingly important therapy in the management of atrial fibrillation (AF), however, the best procedural techniques to ensure success have not been determined. We assessed the incremental benefit of complex fractionated atrial electrograms (CFAEs) ablation for AF rhythm control. PubMed, Embase, CENTRAL, and Clinicaltrials.gov databases were searched up until May 7, 2015. Included were randomized controlled trials that compared PVI with PVI and CFAEs ablation (PVI+) with a minimum of 3 months' follow-up. Statistical analysis was performed with Review Manager version 5.3 (Cochrane Collaboration, Oxford, United Kingdom). Categorical and continuous outcomes were reported as summary risk differences and mean differences (MDs), respectively. P < 0.05 was considered statistically significant for all analyses. Ten randomized controlled trials randomized patients to PVI+ (n = 635) and PVI (n = 427) with follow-up ranging from 3 to 23 months. There was no significant difference in freedom from atrial tachyarrhythmias without antiarrhythmic agents after a single ablation between PVI+ and PVI (313 of 635 vs 230 of 427; risk difference, 0.01 [95% confidence interval (CI)-0.08 to 0.10]; P = 0.78; I(2) = 52%). Findings were not different for any prespecified subgroup analyses, including paroxysmal vs nonparoxysmal AF, automated vs manual detection of CFAEs, and left atrial vs biatrial ablation. PVI+ led to significantly increased procedure time (MD, 49.81 minutes [95% CI 42.86-56.76]; P < 0.001), fluoroscopy time (MD, 11.55 minutes [95% CI 8.02-15.07]; P < 0.001), and radiofrequency energy application time (MD, 19.16 minutes [95% CI 6.61-31.70]; P = 0.003) compared with PVI. Ablation of CFAEs in addition to PVI did not increase freedom from atrial tachyarrhythmias but procedural times were increased. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

  18. Characteristics and Outcomes of Concurrently Diagnosed New Rapid Atrial Fibrillation or Flutter and New Reduced Ejection Fraction.

    PubMed

    Rodriguez, Yasser; Althouse, Andrew D; Adelstein, Evan C; Jain, Sandeep K; Mendenhall, George Stuart; Saba, Samir; Shalaby, Alaa A; Voigt, Andrew H; Wang, Norman C

    2016-12-01

    Characteristics and outcomes of concurrently diagnosed new rapid atrial fibrillation (AF) or atrial flutter (AFL) and new heart failure with reduced left ventricular ejection fraction (LVEF) are not well described. A retrospective cohort study of subjects referred for expedited transesophageal echocardiography-guided rhythm-control strategies for concurrent new rapid AF/AFL and new LVEF ≤ 40% diagnosed during the same admission was analyzed. Twenty-five subjects (median age 57 years; 96% male; 96% Caucasian; median CHA2 DS2 -VASc = 2) presented with new AF (n = 18) or AFL (n = 7) with rapid ventricular rate (median 135 beats/min) and new reduced LVEF (median 27%; range, 10-37.5%). Seven (28%) subjects had left atrial appendage thrombi (LAAT) and five (20%) subjects had heavy or binge alcohol use. Baseline characteristics were similar between those with and without LAAT. Thirteen subjects with AF and without LAAT underwent direct-current cardioversion (DCCV) and 10 (77%) had AF recurrence within 90 days. Improvement of long-term LVEF to >40% was comparable for subjects with and without initial LAAT (83% vs 94%; P = 0.46). Three of four subjects who received primary prophylaxis implantable cardioverter-defibrillators improved their LVEF to >35% after sinus rhythm maintenance. The median long-term follow-up time was 3.0 years. Subjects with concurrently diagnosed new rapid AF/AFL and new reduced LVEF are characterized by a high prevalence of LAAT and significant alcohol use. AF subjects without initial LAAT who underwent DCCV had a high 90-day AF recurrence rate. The presence of LAAT did not have a prognosticative effect on eventual LVEF improvement, which was observed in almost all subjects. © 2016 Wiley Periodicals, Inc.

  19. [Estimation using unipolar transesophageal recording of the interatrial conduction time in patients with paroxysmal atrial flutter and fibrillation].

    PubMed

    Simoncelli, U; Marchetti, A; Sorgato, A; Rusconi, C

    1991-06-01

    Twenty-three consecutive subjects (age 46.7 +/- 21, range 13-78) addressed to our attention for symptoms attributed to documented or suspected supra ventricular arrhythmias underwent transesophageal electrophysiologic study. On the basis of the preliminary investigations 15 proved free from organic heart disease, 2 were affected with ischemic heart disease (secondary angina), 6 with hypertensive cardiomyopathy. In each patient the sensibility, specificity and positive predictive value of the following reports regarding the occurrence of paroxysmal fibrillation and flutter (Ffap) were evaluated: a) echo reports of left atrial enlargement; b) ECG signs of atrial enlargement; c) interatrial conduction time (TCIA) assessed with unipolar transesophageal recording. As TCIA we adopted the time interval intercurrent from the first low-voltage deflection of the esophageal P wave (far field) and the apex of the intrinsecoid deflection of the same wave. TCIA proved significantly longer in the 12 patients affected with Ffap compared with those free from documented paroxysmal or inducible arrhythmias or affected with paroxysmal junctional reciprocating tachycardias: 76.6 +/- 11 vs 51.8 +/- 11.7; p less than 0.001. A TCIA greater than 63 msec characterizes with satisfactory sensibility and specificity the occurrence of Ffap: sens. 75%, spec. 91%, positive predictive value 90%. Echo and ECG reports of atrial enlargement behave as highly specific but not sufficiently sensitive indexes of the occurrence of Ffap: sens. 42%, spec. 100%, pos. pred. val. 100% and sens. 17%, spec. 100%, pos.pred.val. 100% resp. We concluded that TCIA is an index correlated with and predictive of the occurrence of Ffap in patients symptomatic for cardiopalmus or neurologic symptoms in the absence of other arrhythmias detectable with Holter monitoring which are able to produce clinical symptoms.

  20. Poor scar formation after ablation is associated with atrial fibrillation recurrence.

    PubMed

    Parmar, Bhrigu R; Jarrett, Tyler R; Kholmovski, Eugene G; Hu, Nan; Parker, Dennis; MacLeod, Rob S; Marrouche, Nassir F; Ranjan, Ravi

    2015-12-01

    Patients routinely undergo ablation for atrial fibrillation (AF) but the recurrence rate remains high. We explored in this study whether poor scar formation as seen on late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) correlates with AF recurrence following ablation. We retrospectively identified 94 consecutive patients who underwent their initial ablation for AF at our institution and had pre-procedural magnetic resonance angiography (MRA) merged with left atrial (LA) anatomy in an electroanatomic mapping (EAM) system, ablated areas marked intraprocedurally in EAM, 3-month post-ablation LGE-MRI for assessment of scar, and minimum of 3-months of clinical follow-up. Ablated area was quantified retrospectively in EAM and scarred area was quantified in the 3-month post-ablation LGE-MRI. With the mean follow-up of 336 days, 26 out of 94 patients had AF recurrence. Age, hypertension, and heart failure were not associated with AF recurrence, but LA size and difference between EAM ablated area and LGE-MRI scar area was associated with higher AF recurrence. For each percent higher difference between EAM ablated area and LGE-MRI scar area, there was a 7-9% higher AF recurrence (p values 0.001-0.003) depending on the multivariate analysis. In AF ablation, poor scar formation as seen on LGE-MRI was associated with AF recurrence. Improved mapping and ablation techniques are necessary to achieve the desired LA scar and reduce AF recurrence.

  1. Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

    PubMed Central

    Swaans, Martin J.; Alipour, Arash; Rensing, Benno J.W.M.; Post, Martijn C.; Boersma, Lucas V.A.

    2013-01-01

    Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6. Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8. The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16. Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN

  2. ACUTE TERMINATION OF HUMAN ATRIAL FIBRILLATION BY IDENTIFICATION AND CATHETER ABLATION OF LOCALIZED ROTORS AND SOURCES

    PubMed Central

    Shivkumar, Kalyanam; Ellenbogen, Kenneth A.; Hummel, John D.; Miller, John M.; Steinberg, Jonathan S.

    2012-01-01

    Catheter ablation of atrial fibrillation (AF) currently relies on eliminating triggers, and no reliable method exists to map the arrhythmia itself to identify ablation targets. The aim of this multicenter study was to define the use of Focal Impulse and Rotor Modulation (FIRM) for identifying ablation targets. METHODS We prospectively enrolled the first (n=14, 11 males) consecutive patients undergoing FIRM guided ablation for persistent (n=11) and paroxysmal AF at 5 centers. A 64 pole basket catheter was used for panoramic right and left atrial mapping during AF. AF electrograms were analyzed using a novel system to identify sustained rotors (spiral waves), or focal beats (centrifugal activation to surrounding atrium). Ablation was performed first at identified sources. The primary endpoints were acute AF termination or organization (>10 % cycle length prolongation). Conventional ablation was performed only after FIRM guided ablation. RESULTS 12/14 cases were mapped. AF sources were demonstrated in all patients (average of 1.9±0.8 per patient). Sources were left atrial in 18 cases, and right atrial in 5 cases, and 21/23 were rotors. FIRM guided ablation achieved the acute endpoint in all patients, consisting of AF termination in n=8 (4.9±3.9 min at the primary source), and organization in n=4. Total FIRM time for all patients was 12.3±8.6 min. CONCLUSIONS FIRM guided ablation revealed localized AF rotors/focal sources in patients with paroxysmal, persistent and longstanding persistent AF. Brief targeted FIRM guided ablation at a priori identified sites terminated or substantially organized AF in all cases prior to any other ablation. PMID:23130890

  3. Polymorphism rs2200733 at chromosome 4q25 is associated with atrial fibrillation recurrence after radiofrequency catheter ablation in the Chinese Han population

    PubMed Central

    Chen, Feifei; Yang, Yanzong; Zhang, Rongfeng; Zhang, Shulong; Dong, Yingxue; Yin, Xiaomeng; Chang, Dong; Yang, Zhiqiang; Wang, Kejing; Gao, Lianjun; Xia, Yunlong

    2016-01-01

    To test polymorphisms rs2200733 (chromosome 4q25) and rs2106261 (ZFHX3) were associated with AF recurrence after catheter ablation in a Chinese Han cohort. A total of 235 AF patients who underwent catheter ablation were recruited consecutively. Two polymorphisms were amplified by polymerase chain reaction and genotyped using high resolution melting analysis. Primary endpoints for AF recurrence were defined as the time to the first recurrence of atrial tachycardia/flutter/fibrillation (AT/AF). AT/AF recurrence was observed in 76 patients (35%). Allelic analysis demonstrated that rs2200733 was strongly associated with AF recurrence after ablation (P = 0.011) and the minor allele T increased the risk for recurrence (OR = 1.715). Diameters of the right atrium as well as the left and right superior pulmonary veins (PVs) were associated with rs2200733 in different genetic models (P = 0.040, 0.047 and 0.028, respectively). No significant association was detected between rs2106261 and AT/AF recurrence after ablation or atrial/PV diameters in any models. On multivariate Cox regression analysis, only rs2200733 was an independent factor of AF recurrence after ablation (HR = 0.532, P = 0.022). In Chinese Han population, rs2200733 but not rs2106261 is associated with AT/AF recurrence after ablation. The patients with genotype TT have larger size of right atrium and superior PVs than those of CC genotype. The findings suggest that rs2200733 may play a key role in regulating proper development and differentiation of atria/PVs. PMID:27158361

  4. To fumble flutter or tackle "tach"? Toward updated classifiers for atrial tachyarrhythmias.

    PubMed

    Lesh, M D; Kalman, J M

    1996-05-01

    Aristotle proposed in his short work, The Categories, that a definition is a statement of a thing's essential nature, and the essence of a thing are those of its properties that cannot change without losing its identity. But Aristotle was not faced with the flux of new information that confronts modern medicine. Nowadays, the argot of a discipline arises organically at the intersection of a given state of empiric knowledge and the exigencies of present scientific discourse. Thus, when the only treatment for a regular, narrow QRS complex tachycardia was digitalis glycosides or vasopressor infusion, the term "PAT" ("paroxysmal atrial tachycardia") seemed adequate, at least to distinguish it from ventricular tachycardia. We now prefer the term "PSVT" (paroxysmal supraventricular tachycardia) because we understand that most such tachycardias are not in truth "atrial" but involve the AV node and/or an accessory AV connection, and because we wish to report on the results of treatment specific to each of the subcategories of "PSVT." Similarly, as our knowledge of atrial arrhythmias has grown and especially as we need to describe the outcome of new interventional approaches to therapy, it may be prudent to use a nomenclature for atrial tachyarrhythmias that is based on the geometry of the tachycardia substrate, the relationship of that substrate to atrial anatomy, and the type of atrial lesions required to abolish that substrate.

  5. Efficacy of a novel bipolar radiofrequency ablation device on the beating heart for atrial fibrillation ablation: A chronic porcine study

    PubMed Central

    Voeller, Rochus K.; Zierer, Andreas; Lall, Shelly C.; Sakamoto, Shun-ichiro; Schuessler, Richard B.; Damiano, Ralph J.

    2015-01-01

    Background Over the recent years, a variety of energy sources have been used to replace the traditional incisions of the Cox-Maze procedure for the surgical treatment of atrial fibrillation. This study evaluated the safety and efficacy of a new bipolar radiofrequency ablation device for atrial ablation in a chronic porcine model. Methods Six pigs underwent a Cox-Maze IV procedure on a beating heart off cardiopulmonary bypass using the Atricure Isolator II™ bipolar ablation device. In addition, 6 pigs underwent median sternotomy and pericardiotomy alone to serve as a control group. All animals were survived for 30 days. Each pig underwent induction of atrial fibrillation, and was then sacrificed to remove the heart en bloc for histological assessment. MRI scan were also obtained preoperatively and postoperatively to assess atrial and ventricular function, pulmonary vein anatomy, valve function, and coronary artery patency. Results All animals survived the operation. Electrical isolation of the left atrial appendage and the pulmonary veins was documented by pacing acutely and at 30 days in all animals. No animal that underwent the Cox-Maze IV procedure was able to be induced into atrial fibrillation at 30 days postoperatively, compared to all the sham animals. All 257 ablations examined were discrete, linear and transmural, with a mean lesion width of 2.2±1.1 mm and a mean lesion depth of 5.3±3.0 mm. Conclusions The Atricure Isolator II™ was able to create reliable chronic transmural lesions of the modified Cox-Maze procedure on a beating heart without cardiopulmonary bypass 100% of the time. There were no discernible effects on ventricular or valvular function. PMID:20122702

  6. Impact of baseline atrial fibrillation cycle length on acute and long-term outcome of persistent atrial fibrillation ablation.

    PubMed

    Ammar, S; Hessling, G; Paulik, M; Reents, T; Dillier, R; Buiatti, A; Semmler, V; Kolb, C; Haller, B; Deisenhofer, I

    2014-12-01

    A short baseline atrial fibrillation (AF) cycle length (CL) has been associated with a worse outcome after catheter ablation for AF, whereas the impact of a long baseline AFCL is unknown. We investigated the influence of AFCL on acute and long-term success in a large series of patients undergoing catheter ablation for persistent AF. Overall, 177 consecutive patients undergoing catheter ablation of persistent AF using a sequential ablation approach were included in the analysis. AFCL was measured in the left atrial appendage (LAA) at baseline and following each ablation step. The primary endpoint was freedom from any atrial arrhythmia off antiarrhythmic drugs (AAD) with a single ablation procedure after 12 months. Mean AFCL was 164 ± 24 ms. A shorter AFCL was associated with longer AF duration, larger LA diameter, and longer procedure duration. Termination to sinus rhythm (SR) was achieved in 57 (32 %) patients. Baseline AFCL was shorter (161 ± 24 ms) in patients without AF termination compared to patients with AF termination (169 ± 23 m, p = 0.03). The primary endpoint was reached less frequently in patients with a short (<155 ms) AFCL (18 vs. 38.5 %, p = 0.006). Patients with an AFCL between 155 and 200 ms had the best outcome compared to patients with AFCL <155 or ≥200 ms (40 vs. 18 %, p = 0.003). Patients with a baseline AFCL between 155 and 200 ms have the best outcome after a single ablation procedure for persistent AF compared to patients with an AFCL of <155 or ≥200 ms.

  7. The use of balloon atrial septostomy to facilitate difficult transseptal access in patients undergoing catheter ablation for atrial fibrillation.

    PubMed

    Zadeh, Andrew A; Cannom, David S; Macrum, Bruce L; Ho, Ivan C

    2011-07-01

    With the increasing number of patients undergoing repeat catheter ablation procedures for atrial fibrillation, it is not uncommon to encounter a fibrotic interatrial septum that resists the conventional manual advancement of the transseptal sheath. Forceful advancement of the transseptal apparatus can reduce fine control and potentially lead to a higher rate of perforation. We report a case where adjunctive balloon atrial septostomy was used to facilitate transseptal access in a patient with fibrotic interatrial septum. Using a small-caliber angioplasty balloon and under direct fluoroscopic and transesophageal echocardiogram visualization, balloon septostomy was performed with hand inflation until a "waist" was seen. This technique provides a safe way to control the size of the transseptal access created, and allows the passage of a relatively soft-tipped transseptal sheath across a resistive septum. To our knowledge this is the first published use of balloon atrial septostomy during transseptal puncture for left atrium access in a catheter ablation procedure. Balloon atrial septostomy should be considered as an alternative technique for safe transseptal cannulation in select patients in the electrophysiology laboratory or other interventional procedures requiring left atrial access or delivery of large-caliber catheters or sheaths. © 2010 Wiley Periodicals, Inc.

  8. A left atrial ablation with bipolar irrigated radio-frequency for atrial fibrillation during minimally invasive mitral valve surgery.

    PubMed

    Solinas, Marco; Bevilacqua, Stefano; Karimov, Jamshid H; Glauber, Mattia

    2010-04-01

    Minimally invasive mitral valve surgery is becoming increasingly popular worldwide. Mitral valve disease is often associated with atrial fibrillation (AF), also due to the ageing of the population. We present a technique to perform a left atrial ablation with bipolar irrigated radio-frequency (RF) through a single right thoracotomy. We have operated on eight patients: six female with a mean age 68+/-8 years. Six patients suffered from permanent AF and other two from paroxysmal AF. Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

  9. Identification of transmural necrosis along a linear catheter ablation lesion during atrial fibrillation and sinus rhythm.

    PubMed

    Sanchez, Javier E; Kay, G Neal; Benser, Michael E; Hall, Jeffrey A; Walcott, Gregory P; Smith, William M; Ideker, Raymond E

    2003-02-01

    Determining whether a linear catheter radio frequency (RF) ablation lesion is transmural may be difficult, especially during atrial fibrillation. We hypothesized that changes in pacing thresholds and electrogram amplitude during atrial fibrillation and sinus rhythm could be used to assess whether a radiofrequency ablation resulted in transmural necrosis. A hexapolar, linear, RF ablation catheter was positioned between the caval veins in the right atrium of seven sheep. Pacing thresholds and electrogram amplitudes during atrial fibrillation and sinus rhythm were measured before and after the application of RF energy. Sites along the linear lesion were assessed histologically. The electrogram amplitude in atrial fibrillation decreased significantly more at transmural sites (unipolar recording: 33 +/- 11% transmural vs. 22 +/- 13% non-transmural, p < or = 0.01; bipolar recording: 62 +/- 9% transmural vs. 43 +/- 15% non-transmural, p < or = 0.01). The electrogram amplitude in sinus rhythm decreased significantly more at transmural sites (unipolar recording: 49 +/- 18% transmural vs. 15 +/- 20% non-transmural, p < 0.001; bipolar recording: 63 +/- 17% transmural vs. 42 +/- 19% non-transmural, p = 0.002). The pacing threshold increased significantly more at sites with transmural necrosis (unipolar: increased by 378 +/- 103% transmural vs. 207 +/- 93% non-transmural, p < 0.001; bipolar: 370 +/- 80% transmural vs. 259 +/- 60% non-transmural, p < 0.001). The amplitude of the atrial electrogram from an ablation catheter can be used to discriminate areas with transmural necrosis from those without transmural necrosis during either atrial fibrillation or sinus rhythm. Termination of atrial fibrillation may not be necessary to estimate the histologic characteristics of an ablation lesion.

  10. Phrenic nerve injury after atrial fibrillation catheter ablation: characterization and outcome in a multicenter study.

    PubMed

    Sacher, Frédéric; Monahan, Kristi H; Thomas, Stuart P; Davidson, Neil; Adragao, Pedro; Sanders, Prashanthan; Hocini, Mélèze; Takahashi, Yoshihide; Rotter, Martin; Rostock, Thomas; Hsu, Li-Fern; Clémenty, Jacques; Haïssaguerre, Michel; Ross, David L; Packer, Douglas L; Jaïs, Pierre

    2006-06-20

    The purpose of this study was to characterize the occurrence of phrenic nerve injury (PNI) and its outcome after radiofrequency (RF) ablation of atrial fibrillation (AF). It is recognized that extra-myocardial damage may develop owing to penetration of ablative energy. Between 1997 and 2004, 3,755 consecutive patients underwent AF ablation at five centers. Among them, 18 patients (0.48%; 9 male, 54 +/- 10 years) had PNI (16 right, 2 left). The procedure consisted of pulmonary vein (PV) isolation in 15 patients and anatomic circumferential ablation in 3 patients, with additional left atrial lesions (n = 11) and/or superior vena cava (SVC) disconnection (n = 4). Right PNI occurred during ablation of right superior PV (n = 12) or SVC disconnection (n = 3). Left PNI occurred during ablation at the left atrial appendage. Immediate features were dyspnea, cough, hiccup, and/or sudden diaphragmatic elevation in 9, and in the remaining the diagnosis was made after ablation owing to dyspnea (n = 7) or on routine radiographic evaluation (n = 2). Four patients (22%) were asymptomatic. Complete recovery occurred in 12 patients (66%). Recovery occurred within 24 h in the two patients with left PNI and in one patient with right PNI occurring with SVC disconnection. In the other nine patients, right PNI recovery occurred after 4 +/- 5 months (1 to 12 months) with respiratory rehabilitation. After a mean follow-up of 36 +/- 33 months, six patients have persistent PNI (three with partial and three with no recovery). In this multicenter experience, PNI was a rare complication (0.48%) of AF ablation. Ablation of the right superior PV, SVC, and left atrial appendage were associated with PNI. Complete (66%) or partial (17%) recovery was observed in the majority.

  11. Localization of gaps during redo ablations of paroxysmal atrial fibrillation: Preferential patterns depending on the choice of cryoballoon ablation or radiofrequency ablation for the initial procedure.

    PubMed

    Galand, Vincent; Pavin, Dominique; Behar, Nathalie; Auffret, Vincent; Fénéon, Damien; Behaghel, Albin; Daubert, Jean-Claude; Mabo, Philippe; Martins, Raphaël P

    2016-11-01

    Pulmonary vein (PV) isolation, using cryoballoon or radiofrequency ablation, is the cornerstone therapy for symptomatic paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drugs. One-third of the patients have recurrences, mainly due to PV reconnections. To describe the different locations of reconnection sites in patients who had previously undergone radiofrequency or cryoballoon ablation, and to compare the characteristics of the redo procedures in both instances. Demographic data and characteristics of the initial ablation (cryoballoon or radiofrequency) were collected. Number and localization of reconduction gaps, and redo characteristics were reviewed. Seventy-four patients scheduled for a redo ablation of paroxysmal AF were included; 38 had been treated by radiofrequency ablation and 36 by cryoballoon ablation during the first procedure. For the initial ablation, procedural and fluoroscopy times were significantly shorter for cryoballoon ablation (147.8±52.6min vs. 226.6±64.3min [P<0.001] and 37.0±17.7min vs. 50.8±22.7min [P=0.005], respectively). Overall, an identical number of gaps was found during redo procedures of cryoballoon and radiofrequency ablations. However, a significantly higher number of gaps were located in the right superior PV for patients first ablated with radiofrequency (0.9±1.0 vs. 0.5±0.9; P=0.009). Gap localization displayed different patterns. Although not significant, redo procedures of cryoballoon ablation were slightly shorter and needed shorter durations of radiofrequency to achieve PV isolation. During redo procedures, gap localization pattern is different for patients first ablated with cryoballoon or radiofrequency ablation, and right superior PV reconnections occur more frequently after radiofrequency ablation. Redo ablation of a previous cryoballoon ablation appears to be easier. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

  12. Atrial Fibrillation Ablation by Use of Electroanatomical Mapping: Efficacy and Recurrence Factors

    PubMed Central

    Kalil, Carlos; Bartholomay, Eduardo; Borges, Anibal; Gazzoni, Guilherme; de Lima, Edimar; Etchepare, Renata; Moraes, Rafael; Sussenbach, Carolina; Andrade, Karina; Kalil, Renato

    2014-01-01

    Background Radiofrequency catheter ablation guided by electroanatomical mapping is currently an important therapeutic option for the treatment of atrial fibrillation. The complexity of the procedure, the several techniques used and the diversity of the patients hinder the reproduction of the results and the indication for the procedure. Objective To evaluate the efficacy and factors associated with recurrence of atrial fibrillation. Methods Prospective cohort study with consecutive patients submitted to atrial fibrillation ablation treatment guided by electroanatomical mapping. The inclusion criteria were as follows: minimum age of 18 years; presence of paroxysmal, persistent or long-standing persistent AF; AF recording on an electrocardiogram, exercise testing or Holter monitoring (duration longer than 15 minutes); presence of symptoms associated with AF episodes; AF refractoriness to, at least, two antiarrhythmic drugs, one of which being amiodarone, or impossibility to use antiarrhythmic drugs. Results The study included 95 patients (age 55 ± 12 years, 84% men, mean CHADS2 = 0.8) who underwent 102 procedures with a median follow-up of 13.4 months. The recurrence-free rate after the procedure was 75.5% after 12 months. Atrial fibrillation recurred as follows: 26.9% of patients with paroxysmal and persistent atrial fibrillation; 45.8% of patients with long-standing persistent atrial fibrillation (p = 0.04). Of the analyzed variables, the increased size of the left atrium has proven to be an independent predictor of atrial fibrillation recurrence after the procedure (HR = 2.58; 95% CI: 1.26-4.89). Complications occurred in 4.9% of the procedures. Conclusion Atrial fibrillation ablation guided by electroanatomical mapping has shown good efficacy. The increase in left atrium size was associated with atrial fibrillation recurrence. PMID:24162471

  13. Wenxin Keli suppresses atrial substrate remodelling after epicardial ganglionic plexi ablation

    PubMed Central

    Xiao, Jinping; Zhao, Qingyan; Kebbati, A Hafid; Deng, Hongping; Wang, Xule; Dai, Zixuan; Yu, Shengbo; Huang, Congxin

    2013-01-01

    BACKGROUND: The chronic effects of ganglionic plexi (GP) ablation on atrial fibrillation (AF) inducibility have not been elucidated. OBJECTIVE: To investigate the effect of Wenxin Keli (WK) on the inducibility of AF and atrial substrate remodelling after epicardial GP ablation. METHODS: Twenty dogs were randomly divided into a sham-operated group, a GP ablation group and a WK-treated group. All animals underwent a left thoracotomy at the fourth intercostal space. AF inducibility was assessed by burst rapid pacing at the right atrium. Both the GP ablation group and the WK-treated group received four major GP ablations. In the WK-treated group, dogs were treated with oral WK once per day, and all animals were allowed to recover for eight weeks, after which AF inducibility and AF duration were measured again. RESULTS: After eight weeks of WK treatment, AF inducibility was lower than in the GP ablation group, and was similar to that of the sham-operated group. Compared with the sham-operated group, the levels of atrial natriuretic peptide (ANP), tumour necrosis factor-alpha (TNF-α) and interleukin (IL)-6 in right atrial tissues were increased in GP ablation group (143.6±33.7 pg/mg versus 206.2±41.4 pg/mg, P=0.02; 75.3±12.1 pg/mg versus 141.3±64 pg/mg, P=0.03; and 175.1±42.5 pg/mg versus 351.7±101 pg/mg, P<0.01, respectively). There were no significant differences in levels of ANP, TNF-α and IL-6 in atrial tissues between the sham-operated group and WK treated group. Expression of connexin 43 in atrial tissues was increased after eight weeks of GP ablation, while WK administration inhibited connexin 43 remodelling. CONCLUSIONS: Epicardial GP ablation can induce atrial substrate remodelling, including Cx43 upregulation and increased levels of ANP, TNF-α and IL-6. These changes may be suppressed by long-term oral WK administration. PMID:23940442

  14. Body Fat, Body Fat Distribution, Lean Body Mass and Atrial Fibrillation and Flutter. A Danish Cohort Study

    PubMed Central

    Frost, Lars; Benjamin, Emelia J.; Fenger-Grøn, Morten; Pedersen, Asger; Tjønneland, Anne; Overvad, Kim

    2014-01-01

    Objective It is recognized that higher height and weight are associated with higher risk of atrial fibrillation or flutter (AF) but it is unclear whether risk of AF is related to body fat, body fat location, or lean body mass. Design and Methods We studied the Danish population-based prospective cohort Diet, Cancer and Health conducted among 55 273 men and women 50-64 years of age at recruitment. We investigated the associations between bioelectrical impedance derived measures of body composition and combinations of anthropometric measures of body fat distribution and risk of an incident record of AF in the Danish Registry of Patients. Results During follow-up (median 13.5 years) AF developed in 1 669 men and 912 women. Higher body fat at any measured location was associated with higher risk of AF. The adjusted hazard ratio (HR) per 1 sex-specific standard deviation (SD) increment in body fat mass was 1.29 (95% confidence interval [CI], 1.24-1.33). Higher lean body mass was also associated with a higher risk of AF. The adjusted HR for 1 sex-specific SD increment was 1.40 (95% CI, 1.35-1.45). Conclusion Higher body fat and higher lean body mass were both associated with higher risk of AF. PMID:24436019

  15. The Effect of Aggressive Blood Pressure Control on the Recurrence of Atrial Fibrillation After Catheter Ablation: A Randomized, Open Label, Clinical Trial (Substrate Modification with Aggressive Blood Pressure Control: SMAC- AF).

    PubMed

    Parkash, Ratika; Wells, George A; Sapp, John L; Healey, Jeffrey S; Tardif, Jean-Claude; Greiss, Isabelle; Rivard, Léna; Roux, Jean-Francois; Gula, Lorne; Nault, Isabelle; Novak, Paul G; Birnie, David H; Ha, Andrew C; Wilton, Stephen B; Mangat, Iqwal; Gray, Christopher J; Gardner, Martin J; Tang, Anthony S L

    2017-02-22

    Background -Radiofrequency catheter ablation for atrial fibrillation has become an important therapy for AF, however recurrence rates remain high. We proposed to determine whether aggressive blood pressure (BP) lowering prevents recurrent atrial fibrillation (AF) after catheter ablation in patients with AF and a high symptom burden. Methods -We randomly assigned 184 patients with AF and a BP greater than 130/80 mmHg to aggressive BP (target <120/80 mm Hg) or standard BP treatment (target <140/90 mmHg) prior to their scheduled AF catheter ablation. The primary outcome was symptomatic recurrence of AF/atrial tachycardia/atrial flutter lasting greater than 30 seconds, determined 3 months beyond catheter ablation by a blinded endpoint evaluation. Results -The median follow-up was 14 months. At six months, the mean systolic BP in the aggressive BP treatment group was 123.2±13.2 versus 135.4±15.7mm Hg (p<0.001) in the standard treatment group. The primary outcome occurred in 106 patients, 54 (61.4%) in the aggressive BP treatment group, compared to 52 (61.2%) in the standard treatment group, (Hazard Ratio 0.94, 95% Confidence Interval 0.65-1.38, p=0.763). In the prespecified subgroup analysis of the influence of age, patients aged ≥ 61 years had a lower primary outcome event rate with aggressive BP (Hazard Ratio 0.58, 95% Confidence Interval (0.34, 0.97), p=0.013). There was a higher rate of hypotension requiring medication adjustment in the aggressive BP group (26% versus 0%). Conclusions -In this study, this duration of aggressive BP treatment did not reduce atrial arrhythmia recurrence after catheter ablation for AF, but resulted in more hypotension. Clinical Trial Registration -Clinicaltrials.gov Identifier: NCT00438113.

  16. Association Between Local Bipolar Voltage and Conduction Gap Along the Left Atrial Linear Ablation Lesion in Patients With Atrial Fibrillation.

    PubMed

    Masuda, Masaharu; Fujita, Masashi; Iida, Osamu; Okamoto, Shin; Ishihara, Takayuki; Nanto, Kiyonori; Kanda, Takashi; Sunaga, Akihiro; Tsujimura, Takuya; Matsuda, Yasuhiro; Mano, Toshiaki

    2017-08-01

    A bipolar voltage reflects a thick musculature where formation of a transmural lesion may be hard to achieve. The purpose of this study was to explore the association between local bipolar voltage and conduction gap in patients with persistent atrial fibrillation (AF) who underwent atrial roof or septal linear ablation. This prospective observational study included 42 and 36 consecutive patients with persistent AF who underwent roof or septal linear ablations, respectively. After pulmonary vein isolation, left atrial linear ablations were performed, and conduction gap sites were identified and ablated after first-touch radiofrequency application. Conduction gap(s) after the first-touch roof and septal linear ablation were observed in 13 (32%) and 19 patients (53%), respectively. Roof and septal area voltages were higher in patients with conduction gap(s) than in those without (roof, 1.23 ± 0.77 vs 0.73 ± 0.42 mV, p = 0.010; septal, 0.96 ± 0.43 vs 0.54 ± 0.18 mV, p = 0.001). Trisected regional analyses revealed that the voltage was higher at the region with a conduction gap than at the region without. Complete conduction block across the roof and septal lines was not achieved in 3 (7%) and 6 patients (17%), respectively. Patients in whom a linear conduction block could not be achieved demonstrated higher ablation area voltage than those with a successful conduction block (roof, 1.91 ± 0.74 vs 0.81 ± 0.51 mV, p = 0.001; septal, 1.15 ± 0.56 vs 0.69 ± 0.31 mV, p = 0.006). In conclusion, a high regional bipolar voltage predicts failure to achieve conduction block after left atrial roof or septal linear ablation. In addition, the conduction gap was located at the preserved voltage area. Copyright © 2017 Elsevier Inc. All rights reserved.

  17. Radiofrequency catheter ablation versus balloon cryoablation of atrial fibrillation: markers of myocardial damage, inflammation, and thrombogenesis.

    PubMed

    Antolič, Bor; Pernat, Andrej; Cvijić, Marta; Žižek, David; Jan, Matevž; Šinkovec, Matjaž

    2016-07-01

    Evidence from animal and human studies suggests that cryoablation might be associated with a lesser inflammatory response and activation of coagulation compared with radiofrequency ablation. The study was aimed at comparing the effect of cryoballoon and radiofrequency catheter ablation of paroxysmal atrial fibrillation on markers of myocardial damage, inflammation, and activation of coagulation. Forty-one patients received either cryoballoon (n = 23) or radiofrequency (n = 18) ablation of atrial fibrillation. We measured troponin I, high-sensitivity CRP, and interleukin 6 at baseline from the cubital vein, and from the right and left atrium before and after ablation, and from the cubital vein the following day. Prothrombin fragments 1 + 2, soluble P‑selectin, and D‑dimer were measured before and after ablation from both atria. We observed higher troponin I release in the cryoballoon than in the radiofrequency group (7.01 mcg/l (interquartile range [IQR]: 5.30-9.09) vs 2.32 mcg/l (IQR: 1.45-2.98), p < 0.001). The levels of inflammatory markers (high-sensitivity CRP and interleukin 6) in the two groups were comparable, as were the levels of markers of coagulation activation. Procedure duration, fluoroscopy times, and mid-term success (23 months, IQR 7-32) of the two groups were also comparable. Cryoballoon ablation of atrial fibrillation causes more significant myocardial damage, that is, more extensive ablation lesions, compared with radiofrequency catheter ablation. However, no major differences between these two ablation techniques with regard to the inflammatory response and activation of the coagulation system were observed.

  18. Toward standardized mapping for left atrial analysis and cardiac ablation guidance

    NASA Astrophysics Data System (ADS)

    Rettmann, M. E.; Holmes, D. R.; Linte, C. A.; Packer, D. L.; Robb, R. A.

    2014-03-01

    In catheter-based cardiac ablation, the pulmonary vein ostia are important landmarks for guiding the ablation procedure, and for this reason, have been the focus of many studies quantifying their size, structure, and variability. Analysis of pulmonary vein structure, however, has been limited by the lack of a standardized reference space for population based studies. Standardized maps are important tools for characterizing anatomic variability across subjects with the goal of separating normal inter-subject variability from abnormal variability associated with disease. In this work, we describe a novel technique for computing flat maps of left atrial anatomy in a standardized space. A flat map of left atrial anatomy is created by casting a single ray through the volume and systematically rotating the camera viewpoint to obtain the entire field of view. The technique is validated by assessing preservation of relative surface areas and distances between the original 3D geometry and the flat map geometry. The proposed methodology is demonstrated on 10 subjects which are subsequently combined to form a probabilistic map of anatomic location for each of the pulmonary vein ostia and the boundary of the left atrial appendage. The probabilistic map demonstrates that the location of the inferior ostia have higher variability than the superior ostia and the variability of the left atrial appendage is similar to the superior pulmonary veins. This technique could also have potential application in mapping electrophysiology data, radio-frequency ablation burns, or treatment planning in cardiac ablation therapy.

  19. Correlative anatomy for the electrophysiologist: ablation for atrial fibrillation. Part II: regional anatomy of the atria and relevance to damage of adjacent structures during AF ablation.

    PubMed

    Macedo, Paula G; Kapa, Suraj; Mears, Jennifer A; Fratianni, Amy; Asirvatham, Samuel J

    2010-07-01

    Ablation procedures for atrial fibrillation have become an established and increasingly used option for managing patients with symptomatic arrhythmia. The anatomic structures relevant to the pathogenesis of atrial fibrillation and ablation procedures are varied and include the pulmonary veins, other thoracic veins, the left atrial myocardium, and autonomic ganglia. Exact regional anatomic knowledge of these structures is essential to allow correlation with fluoroscopy and electrograms and, importantly, to avoid complications from damage of adjacent structures within the chest. We present this information as a series of 2 articles. In a prior issue, we have discussed the thoracic vein anatomy relevant to paroxysmal atrial fibrillation. In the present article, we focus on the atria themselves, the autonomic ganglia, and anatomic issues relevant for minimizing complications during atrial fibrillation ablation.

  20. Predictors for permanent pacemaker implantation after concomitant surgical ablation for atrial fibrillation.

    PubMed

    Pecha, Simon; Schäfer, Timm; Yildirim, Yalin; Ahmadzade, Teymour; Willems, Stephan; Reichenspurner, Hermann; Wagner, Florian Mathias

    2014-03-01

    Concomitant surgical atrial fibrillation (AF) ablation is a safe and feasible procedure, recommended in guidelines. Pacemaker dependency is a known complication of AF ablation. We sought to determine independent predictors for pacemaker implantation after surgical AF ablation. Between January 2003 and November 2012, 594 patients underwent concomitant surgical AF ablation. Various energy sources, including cryoablation (n = 139), unipolar radiofrequency (n = 278), and bipolar radiofrequency (n = 177), were used. Left atrial (n = 463, 77.9%) and biatrial (n = 131, 22.1%) ablation was performed. Univariate and multivariate logistic regression analysis was used to identify independent predictors for pacemaker implantation within 30 days after surgical AF ablation. The mean patient's age was 68.6 ± 9.4 years, and 66.8% were male. No major ablation-related complications occurred. A total of 41 (6.9%) of patients received pacemaker implantation during the 30-day follow-up period. Indications for pacemaker implantation were atrioventricular block in 25 (60.9%) of patients, sinus bradycardia or sinus arrest in 9 (22.0%) of patients, and bradyarrhythmia in 7 (17.1%) of patients. Demographic data, type of surgical procedure, and type of energy source did not have a significant impact on pacemaker implantation rate. However, biatrial ablation led to a significant pacemaker implantation rate compared with isolated left-sided ablation (6.3% vs 13.6%; P = .028). Concomitant surgical AF ablation showed a pacemaker implantation rate of 6.9% after 30-day follow-up. Univariate and multivariate analysis showed biatrial lesion set as the only statistically significant predictor for pacemaker implantation after surgical AF ablation. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

  1. Catheter Ablation of Paroxysmal Atrial Fibrillation: Have We Achieved Cure with Pulmonary Vein Isolation?

    PubMed Central

    Santangeli, Pasquale; Lin, David

    2015-01-01

    Pulmonary vein isolation (PVI) is the cornerstone of current ablation techniques to eliminate atrial fibrillation (AF), with the greatest efficacy as a stand-alone procedure in patients with paroxysmal AF. Over the years, techniques for PVI have undergone a profound evolution, and current guidelines recommend PVI with confirmation of electrical isolation. Despite significant efforts, PV reconnection is still the rule in patients experiencing post-ablation arrhythmia recurrence. In recent years, use of general anesthesia with or without jet ventilation, open-irrigated ablation catheters, and steerable sheaths have been demonstrated to increase the safety and efficacy of PVI, reducing the rate of PV reconnection over follow-up. The widespread clinical availability of ablation catheters with real-time contact force information will likely further improve the effectiveness and safety of PVI. In a small but definite subset of patients, post-ablation recurrent arrhythmia is due to non-PV triggers, which should be eliminated in order to improve success. Typically, non-PV triggers cluster in specific regions such as the coronary sinus, the inferior mitral annulus, the interatrial septum, the left atrial appendage, the Eustachian ridge, the crista terminalis region, the superior vena cava, and the ligament of Marshall. Focal ablation targeting the origin of the trigger is recommended in most cases. Empirical non-PV ablation targeting the putative substrate responsible for AF maintenance with ablation lines and/or elimination of complex fractionated electrograms has not been shown to improve success compared to PVI alone. Similarly, the role of novel substrate-based ablation approaches targeting putative localized sources of AF (e.g., rotors) identified by computational mapping techniques is unclear, as they have never been compared to PVI and non-PV trigger ablation in an adequately designed randomized trial. This review highlights PVI techniques and outcomes in treating

  2. Efficacy of Left Atrial Voltage-Based Catheter Ablation of Persistent Atrial Fibrillation.

    PubMed

    Yamaguchi, Takanori; Tsuchiya, Takeshi; Nakahara, Shiro; Fukui, Akira; Nagamoto, Yasutsugu; Murotani, Kenta; Eshima, Kenichi; Takahashi, Naohiko

    2016-09-01

    Low-voltage zones (LVZs) represent fibrotic tissue and are substrates for atrial fibrillation (AF). We hypothesized that LVZ-based substrate modification along with pulmonary vein isolation (PVI) would improve outcomes in persistent AF (PeAF) patients with LVZs, whereas PVI alone would work in patients without LVZs. Voltage mapping of the left atrium (LA) was performed during sinus rhythm in 101 PeAF patients in whom LVZ was defined as an area with bipolar electrograms <0.5 mV. Thirty-nine patients had LVZs and underwent ablation of the entire LVZ area after PVI (LVZabl group). In the remaining 62 patients without LVZs, PVI alone was performed with no further substrate modifications (PVI group). An additional group of 16 consecutive PeAF patients with LVZ did not undergo any substrate modification after PVI and were used as a comparison group (LVZnon-abl group) despite having similar size of LVZs to that in the LVZabl group. After a single session, 28 (72%) patients in the LVZabl group had no recurrence, whereas 49 (79%) patients in the PVI group had no recurrence during 18 ± 7 months of follow-up (log-rank, P = 0.400). In the LVZnon-abl group, only 6 patients (38%) had no recurrence during 32 ± 7 months of follow-up, even after a mean number of sessions of 1.8 (log-rank, P < 0.001, compared with the LVZabl group). Additional LVZ-based substrate modification after PVI improved the outcome in PeAF patients with LVZs, whereas PVI alone worked in patients without LVZs, even in those with PeAF. © 2016 Wiley Periodicals, Inc.

  3. The atrial fibrillation ablation pilot study: a European Survey on Methodology and results of catheter ablation for atrial fibrillation conducted by the European Heart Rhythm Association.

    PubMed

    Arbelo, Elena; Brugada, Josep; Hindricks, Gerhard; Maggioni, Aldo P; Tavazzi, Luigi; Vardas, Panos; Laroche, Cécile; Anselme, Frédéric; Inama, Giuseppe; Jais, Pierre; Kalarus, Zbigniew; Kautzner, Josef; Lewalter, Thorsten; Mairesse, Georges H; Perez-Villacastin, Julian; Riahi, Sam; Taborsky, Milos; Theodorakis, George; Trines, Serge A

    2014-06-07

    The Atrial Fibrillation Ablation Pilot Study is a prospective registry designed to describe the clinical epidemiology of patients undergoing an atrial fibrillation (AFib) ablation, and the diagnostic/therapeutic processes applied across Europe. The aims of the 1-year follow-up were to analyse how centres assess in routine clinical practice the success of the procedure and to evaluate the success rate and long-term safety/complications. Seventy-two centres in 10 European countries were asked to enrol 20 consecutive patients undergoing a first AFib ablation procedure. A web-based case report form captured information on pre-procedural, procedural, and 1-year follow-up data. Between October 2010 and May 2011, 1410 patients were included and 1391 underwent an AFib ablation (98.7%). A total of 1300 patients (93.5%) completed a follow-up control 367 ± 42 days after the procedure. Arrhythmia documentation was done by an electrocardiogram in 76%, Holter-monitoring in 52%, transtelephonic monitoring in 8%, and/or implanted systems in 4.5%. Over 50% became asymptomatic. Twenty-one per cent were re-admitted due to post-ablation arrhythmias. Success without antiarrhythmic drugs was achieved in 40.7% of patients (43.7% in paroxysmal AF; 30.2% in persistent AF; 36.7% in long-lasting persistent AF). A second ablation was required in 18% of the cases and 43.4% were under antiarrhythmic treatment. Thirty-three patients (2.5%) suffered an adverse event, 272 (21%) experienced a left atrial tachycardia, and 4 patients died (1 haemorrhagic stroke, 1 ventricular fibrillation in a patient with ischaemic heart disease, 1 cancer, and 1 of unknown cause). The AFib Ablation Pilot Study provided crucial information on the epidemiology, management, and outcomes of catheter ablation of AFib in a real-world setting. The methods used to assess the success of the procedure appeared at least suboptimal. Even in this context, the 12-month success rate appears to be somewhat lower to the one

  4. The impact of left atrial size on long-term outcome of catheter ablation of chronic atrial fibrillation.

    PubMed

    Lo, Li-Wei; Lin, Yenn-Jiang; Tsao, Hsuan-Ming; Chang, Shih-Lin; Udyavar, Ameya R; Hu, Yu-Feng; Ueng, Kwo-Chang; Tsai, Wen-Chin; Tuan, Ta-Chun; Chang, Chien-Jung; Tang, Wei-Hua; Higa, Satoshi; Tai, Ching-Tai; Chen, Shih-Ann

    2009-11-01

    The left atrial (LA) size is an important predictor of atrial fibrillation (AF) procedural termination and the long-term outcome. We sought to evaluate the long-term outcome in regard to the LA size and procedural termination. Eighty-seven consecutive chronic AF patients (72 males, 53 +/- 10 years) underwent 3D mapping (NavX) and ablation. A stepwise approach including circumferential pulmonary vein (PV) isolation, linear ablation, and continuous complex-fractionated electrogram (CFE) ablation (targeting fractionation intervals of < 50 ms). Electrical cardioversion was applied to those without any procedural termination. The freedom from AF was defined as the maintenance of sinus rhythm without the use of any class I or III antiarrhythmic drugs after the blanking period. Among the 87 patients, all received a circumferential PV isolation, 93% a linear ablation, and 59% a continuous CFE ablation. Those with AF procedural termination (n = 30) had a better long-term outcome when compared with those without termination during a follow-up of 21 +/- 12 months. Moreover, a Kaplan-Meier analysis showed that in those with an LA diameter of less than 45 mm (n = 49), the freedom from AF rate was higher when procedural termination was achieved (P = 0.004). On the contrary, the outcome was comparable in those with an LA diameter of >or= 45 mm (n = 38), whether AF procedural termination occurred or not (P = 0.658). AF procedural termination was related to the long-term success during chronic AF ablation, especially in those with an LA diameter of less than 45 mm. The favorable effect of termination decreased when the LA diameter was >or= 45 mm.

  5. Serum Galectin-3 Levels Predict Recurrences after Ablation of Atrial Fibrillation

    PubMed Central

    Clementy, Nicolas; Benhenda, Nazih; Piver, Eric; Pierre, Bertrand; Bernard, Anne; Fauchier, Laurent; Pages, Jean-Christophe; Babuty, Dominique

    2016-01-01

    Galectin-3 is a biomarker of fibrosis and atrial remodeling, involved in the mechanisms of initiation and maintenance of atrial fibrillation (AF). We sought to study the accuracy of galectin-3 level in predicting recurrences of AF after ablation. Serum concentrations of galectin-3 were determined in a consecutive series of patients addressed for AF ablation in our center. After a 3-month blanking period, recurrences of atrial arrhythmias were collected during the first year in all patients, using Holter monitoring at 3, 6 months and 12 months. A total of 160 patients were included, with a mean galectin-3 rate was 14.4 ± 5.6 ng/mL. At 12-month, 55 patients (34%) had reexperienced sustained atrial arrhythmia. Only higher galectin-3 level (HR = 1.07 [1.01–1.12], p = 0.02) and larger left atrial diameter (HR = 1.07 [1.03–1.12], p = 0.001) independently predicted recurrence. Patients with both galectin-3 level <15 ng/mL and left atrial diameter <40 millimeters had a 1-year arrhythmia-free survival rate − after a single procedure without anti-arrhythmic drug − of 91%, as compared with 41% in patients with galectin-3 ≥ 15 and left trial diameter ≥40 (p < 0.0001), whether AF was paroxysmal or persistent. Galectin-3 and left atrial diameters, rather than clinical presentation of AF, predict recurrences after ablation. PMID:27677964

  6. Optimization of Catheter Ablation of Atrial Fibrillation: Insights Gained from Clinically-Derived Computer Models

    PubMed Central

    Zhao, Jichao; Kharche, Sanjay R.; Hansen, Brian J.; Csepe, Thomas A.; Wang, Yufeng; Stiles, Martin K.; Fedorov, Vadim V.

    2015-01-01

    Atrial fibrillation (AF) is the most common heart rhythm disturbance, and its treatment is an increasing economic burden on the health care system. Despite recent intense clinical, experimental and basic research activity, the treatment of AF with current antiarrhythmic drugs and catheter/surgical therapies remains limited. Radiofrequency catheter ablation (RFCA) is widely used to treat patients with AF. Current clinical ablation strategies are largely based on atrial anatomy and/or substrate detected using different approaches, and they vary from one clinical center to another. The nature of clinical ablation leads to ambiguity regarding the optimal patient personalization of the therapy partly due to the fact that each empirical configuration of ablation lines made in a patient is irreversible during one ablation procedure. To investigate optimized ablation lesion line sets, in silico experimentation is an ideal solution. 3D computer models give us a unique advantage to plan and assess the effectiveness of different ablation strategies before and during RFCA. Reliability of in silico assessment is ensured by inclusion of accurate 3D atrial geometry, realistic fiber orientation, accurate fibrosis distribution and cellular kinetics; however, most of this detailed information in the current computer models is extrapolated from animal models and not from the human heart. The predictive power of computer models will increase as they are validated with human experimental and clinical data. To make the most from a computer model, one needs to develop 3D computer models based on the same functionally and structurally mapped intact human atria with high spatial resolution. The purpose of this review paper is to summarize recent developments in clinically-derived computer models and the clinical insights they provide for catheter ablation. PMID:25984605

  7. Pulmonary vein region ablation in experimental vagal atrial fibrillation: role of pulmonary veins versus autonomic ganglia.

    PubMed

    Lemola, Kristina; Chartier, Denis; Yeh, Yung-Hsin; Dubuc, Marc; Cartier, Raymond; Armour, Andrew; Ting, Michael; Sakabe, Masao; Shiroshita-Takeshita, Akiko; Comtois, Philippe; Nattel, Stanley

    2008-01-29

    Pulmonary vein (PV) -encircling radiofrequency ablation frequently is effective in vagal atrial fibrillation (AF), and there is evidence that PVs may be particularly prone to cholinergically induced arrhythmia mechanisms. However, PV ablation procedures also can affect intracardiac autonomic ganglia. The present study examined the relative role of PVs versus peri-PV autonomic ganglia in an experimental vagal AF model. Cholinergic AF was studied under carbachol infusion in coronary perfused canine left atrial PV preparations in vitro and with cervical vagal stimulation in vivo. Carbachol caused dose-dependent AF promotion in vitro, which was not affected by excision of all PVs. Sustained AF could be induced easily in all dogs during vagal nerve stimulation in vivo both before and after isolation of all PVs with encircling lesions created by a bipolar radiofrequency ablation clamp device. PV elimination had no effect on atrial effective refractory period or its responses to cholinergic stimulation. Autonomic ganglia were identified by bradycardic and/or tachycardic responses to high-frequency subthreshold local stimulation. Ablation of the autonomic ganglia overlying all PV ostia suppressed the effective refractory period-abbreviating and AF-promoting effects of cervical vagal stimulation, whereas ablation of only left- or right-sided PV ostial ganglia failed to suppress AF. Dominant-frequency analysis suggested that the success of ablation in suppressing vagal AF depended on the elimination of high-frequency driver regions. Intact PVs are not needed for maintenance of experimental cholinergic AF. Ablation of the autonomic ganglia at the base of the PVs suppresses vagal responses and may contribute to the effectiveness of PV-directed ablation procedures in vagal AF.

  8. Prediction of vascular dementia and Alzheimer's disease in patients with atrial fibrillation or atrial flutter using CHADS2 score.

    PubMed

    Chou, Ruey-Hsing; Chiu, Chun-Chih; Huang, Chin-Chou; Chan, Wan-Leong; Huang, Po-Hsun; Chen, Yu-Chun; Chen, Tzeng-Ji; Chung, Chia-Min; Lin, Shing-Jong; Chen, Jaw-Wen; Leu, Hsin-Bang

    2016-09-01

    Atrial fibrillation (AF) is associated with an increased risk of dementia. However, limited data are available on the predictors of dementia in patients with AF. This study aimed to evaluate whether the CHADS2 score could be a useful tool for risk stratification with regard to dementia occurrence among patients with AF. AF patients were identified from the National Health Insurance sampling database, which has accumulated a total of 1,000,000 participants since 2000. After excluding patients diagnosed with dementia prior to the index day of enrollment, CHADS2 score was measured to investigate its association with the occurrence of dementia, including vascular dementia and Alzheimer's disease. During the mean follow-up period of 3.71 ± 2.78 years, 1135 dementia cases (7.36%) were identified, including 241 cases of vascular dementia and 894 cases of Alzheimer's disease. In multivariate analysis, an increase of 1 point in the CHADS2 score was independently associated with a 54% increase in the risk of vascular dementia (hazard ratio = 1.54; 95% confidence interval, 1.41-1.69; p < 0.001) and a 40% increase in Alzheimer's disease (hazard ratio = 1.40; 95% confidence interval, 1.34-1.46; p < 0.001). CHADS2 score is a useful predictor for the development of vascular dementia as well as Alzheimer's disease in patients with AF. Copyright © 2016. Published by Elsevier Taiwan LLC.

  9. Successful catheter ablation of atrial tachycardia and atrial fibrillation in persistent left superior vena cava.

    PubMed

    Tsutsui, Kenta; Ajiki, Kohsuke; Fujiu, Katsuhito; Imai, Yasushi; Hayami, Noriyuki; Murakawa, Yuji

    2010-01-01

    Atrial tachycardia (AT) and atrial fibrillation (AF) were observed in a 21-year old male who had a history of patch closure for an atrial septal defect (ASD) at the age of 5 and a persistent left superior vena cava (LSVC). During electrophysiologic study, atrial extrastimuli reproducibly induced AT which spontaneously terminated or changed into AF. Electroanatomical mapping revealed focal AT arising from the floor of the proximal LSVC. Radio- frequency applications within LSVC targeted to the earliest activation site of AT as well as the complex fractionated potential eliminated both AT and AF without trans-septal puncture.

  10. Volume Matters: Improved Outcomes for Patients Presenting to High-Volume Emergency Departments with Atrial Flutter and Fibrillation

    PubMed Central

    Graham, Michelle M.; Holroyd, Brian R.

    2016-01-01

    Objectives Clinical familiarity plays a role in health outcomes; the relationship between emergency department (ED) volume and outcomes for atrial fibrillation and flutter (AFF) are not clear. We compared ED presentation outcomes for AFF between high (HV) and low volume (LV) EDs in Alberta, Canada. Methods 45,372 AFF presentations for patients aged ≥ 35 years from all 104 EDs in Alberta during 1999 to 2011 using administrative health databases formed a retrospective cohort. EDs were grouped by annual AFF volume: 11 high (>100 presentations) or 93 low (≤100 presentations). Outcomes included hospital admission rate, return to ED for AFF within 30 and 90 days, and death within 30 and 90 days. Analyses included statistical tests and mixed effects modeling. Results Mean age at ED presentation was 69.8 years (52% male). HV ED presentations were associated with lower admissions (adjusted odds ratio [aOR] = 0.68, 95% confidence interval [CI] 0.64, 0.72; p-value [p]<0.001), ED returns at 90 (aOR = 0.81, 95% CI 0.73, 0.90; p<0.001) days, and a higher likelihood of specialist visits at 30 (aOR = 1.81, 95% CI 1.68, 1.94; p<0.001) and 90 (aOR = 1.82, 95% CI 1.76, 2.03; p<0.001) days. For admitted patients, there were fewer returns to HV EDs at 30 (aOR = 0.37, 95% CI 0.15, 0.87; p = 0.02) and 90 (aOR = 0.48, 95% CI 0.26, 0.89; p = 0.02) days after hospital discharge. There was no difference in death between the two groups. Conclusions AFF patients presenting to HV EDs experienced fewer admissions and AFF ED revisit and higher specialist referrals compared to LV EDs. PMID:27814387

  11. Focal atrial tachycardia originating from the septal mitral annulus: electrocardiographic and electrophysiological characteristics and radiofrequency ablation.

    PubMed

    Wang, Yunlong; Li, Ding; Zhang, Junmeng; Han, Zhihong; Wang, Ye; Ren, Xuejun; Li, Xuebin; Chen, Fang

    2016-07-01

    This study sought to investigate electrocardiographic characteristics, electrophysiological features, and radiofrequency ablation in patients with focal atrial tachycardia (AT) originating from the septal mitral annulus. In 13 patients with AT originating from the septal mitral annulus, activation mapping was performed to identify the earliest activation site. Successful ablation was performed through either a transseptal (n = 12) or a retrograde aortic approach (n = 1). As confirmed by electrogram recordings, fluoroscopy, and three-dimensional (3D) mapping, successful ablation sites were located in the anterior paraseptal, mid- to anteroseptal, and posterior septal mitral annulus in eight, three, and two patients, respectively. Foci for all locations demonstrated a negative/positive appearance in lead V1. Mapping in the right atrium demonstrated that the earliest right atrial activation was near the septum (His-bundle region or proximal coronary sinus). The electrograms at the successful ablation sites were fractionated in 9 patients, and presented with an atrial:ventricular ratio of <1 in all 13 patients. There were no complications in any patients and long-term success was achieved in 12 of 13 patients during the 23 ± 6 months following ablation. The area surrounding the septal mitral annulus, most commonly the anterior paraseptal, is an unusual, but important site of origin for focal AT, which is associated with a distinctive P-wave morphology and atrial endocardial activation sequence. Radiofrequency ablation of AT originating from the septal mitral annulus, through either a transseptal or a retrograde aortic approach appears to be safe and effective. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  12. Epicardial Atrial Ablation Using a Novel Articulated Robotic Medical Probe Via a Percutaneous Subxiphoid Approach.

    PubMed

    Ota, Takeyoshi; Degani, Amir; Zubiate, Brett; Wolf, Alon; Choset, Howie; Schwartzman, David; Zenati, Marco A

    2006-01-01

    OBJECTIVE: Minimally invasive epicardial atrial ablation to cure atrial fibrillation through the use of a percutaneous subxiphoid approach currently has a lack of dedicated technology for intrapericardial navigation around the beating heart. We have developed a novel articulated robotic medical probe and performed preliminary experiments in a porcine preparation. METHODS: In five large, healthy pigs, the teleoperated robotic system was introduced inside the pericardial space through a percutaneous subxiphoid approach. Secondary visualization of the left atrium and left atrial appendage was achieved with the use of a 5-mm scope inserted through a left thoracic port. The operator actively controlled the path of the robot by using a master manipulator. The catheter, with an irrigated radiofrequency tip, was guided through the working port of the robot to achieve epicardial ablation of the left atrium. RESULTS: Access to the pericardial space and progression around the left atrium was successful in all cases, with no interference with the beating heart such as a fatal arrhythmia, unexpected bleeding, and hypotension. Epicardial ablation was successfully performed in all five cases. No adverse hemodynamic or electrophysiological events were noted during the trials. When the animals were killed, there was no visually detected injury on the surrounding mediastinal structures caused by ablation. Transmural ablation was confirmed by histopathology of the left atrium. CONCLUSIONS: We have developed a dedicated articulated robotic medical probe and successfully performed epicardial left atrial radiofrequency ablation. Based on the feedback from these preliminary experiments, the radius of curvature and proper visualization of the device are being improved in the next generation prototype.

  13. Effect of remote ischemic preconditioning on platelet activation and reactivity induced by ablation for atrial fibrillation.

    PubMed

    Stazi, Alessandra; Scalone, Giancarla; Laurito, Marianna; Milo, Maria; Pelargonio, Gemma; Narducci, Maria Lucia; Parrinello, Rossella; Figliozzi, Stefano; Bencardino, Gianluigi; Perna, Francesco; Lanza, Gaetano A; Crea, Filippo

    2014-01-07

    Radiofrequency ablation of atrial fibrillation has been associated with some risk of thromboembolic events. Previous studies showed that preventive short episodes of forearm ischemia (remote ischemic preconditioning [IPC]) reduce exercise-induced platelet reactivity. In this study, we assessed whether remote IPC has any effect on platelet activation induced by radiofrequency ablation of atrial fibrillation. We randomized 19 patients (age, 54.7±11 years; 17 male) undergoing radiofrequency catheter ablation of paroxysmal atrial fibrillation to receive remote IPC or sham intermittent forearm ischemia (control subjects) before the procedure. Blood venous samples were collected before and after remote IPC/sham ischemia, at the end of the ablation procedure, and 24 hours later. Platelet activation and reactivity were assessed by flow cytometry by measuring monocyte-platelet aggregate formation, platelet CD41 in the monocyte-platelet aggregate gate, and platelet CD41 and CD62 in the platelet gate in the absence and presence of ADP stimulation. At baseline, there were no differences between groups in platelet variables. Radiofrequency ablation induced platelet activation in both groups, which persisted after 24 hours. However, compared with control subjects, remote IPC patients showed a lower increase in all platelet variables, including monocyte-platelet aggregate formation (P<0.0001), CD41 in the monocyte-platelet aggregate gate (P=0.002), and CD41 (P<0.0001) and CD62 (P=0.002) in the platelet gate. Compared with control subjects, remote IPC was also associated with a significantly lower ADP-induced increase in all platelet markers. Our data show that remote IPC before radiofrequency catheter ablation for paroxysmal atrial fibrillation significantly reduces the increased platelet activation and reactivity associated with the procedure.

  14. Efficacy and safety of novel epicardial circumferential left atrial ablation with pulmonary vein isolation in sustained atrial fibrillation.

    PubMed

    Jiang, Zhaolei; Yin, Hang; He, Yi; Ma, Nan; Tang, Min; Liu, Hao; Ding, Fangbao; Mei, Ju

    2015-09-01

    The aim of this study was to examine the efficacy and safety of this novel epicardial circumferential left atrial ablation (CLAA) with pulmonary vein isolation (PVI) in sustained atrial fibrillation (AF). Thirty domestic pigs were divided equally into 3 groups: AF without ablation (AF group), AF with PVI (PVI group), and AF with CLAA and PVI (CLAA + PVI group). AF was induced by rapid atrial pacing. After AF was induced, CLAA and PVI were performed for pigs in CLAA + PVI group, and PVI was performed for pigs in PVI group. AF vulnerability, AF duration, and histology were performed in all groups. All pigs developed sustained AF after 6.27 ± 0.69 weeks of rapid atrial pacing. All pigs successfully underwent isolated PVI or CLAA with PVI on the beating heart in PVI group or CLAA + PVI group. Isolated PVI terminated AF in 3 of 20 pigs (15 %), and CLAA with PVI terminated AF in 5 of 8 pigs (62.5 %, P = 0.022). Compared with AF group (10/10), the incidence of sustained AF by burst pacing was significantly decreased in PVI group (3/10, P = 0.003) or CLAA + PVI group (0/10, P < 0.001). There was no significant difference between PVI group and CLAA + PVI group (P = 0.211). AF duration was significantly decreased in CLAA + PVI group (734.70 ± 177.81 s, 95 % CI 607.51-861.89) compared with PVI group (1217.90 ± 444.10 s, 95 % CI 900.21-1535.59, P = 0.008). Also, AF duration was significantly decreased in PVI group (P = 0.003) or CLAA + PVI group (P < 0.001) in comparison with AF duration in AF group (average 1800 s). Epicardial CLAA could ablate the left atrial roof and posterior wall together safely and reliably. Compared with PVI alone, CLAA with PVI may be able to improve the rate of acute termination of persistent AF. It may be useful in selecting the best ablation approaches for patients with persistent AF.

  15. Substrate modification by adding ablation of localized complex fractionated electrograms after stepwise linear ablation in persistent atrial fibrillation.

    PubMed

    Nakahara, Shiro; Kamijima, Tohru; Hori, Yuichi; Tsukada, Naofumi; Okano, Akiko; Takayanagi, Kan

    2014-03-01

    Linear left atrial (LA) ablation in patients with persistent atrial fibrillation (PsAF) resulting in the elimination of most complex fractionated electrogram (CFE) sites has been demonstrated. This study was designed to evaluate the impact of a localized CFE ablation in addition to a representative linear LA ablation in patients with PsAF. A total of 40 consecutive patients with PsAF underwent construction of CFE and dominant frequency (DF) maps using NavX. A stepwise linear ablation including at the PV antra, septum, roof, mitral annulus, and ridge of the appendage was performed followed by additional ablation of localized CFEs detected by an automatic algorithm. A significant reduction in the continuous CFE burden (<50 ms) after the linear ablation (69 vs. 21 %; P < 0.0001) was confirmed, and localized CFEs (40-120 ms) were observed with a significant predilection for the anterior (30 %), posterior (30 %), and inferior LA (38 %) regions (P < 0.01). Comparing the localized CFEs with higher frequency sources, 45 % (70/156) of the localized CFE sites included continuous CFE regions, and 59 % (92/156) of those sites overlapped with the high-DF sites (>8 Hz). Additional localized CFE-targeted ablation further terminated PsAF in 20 % of the patients and further increased the mean CFE cycle length (110 ± 31 to 125 ± 39 ms; P = 0.0033) and decreased the DF (6.0 ± 0.8 to 5.7 ± 0.7 Hz; P = 0.0013) within the CS. The presence of localized CFE sites with a predilection for particular LA regions after a representative linear LA ablation could provide the optimal sites for selective substrate modification of the atrial fibrillation substrate in patients with PsAF.

  16. Outcomes of Cryoballoon Ablation in High- and Low-Volume Atrial Fibrillation Ablation Centres: A Russian Pilot Survey

    PubMed Central

    Mikhaylov, Evgeny N.; Lebedev, Dmitry S.; Pokushalov, Evgeny A.; Davtyan, Karapet V.; Ivanitskii, Eduard A.; Nechepurenko, Anatoly A.; Kosonogov, Alexey Ya.; Kolunin, Grigory V.; Morozov, Igor A.; Termosesov, Sergey A.; Maykov, Evgeny B.; Khomutinin, Dmitry N.; Eremin, Sergey A.; Mayorov, Igor M.; Romanov, Alexander B.; Shabanov, Vitaliy V.; Shatakhtsyan, Victoria; Tsivkovskii, Viktor; Revishvili, Amiran Sh.; Shlyakhto, Evgeny V.

    2015-01-01

    Purpose. The results of cryoballoon ablation (CBA) procedure have been mainly derived from studies conducted in experienced atrial fibrillation (AF) ablation centres. Here, we report on CBA efficacy and complications resulting from real practice of this procedure at both high- and low-volume centres. Methods. Among 62 Russian centres performing AF ablation, 15 (24%) used CBA technology for pulmonary vein isolation. The centres were asked to provide a detailed description of all CBA procedures performed and complications, if encountered. Results. Thirteen sites completed interviews on all CBAs in their centres (>95% of CBAs in Russia). Six sites were high-volume AF ablation (>100 AF cases/year) centres, and 7 were low-volume AF ablation. There was no statistical difference in arrhythmia-free rates between high- and low-volume centres (64.6 versus 60.8% at 6 months). Major complications developed in 1.5% of patients and were equally distributed between high- and low-volume centres. Minor procedure-related events were encountered in 8% of patients and were more prevalent in high-volume centres. Total event and vascular access site event rates were higher in women than in men. Conclusions. CBA has an acceptable efficacy profile in real practice. In less experienced AF ablation centres, the major complication rate is equal to that in high-volume centres. PMID:26640789

  17. Antiarrhythmic Effect Of Antioxidants In Patients With Atrial Fibrillation.

    PubMed

    Khabchabov PhD, Rustam; Rg PhD, Khabchabov; Er PhD, Makhmudova

    2016-01-01

    Resume In accordance with modern concepts, one of the leading roles in the development of paroxysmal atrial fibrillation and flutter, belongs - the restructuring of the myocardium, in second place - sick sinus syndrome and in third place - the presence of accessory pathways and hormonal disorders. The development of atrial fibrillation and flutter in the structural pathology, primarily begins with of drugs if it does not work, we have to carry out ablation. Providing proper, effective and important combination therapy - is the main challenge in cardiology.

  18. Is inducibility of atrial fibrillation after radio frequency ablation really a relevant prognostic factor?

    PubMed

    Richter, Bernhard; Gwechenberger, Marianne; Filzmoser, Peter; Marx, Manfred; Lercher, Peter; Gössinger, Heinz D

    2006-11-01

    The study was intended to assess the prognostic value of inducibility of atrial fibrillation (AF) after radio frequency ablation. Two hundred and thirty four patients with drug-resistant paroxysmal (n=165) or persistent AF (n=69) underwent either Lasso-guided segmental pulmonary vein isolation (n=83) or CARTO-guided left atrial circumferential ablation (n=151). After ablation, two attempts to induce AF (>1 min) by decremental coronary sinus stimulation were performed. Patients were followed for at least 6 months (median: 12.7 months). At 6 months of follow-up, 67% of patients with paroxysmal and 48% of patients with persistent AF were AF-free. Inducibility of AF was a significant predictor of AF recurrence in univariate [hazard ratio (HR)=2.32, P<0.001] and multivariable (HR=2.19, P<0.001) Cox regression analyses. The prognostic value of inducibility was present in both patients with paroxysmal (HR=2.38, P=0.001) and persistent AF (HR=1.91, P=0.034) and did not significantly differ between both ablation techniques. The sensitivity, specificity, positive, and negative predictive values of the AF induction test to predict the 6-month ablation outcome were 46.7, 75, 53.8, and 69.2%, respectively. Inducibility of AF after ablation is a significant predictor of recurrent AF. However, owing to the low diagnostic accuracy of the AF induction test, non-inducibility does not qualify as reliable procedural endpoint.

  19. Percutaneous ablation for atrial fibrillation: the role of cross-sectional imaging.

    PubMed

    Ghaye, Benoit; Szapiro, David; Dacher, Jean-Nicolas; Rodriguez, Luz-Maria; Timmermans, Carl; Devillers, David; Dondelinger, Robert F

    2003-10-01

    Percutaneous ablation is a well-established technique for treating cardiac arrhythmia by removing or isolating tissue at the site of the abnormal impulse formation. Various forms of energy for ablation procedures may be delivered via a catheter with fluoroscopic guidance. The procedures most commonly performed are radiofrequency ablation and cryotherapy. Atrial fibrillation, the most frequently occurring supraventricular tachyarrhythmia, may be initiated by ectopic beats that originate in the ostia of the pulmonary veins. The clinical efficacy of isolation (or focal ablation) of the pulmonary veins for treatment of atrial fibrillation has been well demonstrated. Pre- and postprocedural examinations with computed tomography (CT) or magnetic resonance (MR) imaging are frequently performed to depict the anatomy and to obtain baseline measurements of the pulmonary veins to enable early detection of complications from ablation. Venous stenosis or thrombosis and pulmonary hypertension may occur after radio-frequency ablation. Familiarity with the appearance of normal anatomic variants at CT and MR imaging and with the normal range of pulmonary vein diameters is essential for preoperative management and early detection of procedure-related complications. Copyright RSNA, 2003

  20. Phrenic nerve protection via packing of gauze into the pericardial space during ablation of cristal atrial tachycardia in a child.

    PubMed

    Takahashi, Kazuhiro; Fuchigami, Tai; Nabeshima, Taisuke; Sashinami, Arata; Nakayashiro, Mami

    2016-03-01

    The success of catheter ablation of focal atrial tachycardia is limited by possible collateral damage to the phrenic nerve. Protection of the phrenic nerve is required. Here we present a case of a 9-year-old girl having a history of an unsuccessful catheter ablation of a focal atrial tachycardia near the crista terminalis (because of proximity of the phrenic nerve) who underwent a successful ablation by means of a novel technique for phrenic nerve protection: packing of gauze into the pericardial space. This method is a viable approach for patients with a failed endocardial ablation due to the proximity of the phrenic nerve.

  1. Patient-specific left atrial wall-thickness measurement and visualization for radiofrequency ablation

    NASA Astrophysics Data System (ADS)

    Inoue, Jiro; Skanes, Allan C.; White, James A.; Rajchl, Martin; Drangova, Maria

    2014-03-01

    INTRODUCTION: For radiofrequency (RF) catheter ablation of the left atrium, safe and effective dosing of RF energy requires transmural left atrium ablation without injury to extra-cardiac structures. The thickness of the left atrial wall may be a key parameter in determining the appropriate amount of energy to deliver. While left atrial wall-thickness is known to exhibit inter- and intra-patient variation, this is not taken into account in the current clinical workflow. Our goal is to develop a tool for presenting patient-specific left atrial thickness information to the clinician in order to assist in the determination of the proper RF energy dose. METHODS: We use an interactive segmentation method with manual correction to segment the left atrial blood pool and heart wall from contrast-enhanced cardiac CT images. We then create a mesh from the segmented blood pool and determine the wall thickness, on a per-vertex basis, orthogonal to the mesh surface. The thickness measurement is visualized by assigning colors to the vertices of the blood pool mesh. We applied our method to 5 contrast-enhanced cardiac CT images. RESULTS: Left atrial wall-thickness measurements were generally consistent with published thickness ranges. Variations were found to exist between patients, and between regions within each patient. CONCLUSION: It is possible to visually determine areas of thick vs. thin heart wall with high resolution in a patient-specific manner.

  2. Chronic Atrial Fibrillation Ablation with Harmonic Scalpel during Mitral Valve Surgery

    PubMed Central

    Brick, Alexandre Visconti; Braile, Domingo M.

    2017-01-01

    Objective To evaluate surgical treatment of chronic atrial fibrillation with ultrasound in patients with mitral valve disease, considering preoperative clinical characteristics of patients undergoing surgical procedure and follow-up in the immediate postoperative period, in hospital and up to 60 months after discharge. Methods We studied 100 patients with chronic atrial fibrillation and mitral valve disease who underwent surgical treatment using ultrasound ablation. Patient data were reviewed by consulting the control reports, including signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, immediate complications, and complications at discharged and up to 60 months later. Actuarial curve (Kaplan-Meier) was used for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months. Results 86% of the patients had rheumatic mitral valve disease, 14% had degeneration of the mitral valve, 40% had mitral regurgitation, and 36% had mitral stenosis. Main symptoms included palpitations related to tachycardia by chronic atrial fibrillation (70%), congestive heart failure (70%), and previous episodes of acute pulmonary edema (27%). Early results showed that 94% of the patients undergoing ultrasound ablation reversed the rate of chronic atrial fibrillation, 86% being in sinus rhythm and 8% in atrioventricular block. At hospital discharge, maintenance of sinus rhythm was observed in 86% of patients and there was recurrence of chronic atrial fibrillation in 8% of patients. At follow-up after 60 months, 83.8% of patients maintained the sinus rhythm. Conclusion Surgical treatment of chronic atrial fibrillation with ultrasound concomitant with mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up.

  3. Results of radiofrequency ablation for permanent atrial fibrillation in patients undergoing mitral valve surgery.

    PubMed

    Zhou, Yong-xin; Leobon, Bertrand; Roux, Daniel; Glock, Yves; Mei, Yun-qing; Wang, Yong-wu; Fournial, Gérard

    2009-12-01

    The study aim was to evaluate the safety and feasibility of radiofrequency ablation for the surgical treatment of permanent atrial fibrillation in patients with degenerative mitral valve disease. From August 2000 to August 2003, 40 consecutive patients (mean age 69.0 +/- 9.3 years) with permanent atrial fibrillation and degenerative mitral valve disease underwent surgical radiofrequency ablation in conjunction with 22 mitral valve repairs and 18 mitral valve replacements. The mean duration of chronic AF was 5.1 +/- 3.4 years. The completeness of follow-up was 100%. The mean follow-up time was 4.6 +/- 2.0 years (range 0 to 7.8 years). Thirty-day mortality was 2.5% (1 patient), the cause of death was cardiac failure. Cardiac failure and temporary A-V block were the most common postoperative complications. Both occurred in 10% (4 patients). No complication was related to the ablation procedure. At discharge, 65% (26/40) of the patients were in sinus rhythm. Overall incidence of sinus rhythm at the end of the follow-up was 56.4% (22/39).The 1-, 3- and 5-year survival was 97.5%, 91.8% and 85.9%, respectively. Mitral valve surgery combined with radiofrequency ablation is a safe and effective procedure in patients with permanent atrial fibrillation and degenerative mitral valve disease. The result is encouraging in restoring sinus rhythm, and an excellent postoperative survival rate can be achieved.

  4. Surgical ablation for atrial fibrillation: The efficacy of a novel bipolar pen device in the cardioplegically arrested and beating heart

    PubMed Central

    Sakamoto, Shun-ichiro; Voeller, Rochus K.; Melby, Spencer J.; Lall, Shelly C.; Chang, Nai-lun; Schuessler, Richard B.; Damiano, Ralph J.

    2009-01-01

    Objective The introduction of ablation technology has simplified surgical intervention for atrial fibrillation. However, most ablation devices cannot create focal transmural lesions on the beating heart and have difficulty ablating specific regions of the atria, such as the atrioventricular isthmus, coronary sinus, and ganglionated plexus. The purpose of this study was to examine the efficacy of a pen-type bipolar radiofrequency ablation device on both arrested and beating hearts. Methods Endocardial and epicardial atrial tissues in the free wall, left atrial roof, atrioventricular annuli, and coronary sinus were ablated for varying time intervals (2.5–15 seconds) in porcine cardioplegically arrested (n = 6) and beating (n = 9) hearts. The hearts were stained with 1%2,3,5-triphenyl-tetrazolium chloride solution and sectioned to determine lesion depth and width. In 5 animals epicardial fat pads containing ganglionated plexus were stimulated and ablated. Results Lesion depth increased with ablation time similarly in both arrested and beating hearts. Transmurality was fully achieved in the thin atrial tissue (<4 mm) at 10 seconds in the beating and arrested hearts. The device had a maximal penetration depth of 6.1 mm. Epicardial ablation of the coronary sinus showed complete penetration through the left posterior atrium only in the arrested heart. Seven of 17 fat pads demonstrated a vagal response. All vagal responses were eliminated after ablation. Conclusion The bipolar pen effectively ablated atrial tissue in both arrested and beating hearts. This device might allow the surgeon to ablate tissue in regions not accessible to other devices during atrial fibrillation surgery. PMID:19026819

  5. Ablation of focal atrial tachycardia from the non-coronary aortic cusp: case series and review of the literature.

    PubMed

    Beukema, Rypko J; Smit, Jaap Jan J; Adiyaman, Ahmet; Van Casteren, Lieve; Delnoy, Peter Paul H M; Ramdat Misier, Anand R; Elvan, Arif

    2015-06-01

    Focal atrial tachycardia successfully ablated from the non-coronary cusp (NCC) is rare. Our aim was to describe the characteristics of mapping and ablation therapy of NCC focal atrial tachycardias and to provide a comprehensive review of the literature. Seven patients (age 40 ± 9 years) with symptomatic, drug-refractory atrial tachycardia were referred for electrophysiological study. Extensive right and left atrial mapping revealed atrial tachycardia near His in all patients but either failed to identify a successful ablation site or radiofrequency applications only resulted in temporary termination of the tachycardia. Mapping and ablation of the NCC were performed retrogradely via the right femoral artery. Mapping of the NCC demonstrated earliest atrial activation during atrial tachycardia 38 ± 14 ms (ranging 17-56 ms) before the onset of the P-wave. Earliest atrial activation in the NCC was earlier than earliest activation in the right atrium and left atrium in all patients. The P-wave morphology was predominantly negative in the inferior leads and biphasic in leads V1 and V2. The tachycardia was successfully terminated by radiofrequency application in 10 ± 6 s (2-16 s), without complications. All patients were free of symptoms during a follow-up of 19 ± 9 months. Literature search revealed 18 reports (91 patients) describing NCC focal atrial tachycardia, with 99% long-term ablation success with a 1% complication rate. Symptomatic focal atrial tachycardia near His may originate from the NCC and can be treated safely and effectively with radiofrequency ablation. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

  6. Effects of sex on the incidence of cardiac tamponade after catheter ablation of atrial fibrillation: results from a worldwide survey in 34 943 atrial fibrillation ablation procedures.

    PubMed

    Michowitz, Yoav; Rahkovich, Michael; Oral, Hakan; Zado, Erica S; Tilz, Roland; John, Silke; Denis, Arnaud; Di Biase, Luigi; Winkle, Roger A; Mikhaylov, Evgeny N; Ruskin, Jeremy N; Yao, Yan; Josephson, Mark E; Tanner, Hildegard; Miller, John M; Champagne, Jean; Della Bella, Paolo; Kumagai, Koichiro; Defaye, Pascal; Luria, David; Lebedev, Dmitry S; Natale, Andrea; Jais, Pierre; Hindricks, Gerhard; Kuck, Karl-Heinz; Marchlinski, Francis E; Morady, Fred; Belhassen, Bernard

    2014-04-01

    Cardiac tamponade is the most dramatic complication observed during atrial fibrillation (AF) ablation and the leading cause of procedure-related mortality. Female sex is a known risk factor for complications during AF ablation; however, it is unknown whether women have a higher risk of tamponade. A systematic Medline search was used to locate academic electrophysiological centers that reported cases of tamponade occurring during AF ablation. Centers were asked to provide information on cases of acute tamponade according to sex and their mode of management including any case of related mortality. Nineteen electrophysiological centers provided information on 34 943 ablation procedures involving 25 261 (72%) men. Overall, 289 (0.9%) cases of tamponade were reported: 120 (1.24%) in women and 169 (0.67%) in men (odds ratio, 1.83; P<0.001). There was a reciprocal association between center volume and the occurrence of tamponade with substantially lower risk in high-volume centers. Most cases of tamponade occurred during catheter manipulation or ablation; women tended to develop more tamponades during transseptal catheterization. No sex difference in the mode of management was observed. However, 16% cases of tamponade required surgery with lower rates in high-volume centers. Three cases of tamponade (1%) culminated in death. Tamponade during AF ablation procedures is relatively rare. Women have an ≈2-fold higher risk for developing this complication. The risk of tamponade among women decreases substantially in high-volume centers. Surgical backup and acute management skills for treating tamponade are important in centers performing AF ablation.

  7. Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

    PubMed Central

    Filgueiras-Rama, David; Estrada, Alejandro; Shachar, Josh; Castrejón, Sergio; Doiny, David; Ortega, Marta; Gang, Eli; Merino, José L.

    2013-01-01

    New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate. PMID:23628883

  8. Differentiation of pre-ablation and post-ablation late gadolinium-enhanced cardiac MRI scans of longstanding persistent atrial fibrillation patients

    NASA Astrophysics Data System (ADS)

    Yang, Guang; Zhuang, Xiahai; Khan, Habib; Haldar, Shouvik; Nyktari, Eva; Li, Lei; Ye, Xujiong; Slabaugh, Greg; Wong, Tom; Mohiaddin, Raad; Keegan, Jennifer; Firmin, David

    2017-03-01

    Late Gadolinium-Enhanced Cardiac MRI (LGE CMRI) is an emerging non-invasive technique to image and quantify preablation native and post-ablation atrial scarring. Previous studies have reported that enhanced image intensities of the atrial scarring in the LGE CMRI inversely correlate with the left atrial endocardial voltage invasively obtained by electro-anatomical mapping. However, the reported reproducibility of using LGE CMRI to identify and quantify atrial scarring is variable. This may be due to two reasons: first, delineation of the left atrium (LA) and pulmonary veins (PVs) anatomy generally relies on manual operation that is highly subjective, and this could substantially affect the subsequent atrial scarring segmentation; second, simple intensity based image features may not be good enough to detect subtle changes in atrial scarring. In this study, we hypothesized that texture analysis can provide reliable image features for the LGE CMRI images subject to accurate and objective delineation of the heart anatomy based on a fully-automated whole heart segmentation (WHS) method. We tested the extracted texture features to differentiate between pre-ablation and post-ablation LGE CMRI studies in longstanding persistent atrial fibrillation patients. These patients often have extensive native scarring and differentiation from post-ablation scarring can be difficult. Quantification results showed that our method is capable of solving this classification task, and we can envisage further deployment of this texture analysis based method for other clinical problems using LGE CMRI.

  9. Impact of stepwise ablation on the biatrial substrate in patients with persistent atrial fibrillation and heart failure.

    PubMed

    Jones, David G; Haldar, Shouvik K; Jarman, Julian W E; Johar, Sofian; Hussain, Wajid; Markides, Vias; Wong, Tom

    2013-08-01

    Ablation of persistent atrial fibrillation can be challenging, often involving not only pulmonary vein isolation (PVI) but also additional linear lesions and ablation of complex fractionated electrograms (CFE). We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure. In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ≤35%, high-density CFE maps were recorded biatrially at baseline, in the left atrium (LA) after PVI and linear lesions (roof and mitral isthmus), and biatrially after LA CFE ablation. Surface area of CFE (mean cycle length ≤120 ms) remote to PVI and linear lesions, defined as CFE area, was reduced after PVI (18.3±12.03 to 10.2±7.1 cm(2); P<0.001) and again after linear lesions (7.7±6.5 cm(2); P=0.006). Complete mitral isthmus block predicted greater CFE reduction (P=0.02). Right atrial CFE area was reduced by LA ablation, from 25.9±14.1 to 12.9±11.8 cm(2) (P<0.001). Estimated 1-year arrhythmia-free survival was 72% after a single procedure. Incomplete linear lesion block was an independent predictor of arrhythmia recurrence (hazard ratio, 4.69; 95% confidence interval, 1.05-21.06; P=0.04). Remote LA CFE area was progressively reduced following PVI and linear lesions, and LA ablation reduced right atrial CFE area. Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena. Nevertheless, in an advanced atrial fibrillation substrate, linear lesions after PVI diminished the target area for CFE ablation, and complete lesions resulted in a favorable clinical outcome.

  10. Successful ablation of frequent atrial premature beats from non-coronary aortic cusp with remote magnetic navigation.

    PubMed

    Abdelwahed, Ahmed Taha Hussein; Mäkynen, Heikki; Raatikainen, M J Pekka

    2015-01-01

    A 59-year-old female with structurally normal heart was admitted to our hospital for treatment of highly symptomatic, drug refractory atrial premature beats (APB). ECG revealed atrial parasystolic trigeminy. The arrhythmogenic focus was mapped and ablated using magnetic remote navigation and 3D electroanatomical mapping system. To our knowledge, this is the first report on successful ablation of frequent APBs in the non-coronary aortic cusp.

  11. Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF).

    PubMed

    Lip, Gregory Y H; Hammerstingl, Christoph; Marin, Francisco; Cappato, Riccardo; Meng, Isabelle Ling; Kirsch, Bodo; van Eickels, Martin; Cohen, Ariel

    2016-08-01

    Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non-vitamin K antagonist (VKA) oral anticoagulant treatment are scarce. The primary objective of X-TRA was to explore the use of rivaroxaban for the resolution of LA/LAA thrombi in patients with nonvalvular atrial fibrillation (AF) or atrial flutter, with the CLOT-AF registry providing retrospective data after standard-of-care therapy in this setting. X-TRA was a prospective, single-arm, open-label, multicenter study that investigated rivaroxaban treatment for 6 weeks for LA/LAA thrombus resolution in patients with nonvalvular AF or atrial flutter and LA/LAA thrombus confirmed at baseline on a transesophageal echocardiogram (TEE). CLOT-AF retrospectively collected thrombus-related patient outcome data after standard-of-care anticoagulant treatment for 3 to 12 weeks in patients with nonvalvular AF or atrial flutter who had LA/LAA thrombi on TEE recorded in their medical file. In X-TRA, patients were predominantly (95.0%) from Eastern European countries. The adjudicated thrombus resolution rate was 41.5% (22/53 modified intention-to-treat [mITT] patients, 95% CI 28.1%-55.9%) based on central TEE assessments. Resolved or reduced thrombus was evident in 60.4% (32/53 mITT patients, 95% CI 46.0%-73.6%) of patients. In CLOT-AF, the reported thrombus resolution rate was 62.5% (60/96 mITT patients, 95% CI 52.0%-72.2%) and appeared better in Western European countries (34/50; 68.0%) than in Eastern European countries (26/46; 56.5%). X-TRA is the first prospective, multicenter study examining LA/LAA thrombus resolution with a non-VKA oral anticoagulant in VKA-naïve patients or in patients with suboptimal VKA therapy. Rivaroxaban could be a potential option for the treatment of LA/LAA thrombi. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

  12. Quantitative evaluation of atrial radio frequency ablation using intracardiac shear-wave elastography.

    PubMed

    Kwiecinski, Wojciech; Provost, Jean; Dubois, Rémi; Sacher, Frédéric; Haïssaguerre, Michel; Legros, Mathieu; Nguyen-Dinh, An; Dufait, Rémi; Tanter, Mickaël; Pernot, Mathieu

    2014-11-01

    Radio frequency catheter ablation (RFCA) is a well-established clinical procedure for the treatment of atrial fibrillation (AF) but suffers from a low single-procedure success rate. Recurrence of AF is most likely attributable to discontinuous or nontransmural ablation lesions. Yet, despite this urgent clinical need, there is no clinically available imaging modality that can reliably map the lesion transmural extent in real time. In this study, the authors demonstrated the feasibility of shear-wave elastography (SWE) to map quantitatively the stiffness of RFCA-induced thermal lesions in cardiac tissues in vitro and in vivo using an intracardiac transducer array. SWE was first validated in ex vivo porcine ventricular samples (N = 5). Both B-mode imaging and SWE were performed on normal cardiac tissue before and after RFCA. Areas of the lesions were determined by tissue color change with gross pathology and compared against the SWE stiffness maps. SWE was then performed in vivo in three sheep (N = 3). First, the stiffness of normal atrial tissues was assessed quantitatively as well as its variation during the cardiac cycle. SWE was then performed in atrial tissue after RFCA. A large increase in stiffness was observed in ablated ex vivo regions (average shear modulus across samples in normal tissue: 22 ± 5 kPa, average shear-wave speed (ct): 4.5 ± 0.4 m s(-1) and in determined ablated zones: 99 ± 17 kPa, average ct: 9.0 ± 0.5 m s(-1) for a mean shear modulus increase ratio of 4.5 ± 0.9). In vivo, a threefold increase of the shear modulus was measured in the ablated regions, and the lesion extension was clearly visible on the stiffness maps. By its quantitative and real-time capabilities, Intracardiac SWE is a promising intraoperative imaging technique for the evaluation of thermal ablation during RFCA.

  13. Atrial fibrillation ablation using remote magnetic navigation and the risk of atrial-esophageal fistula: international multicenter experience.

    PubMed

    Danon, Asaf; Shurrab, Mohammed; Nair, Krishnakumar Mohanan; Latcu, Decebal Gabriel; Arruda, Mauricio S; Chen, Xu; Szili-Torok, Tamas; Rossvol, Ole; Wissner, Eric E; Lashevsky, Ilan; Crystal, Eugene

    2015-08-01

    Remote magnetic navigation (RMN) has been used in various electrophysiological procedures, including atrial fibrillation (AF) ablation. Atrial-esophageal fistula (AEF) is one of most disastrous complications of AF ablation. We aimed to evaluate the incidence of AEF during AF ablation using RMN in comparison to manual ablation. We conducted the first international survey among RMN operators for assessment of the prevalence of AEF and procedural parameters affecting the risk. Data from parallel survey of AEF among Canadian interventional electrophysiologists (CIE) using only manual catheters served as control. Fifteen RMN operators (who performed 3637 procedures) and 25 manual CIE operators (7016 procedures) responded to the survey. RMN operators were more experienced than CIE operators (16.3 ± 8.3 vs. 9.2 ± 5.4 practice years in electrophysiology, p = 0.007). The maximal energy output in the posterior wall was higher in the operator using RMN (33 ± 5 vs. 28.6 ± 4.9 W; p = 0.02). Other parameters including use of preprocedural images, irrigated catheter, pump flow rate, esophageal temperature monitoring, intracardiac echocardiography (ICE), and general anesthesia were similar. CIE operators administered proton-pump inhibitors postoperatively significantly more than RMN operators (76 vs. 35%, p = 0.01). AEF was reported in 5 of the 7016 patients in the control group (0.07%) but in none of the RMN group (p = 0.11). AEF is a rare complication and its evaluation necessitates large-scale studies. Although no AEF case with RMN was reported in this large study or previously on the literature, the rarity of this complication prevents firm conclusion about the risk.

  14. U22 protocol as measure of symptomatic improvement after catheter ablation of atrial fibrillation

    PubMed Central

    Höglund, Niklas; Rönn, Folke; Tollefsen, Titti; Jensen, Steen m.

    2013-01-01

    Introduction. Left atrial catheter ablation is useful as symptomatic treatment in selected patients with atrial fibrillation (AF). Evaluation requires measurement of arrhythmia-related symptoms. Many of the published protocols have drawbacks and have been used in AF only, with no possible comparison to other ablations that compete for the same resources. U22 is a published protocol that quantifies paroxysmal tachycardia symptoms through scales with 11 answer alternatives, translated into discrete numerical scales 0–10. It has been shown to reflect the clinical improvement after ablation of supraventricular tachycardia. Here we report the use of U22 in measuring improvement after catheter ablation for AF. Material and methods. A total of 105 patients underwent first-time ablation for AF and answered U22 and SF-36 forms at baseline and follow-up 304 (SD 121) days after ablation. Independently, the patients underwent a clinical follow-up. All decisions regarding medication and reablation were taken without knowledge of the symptom scores. Results. The U22 scores for well-being, arrhythmia as cause for impaired well-being, derived time-aspect score for arrhythmia, and discomfort during attack detected relevant improvements of symptoms after the ablation. U22 showed larger improvement in patients undergoing only one procedure than in patients who later underwent repeated interventions, thus reflecting the independent clinical decision for reablation. Conclusion.U22 quantifies the symptomatic improvement after AF ablation with adequate internal consistency and construct validity. U22 mirrors aspects of the arrhythmia symptomatology other than SF-36. PMID:24102147

  15. Neuropsychological impact of cerebral microemboli in ablation of atrial fibrillation.

    PubMed

    Kochhäuser, S; Lohmann, H H; Ritter, M A; Leitz, P; Güner, F; Zellerhoff, S; Korsukewitz, C; Dechering, D G; Banken, J; Peters, N M; Eckardt, L; Mönnig, G

    2015-03-01

    Clinically silent lesions on cerebral magnet resonance imaging have been found in larger numbers after pulmonary vein isolation (PVI) especially with phased radio frequency (pRF) using all ten electrodes. However, the neuropsychological effects of cerebral microembolism during the procedure remain unclear and data regarding this issue so far are inconsistent. Between August 2011 and June 2012, 76 patients undergoing their first PVI were randomized to ablation with either phased (40) or irrigated (36) radio frequency (iRF). A comprehensive neuropsychological test battery was performed the day before and after PVI as well as 6 months after ablation. The occurrence of cerebral microemboli during the procedure was performed via a transcranial Doppler ultrasound device. PVI using pRF was associated with increased number of microembolic signals (MES) compared to iRF (1530.0 ± 979.8 vs. 645.7 ± 448.7; p < 0.001). Neuropsychological assessment did not reveal any changes in correlation with the used ablation technique. Besides an age-related effect there was a diffuse, sub-clinical impairment of neurologic function depending on age and the number of MES. There was no clinical overt cognitive deficit and no significant difference in cognitive function correlating with the used ablation technique. The number of MES correlated with a subtle, diffuse post-procedural impairment of neuropsychological function highlighting the need to reduce microemboli during ablation.

  16. [Does radiofrequency ablation of the bundle of Kent results in a lower risk of atrial fibrillation?].

    PubMed

    Brembilla-Perrot, B; Beurrier, D; Houriez, P

    2002-02-01

    Radiofrequency ablation of the Bundle of Kent is a common method of treating malignant forms of the Wolff-Parkinson-White syndrome and the paroxysmal junctional tachycardia which may complicate this condition. The aim of this study was to investigate the effects of ablation of a latent or patent Bundle of Kent on the prevention of atrial fibrillation. One hundred and thirty eight patients aged 15 to 81 years of age with one or more patent (Group I) (n = 96) or latent Bundles of Kent (Group II) (n = 42) underwent successful ablation of the Bundle of Kent. Five patients in Group I (5%) and 4 in Group II (9.5%) had spontaneous paroxysmal atrial fibrillation before ablation. During electrophysiological investigation, AF was induced in 7 patients, 2 of whom had spontaneous AF in Group I and 3 in Group II. During follow-up (3 +/- 1 years), 3 patients of Group I went on to develop AF: 2 of them had never had the arrhythmia before: 4 patients of Group II, including 2 with previous AF, went on to develop AF. The risk of spontaneous AF was correlated to older ages. The authors conclude that persistence of the risk of spontaneous AF after ablation of a Bundle of Kent should be investigated especially in patients over 45 years of age.

  17. Effects of two kinds of radio frequency ablations on morphology and function of left atrium in patients with atrial fibrillation.

    PubMed

    Lin, Gang; Yang, Xiang-Jun

    2015-01-01

    This study aims to observe the effects of circumferential pulmonary vein ablation (CPVA) and CPVA combined with complex fractionated atrial electro-gram (CPVA+CFAE) on morphology and function of left atrium in patients with atrial fibrillation (AF). To evaluate the effects of CPVA and CPVA+CFAE on morphology and function of left atrium, the left atrial volume and late diastolic velocity peak (Va) were determined by tissue Doppler imaging before and after CPVA and CPVA+CFAE, respectively. There was no statistical difference in the left atrial volume before and after CPVA. However, Va was significantly higher after CPVA (P=0.001). There was no statistical difference in both the left atrial volume and Va before and after CPVA+CFAE. Va after ablation was significantly higher in CPVA group than in CPVA+CFAE group (P=0.031). The left atrial function was significantly improved after CPVA, but CPVA+CFAE failed to markedly improve the left atrial function. This suggests that excessive atrial substrate ablation may damage the left atrial function.

  18. First description of a double-wall balloon breach during cryoballoon ablation for atrial fibrillation.

    PubMed

    Suarez, Keith; Banchs, Javier E; Lim, Hae W; Black, James N

    2017-08-01

    To date, this is the first published report of a double-wall breach while using the cryoballoon ablation catheter during the treatment of a patient with atrial fibrillation; however, there have been previous balloon breaches in both the second and third-generation cryoballoon ablation catheter usage. In this report, we describe the case of a double-wall balloon breach and the intraoperative care that was necessary to stabilize the patient. Additionally, we review other known cases of double-wall balloon breaches, and we examine the safety systems of the cryoballoon catheter that mitigate some of the potential patient complications. © 2017 Wiley Periodicals, Inc.

  19. Adenosine testing during cryoballoon ablation and radiofrequency ablation of atrial fibrillation: A propensity score-matched analysis.

    PubMed

    Tokuda, Michifumi; Matsuo, Seiichiro; Isogai, Ryota; Uno, Goki; Tokutake, Kenichi; Yokoyama, Kenichi; Kato, Mika; Narui, Ryohsuke; Tanigawa, Shinichi; Yamashita, Seigo; Inada, Keiichi; Yoshimura, Michihiro; Yamane, Teiichi

    2016-11-01

    The infusion of adenosine triphosphate after radiofrequency (RF) pulmonary vein (PV) isolation (PVI), which may result in acute transient PV-atrium reconnection, can unmask dormant conduction. The purpose of this study was to compare the incidence and characteristics of dormant conduction after cryoballoon (CB) and RF ablation of atrial fibrillation (AF). Of 414 consecutive patients undergoing initial catheter ablation of paroxysmal AF, 246 (59%) propensity score-matched patients (123 CB-PVI and 123 RF-PVI) were included. Dormant conduction was less frequently observed in patients who underwent CB-PVI than in those who underwent RF-PVI (4.5% vs 12.8% of all PVs; P < .0001). The incidence of dormant conduction in each PV was lower in patients who underwent CB-PVI than in those who underwent RF-PVI in the left superior PV (P < .0001) and right superior PV (P = .001). The site of dormant conduction was mainly located around the bottom of both inferior PVs after CB-PVI. Multivariable analysis revealed that a longer time to the elimination of the PV potential (odds ratio 1.018; 95% confidence interval 1.001-1.036; P = .04) and the necessity of touch-up ablation (odds ratio 3.242; 95% confidence interval 2.761-7.111; P < .0001) were independently associated with the presence of dormant conduction after CB-PVI. After the elimination of dormant conduction by additional ablation, the AF-free rate was similar in patients with and without dormant conduction after both CB-PVI and RF-PVI (P = .28 and P = .73, respectively). The results of the propensity score-matched analysis showed that dormant PV conduction was less frequent after CB ablation than after RF ablation and was not associated with ablation outcomes. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  20. Ablation for atrial fibrillation during mitral valve surgery: 1-year results through continuous subcutaneous monitoring.

    PubMed

    Bogachev-Prokophiev, Alexandr; Zheleznev, Sergey; Romanov, Alexander; Pokushalov, Evgeny; Pivkin, Alexey; Corbucci, Giorgio; Karaskov, Alexander

    2012-07-01

    Continuous monitoring of cardiac rhythm may play an important role in measuring the true symptomatic/asymptomatic atrial fibrillation (AF) burden and improve the management of anti-arrhythmic and anti-thrombotic therapies. Forty-seven patients with mitral valve disease and longstanding persistent AF (LSPAF) underwent a left atrial maze procedure with bipolar radiofrequency and valve surgery. The follow-up data recorded by an implanted loop recorder were analysed after 3, 6 and 12 months. On discharge, 40 (85.1%) patients were in stable sinus rhythm, as documented by in-office electrocardiography (ECG), 4 (8.5%) were in pacemaker rhythm and 3 (6.4%) were in AF. One (2.1%) patient died after 7 months. On 12-month follow-up examination, 30 (65.2%) patients had an AF burden <0.5% and were classified as responders. Three (6.5%) of the 16 non-responders had atrial flutter and 13 (27.7%) had documented AF recurrences with an AF burden >0.5%. Two (4.3%) patients with AF recurrences were completely asymptomatic. Among the symptomatic events stored by the patients, only 27.6% was confirmed as genuine AF recurrences according to the concomitant ECG recorded by the implanted loop recorder. A concomitant bipolar maze procedure during mitral valve surgery is effective in treating AF, as proved by detailed 1-year continuous monitoring.

  1. Ablation for atrial fibrillation during mitral valve surgery: 1-year results through continuous subcutaneous monitoring†

    PubMed Central

    Bogachev-Prokophiev, Alexandr; Zheleznev, Sergey; Romanov, Alexander; Pokushalov, Evgeny; Pivkin, Alexey; Corbucci, Giorgio; Karaskov, Alexander

    2012-01-01

    Continuous monitoring of cardiac rhythm may play an important role in measuring the true symptomatic/asymptomatic atrial fibrillation (AF) burden and improve the management of anti-arrhythmic and anti-thrombotic therapies. Forty-seven patients with mitral valve disease and longstanding persistent AF (LSPAF) underwent a left atrial maze procedure with bipolar radiofrequency and valve surgery. The follow-up data recorded by an implanted loop recorder were analysed after 3, 6 and 12 months. On discharge, 40 (85.1%) patients were in stable sinus rhythm, as documented by in-office electrocardiography (ECG), 4 (8.5%) were in pacemaker rhythm and 3 (6.4%) were in AF. One (2.1%) patient died after 7 months. On 12-month follow-up examination, 30 (65.2%) patients had an AF burden <0.5% and were classified as responders. Three (6.5%) of the 16 non-responders had atrial flutter and 13 (27.7%) had documented AF recurrences with an AF burden >0.5%. Two (4.3%) patients with AF recurrences were completely asymptomatic. Among the symptomatic events stored by the patients, only 27.6% was confirmed as genuine AF recurrences according to the concomitant ECG recorded by the implanted loop recorder. A concomitant bipolar maze procedure during mitral valve surgery is effective in treating AF, as proved by detailed 1-year continuous monitoring. PMID:22514258

  2. Pheochromocytoma diagnosed after anticoagulation for atrial fibrillation ablation procedure: a giant in disguise.

    PubMed

    Galvão Braga, Carlos; Ribeiro, Sílvia; Martins, Juliana; Arantes, Carina; Ramos, Vítor; Primo, João; Magalhães, Sónia; Correia, Adelino

    2014-04-01

    Pheochromocytoma is a rare catecholamine-producing tumor, discovered incidentally in 50% of cases. We present the case of a 44-year-old male with a history of paroxysmal palpitations. Baseline ECG, transthoracic echocardiogram and ECG stress test showed no relevant alterations. Paroxysmal atrial fibrillation was detected on 24-hour Holter ECG. After antiarrhythmic therapy, the patient remained symptomatic, and was accordingly referred for electrophysiological study and atrial fibrillation ablation. Anticoagulation was initiated before the procedure. After ablation and still anticoagulated, he complained of hematospermia. The abdominal and pelvic imaging study showed a 10-cm left adrenal mass, predominantly cystic, compatible with pheochromocytoma, which was confirmed after biochemical tests (increased urine metanephrines and plasma catecholamines). Metaiodobenzylguanidine scintigraphy scanning confirmed localized disease in the adrenal gland, excluding other uptake foci. Following appropriate preoperative management, surgical resection of the giant mass was performed successfully and without complications.

  3. Complex fractionated electrogram distribution and temporal stability in patients undergoing atrial fibrillation ablation.

    PubMed

    Roux, Jean-François; Gojraty, Sattar; Bala, Rupa; Liu, Christopher F; Hutchinson, Mathew D; Dixit, Sanjay; Callans, David J; Marchlinski, Francis; Gerstenfeld, Edward P

    2008-08-01

    Targeting of complex fractionated electrograms (CFEs) has been described as an approach for catheter ablation of atrial fibrillation (AF); however, the distribution and temporal stability of CFE regions remain poorly defined. In patients with persistent AF referred for ablation, we performed two consecutive left atrial (LA) CFE maps prior to AF ablation. Bipolar electrograms were acquired during AF, and the mean AF cycle length and electrogram voltage were automatically determined at each point. Sites with mean CL ablation were studied. The two maps were separated in time by 31 +/- 10 minutes. There was no significant difference in the number of CFE-positive regions (12.3 +/- 5.2 vs 11.3 +/- 4.7; P = 0.06) between the maps. While CFEs were widely distributed within the LA, the PV/left atrial junction (73%) and left atrial appendage (77%) were most often CFE positive. The presence of CFEs at each region was concordant 78% of the time. There was a significant correlation between the two maps (r = 0.35 +/- 0.21, range 0.1-0.84; P < 0.001) with a percent difference of 17.5 +/- 9.4%. During persistent AF, most CFE regions are found in the vicinity of the PVs. There is a significant correlation between two CFE maps constructed 31 minutes apart, with 78% concordance of CFE sites.

  4. A prospective, multicenter evaluation of ablating complex fractionated electrograms (CFEs) during atrial fibrillation (AF) identified by an automated mapping algorithm: acute effects on AF and efficacy as an adjuvant strategy.

    PubMed

    Verma, Atul; Novak, Paul; Macle, Laurent; Whaley, Bonnie; Beardsall, Marianne; Wulffhart, Zaev; Khaykin, Yaariv

    2008-02-01

    Complex fractionated electrograms (CFEs) are continuous electrograms (EGMs) of very short cycle length (CL) representing substrate for atrial fibrillation (AF) perpetuation. Ablation of CFEs may result in AF slowing, termination, and prevention, but identifying them can be subjective. The purpose of this study was to prospectively assess (1) whether an automated algorithm can identify CFE regions, (2) the acute effects of ablating these regions on AF, and (3) the long-term efficacy as an adjuvant strategy to pulmonary vein antrum isolation (PVAI). Thirty-five patients (three centers, 61 +/- 9 years, left atrium [LA] 43 +/- 9 mm, ejection fraction 53% +/- 7%) with symptomatic paroxysmal (n = 21) or persistent (n = 14) AF were studied. A decapolar lasso (2-mm spacing) was used for mapping. A three-dimensional shell of the LA and pulmonary veins (PVs) was created. If not already in AF, AF was induced by burst pacing (with or without isoproterenol). Atrial EGMs during AF were mapped/analyzed using an automated CFE algorithm. The algorithm measures the time between discrete deflections in a local EGM over 5 seconds (based on selectable width and peak-to-peak [>0.03 mV] criteria). The mean CL of the local EGM is projected onto the LA shell as a color-coded display. Regions of CL <120 ms (published criteria) were targeted for ablation/elimination. Atrial fibrillation cycle length (AFCL) and regularity were measured from the CS. After CFE ablation, further ablation was done to achieve complete PVAI. AF was spontaneous (n = 20) or induced (n = 15) in all patients. CFEs were most commonly found along the septum (97%), anterior LA (97%), PV antra (83%), base of appendage (83%), and annulus (71%). CFE ablation alone prolonged the AFCL (171 +/- 27 vs. 304 +/- 41 ms; P = .03) and regularized AF to left/right flutter (AFL) in 74% of patients. CFE ablation terminated AF/AFL in 19 patients (54%)-the other 16 were cardioverted-and AF became noninducible in 77%. CFE ablation alone

  5. Stroke prevention following modified endoscopic ablation and appendectomy for atrial fibrillation.

    PubMed

    Ma, Nan; Jiang, Zhaolei; Chen, Fei; Yin, Hang; Ding, Fangbao; Mei, Ju

    2016-09-01

    We reported the results of stroke prevention following modified endoscopic procedure for atrial fibrillation. 82 patients underwent modified endoscopic procedure for atrial fibrillation (AF), in whom 47 had paroxysmal, 28 had persistent, and 7 had long-standing atrial fibrillation. CHA2DS2VASC median score was 3 (range from 0 to 8). The procedure was performed on the beating heart, through 3 ports on the left chest wall. Pulmonary vein isolation and ablation of the left atrium were achieved by bipolar radiofrequency ablation. Left atrial appendage (LAA) was excluded by stapler. Brain CT, cardiac CT and 24-h Holter monitoring were performed following the procedure. The procedure was successfully completed for all patients. The mean duration was 122 ± 40.1 min. LAA was excluded after appendectomy and checked by intraoperative transesophageal echocardiography. The mean follow-up duration was 24.3 ± 3.5 months. No patients showed signs and symptoms of transient ischemic attack or stroke. No new positive findings were demonstrated by recurring brain CT scan performed after the procedure. Cardiac CT confirmed the absence of LAA and thrombosis in the left atrium. 87.8 % (72/82) of all patients were in sinus rhythm. Our results demonstrate that the modified endoscopic procedure is a safe, effective, and appropriate treatment for AF, which restores sinus rhythm and may be associated with the prevention of AF-related stroke.

  6. Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes

    PubMed Central

    Calvo, Naiara; Mont, Lluís; Tamborero, David; Berruezo, Antonio; Viola, Graziana; Guasch, Eduard; Nadal, Mercè; Andreu, David; Vidal, Barbara; Sitges, Marta; Brugada, Josep

    2010-01-01

    Aims Long-term endurance sport practice has been increasingly recognized as a risk factor for lone atrial fibrillation (AF). However, data on the outcome of circumferential pulmonary vein ablation (CPVA) in endurance athletes are scarce. The aim of the study was to evaluate the efficacy of CPVA in AF secondary to endurance sport practice. Methods and results Patients submitted to CPVA answered a questionnaire about lifetime history of endurance sport practice. Endurance athletes were defined as those who engaged in >3 h per week of high-intensity exercise for at least the 10 years immediately preceding their AF diagnosis. A series of 182 consecutive patients was included (51 ± 11 years, 65% with paroxysmal AF, 81% men, 42 ± 6 mm mean left atrial diameter); 107 (59%) patients had lone AF, and 42 of them (23% of the study population) were classified as endurance athletes (lone AF sport group). Freedom from arrhythmia after a single CPVA was similar in the lone AF sport group compared with the remaining patients (P = 0.446). Left atrial size and long-standing AF were the only independent predictors for arrhythmia recurrence after ablation. Conclusion Circumferential pulmonary vein ablation was as effective in AF secondary to endurance sport practice as in other aetiologies of AF. PMID:19923171

  7. Anatomic relations between the esophagus and left atrium and relevance for ablation of atrial fibrillation.

    PubMed

    Sánchez-Quintana, Damian; Cabrera, José Angel; Climent, Vicente; Farré, Jerónimo; Mendonça, Maria Cristina de; Ho, Siew Yen

    2005-09-06

    Esophageal injury is a potential complication after intraoperative or percutaneous transcatheter ablation of the posterior aspect of the left atrium. Understanding the spatial relations between the esophagus and the left atrium is essential to reduce risks. We examined by gross dissection the course of the esophagus in 15 cadavers. We measured the minimal distance of the esophageal wall to the endocardium of the left atrium with histological studies in 12 specimens. To measure the transmural thickness of the atrial wall, we sectioned another 30 human heart specimens in the sagittal plane at 3 different regions of the left atrium. The esophagus follows a variable course along the posterior aspect of the left atrium; its wall was <5 mm from the endocardium in 40% of specimens. The posterior left atrial wall has a variable thickness, being thickest adjacent to the coronary sinus and thinnest more superiorly. Behind is a layer of fibrous pericardium and fibrofatty tissue of irregular thickness that contains esophageal arteries of 0.4+/-0.2-mm external diameters. The nonuniform thickness of the posterior left atrial wall and the variable fibrofatty layer between the wall and the esophagus are risk factors that must be considered during ablation procedure. Esophageal arteries and vagus nerve plexus on the anterior surface of the esophagus may be affected by ablative procedures.

  8. Physician-controlled costs: the choice of equipment used for atrial fibrillation ablation.

    PubMed

    Winkle, Roger A; Mead, R Hardwin; Engel, Gregory; Kong, Melissa H; Patrawala, Rob A

    2013-03-01

    Atrial fibrillation (AF) ablation uses expensive technology and equipment. Physicians have considerable latitude over equipment choice. Average Medicare reimbursement is $10,338 for uncomplicated AF ablations. The purpose of this study is to evaluate the cost of special equipment chosen by physicians to perform AF ablation. We obtained the list price cost of special capital equipment and of disposable equipment (intracardiac ultrasound probes, transseptal needles/sheaths, and ablation/recording catheters) commonly used for radiofrequency (RF) AF ablation. We also evaluated the equipment cost of using robotic magnetic navigation and cryoablation. Then we evaluated costs for several physician equipment choice scenarios. Using open irrigated-tip catheters, the lowest estimated cost-per-case for manual RF ablation of AF was $6,637, and the highest estimated cost of manual RF ablation was $12,603. Assuming 200 AF ablations/year and a 6-year magnet life, the cost-per-case of using magnetic navigation ablation ranged from $12,261-$15,464. The cost-per-case using cryoballoons alone ranged from $12,847-$15,320, and if focal cryoablation or RF touch-up is needed, cryoablation cost increased to $15,942-$22,284. Physicians have many choices in AF ablation equipment. Equipment costs in our arbitrary scenarios range from $6,637 to $22,284 per case. More important than the specific cost of each scenario is the concept that these are physician-driven costs, and as such, physicians will need to determine if more expensive technologies increase procedural efficacy and/or patient safety enough to justify the greater procedural equipment costs.

  9. Catheter Ablation of Pediatric Focal Atrial Tachycardia: Ten-Year Experience Using Modern Mapping Systems.

    PubMed

    Dieks, Jana-K; Müller, Matthias J; Schneider, Heike E; Krause, Ulrich; Steinmetz, Michael; Paul, Thomas; Kriebel, Thomas

    2016-03-01

    Experience of catheter ablation of pediatric focal atrial tachycardia (FAT) is still limited. There are data which were gathered prior to the introduction of modern 3D mapping and navigation systems into the clinical routine. Accordingly, procedures were associated with significant fluoroscopy and low success rates. The aim of this study was to present clinical and electrophysiological details of catheter ablation of pediatric FAT using modern mapping systems. Since March 2003, 17 consecutive patients <20 years underwent electrophysiological study (EPS) for FAT using the NavX(®) system (n = 7), the non-contact mapping system (n = 6) or the LocaLisa(®) system (n = 4), respectively. Radiofrequency was the primary energy source; cryoablation was performed in selected patients with a focus close to the AV node. In 16 patients, a total number of 19 atrial foci (right-sided n = 13, left-sided n = 6) could be targeted. In the remaining patient, FAT was not present/inducible during EPS. On an intention-to-treat basis, acute success was achieved in 14/16 patients (87.5 %) with a median number of 11 (1-31) energy applications. Ablation was unsuccessful in two patients due to an epicardial location of a right atrial focus (n = 1) and a focus close to the His bundle (n = 1), respectively. Median procedure time was 210 (84-332) min, and median fluoroscopy time was 13.1 (4.5-22.5) min. In pediatric patients with FAT, 3D mapping and catheter ablation provided improved clinical quality of care. Catheter ablation may be considered early in the course of treatment of this tachyarrhythmia in symptomatic patients.

  10. Remotely controlled steerable sheath improves result and procedural parameters of atrial fibrillation ablation with magnetic navigation

    PubMed Central

    Errahmouni, Abdelkarim; Latcu, Decebal Gabriel; Bun, Sok-Sithikun; Rijo, Nicolas; Dugourd, Céline; Saoudi, Nadir

    2015-01-01

    Aims The magnetic navigation (MN) system may be coupled with a new advancement system that fully controls both the catheter and a robotic deflectable sheath (RSh) or with a fixed-curve sheath and a catheter-only advancement system (CAS). We aimed to compare these approaches for atrial fibrillation (AF) ablation. Methods and results Atrial fibrillation ablation patients (45, 23 paroxysmal and 22 persistent) performed with MN–RSh (RSh group) were compared with a control group (37, 18 paroxysmal and19 persistent) performed with MN–CAS (CAS group). Setup duration was measured from the procedure's start to operator transfer to control room. Ablation step duration was defined as the time from the beginning of the first radiofrequency (RF) pulse to the end of the last one and was separately acquired for the left and the right pulmonary vein (PV) pairs. Clinical characteristics, left atrial size, and AF-type distribution were similar between the groups. Setup duration as well as mapping times was also similar. Ablation step duration for the left PVs was similar, but was shorter for the right PVs in RSh group (46 ± 9 vs. 63 ± 12 min, P < 0.0001). Radiofrequency delivery time (34 ± 9 vs. 40 ± 11 min, P = 0.007) and procedure duration (227 ± 36 vs. 254 ± 62 min, P = 0.01) were shorter in RSh group. No complication occurred in RSh group. During follow-up, there were five recurrences (11%) in RSh group and 11 (29%) in CAS group (P = 0.027). Conclusion The use of the RSh for AF ablation with MN is safe and improves outcome. Right PV isolation is faster, RF delivery time and procedure time are reduced. PMID:25662989

  11. Mapping of focal atrial tachycardia with an uninterpretable activation map after extensive atrial ablation: tricks and tips.

    PubMed

    Ju, Weizhu; Yang, Bing; Chen, Hongwu; Zhang, Fengxiang; Gu, Kai; Yu, Jinbo; Li, Mingfang; Yang, Gang; Cao, Kejiang; Chen, Minglong

    2014-08-01

    Atrial tachycardias (ATs) after extensive ablation are increasingly common and challenging arrhythmias. The prolonged intra-atrial conduction time (IACT) during ATs in the milieu may complicate the mapping of focal ATs. In this present study, we aim to characterize the electrophysiological features of ATs in this unique setting and to delineate an effective mapping strategy further. In total, 13 patients (average age, 59±7 years) in a cohort of 80 patients referred for AT ablation were selected for the study. The patients all demonstrated an undistinguishable map not ready to be interpreted the 3-dimensional mapping. A total of 13 ATs were mapped with mean tachycardia cycle length of 296±70 ms. Two activation patterns were identified, which were referred to as pseudo-macroreentry and chaotic activation. The former was a focal AT originating from the vicinity of an area of conduction block with the IACT less than the window of interest duration (4 cases; IACT/window of interest ratio range, 0.93-0.98). The latter refers to a focal AT exhibiting a disorderly color mapping display with IACT exceeding the window of interest duration (9 cases; IACT/window of interest ratio range, 1.02-1.29). The IACT was determined after resetting the annotation. All ATs were successfully eliminated at the originating site. We delineated a series of focal ATs in the setting of a significantly prolonged IACT encountered in patients after previous extensive ablation. Two activation patterns were identified, which may help facilitate the mapping of focal ATs in this setting. © 2014 American Heart Association, Inc.

  12. Impact of metabolic syndrome on left atrial electroanatomical remodeling and outcomes after radiofrequency ablation of nonvalvular atrial fibrillation.

    PubMed

    Dinov, Borislav; Kosiuk, Jedrzej; Kircher, Simon; Bollmann, Andreas; Acou, Willem-Jan; Arya, Arash; Hindricks, Gerhard; Rolf, Sascha

    2014-06-01

    Recent studies reported worse outcomes after atrial fibrillation (AF) ablation in patients with metabolic syndrome (MetS). However, mechanisms of AF recurrence in MetS remain unclear. We performed pulmonary vein isolation and voltage mapping in 236 patients with AF (age 61±9.6 years; persistent AF 64%; MetS 54%). Left atrial (LA) low voltage areas were semiquantitatively estimated and presented as low voltage index. MetS was defined according to National Cholesterol Education Program Adult Treatment Panel III. Follow-up for AF recurrence ≤12 months was performed. LA low voltage areas were observed in 46% of patients with MetS versus 8.2% patients without MetS ; P<0.0001. MetS was an independent predictor of LA low voltage areas: odds ratio, 11.64; 95% confidence interval, 4.381-30.903; P<0.0001. Observed AF recurrence at 12 months was 42.7% in MetS versus 36.1% in the non-MetS group (P=0.303). The presence of LA low voltage areas was a predictor of 12-month AF recurrence: odds ratio, 2.99; 95% confidence interval, 1.36-6.56; P=0.006. Probability of 12-month AF recurrence increased with 84.5% for every unit of low voltage Index. MetS was not associated with worse outcomes after radiofrequency catheter ablation of AF, but LA low voltage areas were more frequently observed in patients with MetS. The presence and extent of LA low voltage areas may influence the long-term outcomes after catheter ablation. © 2014 American Heart Association, Inc.

  13. The efficacy of ablation based on the combined use of the dominant frequency and complex fractionated atrial electrograms for non-paroxysmal atrial fibrillation.

    PubMed

    Kumagai, Koji; Nakano, Masahiro; Kutsuzawa, Daisuke; Yamaguchi, Yoshiaki; Minami, Kentaro; Oshima, Shigeru

    2016-06-01

    This study aimed to evaluate an approach for an endpoint of non-inducibility using a combined high-dominant frequency (DF) and continuous complex fractionated atrial electrogram (CFAE) ablation following circumferential pulmonary vein isolation (PVI) in a sequential fashion, including linear ablation as compared to PVI alone. A total of 84 non-paroxysmal patients with atrial fibrillation (AF) were investigated retrospectively. The AF patients were divided into two groups: patients with PVI following a combined high-DF and continuous CFAE ablation with linear ablation (substrate modification group, n=59) and those with PVI alone (n=25). DF sites of ≥8Hz and then continuous CFAE sites defined by fractionation intervals of ≤50ms were modified after PVI. The ablation endpoint was non-inducibility. Atrial tachyarrhythmias (ATs) could not be induced in 54 of 59 (92%) patients after a sequential ablation, and in 18 of 25 (64%) with PVI alone. The ATs freedom without antiarrhythmic drugs in the substrate modification group was significantly greater than that in those with PVI alone after 1 procedure during 12 months of follow-up (78.6% vs. 53.8%, log-rank test p=0.039). This sequential approach using a substrate based ablation was associated with a better clinical long-term outcome as compared to PVI alone. Copyright © 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

  14. Early morphologic changes following microwave endocardial ablation for treatment of chronic atrial fibrillation during mitral valve surgery.

    PubMed

    Climent, Vicente; Hurlé, Aquilino; Ho, Siew Yen; Sáenz-Santamaría, Javier; Nogales, Agustín G; Sánchez-Quintana, Damián

    2004-11-01

    The aim of this study was to investigate the early qualitative and quantitative structural changes in the left atrial wall after endocardial microwave ablation in patients with chronic atrial fibrillation (AF) undergoing mitral surgery. Seven patients with chronic AF of for at least 6 months underwent surgical microwave energy ablation. Linear isolation of pulmonary veins was performed in all patients by microwave energy applications to the endocardial surface delivered by catheter at 65-W constant power for 45 seconds. Biopsies were obtained from a selected site (below the right lower pulmonary vein) of the left atrial posterior wall before and after the ablation procedure in all patients. Control tissues from the same sites were obtained at autopsy from patients with noncardiac causes of death. Light and electron microscopy was used to examine qualitative and quantitative changes in tissue morphology. Tissues after endocardial ablation procedure showed significantly increased loss of contractile material. Electron microscopy of atrial tissue demonstrated loss of profile of perinuclear and plasma membranes of myocytes, disruption of the endothelial cells of capillary vessels, and presence of macrophages. Lesions created by endocardial microwave energy ablation revealed a transmural effect on the left atrial wall without a significant reduction in thickness but a significant increase in the myolytic areas involving the entire cytosol and occlusion of the small intramyocardial vessels within the ablative lesion.

  15. Left atrial reservoir function predicts atrial fibrillation recurrence after catheter ablation: a two-dimensional speckle strain study

    PubMed Central

    Mirza, Mahek; Caracciolo, Giuseppe; Khan, Uzma; Mori, Naoyo; Saha, Samir K.; Srivathsan, Komandoor; Altemose, Gregory; Scott, Luis; Sengupta, Partho

    2011-01-01

    Background Predictors of atrial fibrillation (AF) recurrence after catheter ablation (CA) are not fully defined. We hypothesized that 2D left atrial (LA) regional strain maps would help identify abnormal atrial substrate that increases susceptibility to AF recurrence post-CA. Methods and Results Sixty-three patients (63±10 years, 60% male) underwent CA for symptomatic paroxysmal (75%) or persistent (25%) AF. Baseline LA mechanical function determined using speckle tracking echocardiography was compared between those with AF recurrence (AFR) and no recurrence post-CA. Bi-dimensional global and regional maps of LA wall velocity, strain, and strain rate (SR) were obtained during end ejection and early diastole. After 18±12 months of follow-up, 34 patients were free of AFR post-CA. There were no differences in clinical characteristics, LA and LV volumes, and Doppler estimates of LV diastolic function and filling pressures at baseline between patients with recurrent AF and those that maintained sinus rhythm. However, the LA emptying fraction (55±17% vs. 64±14%, p=0.04), global and regional systolic and diastolic strains, SR, and velocities were reduced in patients with recurrent AF. There was marked attenuation of peak LA lateral wall longitudinal strain (LS; 11±7% vs. 20±14%, p=0.007) and SR (0.9±0.4 vs. 1.3±0.6 s−1, p=0.01). Multivariate analysis revealed lateral wall LS (odds ratio=1.15, 95% CI=1.02–1.28, p=0.01) as an independent predictor of AFR. Conclusions Regional LA lateral wall LS is a pre-procedural determinant of AFR in patients undergoing CA, independent of LA enlargement. Characterization of atrial myocardial tissue properties by speckle tracking echo may aid the appropriate selection of adjunctive strategies and prognostication of patients undergoing CA. PMID:21424845

  16. Association of Single Nucleotide Polymorphisms with Atrial Fibrillation and the Outcome after Catheter Ablation

    PubMed Central

    Hu, Yu-Feng; Wang, Hsueh-Hsiao; Yeh, Hung-I; Lee, Kun-Tai; Lin, Yenn-Jiang; Chang, Shih-Lin; Lo, Li-Wei; Tuan, Ta-Chuan; Li, Cheng-Hung; Chao, Tze-Fan; Chung, Fa-Po; Liao, Jo-Nan; Tang, Paul Wei Hua; Tsai, Wei-Chung; Chiou, Chuen-Wang; Chen, Shih-Ann

    2016-01-01

    Background The association of gene variants with atrial fibrillation (AF) type and the recurrence of AF after catheter ablation in Taiwan is still unclear. In this study, we aimed to investigate the relationships between gene variants, AF type, and the recurrence of AF. Methods In our investigation, we examined 383 consecutive patients with AF (61.9 ± 14.0 years; 63% men); of these 383 patients, 189 underwent catheter ablation for drug-refractory AF. Thereafter, the single nucleotide polymorphisms rs2200733, and rs7193343 were genotyped using real-time polymerase chain reaction. Results The rs7193343 variant was independently associated with non-paroxysmal AF (non-PAF). In the PAF group, the rs7193343 variant was independently associated with AF recurrence after catheter ablation. However, the rs2200733 variant was not associated with AF recurrence in this group. The combination of the rs7193343 and rs2200733 risk alleles was associated with a better predictive power in the PAF patients. In contrast, in the non-PAF group, the SNPs were not associated with recurrence. The rs7193343 and rs2200733 variants were not associated with different atrial voltage and activation times. Conclusions The rs7193343 variants were associated with AF recurrence after catheter ablation in PAF patients but not in non-PAF patients. The rs7193343 CC variant was independently associated with non-PAF. PMID:27713600

  17. Radiofrequency ablation of focal atrial tachycardia: Benefit of electroanatomical mapping over conventional mapping.

    PubMed

    Szegedi, N; Zima, E; Clemens, M; Szekely, A; Kiss, R G; Szeplaki, G; Geller, L; Merkely, B; Csanadi, Z; Duray, G

    2015-09-01

    Catheter ablation is a proven therapy of focal atrial tachycardia. However limited information is available about the additional value of electroanatomical over conventional mapping methods for this specific arrhythmia. Consecutive catheter ablation procedures of FAT were analyzed in two cardiology centres. Only conventional mapping was used in 30 of the 60 procedures whereas additionally CARTO mapping was performed in another 30 procedures. Acute, six-month success rate, and procedural data were analyzed. Localization of ectopic foci is congruent with previously published data. There was no statistically significant difference between procedure time and fluoroscopy time using additionally CARTO mapping, compared to conventional mapping only. Acute success rate was higher in procedures guided by CARTO mapping than in procedures based on conventional mapping (27/30 vs. 18/30, p = 0.0081). During the 6-month follow-up period there was a better outcome (p = 0.045) in case of CARTO guided procedures (success: 11 cases, partial success: 12 cases, failure: 4 cases) compared to conventional mapping (success: 4 cases, partial success: 18 cases, failure: 7 cases). Catheter ablation of focal atrial tachycardias using the CARTO electroanatomical mapping system seems to provide higher acute and 6-month success rate compared to ablation using conventional mapping methods only.

  18. [Catheter ablation in supraventricular tachycardia].

    PubMed

    Pitschner, H F; Neuzner, J

    1996-01-01

    The first report about successful radio frequency ablation of a right-posterior-septal accessory pathway appeared in 1986. Since then, the technology of both guidable ablation catheters and radio frequency generators has been considerably improved in an initially clinical-experimental phase. At the same time, electrophysiologists were equally able to enlarge their knowledge in the field of signal characteristics of arrhythmogenic substrates. This included the discovery of action potentials of accessory pathways (preexcitation syndromes), the location of fast and slow AV node conduction (AV nodal reentrant tachycardia, AVNRT), the functional importance of the anatomical isthmus between the os of the coronary sinus, the tricuspid valve and the inferior caval vein (atrial flutter). Mapping techniques such as transient and concealed entrainment became, among others, significant tools in finding the best localization for radio frequency catheter ablation. Thus, technical development and the increased knowledge of clinical electrophysiologists resulted in firmly establishing the procedure of catheter ablation as the method of first choice in the curative treatment of supraventricular tachycardias in a potential collective of about 5 per mill of the normal population (without atrial fibrillation). Supraventricular tachycardias with a reentry mechanism in the broadest sense (> 95% of all pts. with SVT) and those with focal automaticity (< 5%) occur as atrial fibrillation or atrial flutter in about 60% of all pts. (4-6 per mill of the normal population). Manifestation of the remaining reentrant tachycardias is mainly in the form of AVNRT (retrograde conduction via the fast pathway > 90% versus uncommon type < 10%). AV reentry via accessory pathways is found in about 15%, with orthodromic conduction via the AV node (> 90%). Atrial reentrant tachycardias are rather rare (with the exception of atrial fibrillation/flutter). The literature suggests medical therapy to be

  19. Atrial Substrate Modification in Atrial Fibrillation: Targeting GP or CFAE? Evidence from Meta-Analysis of Clinical Trials

    PubMed Central

    Qin, Mu; Liu, Xu; Wu, Shao-Hui; Zhang, Xiao-Dong

    2016-01-01

    Several clinically relevant outcomes post atrial substrate modification in patients with atrial fibrillation (AF) have not been systematically analyzed among published studies on adjunctive cardiac ganglionated plexi (GP) or complex fractionated atrial electograms (CFAE) ablation vs. pulmonary vein isolation (PVI) alone. Out of 176 reports identified, the present meta-analysis included 14 randomized and non-randomized controlled trials (1613 patients) meeting inclusion criteria. Addition of GP ablation to PVI significantly increased freedom from atrial tachyarrhythmia in short- (OR: 1.72; P = 0.003) and long-term (OR: 2.0, P = 0.0006) follow-up, while adjunctive CFAE ablation did not after one or repeat procedure (P<0.05). The percentage of atrial tachycardia or atrial flutter (AT/AFL) after one procedure was higher for CFAE than GP ablation. In sub-analysis of non-paroxysmal AF, relative to PVI alone, adjunctive GP but not CFAE ablation significantly increased sinus rhythm maintenance (OR: 1.88, P = 0.01; and OR:1.24, P = 0.18, respectively). Meta regression analysis of the 14 studies indicated that sample size was significant source of heterogeneity either in outcomes after one or repeat procedure. In conclusion, in patients with AF, adjunctive GP but not CFAE ablation appeared to significantly add to the beneficial effects on sinus rhythm maintenance of PVI ablation alone; and CFAE ablation was associated with higher incidence of subsequent AT/AFL. PMID:27764185

  20. Atrial Substrate Modification in Atrial Fibrillation: Targeting GP or CFAE? Evidence from Meta-Analysis of Clinical Trials.

    PubMed

    Qin, Mu; Liu, Xu; Wu, Shao-Hui; Zhang, Xiao-Dong

    2016-01-01

    Several clinically relevant outcomes post atrial substrate modification in patients with atrial fibrillation (AF) have not been systematically analyzed among published studies on adjunctive cardiac ganglionated plexi (GP) or complex fractionated atrial electograms (CFAE) ablation vs. pulmonary vein isolation (PVI) alone. Out of 176 reports identified, the present meta-analysis included 14 randomized and non-randomized controlled trials (1613 patients) meeting inclusion criteria. Addition of GP ablation to PVI significantly increased freedom from atrial tachyarrhythmia in short- (OR: 1.72; P = 0.003) and long-term (OR: 2.0, P = 0.0006) follow-up, while adjunctive CFAE ablation did not after one or repeat procedure (P<0.05). The percentage of atrial tachycardia or atrial flutter (AT/AFL) after one procedure was higher for CFAE than GP ablation. In sub-analysis of non-paroxysmal AF, relative to PVI alone, adjunctive GP but not CFAE ablation significantly increased sinus rhythm maintenance (OR: 1.88, P = 0.01; and OR:1.24, P = 0.18, respectively). Meta regression analysis of the 14 studies indicated that sample size was significant source of heterogeneity either in outcomes after one or repeat procedure. In conclusion, in patients with AF, adjunctive GP but not CFAE ablation appeared to significantly add to the beneficial effects on sinus rhythm maintenance of PVI ablation alone; and CFAE ablation was associated with higher incidence of subsequent AT/AFL.

  1. Gender, Race, and Health Insurance Status in Patients Undergoing Catheter Ablation for Atrial Fibrillation.

    PubMed

    Patel, Nileshkumar; Deshmukh, Abhishek; Thakkar, Badal; Coffey, James O; Agnihotri, Kanishk; Patel, Achint; Ainani, Nitesh; Nalluri, Nikhil; Patel, Nilay; Patel, Nish; Patel, Neil; Badheka, Apurva O; Kowalski, Marcin; Hendel, Robert; Viles-Gonzalez, Juan; Noseworthy, Peter A; Asirvatham, Samuel; Lo, Kaming; Myerburg, Robert J; Mitrani, Raul D

    2016-04-01

    Catheter ablation for atrial fibrillation (AF) has emerged as a popular procedure. The purpose of this study was to examine whether there exist differences or disparities in ablation utilization across gender, socioeconomic class, insurance, or race. Using the Nationwide Inpatient Sample (2000 to 2012), we identified adults hospitalized with a principal diagnosis of AF by ICD 9 code 427.31 who had catheter ablation (ICD 9 code-37.34). We stratified patients by race, insurance status, age, gender, and hospital characteristics. A hierarchical multivariate mixed-effect model was created to identify the independent predictors of AF ablation. Among an estimated total of 3,508,122 patients (extrapolated from 20% Nationwide Inpatient Sample) hospitalized with a diagnosis of AF in the United States from the year 2000 to 2012, 102,469 patients (2.9%) underwent catheter ablations. The number of ablations was increased by 940%, from 1,439 in 2000 to 15,090 in 2012. There were significant differences according to gender, race, and health insurance status, which persisted even after adjustment for other risk factors. Female gender (0.83 [95% CI 0.79 to 0.87; p <0.001]), black (0.49 [95% CI 0.44 to 0.55; p <0.001]), and Hispanic race (0.64 [95% CI 0.56 to 0.72; p <0.001]) were associated with lower likelihoods of undergoing an AF ablation. Medicare (0.93, 0.88 to 0.98, <0.001) or Medicaid (0.67, 0.59 to 0.76, <0.001) coverage and uninsured patients (0.55, 0.49 to 0.62, <0.001) also had lower rates of AF ablation compared to patients with private insurance. In conclusion we found differences in utilization of catheter ablation for AF based on gender, race, and insurance status that persisted over time.

  2. New-onset ventricular arrhythmias post radiofrequency catheter ablation for atrial fibrillation

    PubMed Central

    Wu, Lingmin; Lu, Yanlai; Yao, Yan; Zheng, Lihui; Chen, Gang; Ding, Ligang; Hou, Bingbo; Qiao, Yu; Sun, Wei; Zhang, Shu

    2016-01-01

    Abstract As a new complication, new-onset ventricular arrhythmias (VAs) post atrial fibrillation (AF) ablation have not been well defined. This prospective study aimed to describe the details of new-onset VAs post AF ablation in a large study cohort. One thousand fifty-three consecutive patients who underwent the first radiofrequency catheter ablation for AF were enrolled. All patients had no evidence of pre-ablation VAs. New-onset VAs were defined as new-onset ventricular tachycardia (VT) or premature ventricular contractions (PVC) ≥1000/24 h within 1 month post ablation. There were 46 patients (4.4%) who had 62 different new-onset VAs, among whom 42 were PVC alone, and 4 were PVC coexisting with nonsustained VT. Multivariate analysis showed that increased serum leukocyte counts ≥50% post ablation were independently associated with new-onset VAs (OR: 1.9; 95% CI: 1.0–3.5; P = 0.043). The median number of PVC was 3161 (1001–27,407) times/24 h. Outflow tract VAs were recorded in 35 (76.1%) patients. No significant differences were found in origin of VAs (P = 0.187). VAs disappeared without any treatment in 6 patients (13.0%). No VAs-related adverse cardiac event occurred. The study revealed a noticeable prevalence but relatively benign prognosis of new-onset VAs post AF ablation. Increased serum leukocyte counts ≥50% post ablation appeared to be associated with new-onset VAs, implying that inflammatory response caused by ablation might be the mechanism. PMID:27603357

  3. Mechanisms for the Termination of Atrial Fibrillation by Localized Ablation: Computational and Clinical Studies

    PubMed Central

    Rappel, Wouter-Jan; Zaman, Junaid A. B.; Narayan, Sanjiv M.

    2015-01-01

    Background Human atrial fibrillation (AF) can terminate after ablating localized regions, that supports the existence of localized rotors (spiral waves) or focal drivers. However, it is unclear why ablation near a spiral wave tip would terminate AF and not anchor reentry. We addressed this question by analyzing competing mechanisms for AF termination in numerical simulations, referenced to clinical observations. Methods and Results Spiral wave reentry was simulated in monodomain 2D myocyte sheets using clinically realistic rate-dependent values for repolarization and conduction. Heterogeneous models were created by introduction of parameterized variations in tissue excitability. Ablation lesions were applied as non-conducting circular regions. Computational models confirmed localized ablation may anchor spiral wave reentry, producing organized tachycardias. Several mechanisms also explained termination of AF to sinus rhythm. First, lesions may create an excitable gap vulnerable to invasion by fibrillatory waves. Second, ablation of rotors in regions of low-excitability (from remodeling) produced reentry in more excitable tissue allowing collision of wave-front and back. Conversely, ablation of rotors in high-excitability regions migrated spiral waves to less excitable tissue, where they detached to collide with non-conducting boundaries. Third, ablation may connect rotors to non-conducting anatomic orifices. Fourth, reentry through slow conducting channels may terminate if ablation closes these channels. Conclusions Limited ablation can terminate AF by several mechanisms. These data shed light on how clinical AF may be sustained in patients’ atria, emphasizing heterogeneities in tissue excitability, slow-conducting channels and obstacles that are increasingly detectable in patients and should be the focus of future translational studies. PMID:26359479

  4. Anatomical Substrates and Ablation of Reentrant Atrial and Ventricular Tachycardias in Repaired Congenital Heart Disease

    PubMed Central

    Brouwer, Charlotte; Hazekamp, Mark G

    2016-01-01

    Advances in surgical repair techniques for various types of congenital heart disease have improved survival into adulthood over the past decades, thus exposing these patients to a high risk of atrial and ventricular arrhythmias later in life. These arrhythmias arise from complex arrhythmogenic substrates. Substrate formation may depend on both pathological myocardial remodelling and variable anatomical boundaries, determined by the type and timing of prior corrective surgery. Accordingly, arrhythmogenic substrates after repair have changed as a result of evolving surgical techniques. Radiofrequency catheter ablation offers an important therapeutic option but remains challenging due to the variable anatomy, surgically created obstacles and the complex arrhythmogenic substrates. Recent technical developments including electroanatomical mapping and image integration for delineating the anatomy facilitate complex catheter ablation procedures. The purpose of this review is to provide an update on the changing anatomical arrhythmogenic substrates and their potential impact on catheter ablation in patients with repaired congenital heart disease and tachyarrhythmias. PMID:27617095

  5. An overview of energy sources in clinical use for the ablation of atrial fibrillation.

    PubMed

    Comas, George M; Imren, Yildirim; Williams, Mathew R

    2007-01-01

    Recent years have seen many developments in the field of alternative energy sources for arrhythmia surgery. The impetus behind these advances is to replace the traditional, "cut-and-sew" Cox maze III procedure with lesion sets that are simpler, shorter, and safer but just as effective. There is demand for technology to make continuous, linear, transmural ablations reliably with a versatile energy source via an epicardial approach. This would make minimally invasive endoscopic surgical ablation of atrial fibrillation (AF) without cardiopulmonary bypass and with a closed chest feasible. These advances would shorten cardio-pulmonary bypass and improve outcomes in patients having surgical ablation and concomitant cardiac surgery. This review summarizes the technology behind alternative energy sources used to treat AF. Alternative energy sources include hypothermic sources (cryoablation) and hyperthermic sources (radiofrequency, microwave, laser, ultrasound). For each source, the biophysical background, mode of tissue injury, factors affecting lesion size, and advantages and complications are discussed.

  6. Pulmonary hemorrhage after cryoballoon ablation for pulmonary vein isolation in the treatment of atrial fibrillation.

    PubMed

    Martí-Almor, Julio; Jauregui-Abularach, Miguel E; Benito, Begoña; Vallès, Ermengol; Bazan, Victor; Sánchez-Font, Albert; Vollmer, Ivan; Altaba, Carmen; Guijo, Miguel A; Hervas, Manel; Bruguera-Cortada, Jordi

    2014-01-01

    Pulmonary vein isolation has evolved over the past years as an alternative for the treatment of symptomatic recurrences of atrial fibrillation refractory to antiarrhythmic drug treatment. Both radiofrequency energy and cryoballoon ablation have proven useful in this setting. We present the case of a 55-year-old male patient undergoing cryoballoon ablation complicated with pulmonary hemorrhage. The cause of this rare complication may be found in the damage of vascular venous structures near the ablation zone or, alternatively, in hemorrhagic damage of the pulmonary vein surrounding tissue (or less probably to direct injury of the lingular bronchus). The extremely low temperatures achieved in this case (which are often associated with deep balloon position inside the veins) are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the cryoablation balloon.

  7. Catheter ablation of atrial fibrillation in patients with severely impaired left ventricular systolic function.

    PubMed

    Kato, Ken; Ejima, Koichiro; Fukushima, Noritoshi; Ishizawa, Makoto; Wakisaka, Osamu; Henmi, Ryuta; Yoshida, Kentaro; Nuki, Toshiaki; Arai, Kotaro; Yashiro, Bun; Manaka, Tetsuyuki; Ashihara, Kyomi; Shoda, Morio; Hagiwara, Nobuhisa

    2016-04-01

    Little is known about the outcome of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) and a severely reduced left ventricular ejection fraction (LVEF). We aimed to clarify the effectiveness of catheter ablation of AF in patients with a severely low LVEF. This retrospective study included 18 consecutive patients with HF and an LVEF of ≤ 35 % who underwent catheter ablation of AF. We investigated the clinical parameters, echocardiographic parameters and the incidence of hospitalizations for HF. During a median follow-up of 21 months (IQR, 13-40) after the final procedure (9 with repeat procedures), 11 patients (61 %) maintained sinus rhythm (SR) (6 with amiodarone). The LVEF and NYHA class significantly improved at 6 months after the CA in 12 patients (67 %) who were in SR or had recurrent paroxysmal AF (from 25.8 ± 6.3 to 37.0 ± 11.7 %, P = 0.02, and from 2.3 ± 0.5 to 1.5 ± 0.7, P < 0.01, respectively) but not in patients who experienced recurrent persistent AF. The patients with SR or recurrent paroxysmal AF had significantly fewer hospitalizations for HF than those with recurrent persistent AF after the AF ablation (log-rank test; P < 0.01). Catheter ablation of AF improved the clinical status in patients with an LVEF of ≤ 35 %. A repeat ablation procedure and amiodarone were often necessary to obtain a favorable outcome.

  8. Cost-Effectiveness of Catheter Ablation for Rhythm Control of Atrial Fibrillation

    PubMed Central

    Blackhouse, Gord; Assasi, Nazila; Xie, Feng; Gaebel, Kathryn; Campbell, Kaitryn; Healey, Jeff S.; O'Reilly, Daria

    2013-01-01

    Objective. The objective of this study is to evaluate the cost-effectiveness of catheter ablation for rhythm control compared to antiarrhythmic drug (AAD) therapy in patients with atrial fibrillation (AF) who have previously failed on an AAD. Methods. An economic model was developed to compare (1) catheter ablation and (2) AAD (amiodarone 200 mg/day). At the end of the initial 12 month phase of the model, patients are classified as being in normal sinus rhythm or with AF, based on data from a meta-analysis. In the 5-year Markov phase of the model, patients are at risk of ischemic stroke each 3-month model cycle. Results. The model estimated that, compared to the AAD strategy, ablation had $8,539 higher costs, 0.033 fewer strokes, and 0.144 more QALYS over the 5-year time horizon. The incremental cost per QALY of ablation compared to AAD was estimated to be $59,194. The probability of ablation being cost-effective for willingness to pay thresholds of $50,000 and $100,000 was estimated to be 0.89 and 0.90, respectively. Conclusion. Based on current evidence, pulmonary vein ablation for treatment of AF is cost-effective if decision makers willingness to pay for a QALY is $59,194 or higher. PMID:24089640

  9. Impact of atrial remodeling on heart rhythm after radiofrequency ablation and mitral valve operations.

    PubMed

    Olasinska-Wisniewska, Anna; Mularek-Kubzdela, Tatiana; Grajek, Stefan; Marszalek, Andrzej; Sarnowski, Wojciech; Jemielity, Marek; Seniuk, Wojciech; Lesiak, Maciej; Prech, Marek; Podzerek, Tomasz

    2012-05-01

    This study was conducted to determine the effect of left atrial structural remodeling on heart rhythm after radiofrequency ablation concomitant to mitral valve operation. Sixty-six consecutive patients with of atrial fibrillation (AF) and mitral valve disease underwent radiofrequency ablation and mitral valve operation. Heart rhythm was evaluated before and at 3, 6, and 12 months postoperatively. Biopsy specimens of the posterior wall of the left atrium were evaluated for the extent of fibrosis, myocyte diameter, intensity of inflammatory infiltrates, degree of myocytolysis, and capillary density. Ten patients died and 1 patient was lost to follow-up. Heart rhythm at 12 months was used to divide the remaining 55 patients into two groups: group I, 34 with sinus rhythm; group II, 21 with AF. Paroxysmal AF preoperatively was more frequent among group I patients, and persistent/long-standing persistent AF in group II (p=0.0006). Groups I and II differed significantly in myocyte diameter (17.9±3.5 vs 20.3±4.6 μm, p=0.04), fibrosis percentage (38.7%±11.2% vs 47.6%±12.3%, p=0.009), inflammatory infiltrates (p=0.02), and preoperative left atrial diameter (5.03±0.7 vs 5.5±0.8 cm, p=0.04). No differences were found in capillary density (797.9±500.6 vs 946.0±373.7/mm2, p=0.3) and myocytolysis (p=0.4). Multivariate analysis showed myocyte diameter (p=0.047) and fibrosis (p=0.014) were independent predictors for an AF persistence at 12 months. Left atrial structural remodeling strongly affects heart rhythm after concomitant radiofrequency ablation and mitral valve operation. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

  10. Fluoroscopy-free recrossing of the interatrial septum during left atrial ablation procedures.

    PubMed

    Pavlović, Nikola; Reichlin, Tobias; Kühne, Michael; Knecht, Sven; Osswald, Stefan; Sticherling, Christian

    2014-12-01

    The purpose of this is to evaluate the safety and feasibility of recrossing the interatrial septum in case of inadvertent loss of or need for repeated left atrial access using a simple electroanatomical landmark without the use of fluoroscopy. Twenty-five consecutive patients undergoing pulmonary vein isolation (PVI) for paroxysmal (n = 12) or persistent (n = 13) atrial fibrillation ablation were included. All procedures were performed using an electroanatomical mapping system (Carto 3, Biosense Webster, Diamond Bar, USA). After fluoroscopy-guided double transseptal puncture and fast anatomical mapping of the left atrium, a reconstruction of the transseptal access was created by retracting the mapping catheter into the sheath to the level of the inferior vena cava. After completing the left sided ablation, both sheaths and catheters were withdrawn to the inferior vena cava. Recrossing was then attempted by fellows (EF) and experienced operators (EO) using the reconstruction of the transseptal access in a standard right anterior oblique (RAO) and left anterior oblique (LAO) projection without the use of fluoroscopy. Using the described technique, EP fellows and experienced operators could recross the interatrial septum without fluoroscopy in all patients. Median time needed for recrossing was 14 s (interquartile range (IQR) 7-20). Median recrossing times did not differ significantly between EF and EO (14 (IQR 8-26.5 s) versus 12 (IQR 6.5-17.5 s), p = 0.26). In five (20 %) procedures, recrossing was necessary during the procedure after intermittent mapping of the right atrium or inadvertent catheter dislodgment. Adding a simple and fast anatomical reconstruction of the transseptal access to the standard left atrial mapping procedure allows for easy and fluoroscopy-free recrossing of the interatrial septum during atrial fibrillation ablation and further reduces radiation exposure.

  11. The impact of adjunctive complex fractionated atrial electrogram ablation and linear lesions on outcomes in persistent atrial fibrillation: a meta-analysis.

    PubMed

    Scott, Paul A; Silberbauer, John; Murgatroyd, Francis D

    2016-03-01

    In persistent atrial fibrillation (PsAF), success rates for pulmonary vein isolation (PVI) alone are limited and additional substrate modification is often performed. The two most widely used substrate-based strategies are the ablation of complex fractionated atrial electrograms (CFAE) and left atrial linear ablation (LALA) at the roof and mitral isthmus. However, it is unclear whether adjunctive CFAE ablation or LALA add significant benefit to PVI alone. We performed a meta-analysis to better gauge the benefit of adjunctive CFAE ablation and LALA in PsAF. Electronic databases were systematically searched. We included studies that examined the impact of CFAE ablation or LALA in addition to a PVI-based strategy on clinical outcomes in PsAF. We included both randomized and non-randomized studies. Totally 10 studies (n = 1821) were included: 6 evaluating CFAE ablation, 3 LALA, and 1 both approaches. In comparison with PVI alone, the addition of CFAE ablation [RR 0.86; 95% confidence intervals (CI) 0.64, 1.16; P = 0.32] or LALA (RR 0.64; 95% CI 0.37, 1.09; P = 0.10) offered no significant improvement in arrhythmia-free survival. However, adjunctive CFAE ablation was associated with significant increases (P < 0.05) and LALA non-significant increases in procedure and fluoroscopy times. In PsAF, the addition of CFAE ablation or LALA, in comparison with PVI alone, offers no significant improvement in arrhythmia-free survival. Furthermore, they are associated with increases in both procedural and fluoroscopy times. The optimal ablation strategy for PsAF is currently unclear and needs further refinement. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

  12. Theoretical and experimental analysis of amplitude control ablation and bipolar ablation in creating linear lesion and discrete lesions for treating atrial fibrillation.

    PubMed

    Yan, Shengjie; Wu, Xiaomei; Wang, Weiqi

    2017-09-01

    Radiofrequency (RF) energy is often used to create a linear lesion or discrete lesions for blocking the accessory conduction pathways for treating atrial fibrillation. By using finite element analysis, we study the ablation effect of amplitude control ablation mode (AcM) and bipolar ablation mode (BiM) in creating a linear lesion and discrete lesions in a 5-mm-thick atrial wall; particularly, the characteristic of lesion shape has been investigated in amplitude control ablation. Computer models of multipolar catheter were developed to study the lesion dimensions in atrial walls created through AcM, BiM and special electrodes activated ablation methods in AcM and BiM. To validate the theoretical results in this study, an in vitro experiment with porcine cardiac tissue was performed. At 40 V/20 V root mean squared (RMS) of the RF voltage for AcM, the continuous and transmural lesion was created by AcM-15s, AcM-5s and AcM-ad-20V ablation in 5-mm-thick atrial wall. At 20 V RMS for BiM, the continuous but not transmural lesion was created. AcM ablation yielded asymmetrical and discrete lesions shape, whereas the lesion shape turned to more symmetrical and continuous as the electrodes alternative activated period decreased from 15 s to 5 s. Two discrete lesions were created when using AcM, AcM-ad-40V, BiM-ad-20V and BiM-ad-40V. The experimental and computational thermal lesion shapes created in cardiac tissue were in agreement. Amplitude control ablation technology and bipolar ablation technology are feasible methods to create continuous lesion or discrete for pulmonary veins isolation.

  13. Right atrial aneurysm with downward displacement of the anterior leaflet that resembled Ebstein's anomaly.

    PubMed

    Yamauchi, Sanae; Suzuki, Yasuyuki; Daitoku, Kazuyuki; Kimura, Masaomi; Okumura, Ken; Fukuda, Ikuo

    2016-06-08

    A 13-year-old boy presented with right atrial aneurysm and downward displacement of the anterior leaflet in the tricuspid valve into the right ventricle, without tricuspid valve regurgitation. Paroxysmal atrial flutter was caused by an abnormal electrical re-entry circuit, which could not be treated using catheter radiofrequency ablation. Therefore, the patient underwent surgical ablation and resection of the enlarged right atrial wall. The anterior leaflet of the tricuspid valve was plastered and displaced downward into the right ventricle, which resembled Ebstein's anomaly. Pathological evaluation revealed a thin wall that contained fibrous tissue with lipomatous degeneration and few muscular elements. No postoperative arrhythmia was observed.

  14. A clinical and health-economic evaluation of pulmonary vein encircling ablation compared with antiarrhythmic drug treatment in patients with persistent atrial fibrillation (Catheter Ablation for the Cure of Atrial Fibrillation-2 study).

    PubMed

    Bertaglia, Emanuele; Stabile, Giuseppe; Senatore, Gaetano; Colella, Andrea; Del Greco, Maurizio; Goessinger, Heinz; Lamberti, Filippo; Lowe, Martin; Mantovan, Roberto; Peters, Nicholas; Pratola, Claudio; Raatikainen, Pekka; Turco, Pietro; Verlato, Roberto

    2007-03-01

    Catheter Ablation for the Cure of Atrial Fibrillation 2 study is a prospective, randomized trial aimed to demonstrate the efficacy of catheter ablation with combined lesions in the right and left atria, in preventing atrial fibrillation (AF) recurrences among patients with recurrent persistent AF refractory to one antiarrhythmic drug, in comparison with the best pharmacological therapy. Enrolment is limited to patients aged between 18 and 70 years who have experienced at least one documented relapse of persistent AF during antiarrhythmic drug therapy. One hundred and twenty-six patients will be randomized to ablation or antiarrhythmic drug therapy in a 2 : 1 manner. In the ablation group, the patients will undergo right and left atrial linear ablation. Control group patients will be treated with the best antiarrhythmic drug. After an initial blanking period of 2 months patients will be followed for 24 months. Primary endpoint of the study is the absence of documented persistent atrial tachyarrhythmias relapse during the first 24 months after the blanking period. Enrolment is scheduled in 14 centres in Italy, UK, Austria, and Finland. Seventy-two patients have currently been enrolled. This study will provide important data about the efficacy of catheter ablation in comparison with antiarrhythmic drugs for the treatment of persistent AF.

  15. [1:1 atrial flutter in an elderly patient: one of the methods of discovering Wolff-Parkinson-White syndrome. Apropos of a case in an adult].

    PubMed

    Parmeggiani, L; Adamec, R; Perrenoud, J J

    1984-01-01

    Atrial flutter with 1:1 atrioventricular conduction giving rise to a ventricular rhythm of 240/min in an 80 year old man was the first sign of the Wolff-Parkinson-White syndrome; all previous electrocardiogrammes had shown no evidence of pre-excitation. It was only on the fifth day of hospitalisation that the ECG showed a short PR interval with a delta wave. This case illustrates that: --all supraventricular arrhythmias with abnormally high ventricular rates (over 220/min in adults) should alert to the possibility of an accessory atrioventricular pathway; --rapid atrioventricular conduction may be the first sign of an accessory pathway; --the differential diagnosis lies between an accessory atrioventricular pathway and an atriohisian tract; --digitalis, which may shorten the refractory period of the accessory pathway, is contraindicated in patients with a Kent bundle.

  16. Successful treatment of macroreentrant atrial tachycardia by radiofrequency ablation targeting channels with continuous activation.

    PubMed

    Wo, Hung-Ta; Wen, Ming-Shien; Chang, Po-Cheng; Chou, Chung-Chuan; Wang, Chun-Chieh; Yeh, San-Jou; Wu, Delon

    2014-08-01

    Macroreentrant atrial tachycardia (MRAT) is frequently unresponsive to antiarrhythmic drugs. The application of three-dimensional (3D) mapping and entrainment pacing contributes to a high success rate for radiofrequency ablation, but programmed electrical pacing may either terminate or transform clinical tachyarrhythmias. On the basis of clinical experiences of the use of ventricular tachycardia ablation, channels with continuous activation are suitable for reentrant circuits, and ablation at these channels can lead to noninducibility of ventricular tachycardias. We reviewed patients referred for symptomatic MRAT with identified channels with continuous activation and evaluated the efficacy of MRAT ablation by targeting these channels. Fifteen consecutive patients (10 men, 49 ± 14 years) with MRAT illustrated by endocardial activation maps using a 3D electroanatomical mapping system (CARTO™, Biosense Webster, Diamond Bar, CA, USA) were included in this study. Continuous activation was defined as double or continuous potentials without an isoelectric interval, and sites with continuous activation were tagged for measurements of channel properties. Radiofrequency ablation was performed at those targeted sites located within the reentrant circuit. Radiofrequency ablation successfully eliminated MRAT in all patients. The mean cycle length was 283 ± 60 ms, and the longest activation duration was 112 ± 38 ms. The minimal and maximal bipolar voltage amplitudes were 0.13 ± 0.1 mV and 0.7 ± 0.6 mV, respectively. The targeted ablation length and width were 28.9 ± 15.3 mm and 9.4 ± 3.3 mm, respectively. Radiofrequency ablation of MRAT targeting channels with continuous activation using a 3D electroanatomical mapping system yields a high success rate. ©2014 Wiley Periodicals, Inc.

  17. Modified phased radiofrequency ablation of atrial fibrillation reduces the number of cerebral microembolic signals.

    PubMed

    Zellerhoff, Stephan; Ritter, Martin A; Kochhäuser, Simon; Dittrich, Ralf; Köbe, Julia; Milberg, Peter; Korsukewitz, Catharina; Dechering, Dirk G; Pott, Christian; Wasmer, Kristina; Leitz, Patrick; Güner, Fatih; Eckardt, Lars; Mönnig, Gerold

    2014-03-01

    Phased radiofrequency (RF) ablation for atrial fibrillation is associated with an increased number of silent cerebral lesions on magnetic resonance imaging and cerebral microembolic signals (MESs) on transcranial Doppler ultrasound imaging compared with irrigated RF. The increased rate of embolic events may be due to a specific electrical interference of ablation electrodes attributed to the catheter design. The purpose of this study was to elucidate the effect of deactivating the culprit electrodes on cerebral MESs. Twenty-nine consecutive patients (60 ± 11 years, 10 female) underwent their first pulmonary vein isolation using phased RF energy. Electrode pairs 1 or 5 were deactivated to avoid electrical interference between electrodes 1 and 10 ('modified'). Detection of MESs by transcranial Doppler ultrasound was performed throughout the procedure to assess cerebral microembolism. Results were compared with the numbers of MESs in 31 patients ablated using all available electrodes ('conventional') and to 30 patients undergoing irrigated RF ablation of a previous randomized study. Ablation with 'modified' phased RF was associated with a marked decrease in MESs when compared with 'conventional' phased RF (566 ± 332 vs. 1530 ± 980; P < 0.001). This difference was mainly triggered by the reduction of MES during delivery of phased RF energy, resulting in MES numbers comparable to irrigated RF ablation (646 ± 449; P = 0.7). Total procedure duration as well as time of RF delivery was comparable between phased RF groups. Both times, however, were significantly shorter compared with the irrigated RF group (123 ± 28 vs. 195 ± 38; 15 ± 4 vs. 30 ± 9; P < 0.001, respectively). Pulmonary vein isolation with 'modified' phased RF is associated with a decreased number of cerebral microembolism especially during the delivery of ablation impulses, supporting the significance of electrical interference between ablation electrodes 1 and 10. Deactivation of electrode pairs 1 or

  18. Between- and within-site variation in medication choices and adverse events during procedural sedation for electrical cardioversion of atrial fibrillation and flutter.

    PubMed

    Clinkard, David; Stiell, Ian; Lang, Eddy; Rose, Stuart; Clement, Catherine; Brison, Robert; Rowe, Brian H; Borgundvaag, Bjug; Langhan, Trevor; Magee, Kirk; Stenstrom, Rob; Perry, Jeffery J; Birnie, David; Wells, George; McRae, Andrew

    2017-06-07

    Although procedural sedation for cardioversion is a common event in emergency departments (EDs), there is limited evidence surrounding medication choices. We sought to evaluate geographic and temporal variation in sedative choice at multiple Canadian sites, and to estimate the risk of adverse events due to sedative choice. This is a secondary analysis of one health records review, the Recent Onset Atrial Fibrillation or Flutter-0 (RAFF-0 [n=420, 2008]) and one prospective cohort study, the Recent Onset Atrial Fibrillation or Flutter-1 (RAFF-1 [n=565, 2010 - 2012]) at eight and six Canadian EDs, respectively. Sedative choices within and among EDs were quantified, and the risk of adverse events was examined with adjusted and unadjusted comparisons of sedative regimes. In RAFF-0 and RAFF-1, the combination of propofol and fentanyl was most popular (63.8% and 52.7%) followed by propofol alone (27.9% and 37.3%). There were substantially more adverse events in the RAFF-0 data set (13.5%) versus RAFF-1 (3.3%). In both data sets, the combination of propofol/fentanyl was not associated with increased adverse event risk compared to propofol alone. There is marked variability in procedural sedation medication choice for a direct current cardioversion in Canadian EDs, with increased use of propofol alone as a sedation agent over time. The risk of adverse events from procedural sedation during cardioversion is low but not insignificant. We did not identify an increased risk of adverse events with the addition of fentanyl as an adjunctive analgesic to propofol.

  19. Lone Atrial Fibrillation Is Associated With Impaired Left Ventricular Energetics That Persists Despite Successful Catheter Ablation

    PubMed Central

    Wijesurendra, Rohan S.; Liu, Alexander; Eichhorn, Christian; Ariga, Rina; Levelt, Eylem; Clarke, William T.; Rodgers, Christopher T.; Karamitsos, Theodoros D.; Bashir, Yaver; Ginks, Matthew; Rajappan, Kim; Betts, Tim; Ferreira, Vanessa M.; Neubauer, Stefan

    2016-01-01

    Background: Lone atrial fibrillation (AF) may reflect a subclinical cardiomyopathy that persists after sinus rhythm (SR) restoration, providing a substrate for AF recurrence. To test this hypothesis, we investigated the effect of restoring SR by catheter ablation on left ventricular (LV) function and energetics in patients with AF but no significant comorbidities. Methods: Fifty-three patients with symptomatic paroxysmal or persistent AF and without significant valvular disease, uncontrolled hypertension, coronary artery disease, uncontrolled thyroid disease, systemic inflammatory disease, diabetes mellitus, or obstructive sleep apnea (ie, lone AF) undergoing ablation and 25 matched control subjects in SR were investigated. Magnetic resonance imaging quantified LV ejection fraction (LVEF), peak systolic circumferential strain (PSCS), and left atrial volumes and function, whereas phosphorus-31 magnetic resonance spectroscopy evaluated ventricular energetics (ratio of phosphocreatine to ATP). AF burden was determined before and after ablation by 7-day Holter monitoring; intermittent ECG event monitoring was also undertaken after ablation to investigate for asymptomatic AF recurrence. Results: Before ablation, both LV function and energetics were significantly impaired in patients compared with control subjects (LVEF, 61% [interquartile range (IQR), 52%–65%] versus 71% [IQR, 69%–73%], P<0.001; PSCS, –15% [IQR, –11 to –18%] versus −18% [IQR, –17% to –19%], P=0.002; ratio of phosphocreatine to ATP, 1.81±0.35 versus 2.05±0.29, P=0.004). As expected, patients also had dilated and impaired left atria compared with control subjects (all P<0.001). Early after ablation (1–4 days), LVEF and PSCS improved in patients recovering SR from AF (LVEF, 7.0±10%, P=0.005; PSCS, –3.5±4.3%, P=0.001) but were unchanged in those in SR during both assessments (both P=NS). At 6 to 9 months after ablation, AF burden reduced significantly (from 54% [IQR, 1.5%–100%] to

  20. Catheter ablation of atrial fibrillation supported by novel nonfluoroscopic 4D navigation technology.

    PubMed

    Rolf, Sascha; John, Silke; Gaspar, Thomas; Dinov, Boris; Kircher, Simon; Huo, Yan; Bollmann, Andreas; Richter, Sergio; Arya, Arash; Hindricks, Gerhard; Piorkowski, Christopher; Sommer, Philipp

    2013-09-01

    The MediGuide technology (MGT) represents a novel sensor-based electromagnetic 4-dimensional (4D) navigation system allowing real-time catheter tracking in the environment of prerecorded X-ray loops. To report on our clinical experience in atrial fibrillation (AF) ablation with recently available MGT-enabled ablation catheters. The MGT was used in addition to a conventional 3D mapping system in 80 patients with AF (age 61 ± 10 years; 47 men; 40 with persistent AF), who underwent circumferential pulmonary vein isolation and voltage mapping with and without substrate modification. Short native right anterior oblique/left anterior oblique loops were used as background movies for the nonfluoroscopic placement of sensor-equipped diagnostic catheters into the coronary sinus and the right ventricle. After single transseptal puncture, selective angiograms of the pulmonary veins were used as background movies for near nonfluoroscopic left atrial reconstruction. Computed tomography registration as well as mapping/ablation was performed by using the new open-irrigated MGT-enabled ablation catheter. MGT application was not associated with a change in established workflow. Large parts of the procedure (mean entire duration 167 ± 47 minutes) could be done without additional fluoroscopy, whereas median residual fluoroscopy duration of 4.6 (interquartile range: 2.9, 7.1) minutes was mainly used for the acquisition of background loops, transseptal puncture, occasional verification of transseptal sheath position, and manipulation of the circular mapping catheter. Three (4%) minor complications occurred. The MGT integrates easily into the workflow of standard AF ablation and allows for high-quality nonfluoroscopic 4D catheter tracking. This results in low radiation exposure for patients and staff without complicating the workflow of the procedure. Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  1. Documentation of pulmonary vein isolation improves long term efficacy of persistent atrial fibrillation catheter ablation.

    PubMed

    Bertaglia, Emanuele; Stabile, Giuseppe; Senatore, Gaetano; Pratola, Claudio; Verlato, Roberto; Lowe, Martin; Raatikainen, Pekka; Lamberti, Filippo; Turco, Pietro

    2014-02-01

    The aim of this study was to investigate the efficacy of catheter ablation in the treatment of persistent atrial fibrillation (AF) and the predictors of arrhythmia recurrence. Absence of atrial tachyarrhythmia (AT) recurrence during a mid-term follow-up was correlated with several clinical and procedural characteristics in a population of 82 patients aged 20-70 years who had experienced at least one documented relapse of persistent AF during a single trial of antiarrhythmic drug therapy. Electrophysiological success of ablation was declared when all identified PVs were isolated (confirmation of entry and exit block). Patients were followed for a maximum of 24 months after the blanking period with outpatient visits, ECG recordings, 24-hour Holter monitoring, and weekly transtelephonic monitoring for 30s. Electrophysiological success was documented in 38/82 (46.3%) patients. During a mean follow-up of 24.7 ± 4.2 months, 69/82 (84.1%) patients presented at least one episode of AT after the 2 month blanking period. According to univariate and multivariate logistic regression analyses, only an electrophysiologically successful ablation significantly correlated with the absence of documented AT relapse (OR 5.32, 95% CL 1.02-27.72; p=.0472). Mid-term outcome of a single procedure of catheter ablation without the adjunction of antiarrhythmic drug therapy is poor in patients with persistent AF. Documented PV isolation is useful to increase the success rate of circumferential PV ablation even in persistent AF patients. Copyright © 2013. Published by Elsevier Ireland Ltd.

  2. Hybrid approach to atrial fibrillation ablation using bipolar radiofrequency devices epicardially and cryoballoon endocardially.

    PubMed

    Kumar, Narendra; Pison, Laurent; La Meir, Mark; Maessen, Jos; Crijns, Harry J

    2014-10-01

    Bipolar radiofrequency (RF) devices are used epicardially by cardiac surgeons and cryoballoon endocardially by cardiac electrophysiologists for atrial fibrillation (AF) ablation, but in separate entities. The study's objective was to evaluate the feasibility and safety of combining an endocardial cryoballoon with epicardial bipolar RF ablation for the treatment of AF. A cohort of 7 patients with AF underwent a hybrid thoracoscopic surgical and endocardial ablation. To prevent bilateral sequential lung deflation in these patients with severe chronic obstructive pulmonary disease, the right pulmonary veins (PVs) were isolated using an epicardial bipolar RF clamp and the contralateral veins with an endocardial cryoballoon. A box lesion set was made epicardially using a bipolar RF pen. Acutely, pacing manoeuvres proved a bidirectional block in all PVs in all patients. No complications were seen. A box lesion was made in 5 patients. During follow-up, 2 of them had AF recurrence: 1 was treated successfully with sotalol and another underwent redo RF catheter ablation with reisolation of the right inferior PV. At present, 6 of 7 patients are in sinus rhythm without any anti-arrythmic drugs during a follow-up of more than 40 ± 3 months. A hybrid approach to AF ablation using a cryoballoon endocardially and a bipolar RF device epicardially is feasible and safe. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

  3. Computed tomography-fluoroscopy overlay evaluation during catheter ablation of left atrial arrhythmia.

    PubMed

    Knecht, Sébastien; Skali, Hicham; O'Neill, Mark D; Wright, Matthew; Matsuo, Seiichiro; Chaudhry, Ghulam Muqtada; Haffajee, Charles I; Nault, Isabelle; Gijsbers, Geert H M; Sacher, Frederic; Laurent, Francois; Montaudon, Michel; Corneloup, Olivier; Hocini, Mélèze; Haïssaguerre, Michel; Orlov, Michael V; Jaïs, Pierre

    2008-08-01

    Proper visualization of left atrial (LA) and pulmonary vein (PV) anatomy is of crucial importance during atrial fibrillation (AF) ablation. This two-centre study evaluated a new automatic computed tomography (CT)-fluoroscopy overlay system (EP navigator, Philips Medical Systems, Best, The Netherlands) and the accuracy of different registration methods. Fifty-six consecutive patients (age: 56 +/- 14) with symptomatic AF underwent contrast CT of the LA/PV prior to ablation. Three registration methods were evaluated and validated by comparison with LA angiography: (i) catheter registration: the placement of catheters in identifiable anatomical structures; (ii) heart contour: based on aligning the fluoroscopy heart contours and the 3D-rendered CT volume; and (iii) spine registration: based on automatically aligning the segmented CT spine on fluoroscopy. Computed tomography segmentation was achieved in all but one patient due to motion artefacts. The mean duration of segmentation was 10 min and average registration lasted 7 min. Catheter and heart contour registration were highly accurate (discrepancy of 1.3 +/- 0.6 and 0.3 +/- 0.5 mm, respectively) when compared with spine registration (17 +/- 9 mm, P < 0.05). The EP navigator was helpful during trans-septal puncture, gave an internal view of the atria and allowed tracking of ablation lesions. The EP navigator enabled accurate live integration of CT images and real-time fluoroscopy. Registration utilizing catheter placement or heart contours was stable and reliable.

  4. Metabolic syndrome and risk of recurrence of atrial fibrillation after catheter ablation.

    PubMed

    Tang, Ri-Bo; Dong, Jian-Zeng; Liu, Xing-Peng; Long, De-Yong; Yu, Rong-Hui; Kalifa, Jérôme; Ma, Chang-Sheng

    2009-03-01

    Metabolic syndrome (MetS), as well as several risk factors of cardiovascular diseases, is known to be associated with atrial fibrillation (AF), but its impact on the recurrence of AF after catheter ablation has not been explored. The data for 654 consecutive AF patients who underwent an index circumferential pulmonary vein ablation were retrospectively analyzed. Of them, 323 (49.4%) had MetS according to the modified National Cholesterol Education Program-Adult Treatment Panel III criteria and Chinese ethnic criteria. After a mean follow-up of 470+/-323 (91-1,245) days, patients with MetS had a significantly higher incidence of AF recurrence (43.7%) compared with non-MetS patients (30.5%, P<0.001). Univariate analysis revealed that nonparoxysmal AF, left atrial size, MetS and body mass index were predictors of AF recurrence. Multivariate analysis revealed that MetS (hazard ratio =1.64, 95% confidence interval (CI) 1.07-2.49, P=0.022) and nonparoxysmal AF (hazard ratio =1.57, 95% CI 1.15-2.14, P=0.004) were independent predictors of AF recurrence. The major complications rate did not differ between the MetS and the non-MetS groups (1.86% vs 2.42%, P=0.621). MetS diagnosed prior to AF ablation is an independent predictor of AF recurrence.

  5. Avoiding tachycardia alteration or termination during attempted entrainment mapping of atrial tachycardia related to atrial fibrillation ablation.

    PubMed

    Barbhaiya, Chirag R; Kumar, Saurabh; Ng, Justin; Nagashima, Koichi; Choi, Eue-Keun; Enriquez, Alan; Chinitz, Jason; Epstein, Laurence M; Tedrow, Usha B; John, Roy M; Stevenson, William G; Michaud, Gregory F

    2015-01-01

    Entrainment can be useful for mapping atrial tachycardias (ATs) after atrial fibrillation (AF) ablation but may result in AT alteration or termination. We aimed to determine the incidence and risk factors for AT alteration or termination. In 30 consecutive patients, 62 ATs (mean cycle length [CL] 268 ± 53 ms) in which overdrive pacing for entrainment mapping was performed were retrospectively analyzed. AT was classified as altered if the CL or activation pattern remained altered 10 seconds after pacing. The variability in the PP intervals was determined over 10 beats from 2 measures: (1) the difference between the shortest and the longest CL expressed as a percentage of the CL and (2) the mean difference between sequential PP intervals expressed as a percentage of the AT CL (CLDmean). Of 386 total pacing attempts (tachycardia CL [TCL] - pacing CL [PCL] difference 15 ± 6 ms), 5 (1.3%) altered or terminated AT and 381 did not change AT (98.7%). When the TCL - PCL difference was ≤20 ms, only 2 of 353 (0.5%) attempts altered or terminated AT. When the TCL - PCL difference was >20 ms, 3 of 33 (9%) attempts altered or terminated AT. The difference between the shortest and the longest CL expressed as a percentage of the CL was significantly greater in ATs that were altered or terminated by pacing than in those unchanged (11.0% ± 9.6% vs 4.5% ± 4.5%; P = .007), but the mean difference between sequential PP intervals expressed as a percentage of the AT CL was not significantly different (3.8% ± 2.6% vs 1.9% ± 2.1%; P = .06). Overdrive pacing for entrainment mapping rarely alters or terminates after atrial fibrillation AT, provided that AT is stable before pacing and that the PCL is ≤20 ms shorter than the AT CL. Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

  6. Prognostic value of total atrial conduction time estimated with tissue Doppler imaging to predict the recurrence of atrial fibrillation after radiofrequency catheter ablation.

    PubMed

    den Uijl, Dennis W; Gawrysiak, Marcin; Tops, Laurens F; Trines, Serge A; Zeppenfeld, Katja; Schalij, Martin J; Bax, Jeroen J; Delgado, Victoria

    2011-11-01

    Total atrial activation time has been identified as an independent predictor of new-onset atrial fibrillation (AF). Echocardiographic assessment of PA-TDI duration provides an estimation of total atrial conduction time. The aim of this study was to investigate the prognostic value of total atrial conduction time to predict AF recurrence after radiofrequency catheter ablation (RFCA). In 213 patients undergoing RFCA for symptomatic drug-refractory paroxysmal AF, the total atrial conduction time was estimated by measuring the time delay between the onset of the P-wave in lead II of the surface electrocardiogram and the peak A'-wave on the tissue Doppler tracing of the left atrial (LA) lateral wall (PA-TDI duration). After RFCA, all patients were evaluated on a systematic basis at the outpatient clinic. After a mean follow-up of 13 ± 3 months, 74 patients (35%) had recurrent AF whereas 139 patients (65%) maintained sinus rhythm. Left atrial maximum volume index and PA-TDI duration were identified as independent predictors of AF recurrence after RFCA. However, receiver operator characteristics curve analyses demonstrated that PA-TDI duration had a superior accuracy to predict AF recurrence compared with LA maximum volume index (area under the curve 0.765 vs. 0.561, respectively). Assessment of total atrial conduction time using tissue Doppler imaging can be used to predict AF recurrence after RFCA.

  7. Early release of high-sensitive cardiac troponin during complex catheter ablation for ventricular tachycardia and atrial fibrillation.

    PubMed

    Reichlin, Tobias; Lockwood, Stephen J; Conrad, Michael J; Nof, Eyal; Michaud, Gregory F; John, Roy M; Epstein, Laurence M; Stevenson, William G; Jarolim, Petr

    2016-10-01

    Radiofrequency ablation results in intentional cardiac injury. We aimed to assess the kinetics of cardiac injury as measured by cardiac troponin release following ventricular ablation and atrial ablation. Patients undergoing ablation for ventricular tachycardia (VT) with structural heart disease (19 patients) or atrial fibrillation (AF, 24 patients) were prospectively enrolled. High-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI) were measured before ablation as well as 30 min, 60 min, 90 min, 120 min, 4 h, 8 h, and 24 h after applying the first ablation lesion. Median ablation time, power used, and energy delivered were 28 min, 39 W, and 69,713 J in VT ablations and 55 min, 29 W, and 95,425 J in AF ablations, respectively. Release of hs-cTnT occurred promptly with both, but reached greater levels earlier for ventricular compared to atrial ablation (hs-cTnT after 30 min 191 vs. 31 ng/l, after 1 h 467 vs. 80 ng/l; hs-cTnI after 30 min 132 vs. 30 ng/l, after 1 h 331 vs. 76 ng/l; p < 0.001 for all comparisons). After 24 h, levels were similar (hs-cTnT 1325 vs. 1303 ng/l, p = 0.92; hs-cTnI 2165 vs. 1996 ng/l, p = 0.55). Levels of hs-cTnT after 24 h correlated well with the energy delivered in AF ablations (r = 0.81 and r = 0.75, p < 0.001), but not in VT ablations (r = 0.35 and r = 0.44, p = ns). Evidence of cardiac injury as indicated by the release of hs-cTnT and hs-cTnI occurs early with atrial and ventricular ablation. Higher early levels are observed in ventricular ablations, but levels are similar after 24 h. The extent of total troponin release seems to correlate well with the amount of energy delivered in AF ablations, but not in VT ablations.

  8. Internal atrial defibrillation during electrophysiological studies and focal atrial fibrillation ablation procedures.

    PubMed

    Karch, M R; Schmieder, S; Ndrepepa, G; Schneider, M A; Zrenner, B; Schmitt, C

    2001-10-01

    Induction of sustained AF during electrophysiological studies requires electrical cardioversion to restore sinus rhythm for continuation of the electrophysiological study and mapping procedure. The study included 104 consecutive patients (age 59 +/- 12 years, 74 men), who were in stable sinus rhythm at the beginning of the electrophysiological study, underwent internal atrial defibrillation (IAD) of AF (> 15 minutes) that was induced during electrophysiological study. In 21 patients, AF was regarded to be the clinical problem (group I), and in the remaining 83 patients other arrhythmias represented the primary target of the electrophysiological study (group II). A 7.5 Fr cardioversion catheter (EP Medical) equipped with a distal array was used and placed in the left pulmonary artery and a proximal array of the same size was located along the lateral right atrial wall. All patients were successfully cardioverted with a mean energy of 6.2 +/- 4.0 1. In 18 (78%) of 21 group I patients and in 12 (14%) of 81 group II patients, AF recurred 3.7 +/- 3.4 and 2.4 +/- 1.4 times during electrophysiological study, respectively. The IAD shock did not suppress focal activity, thus the mapping of atrial foci responsible for AF could be continued even after several IADs. No IAD related complications occurred during the study. In conclusion, (1) IAD can be safely and successfully performed during electrophysiological study without using narcotic drugs or high electric energies; (2) IAD does not suppress focal activity; and (3) even if AF recurs frequently during the electrophysiological study, IAD can be performed several times without significant time delay.

  9. Impact of esophageal temperature monitoring guided atrial fibrillation ablation on preventing asymptomatic excessive transmural injury.

    PubMed

    Kiuchi, Kunihiko; Okajima, Katsunori; Shimane, Akira; Kanda, Gaku; Yokoi, Kiminobu; Teranishi, Jin; Aoki, Kousuke; Chimura, Misato; Toba, Takayoshi; Oishi, Shogo; Sawada, Takahiro; Tsukishiro, Yasue; Onishi, Tetsuari; Kobayashi, Seiichi; Taniguchi, Yasuyo; Yamada, Shinichiro; Yasaka, Yoshinori; Kawai, Hiroya; Yoshida, Akihiro; Fukuzawa, Koji; Itoh, Mitsuaki; Imamura, Kimitake; Fujiwara, Ryudo; Suzuki, Atsushi; Nakanishi, Tomoyuki; Yamashita, Soichiro; Hirata, Ken-Ichi; Tada, Hiroshi; Yamasaki, Hiro; Naruse, Yoshihisa; Igarashi, Miyako; Aonuma, Kazutaka

    2016-02-01

    Even with the use of a reduced energy setting (20-25 W), excessive transmural injury (ETI) following catheter ablation of atrial fibrillation (AF) is reported to develop in 10% of patients. However, the incidence of ETI depends on the pulmonary vein isolation (PVI) method and its esophageal temperature monitor setting. Data comparing the incidence of ETI following AF ablation with and without esophageal temperature monitoring (ETM) are still lacking. This study was comprised of 160 patients with AF (54% paroxysmal, mean: 24.0±2.9 kg/m(2)). Eighty patients underwent ablation accompanied by ETM. The primary endpoint was defined as the occurrence of ETI assessed by endoscopy within 5 d after the AF ablation. The secondary endpoint was defined as AF recurrence after a single procedure. If the esophageal temperature probe registered >39 °C, the radiofrequency (RF) application was stopped immediately. RF applications could be performed in a point-by-point manner for a maximum of 20 s and 20 W. ETI was defined as any injury that resulted from AF ablation, including esophageal injury or periesophageal nerve injury (peri-ENI). The incidence of esophageal injury was significantly lower in patients whose AF ablation included ETM compared with patients without ETM (0 [0%] vs. 6 [7.5%], p=0.028), but not the incidence of peri-ENI (2 [2.5%] vs. 3 [3.8%], p=1.0). AF recurrence 12 months after the procedure was similar between the groups (20 [25%] in the ETM group vs. 19 [24%] in the non-ETM group, p=1.00). Catheter ablation using ETM may reduce the incidence of esophageal injury without increasing the incidence of AF recurrence but not the incidence of peri-ENI.

  10. Impact of esophageal temperature monitoring guided atrial fibrillation ablation on preventing asymptomatic excessive transmural injury

    PubMed Central

    Kiuchi, Kunihiko; Okajima, Katsunori; Shimane, Akira; Kanda, Gaku; Yokoi, Kiminobu; Teranishi, Jin; Aoki, Kousuke; Chimura, Misato; Toba, Takayoshi; Oishi, Shogo; Sawada, Takahiro; Tsukishiro, Yasue; Onishi, Tetsuari;