Purpose
Antral pulmonary vein isolation (PVI) using a radiofrequency hot balloon catheter (RHB) is a feasible therapeutic option for treating atrial fibrillation (AF). Lesion durability after antral ...RHB-PVI remains unknown. This study aimed to evaluate lesion durability and the associations between procedural characteristics after antral RHB-PVI.
Methods
A total of 200 patients received antral RHB-PVI using the single-shot technique between April 2016 and March 2018. Antral RHB-PVI was performed following a pre-specified protocol and RHB energy application was performed for a maximum of two times for each PV. Consecutive patients who underwent repeated procedures for recurrence of any type of atrial tachyarrhythmia were enrolled.
Results
Twenty-six (13%) patients underwent repeated ablation and 20 patient documented AF recurrence (AF group) and 6 patients documented non-AF recurrence (non-AF group). Repeated ablation was performed at a median (25th, 75th percentiles) of 378 days (217, 487) after the initial procedure and durable PVI was observed in 86 (83.5%) PVs. Durability reached 89.7% when PVI was achieved only using an RHB. In the AF group (79 PVs), durable PVI was observed in 62 (78.5%) PVs, whereas all 24 PVs were still isolated in the non-AF group. The majority of reconnection sites were around the superior PVs.
Conclusions
Antral RHB-PVI shows high lesion durability, especially with both inferior PVs.
A 53‐year‐old male underwent a pulmonary vein isolation (PVI) of atrial fibrillation (AF) with a second‐generation cryoballoon (CB). Although the patient maintained sinus rhythm after the PVI, a ...superior vena cava (SVC) fibrillation was recorded by a circular‐multipolar‐electrode catheter positioned inside the SVC that suggested conduction block between the right atrium (RA)‐SVC connection. An adenosine triphosphate intravenous injection induced a dormant reconnection of the SVC myocardial sleeve and converted sinus rhythm to an AF rhythm. This case demonstrated that a CB application for the isolation of a right superior pulmonary vein could induce an electrical conduction block between the RA‐SVC connection.
Background
The intrinsic cardiac autonomic nervous system (ANS) plays a significant role in atrial fibrillation (AF) mechanisms. This study evaluated the incidence and impact of intraprocedural vagal ...reactions and ANS modulation by pulmonary vein isolation (PVI) using second‐generation cryoballoons on outcomes.
Methods
One hundred three paroxysmal AF patients underwent PVI with one 28‐mm second‐generation balloon. The median follow‐up was 15.0 (12.0–18.0) months. ANS modulation was defined as a >20% cycle length decrease on 3‐minute resting electrocardiograms at 1, 3, 6, and 12 months postindex procedure relative to baseline if sinus rhythm was maintained.
Results
Marked sinus arrests/bradycardia and atrioventricular block (intraprocedural vagal reaction) occurred in 14 and 2 patients, and all sinus arrest/bradycardia occurred in 44 patients with left superior pulmonary veins (PVs) targeted before right PVs. ANS modulation was identified in 66 of 95 (69.5%) patients, and it persisted 12‐month postprocedure in 36 (37.9%) patients. Additional β‐blocker administration was required in 9 patients for sinus tachycardia. ANS modulation was similarly observed in patients with and without intraprocedural vagal reactions (P = 0.443). Forty‐eight (46.6%) patients experienced early recurrences, and the single procedure success at 12 months was 72.7%. Neither intraprocedural vagal reactions nor ANS modulation predicted AF freedom within or after the blanking period. Thirty‐three patients underwent second procedures, and reconnections were detected in 39 of 130 (30.0%) PVs among 23 (69.7%) patients. The incidence of reconnections was similar in patients with and without ANS modulation.
Conclusions
Increased heart rate persisted in 37.9% of patients even at 12‐month post‐second‐generation cryoballoon PVI. Neither intraprocedural vagal reactions nor increased heart rate predicted a single procedure clinical outcome.
Background: The long-term effects of catheter ablation (CA) on the left atrium and left atrial appendage (LAA) are unknown in persistent atrial fibrillation (AF). This study investigated left atrial ...(LA) reverse remodeling and evolution of LA/LAA function after successful CA for persistent AF and identified predictors for maintenance of sinus rhythm (SR) and LA reverse remodeling. Methods and Results: CA was performed in 123 patients with persistent AF. LA volumes, LA strain and LAA wall velocity were assessed both at baseline and at 12 months after ablation. Patients who maintained SR were divided into 2 groups according to whether LA volume decreased by ≥15% at follow-up (responders) or not (non-responders). During a follow-up period of 18±2 months, AF recurred in 45 patients (37%). Of the remaining 78 patients (63%) without recurrent AF, 62 patients (79%) were classified as responders. LA/LAA function significantly improved and the prevalence of spontaneous echo contrast decreased only in responders at follow-up. LA systolic strain and LAA wall velocity were independent predictors of both maintenance of SR (odds ratio OR, 2.57; P=0.003; OR, 3.02; P=0.002, respectively) and LA reverse remodeling (OR, 4.44; P=0.007; OR, 3.52; P=0.01, respectively). Conclusions: Successful CA is associated with LA reverse remodeling and LA/LAA functional recovery in patients with persistent AF. LA systolic strain and LAA wall velocity at baseline predicted both maintenance of SR and LA reverse remodeling. (Circ J 2013; 77: 1695–1704)
•A novel dedicated package for left atrial-3D echocardiography was tested.•3D speckle tracking-derived left atrial volume and computed tomography measurements correlated.•Lateral and inferior left ...atrial strains are sensitive early markers of dysfunction.
Left atrial (LA) global strain has been studied as an early marker of LA dysfunction, followed by LA dilatation. Recently, a novel dedicated software for LA 3-dimensional speckle tracking echocardiography (LA-3DSTE) has allowed us to assess anatomy-based six-segmental LA deformation. This study aimed to assess the accuracy of LA-3DSTE software in measuring LA volume and to reveal the characteristics of regional LA reservoir strain.
Fifty patients with paroxysmal atrial fibrillation who underwent computed tomography (CT) and 3D-STE were enrolled. The LA volumes obtained by 3D-STE and CT were compared, and regional LA strain was analyzed. Six LA segments (anterior, septal, inferior, lateral, roof, and posterior) were determined on the basis of LA anatomy.
In 50 patients (mean age, 64 years; 62% male), the 3D-STE-derived LA volume index (LAVI) showed good correlation with the CT-derived index, (r = 0.78, p < 0.001) with an underestimate bias of 10.5 ± 11.0 ml/m2 (p < 0.001). The lateral LA strain was negatively correlated with LAVI and emptying fraction, while the anterior and septal strains were not. In the 1st quantile LA volume group, the segmental LA strain was heterogeneous, that is, the lateral and inferior strains were greater than the anterior strain. While in the 3rd quantile LA volume group, the lateral and inferior strains were decreased, and there was no regional difference.
LA volume obtained by 3D-STE and CT showed a good correlation. LA segmental analysis by 3D-STE enables early identification of how LA dysfunction affects lateral and inferior LA strains, consistent with anatomical features.
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Identifying the optimal atrioventricular (AV) or interventricular (VV) delay is beneficial for patients using cardiac resynchronization therapy (CRT) devices. Ultrasonic echocardiography (UCG) has ...been the most commonly used method; however, it requires high technical knowledge. Impedance cardiography (ICG) can calculate stroke volume by measuring changes in transthoracic electric impedance. This study sought to assess the clinical utility of ICG in comparison with that of UCG for the optimization of CRT devices.Patients who underwent CRT device implantation were retrospectively analyzed. One week after implantation, optimization of AV delay (AVD) was performed in every patient with ICG (AVD-ICG) and UCG (AVD-UCG). VV delay (VVD) was then determined according to the optimal AVD using these two methods.Forty-two patients were enrolled. Average AVD-ICG was significantly shorter than AVD-UCG (128 ± 49 versus 146 ± 41 milliseconds, P = 0.018). Five patients (12%) had the same optimized AVD with two methods, and the difference between AVD-ICG and AVD-UCG was ≤ 20 milliseconds in 19 patients (45%). In the multivariate analysis, the presence of postoperative mitral regurgitation (MR) was an independent predictor of AVD-ICG/AVD-UCG mismatch, defined as a difference over 20 milliseconds (odds ratio = 10.71; 95% confidence interval = 1.72 to 66.72; P = 0.018). The results of optimized VVD were similar using both methods.ICG might be a promising tool for the rapid optimization of CRT devices. However, in patients with moderate-to-severe MR, ICG may not be able to optimize AVD.
On the basis of the electromechanical coupling theory, an activation imaging system has been developed with three-dimensional speckle-tracking echocardiography. The aim of this study was to determine ...the association between left ventricular (LV) propagation patterns by activation imaging and response to cardiac resynchronization therapy (CRT).
This was a retrospective, single-center study. Eighty-one patients undergoing CRT, of whom 50 (61.7%) had left bundle branch block (LBBB), were enrolled. Activation imaging studies were performed with a three-dimensional speckle-tracking echocardiographic system, which allowed visualization of LV activation propagation and measurement of the time from the QRS complex to activation onset. A CRT volume responder was defined as a patient with ≥15% reduction of LV end-systolic volume at 6 months after CRT. Clinical outcomes were assessed with the composite end point of death due to cardiac causes or unplanned hospitalization for cardiac diseases.
In patients with LBBB, the main activation pattern (74%) was a U-shaped propagation pattern, which was characterized as propagation from the midseptum to the lateral or posterior wall through the apex. In patients without LBBB, various non-U-shaped propagation patterns were observed in the majority of patients (97%). Among the 41 CRT responders, almost all (87.8%) had the U-shaped propagation pattern. During follow-up (median, 20 months), 29 patients (35.8%) reached the clinical end points. In a multivariate Cox proportional hazards model, a U-shaped propagation pattern was associated with the end points independently of LBBB or LV end-diastolic volume.
The U-shaped propagation pattern on three-dimensional speckle-tracking echocardiography was significantly associated with a favorable CRT response. Activation pattern analysis may provide additional information to predict response to CRT.
Background:
Holter electrocardiogram (ECG) is the gold standard for ambulatory monitoring of atrial fibrillation (AF) but it is insufficient because of its limited recording time. Although several ...consumer ECG devices provide longer recording time, they generally do not undergo the regulatory process for medical use. Furthermore, current medical-grade devices for longer ECG monitoring are not continuous or too invasive for AF monitoring. A wearable ECG with a medical-grade dry textile electrode is a promising technology to remedy this limitation.
This pilot study aimed to simultaneously compare the wearable and Holter ECGs for ambulatory monitoring in a clinical setting.
Methods: This prospective observational study enrolled 18 patients who underwent AF ablation. One day after AF ablation, ambulatory ECG was obtained for three hours simultaneously using both the wearable and Holter ECG devices. Automatic ECG interpretations between devices were compared with correlation and agreement analyses.
Results: Simultaneous ECG monitoring demonstrated a comparable analysis time and total heart beats between the two devices. Almost complete correlation and agreement were also demonstrated in all clinically relevant testing aspects except in R-wave amplitude (r = 0.743, p < .001). AF was detected in three patients. AF duration was the same in both ECG devices in two patients with continuous AF. In the remaining patient with intermittent AF, AF duration was shortened by 0.6% with the wearable ECG as compared to that with the Holter ECG.
Conclusions: Simultaneous ECG comparison revealed a high consistency between the wearable and Holter ECG devices. The results of this study warrant further clinical studies for long-term monitoring of ambulatory ECG after AF ablation.
•Dabigatran administration protocols undergoing atrial fibrillation ablation are diverse.•We evaluated the optimal interruption time of dabigatran administration to ablation.•No major bleeding events ...occurred in the 8–24 h group.•8 to 24 h interruption may be optimal when considering the perspective of bleeding risk.
RE-CIRCUIT (NCT02348723) and ABRIDGE-J (UMIN000013129) are recently published randomized clinical trials showing that anticoagulation therapy with dabigatran during the periprocedural period of catheter ablation (CA) for atrial fibrillation (AF) was associated with fewer complications. However, the dabigatran administration protocols were different (uninterrupted in RE-CIRCUIT and minimally interrupted in ABRIDGE-J). The aim of this present study was to clarify the optimal interruption time of dabigatran Oral administration to Ablation (O-A time).
We conducted an integrated analysis of the 2 prospective trials. The endpoint of the study was the incidence of major bleeding events during and up to 8 weeks after CA across participants with different O-A times.
The 535 patients in the dabigatran groups of the 2 trials were divided into 3 groups based on their O-A times (<8 h, n = 258; 8–24 h, n = 191; >24 h, n = 86). Major bleeding events occurred in 5 patients (1.9%) in the <8 h group, and 3 (3.5%) in the >24 h group; however, no major bleeding events occurred in the 8–24 h group (3 group-comparison, p = 0.026). No thromboembolic complication was observed in any of the 3 O-A time groups.
In patients undergoing CA for AF using dabigatran as a periprocedural anticoagulant, an O-A time of 8–24 h was associated with no bleeding complications. These data suggest that an O-A time of 8–24 h may be an appropriate option, especially in a low thromboembolic-risk patient.
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