Objectives Our purpose was to evaluate the efficacy of antiarrhythmic drugs (AADs) in recurrent ventricular fibrillation (VF) associated with inferolateral early repolarization pattern on the ...electrocardiogram. Background Although an implantable cardioverter-defibrillator is the treatment of choice, additional AADs may be necessary to prevent frequent episodes of VF and reduce implantable cardioverter-defibrillator shock burden or as a lifesaving therapy in electrical storms. Methods From a multicenter cohort of 122 patients (90 male subjects, age 37 ± 12 years) with idiopathic VF and early repolarization abnormality in the inferolateral leads, we selected all patients with more than 3 episodes of VF (multiple) including those with electrical storms (≥3 VF in 24 h). The choice of AAD was decided by individual physicians. Follow-up data were obtained for all patients using monitoring with implantable defibrillator. Successful oral AAD was defined as elimination of all recurrences of VF with a minimal follow-up period of 12 months. Results Multiple episodes of VF were observed in 33 (27%) patients. Electrical storms (34 ± 47 episodes) occurred in 16 and were unresponsive to beta-blockers (11 of 11), lidocaine/mexiletine (9 of 9), and verapamil (3 of 3), while amiodarone was partially effective (3 of 10). In contrast, isoproterenol infusion immediately suppressed electrical storms in 7 of 7 patients. Over a follow-up of 69 ± 58 months, oral AADs were poorly effective in preventing recurrent VF: beta-blockers (2 of 16), verapamil (0 of 4), mexiletine (0 of 4), amiodarone (1 of 7), and class 1C AADs (2 of 9). Quinidine was successful in 9 of 9 patients, decreasing recurrent VF from 33 ± 35 episodes to nil for 25 ± 18 months. In addition, quinidine restored a normal electrocardiogram. Conclusions Multiple recurrences of VF occurred in 27% of patients with early repolarization abnormality and may be life threatening. Isoproterenol in acute cases and quinidine in chronic cases are effective AADs.
Abstract Background Pulmonary vein (PV) isolation (PVI) has emerged as an effective therapy for paroxysmal atrial fibrillation (AF). However, AF recurs in up to 50% of patients, generally because of ...recovery of PV conduction. Adenosine given during the initial procedure may reveal dormant PV conduction, thereby identifying the need for additional ablation, leading to improved outcomes. The Adenosine Following Pulmonary Vein Isolation to Target Dormant Conduction Elimination (ADVICE) study is a prospective multicentre randomized trial assessing the impact of adenosine-guided PVI in preventing AF recurrences. Methods Patients undergoing a first PVI procedure for paroxysmal AF will be recruited. After standard PVI is completed, all patients will receive intravenous adenosine in an attempt to unmask dormant conduction. If dormant conduction is elicited, patients will be randomized to no further ablation (control group) or additional adenosine-guided ablation until dormant conduction is abolished. If no dormant conduction is revealed, randomly selected patients will be followed in a registry. The primary outcome is time to first documented symptomatic AF recurrence. Assuming that dormant conduction is present in 50% of patients post PVI and symptomatic AF recurs in 45% of controls, 244 patients with dormant conduction will be required to obtain > 90% power to detect a difference of 20%. Thus, a total of 488 patients will be enrolled and followed for 12 months. Conclusion The ADVICE trial will assess whether a PVI strategy incorporating elimination of dormant conduction unmasked by intravenous adenosine will decrease the rate of recurrent symptomatic AF compared with standard PVI.
Summary Background Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by ...unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. We assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation. Methods We did this randomised trial at 18 hospitals in Australia, Europe, and North America. We enrolled patients aged older than 18 years who had had at least three symptomatic atrial fibrillation episodes in the past 6 months, and for whom treatment with an antiarrhythmic drug failed. After pulmonary vein isolation, intravenous adenosine was administered. If dormant conduction was present, patients were randomly assigned (1:1) to additional adenosine-guided ablation to abolish dormant conduction or to no further ablation. If no dormant conduction was revealed, randomly selected patients were included in a registry. Patients were masked to treatment allocation and outcomes were assessed by a masked adjudicating committee. Patients were followed up for 1 year. The primary outcome was time to symptomatic atrial tachyarrhythmia after a single procedure in the intention-to-treat population. The trial is registered with ClinicalTrials.gov , number NCT01058980. Findings Adenosine unmasked dormant pulmonary vein conduction in 284 (53%) of 534 patients. 102 (69·4%) of 147 patients with additional adenosine-guided ablation were free from symptomatic atrial tachyarrhythmia compared with 58 (42·3%) of 137 patients with no further ablation, corresponding to an absolute risk reduction of 27·1% (95% CI 15·9–38·2; p<0·0001) and a hazard ratio of 0·44 (95% CI 0·31–0·64; p<0·0001). Of 115 patients without dormant pulmonary vein conduction, 64 (55·7%) remained free from symptomatic atrial tachyarrhythmia (p=0·0191 vs dormant conduction with no further ablation). Occurrences of serious adverse events were similar in each group. One death (massive stroke) was deemed probably related to ablation in a patient included in the registry. Interpretation Adenosine testing to identify and target dormant pulmonary vein conduction during catheter ablation of atrial fibrillation is a safe and highly effective strategy to improve arrhythmia-free survival in patients with paroxysmal atrial fibrillation. This approach should be considered for incorporation into routine clinical practice. Funding Canadian Institutes of Health Research, St Jude Medical, Biosense-Webster, and M Lachapelle (Montreal Heart Institute Foundation).
Controversy exists about the impact of acute atrial fibrillation (AF) termination and prolongation of atrial fibrillation cycle length (AFCL) during ablation on long-term procedural outcome.
The ...purpose of this study was to analyze the influence of AF termination and AFCL prolongation on freedom from AF in patients from the STAR AF II (Substrate and Trigger Ablation for Reduction of Atrial Fibrillation Trial-Part II) trial.
Acute changes in AFCL and AF termination were collected during the index procedure of the STAR AF II trial and compared to recurrence of AF at 18 months. Recurrence was assessed by ECG, Holter (3, 6, 9, 12, 18 months), and weekly transtelephonic ECG monitoring for 18 months.
AF terminated in 8% of the pulmonary vein isolation (PVI) arm, 45% in the PVI+complex electrogram arm, and 22% of the PVI+linear ablation arm (P <.001), but freedom from AF did not differ among the 3 groups (P = .15). Freedom from AF was significantly higher in patients who presented to the laboratory in sinus rhythm (SR) compared to those without AF termination (63% vs 44%, P = .007). Patients with AF termination had an intermediate outcome (53%) that was not significantly different from those in SR (P = .84) or those who did not terminate (P = .08). AF termination was a univariable predictor of success (P = .007), but by multivariable analysis, presence of early SR was the strongest predictor of success (hazard ratio 0.67, P = .004). Prolongation of AFCL was not predictive of 18-month freedom from AF.
Acute AF termination and prolongation in AFCL did not consistently predict 18-month freedom from AF. Presence of SR before or early during the ablation was the strongest predictor of better outcome.
Abstract Purpose Catheter ablation of atrial fibrillation (AF) is now one of the most frequently performed ablation procedures, but there are currently 2 important challenges: achieving ...permanent/durable rather than transient pulmonary vein isolation (PVI) and improving the results of ablation for the wider patient population with persistent AF. Methods Recent technical advances in the technique of ablation and the results of clinical trials aimed at achieving more permanent and durable PVI are reviewed. We also summarize recent advances in identifying atrial fibrosis and in understanding the pathophysiology of AF relevant to selecting patients for ablation of persistent AF. Findings The use of contact force–sensing technology, adenosine testing after ablation, and pace capture–guided ablation all have the potential for achieving more durable ablation. Selection of patients suitable for ablation of persistent AF may be improved by assessing the extent of atrial fibrosis with delayed enhancement imaging with cardiac magnetic resonance or by assessing the pattern of atrial electrical activity with the use of complex atrial electrograms. Advances in treatment are likely to result from the recognition of localized rotors and focal sources as primary sustaining mechanisms for all types of human AF and in the use of noninvasive mapping for their identification. Linear ablation to supplement PVI may improve the results of AF ablation. Implications Rapidly unfolding advances in the techniques of AF ablation and the understanding of mechanisms of AF hold promise for improving the durability of PVI and for extending the technique to carefully selected patients with persistent AF.
Objectives This multicenter study sought to evaluate the long-term follow-up of patients ablated for idiopathic ventricular fibrillation (VF). Background Catheter ablation of idiopathic VF that ...targets ventricular premature beat (VPB) triggers has been shown to prevent VF recurrences on short-term follow-up. Methods From January 2000, 38 consecutive patients from 6 different centers underwent ablation of primary idiopathic VF initiated by short coupled VPB. All patients had experienced at least 1 documented VF, with 87% having experienced ≥2 VF episodes in the preceding year. Catheter ablation was guided by activation mapping of VPBs or pace mapping during sinus rhythm. Results There were 38 patients (21 men) age 42 ± 13 years, refractory to a median of 2 antiarrhythmic drugs. Triggering VPBs originated from the right (n = 16), the left (n = 14), or both (n = 3) Purkinje systems and from the myocardium (n = 5). During a median post-procedural follow-up of 63 months, 7 (18%) of 38 patients experienced VF recurrence at a median of 4 months. Five of these 7 patients underwent repeat ablation without VF recurrence. Survival free of VF was predicted only by transient bundle-branch block in the originating ventricle during the electrophysiological study (p < 0.0001). The number of significant events (confirmed VF or aborted sudden death) was reduced from 4 (interquartile range 3 to 9) before to 0 (interquartile range 0 to 4) after ablation (p = 0.01). Conclusions Ablation for idiopathic VF that targets short coupled VPB triggers is associated with a long-term freedom from VF recurrence.
Catheter Ablation for Atrial Fibrillation Weerasooriya, Rukshen, BMedSc(Hons), MBBS; Khairy, Paul, MD, PhD; Litalien, Jean, MD ...
Journal of the American College of Cardiology,
2011, Letnik:
57, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Objectives This study describes 5-year follow-up results of catheter ablation for atrial fibrillation (AF). Background Long-term efficacy following catheter ablation of AF remains unknown. Methods A ...total of 100 patients (86 men, 14 women), age 55.7 ± 9.6 years, referred to our center for a first AF ablation (63% paroxysmal; 3.5 ± 1.4 prior ineffective antiarrhythmic agents) were followed for 5 years. Complete success was defined as absence of any AF or atrial tachycardia recurrence (clinical or by 24-h Holter monitoring) lasting ≥30 s. Results Arrhythmia-free survival rates after a single catheter ablation procedure were 40%, 37%, and 29% at 1, 2, and 5 years, respectively, with most recurrences over the first 6 months. Patients with long-standing persistent AF experienced a higher recurrence rate than those with paroxysmal or persistent forms (hazard ratio HR: 1.9, 95% confidence interval CI: 1.0 to 3.5; p = 0.0462). In all, 175 procedures were performed, with a median of 2 per patient. Arrhythmia-free survival following the last catheter ablation procedure was 87%, 81%, and 63% at 1, 2, and 5 years, respectively. Valvular heart disease (HR: 6.0, 95% CI: 2.0 to 17.6; p = 0.0012) and nonischemic dilated cardiomyopathy (HR: 34.0, 95% CI: 6.3 to 182.1; p < 0.0001) independently predicted recurrences. Major complications (cardiac tamponade requiring drainage) occurred in 3 patients (3%). Conclusions In selected patients with AF, a catheter ablation strategy with repeat intervention as necessary provides acceptable long-term relief. Although most recurrences transpire over the first 6 to 12 months, a slow but steady decline in arrhythmia-free survival is noted thereafter.
Abstract Objectives The aim of this study was to perform a collaborative meta-analysis of published and unpublished quality-of-life, morbidity, and mortality data from randomized controlled trial ...comparisons of radiofrequency ablation (RFA) and antiarrhythmic drug therapy (AAD) in symptomatic atrial fibrillation. Background RFA is superior to AAD in decreasing recurrences of atrial fibrillation, but the effects on other clinical outcomes are not well established. Methods The primary investigators of eligible randomized controlled trials were invited to contribute standardized outcome data. Random-effects summary estimates were calculated as standardized mean differences and risk ratios with 95% confidence intervals for continuous and binary outcomes, respectively. Fixed effects were used in subgroup analyses. Results Twelve randomized controlled trials (n = 1,707) were included. RFA led to greater improvements in 4 36-Item Short Form Health Survey areas and the symptom frequency score from baseline to 3 months. In all quality-of-life metrics, there was a trend toward diminution of the differences between the 2 approaches with follow-up. There were 7 of 866 (5 in a study using phased RFA) and 0 of 704 strokes in the RFA and AAD arms, respectively (p = 0.02, Fisher exact test). Bleeding and mortality events were not significantly different between the 2 arms. There was high heterogeneity for hospitalizations, with decreased hospitalization risk with RFA when it was not first-line therapy (risk ratio: 0.34; 95% confidence interval: 0.24 to 0.46) and increased risk as first-line therapy (risk ratio: 1.22; 95% confidence interval: 1.03 to 1.45). Conclusions RFA demonstrates an early but nonsustained superiority over AAD for the improvement of quality of life. There are no obvious differences in other clinical outcomes, and the periprocedural stroke risk is non-negligible.
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