Although a left atrial posterior wall isolation (LAPWI) in addition to a pulmonary vein isolation is a well-accepted option for persistent atrial fibrillation (AF), a complete isolation can be ...challenging. This study aimed to evaluate the performance of a modified ablation index (AI) (AI/bipolar voltage along the ablation line) for predicting a durable LAPWI. The study included 55 consecutive patients, aged 65 ± 11 years, who underwent an electroanatomic mapping-guided LAPWI of AF. The association between the gaps (first-pass LAPWI failure and/or acute LAPW reconnections), voltage amplitude along the roof and floor lines, and thickness of the LAPW was investigated. Gaps occurred in 22 patients (40%) and in 26 (8%) of the 330 line segments. Gaps were associated with a relatively high bipolar voltage (3.38 ± 1.83 vs. 1.70 ± 1.12 mV,
P
< 0.0001) and thick LA wall (2.52 ± 1.15 vs. 1.42 ± 0.44 mm,
P
< 0.0001). A modified AI ≤ 199 AU/mV, bipolar voltage ≥ 2.64 mV, wall thickness ≥ 2.04 mm, and roof ablation line ≥ 43.4 mm well predicted gaps (AUCs: 0.783, 0.787, 0.858, and 0.752, respectively). A high-voltage zone, thick LAPW, and long roof ablation line appeared to be determinants of gaps, and a modified AI ≥ 199 AU/mV along the ablation lines appeared to predict an acute durable LAPWI.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Introduction
Although electrophysiologic and anatomic factors associated with the need for touch‐up radiofrequency (RF) applications after cryoballoon ablation (CBA) for atrial fibrillation (AF) have ...been well described, those associated with the need for such touch‐up after hot balloon ablation (HBA) have not. We aimed to identify factors predictive of the need for touch‐up applications following HBA.
Methods
Anatomic and electrophysiologic factors predictive of the need for touch‐up RF ablation were compared between 46 propensity score‐matched pairs of patients who underwent HBA or CBA for AF.
Results
Touch‐up RF ablation was more frequently required after HBA than after CBA (57% vs 30%, respectively; P = .01), and mostly at the anterior aspect of the left superior pulmonary vein (LSPV) carina after HBA (35%) but at the inferior aspect of the right inferior PV (RIPV) after CBA (71%). Post HBA touch‐up was associated with male gender, a CHA
2DS
2‐VASc score ≤ 2, PV‐left atrial bipolar voltage ≥ 1.35 mV, and PV trunk length ≥ 24.0 mm; post CBA touch‐up associated with a history of heart failure.
Conclusion
Following balloon ablation for AF, there may be a need for touch‐up applications, especially at the LSPV ridge after HBA but at the RIPV after CBA. It may behoove operators to expect a need for touch‐up following HBA when patients are male, have a CHA2DS
2‐VASc score ≤ 2 points, when PV‐LA bipolar voltage is ≥ 1.35 mV, or when the PV trunk is ≥ 24.0 mm or following CBA when there is a history of heart failure.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Acute type B aortic dissection is sometimes complicated by acute respiratory failure requiring mechanical ventilation. Herein, we describe our experience in a rare acute type B aortic ...dissection-associated respiratory failure case culminating in acute respiratory distress syndrome. The patient was a 45-year-old man admitted with a complaint of sudden chest pain radiating to his back. On computed tomography, an acute type B aortic dissection was diagnosed. He had no dyspnea on admission, but his respiratory function subsequently deteriorated, and severe acute respiratory distress syndrome was diagnosed on Day 4. Venovenous extracorporeal membrane oxygenation with anticoagulation plus continuous renal replacement therapy for oliguria improved the oxygenation, and the patient was weaned from the extracorporeal membrane oxygenation on Day 8. This patient fully recovered without worsening the aortic dissection, using venovenous extracorporeal membrane oxygenation with anticoagulation plus a continuous renal replacement therapy.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Pulmonary vein isolation (PVI) of atrial fibrillation (AF) can reduce the AF burden and, potentially, reduce the long-term risk of strokes and death. However, it remains unclear whether ...anticoagulants can be stopped after PVI because of post-ablation AF recurrence in some patients. This study aimed to investigate the discontinuation rate of anticoagulants and long-term incidence of strokes after PVI.We enrolled 512 consecutive Japanese patients with AF (mean age, 63.4 ± 10.4 years; 123 women; 234 with non-paroxysmal AF; CHADS2 score/CHA2DS2-VASC score, 1.32 ± 1.12/2.21 ± 1.54) who underwent PVI between 2012 and 2015. During a 28.0 ± 17.1 -month follow-up, anticoagulants were terminated in 230 (44.9%) of the 512 patients, AF recurred in 200 (39.1%), and 10 (1.95%) suffered from a stroke. Death occurred in 5 (0.98%) patients. Although the incidence of strokes, by a Kaplan-Meier analysis, was similar, the incidence of death was lower (Hazard ratio 0.37, 95% confidence interval 0.12-0.93, P = 0.041) in the AF ablation group than the control group without ablation after 1:1 propensity score matching (the control data was derived from 2,986 patients in the SAKURA AF Registry, a large-cohort AF registry).Anticoagulants were discontinued in nearly half the patients who underwent AF ablation; of these, 39.1% experienced AF recurrences, 1.95% suffered from strokes, and 0.98% died, but the risk of death after AF ablation appeared to be lower than that in a propensity score-matched control group without ablation during long-term follow-up.
Purpose
Entrainment is a useful method for locating reentrant atrial tachycardia (AT) circuits, but alterations or termination of the AT can derail this process. We assessed whether resetting an ...upstream site of a neighboring electrode by a scanned extrastimulus at a downstream site (when the upstream tissue was refractory) could diagnose that site within the AT circuit.
Methods
The procedure was applied to 48 ATs with a cycle length (CL) of 238 ± 42 ms (26 common flutters, 8 perimitral flutters, 7 left atrial LA roof-dependent AT, 3 LA scar-related macroreentrant ATs, 2 pulmonary vein-gap reentry tachycardias, 1 right atrial scar-related macroreentrant AT, and 1 with an unidentified circuit). Entrainment and scanned extrastimulation were attempted at the cavotricuspid isthmus, LA roof, and mitral isthmus and/or critical AT isthmus.
Results
Within the circuit, the post-pacing interval minus the ATCL after entrainment was < 30 ms for all ATs and resetting of the AT cycle by ≥ 5 ms occurred in 94% of the ATs. No ATs were reset by extrastimulation outside the circuit. The positive predictive value of both maneuvers for locating the circuit was 100%, and the negative predictive value of the extrastimulation was similar to that of entrainment (96% vs. 100%,
P
= 0.25). The incidence of an AT alteration was lower with extrastimulation than with entrainment (1% vs. 9%,
P
= 0.01). For ATs with a CL < 210 ms, extrastimulation yielded a good diagnostic performance without any AT alterations.
Conclusion
AT resetting by a scanned extrastimulus is diagnostic and avoids AT alterations.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Objective: Left atrial (LA) stretch attributable to elevated LA pressure is known to play an important role in theperpetuation of atrial fibrillation (AF). However, the relation between LA pressure ...and the outcome of pulmonaryvein isolation (PVI) for AF remains to be elucidated. Therefore, we investigated the relationships between postPVIrecurrence of AF, LA pressure, and pre-ablation variables.Methods and Results: The study group comprised 60 consecutive patients who were undergoing ablation forAF (46 men, 14 women; mean age, 59.5 ± 11 years; paroxysmal AF PAF, n = 35; persistent AF Per AF, n =25). The patient characteristics and biomarkers of inflammation, fibrosis and heart failure measured before ablationwere compared between patients in whom AF recurred after a 3-month blanking period and those in whom itdid not. No significant differences were found in clinical or echocardiographic variables or biomarker concentrationsbetween the patients with and without recurrence. However, the mean LA pressure was elevated in patientsin whom AF recurred (12.2 ± 0.99 vs. 7.99 ± 0.62 mmHg, respectively, P < 0.001). Body mass index and serumatrial natriuretic peptide (ANP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations werehigher; hypertension was more prevalent, and the LA diameter and volume were greater in patients with a meanLA pressure ? the median value of 10 mmHg compared with those patients with a mean LA pressure < 10mmHg), despite a similarity in the left ventricular ejection fraction.Conclusions: Elevated LA pressure is associated with post-PVI AF recurrence. Therefore, measuring LA pressurebefore PVI might be useful in identifying patients at risk for post-ablation AF recurrence, and an aggressiveablation strategy might be needed for these patients.
Background: Similar clinical outcomes have been demonstrated following pulmonary vein (PV) isolation (I)by radiofrequency catheter and cryoballoon ablation (CBA) in patients with paroxysmal atrial ...fibrillation (PAF).However, no comparison of the clinical outcome in patients with PAF and persistent AF (PerAF) by CBA hasbeen reported to date. The purpose of this study was to compare the efficacy of PVI in patients with PAF andPerAF.Methods: CBA based PVI using a second-generation 28-mm balloon was performed in 58 patients with PAFand 32 with PerAF. Follow-up (FU) was based on outpatient clinic visits at 1, 3, 6, and 12 months, which includedHolter electrocardiograms and ambulatory event electrocardiograms.Results: The freedom from atrial tachyarrhythmia recurrences following a single cryoballoon ablation inpatients with PAF and PerAF did not differ significantly between the PAF and PerAF patients over a relativelyshorter follow-up period, as estimated by the Kaplan-Meir method.Conclusion: CB-based PVI had similar efficacy for both PAF and PerAF.
Background: Recurrences within 3 months after radiofrequency catheter ablation of atrial fibrillation (AF)have been reported to be associated with the onset of recurrence after 3 months. Although ...very early recurrence ofAF (VERAF) and early recurrence of AF (ERAF) after cryoballoon (CB) ablation are sometimes observed, littleis known about their impact on recurrence beyond a recovery period of 3 months. This study aimed to clarify thecharacteristics of the VERAF and ERAF of AF after CB ablation.Methods and Results: Ninety patients with PAF (n = 58) and PerAF (n = 32), with a median AF duration sincethe first diagnosis of 2.5 (5, 48) months, underwent CB-based pulmonary vein isolation (PVI). The freeze cycleduration was set at 180 sec, and an additional freeze cycle of 120 sec was applied. The ECG monitor was recordedduring hospitalization, and at the outpatient clinic visits at 2 weeks and 1, 3, 6, and 12 months, including Holterelectrocardiograms and ambulatory event electrocardiograms. VERAF (within 3 days) and ERAF (< 3 months)were observed in 14 (16%) and 12 (13%) patients, respectively. Nine patients with VERAF and six with ERAFwere AF free during a mean followup period of 12 months.Conclusion: While very early recurrence of AF after cryoballoon-based PVI did not correlate with the clinicaloutcome, early recurrence of AF after cryoballoon-based PVI correlated with a worse clinical outcome.
Background: The success rates for ablation of persistent atrial fibrillation (PerAF) are lower than those for ablation of paroxysmal AF (PAF). We investigated whether a relation exists between the ...presence of sinus rhythm(SR) early in the procedure and the ablation outcome in patients with PerAF.Methods and Results: The study involved 46 patients with persistent AF (< 7 days duration; 7 women, 39men, aged 60.8 ± 10.0 years; AF duration, 14 5, 48 months) who underwent pulmonary vein isolation (PVI). Ablation outcomes were compared between patients who were in SR early during the procedure, because 1) SR waspresent at the start of the procedure (SR group), 2) AF was electrically cardioverted to SR before PVI (DC group),or 3) PVI was performed during AF (AF group). After a 3-month blank period, the incidence of freedom from AFafter the single procedure was significantly higher in the SR group compared with that in the DC and AF groups(100%, 46% and 50%, respectively, P = 0.0110), during median follow-up periods of 15.5, 19.4, and 28.2 months,respectively.Conclusion: The presence of spontaneous SR before ablation for PerAF appears to be related to AF-free survival.
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