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
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
Introduction
Preferential pathway conduction is mostly detected as fractionated presystolic‐potentials preceding the QRS during premature ventricular contractions (PVCs) and late‐potentials during ...sinus rhythm (SR), but the electrophysiologic mechanisms and significance of these potentials have not been fully clarified. We describe a PVC case series in which the preferential pathway conduction was three‐dimensionally visualized.
Methods
Five PVCs (two from the left coronary cusp, two from the commissure of the left and right coronary cusps, and one from the pulmonary artery) in four patients for which a fractionated presystolic‐potential during the PVCs and late‐potential during SR were recorded at the successful ablation site were reviewed, and three‐dimensional coherent activation maps with the conduction velocity vector during the PVCs and SR were reconstructed.
Results
At the successful ablation site, an “M”‐shaped discrete presystolic‐potential and “W”‐shaped discrete late‐potential were recorded in all patients. The configuration of the inverted electrogram of the presystolic‐potential was similar to that of the electrogram exhibiting the late‐potential. We created coherent activation maps annotating the onset of the presystolic‐potentials during the PVCs and offset of the late‐potentials during SR, which suggested bidirectional conduction of the preferential pathway connecting the PVC origin to the myocardium.
Conclusion
Detailed activation mapping of these PVCs is consistent with the presence of fibers along the aortic or pulmonic valve ring that have preferential directions for conduction. PVCs produce a presystolic‐potential. In SR, the fiber is activated late and from the opposite direction, producing an inverted potential inscribed on the end of the QRS.
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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
Background
Although low‐voltage zones (LVZs) in the left atrium (LA) are considered arrhythmogenic substrates in some patients with atrial fibrillation (AF), the pathophysiologic factors responsible ...for LVZ formations remain unclear.
Objective
To elucidate the anatomical relationship between the LA and ascending aorta responsible for anterior LA wall remodeling.
Methods
We assessed the relationship between existence of LVZs on the anterior LA wall and the three‐dimensional computed tomography image measurements in 102 patients who underwent AF ablation.
Results
Twenty‐nine patients (28%) had LVZs grearer than 1.0 cm2 on the LA wall in the LA‐ascending aorta contact area (LVZ group); no LVZs were seen in the other 73 patients (no‐LVZ group). The LVZ group (vs. no‐LVZ group) had a smaller aorta‐LA angle (21.0 ± 7.7° vs. 24.9 ± 7.1°, p = .015), greater aorta‐left‐ventricle (LV) angle (131.3 ± 8.8° vs. 126.0 ± 7.9°; p = .005), greater diameter of the noncoronary cusp (NCC; 20.4 ± 2.2 vs. 19.3 ± 2.5 mm; p = .036), thinner LA wall‐thickness adjacent to the NCC (2.3 ± 0.7 vs. 2.8 ± 0.8 mm; p = .006), and greater cardiothoracic ratio (percentage of the area in the thoracic area, 40.1 ± 7.1% vs. 35.4 ± 5.7%, p < .001). The aorta‐LA angle correlated positively with the patients’ body mass index (BMI), and the aorta‐LV angle correlated negatively with the body weight and BMI.
Conclusion
Deviation of the ascending aorta's course and distention of the NCC appear to be related to the development of LA anterior wall LVZs in the LA‐ascending aorta contact area. Mechanical pressure exerted by extracardiac structures on the LA along with the limited thoracic space may contribute to the development of LVZs associated with AF.
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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
Background
How obesity and epicardial fat influence atrial fibrillation (AF) is unknown.
Methods
To investigate the effect of obesity/epicardial fat on the AF substrate, we divided 20 beagle dogs of ...normal weight into four groups (n = 5 each): one of the four groups (Obese‐rapid atrial pacing RAP group) served as a novel canine model of obesity and AF. The other three groups comprised dogs fed a standard diet without RAP (Control group), dogs fed a high‐fat diet without RAP (Obese group), or dogs fed a standard diet with RAP (RAP group). All underwent electrophysiology study, and hearts were excised for histopathologic and fibrosis‐related gene expression analyses.
Results
Left atrial (LA) pressure was significantly higher in the Obese group than in the Control, RAP, and Obese‐RAP groups (23.4 ± 6.9 vs. 11.4 ± 2.1, 11.9 ± 6.4, and 13.5 ± 2.9 mmHg; p = .005). The effective refractory period of the inferior PV was significantly shorter in the RAP and Obese‐RAP groups than in the Control group (p = .043). Short‐duration AF was induced at greatest frequency in the Obese‐RAP and Obese groups (p < .05). Epicardial fat/Fatty infiltration was greatest in the Obese‐RAP group, and greater in the Obese and RAP groups than in the Control group. %interstitial fibrosis/fibrosis‐related gene expression was significantly greater in the Obese‐RAP and RAP groups (p < .05).
Conclusions
Vulnerability to AF was associated with increased LA pressure and increased epicardial fat/fatty infiltration in our Obese group, and with increased epicardial fat/fibrofatty infiltration in the RAP and Obese‐RAP groups. These may explain the role of obesity/epicardial fat in the pathogenesis of AF.
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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
Background
A novel steerable sheath visualized on a three‐dimensional mapping system has become available in this era in which a durable pulmonary vein (PV) isolation (PVI) with reduced fluoroscopy ...is required.
Methods
In 60 patients who underwent a PVI with a visualized sheath (n = 30) and non‐visualized conventional sheath (n = 30), the fluoroscopic time and catheter stability during the PVI were analyzed.
Results
The fluoroscopic time during the transseptal access (0 0, 0.1 vs. 1.4 0.8, 2.3 minutes, P < .001) and PVI (0 0, 0.1 vs. 0.4 0.2, 1.1 minutes, P < .001) were shorter in the visualized sheath group than conventional sheath group. The procedure time during the PVI (32.0 26.8, 36.3 vs. 41.0 31.8, 47.3 minutes, P = .01), particularly during the right PVI (15.0 12.8, 18.0 vs. 23.0 15.8, 26.3 minutes, P = .009), was shorter in the visualized sheath group than conventional sheath group, however, that during the other steps was equivalent. The standard deviation of the catheter contact force during each radiofrequency application was smaller in the visualized sheath group than conventional sheath group (4.5 ± 2.7 vs. 4.9 ± 3.1 g, P = .001). The impedance drop for each lesion was larger in the visualized sheath group than conventional sheath group (10.7 ± 6.5 vs. 9.8 ± 5.5 ohms, P < .001). The incidence of acute PV reconnections per patient (30% vs. 23%, P = .56) and per PV segment (2.5% vs. 2.3%, P = .83) were similar between the two groups. No major complications occurred in either sheath group.
Conclusions
The use of visualized sheaths may reduce the fluoroscopic time and improve the catheter stability during the PVI.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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