Atrial fibrillation (AF) occurs frequently after mitral valve (MV) surgery. This study aims to evaluate the efficacy and long-term clinical outcomes after the first AF ablation in patients with prior ...MV surgery.
Sixty consecutive patients with a history of MV surgery without MAZE referred to three European centers for a first AF ablation between 2007 and 2017 (group 1) were retrospectively enrolled. They were matched (propensity score match) with 60 patients referred for AF ablation without prior MV surgery (group 2).
After the index ablation, 19 patients (31.7%) from group 1 and 24 (40%) from group 2 had no recurrence of atrial arrhythmias (ATa) (
= 0.3). After 62 (48-84) months of follow-up and 2 (2-2) procedures, 90.0% of group 1 and 95.0% of group 2 patients were in sinus rhythm (
= 0.49). In group 1, 19 (31.7%) patients had mitral stenosis, and 41 (68.3%) had mitral regurgitation. Twenty-seven (45.0%) patients underwent mechanical valve replacement and 33 (55.0%) MV annuloplasty. At the final follow-up, 28 (46.7%) and 33 (55.0%) patients were off antiarrhythmic drugs (
= 0.46). ATa recurrence was seen more commonly in patients with prior MV surgery (54 vs. 22%, respectively,
< 0.05). No major complication occurred.
Long-term freedom of atrial arrhythmias after atrial fibrillation catheter ablation is achievable and safe in patients with a history of mitral valve surgery. In AF patients without a history of mitral valve surgery, repeated procedures are needed to maintain sinus rhythm.
Prior reports using pacing manoeuvres, demonstrated an up to 42% prevalence of residual pulmonary vein to left atrium (PV-LA) exit conduction after apparent LA-PV entry block. We aimed to determine ...in a two-centre study the prevalence of residual PV-LA exit conduction in the presence of unambiguously proven entry block and without pacing manoeuvres.
Of 378 patients, 132 (35%) exhibited spontaneous pulmonary vein (PV) potentials following circumferential PV isolation guided by three-dimensional mapping and a circular mapping catheter. Pulmonary vein automaticity was regarded as unambiguous proof of LA-PV entry block. We determined the prevalence of spontaneous exit conduction of the spontaneous PV potentials toward the LA. Pulmonary vein automaticity was observed in 171 PVs: 61 right superior PV, 33 right inferior PV, 47 left superior PV, and 30 left inferior PV. Cycle length of the PV automaticity was >1000 ms in all cases. Spontaneous PV-LA exit conduction was observed in one of 171 PVs (0.6%). In a subset of 69 PVs, pacing from within the PV invariably confirmed PVLA exit block.
Unidirectional block at the LA-PV junction is unusual (0.6%). This observation is supportive of LA-PV entry block as a sufficient electrophysiological endpoint for PV isolation.
The mechanisms of the atrial contractile dysfunction induced by atrial fibrillation (AF) are not completely understood. In particular, the relation between the atrial dysfunction and electrical ...remodeling has not yet been studied.
Seven goats were chronically instrumented with electrodes sutured to the atria and with ultrasonic piezoelectric crystals to record the atrial diameters. A pressure transducer was implanted in the right atrium. After 5 minutes, 3 hours, and throughout the first 5 days of artificially maintained AF, atrial contractile function was measured and the atrial effective refractory period (AERP) was monitored for comparison. Also, the positive inotropic effects of the L-type Ca2+-channel agonist BayY5959 and short trains of rapid atrial pacing were studied. After resumption of sinus rhythm, the recovery of atrial contractile function was followed. After 5 minutes of AF, atrial contractility was decreased by approximately 55% but recovered completely within 10 minutes. Five days of AF nearly completely abolished the atrial contractile function, and recovery took 2 days. During the first days of AF, the development of the contractile dysfunction followed the same time course as the shortening of AERP (electrical remodeling). In remodeled atria, BayY5959 increased atrial contractility to the same extent as it prolonged AERP. The inotropic effect of short trains of rapid atrial pacing was similar in normal and remodeled atria.
Depending on the duration of AF, different mechanisms contribute to the AF-induced atrial hypocontractility. Atrial contractile remodeling during several days of AF goes hand in hand with electrical remodeling and might be caused by a reduction of the L-type Ca2+-current.
The risk of pulmonary vein narrowing (PVN) after pulmonary vein isolation, using a novel multi-electrode ablation catheter, is unknown.
Left atrial volume and PV diameters were compared by computed ...tomography (CT) before and 3 months after pulmonary vein isolation using duty-cycled phased radio frequency energy (2:1 or 4:1 bipolar/unipolar ratio) in 50 patients. Pulmonary vein diameter was measured in a coronal and axial view at 3 levels (A, ostium; B, 1 cm more distal; C, 2 cm more distal). Moderate PVN was defined as a pulmonary vein diameter reduction of 25 to 50%, and severe PVN as >50%. Left atrial volume decreased by 12±12% (P<0.01). Axial pulmonary vein diameter shortened by a median of 16% (interquartile range IQR 28 to 5%), 13% (IQR 25 to 5%), and 9% (IQR 21 to -3%) at level A, B, and C, respectively (P<0.01 for all); coronal pulmonary vein diameter decreased by a median of 16% (IQR 24 to 7%), 11% (IQR 21 to 4%), and 8% (IQR 18 to -2%; P<0.01 for all). Moderate PVN occurred in 30% of the PVs, in 78% of the patients; severe PVN occurred in 4% of the PVs, in 15% of the patients. PV diameter reduction was not related to changes in left atrial volume.
Isolation of the pulmonary veins using a multielectrode ablation catheter and duty cycled phased radiofrequency energy delivery results in a consistent moderate reduction of the PV diameters predominantly at the ostium. Severe PVN in 15% of patients raises concerns about the risk for clinical PV stenosis.
Time delay between onset of symptoms and seeking medical attention is a major determinant of mortality and morbidity in patients with acute coronary artery occlusion. Response time might be reduced ...by reliable self-detection. We aimed to formally assess the proof-of-concept and accuracy of self-detection of acute coronary artery occlusion by patients during daily life situations and during the very early stages of acute coronary artery occlusion.
In this multicentre, observational study, we tested the operational feasibility, specificity, and sensitivity of our RELF method, a three-lead detection system with an automatic algorithm built into a mobile handheld device, for detection of acute coronary artery occlusion. Patients were recruited continuously by physician referrals from three Belgian hospitals until the desired sample size was achieved, had been discharged with planned elective percutaneous coronary intervention, and were able to use a smartphone; they were asked to perform random ambulatory self-recordings for at least 1 week. A similar self-recording was made before percutaneous coronary intervention and at 60 s of balloon occlusion. Patients were clinically followed up until 1 month after discharge. We quantitatively assessed the operational feasibility with an automated dichotomous quality check of self-recordings. Performance was assessed by analysing the receiver operator characteristics of the ST difference vector magnitude. This trial is registered with ClinicalTrials.gov, number NCT02983396.
From Nov 18, 2016, to April 25, 2018, we enrolled 64 patients into the study, of whom 59 (92%) were eligible for self-applications. 58 (91%) of 64 (95% CI 81·0-95·6) patients were able to perform ambulatory self-recordings. Of all 5011 self-recordings, 4567 (91%) were automatically classified as successful within 1 min. In 65 balloon occlusions, 63 index tests at 60 s of occlusion in 55 patients were available. The mean specificity of daily life recordings was 0·96 (0·95-0·97). The mean false positive rate during daily life conditions was 4·19% (95% CI 3·29-5·10). The sensitivity for the target conditions was 0·87 (55 of 63; 95% CI 0·77-0·93) for acute coronary artery occlusion, 0·95 (54 of 57; 0·86-0·98) for acute coronary artery occlusion with electrocardiogram (ECG) changes, and 1·00 (35 of 35) for acute coronary artery occlusion with ECG changes and ST-segment elevation myocardial infarction criteria (STEMI). The index test was more sensitive to detect a 60 s balloon occlusion than the STEMI criteria on 12-lead ECG (87% vs 56%; p<0·0001). The proportion of total variation in study estimates due to heterogeneity between patients (I
) was low (12·6%). The area under the receiver operator characteristics curve was 0·973 (95% CI 0·956-0·990) for acute coronary artery occlusion at different cutoff values of the magnitude of the ST difference vector. No patients died during the study.
Self-recording with our RELF device is feasible for most patients with coronary artery disease. The sensitivity and specificity for automatic detection of the earliest phase of acute coronary artery occlusion support the concept of our RELF device for patient empowerment to reduce delay and increase Survival without overloading emergency services.
Ghent University, Industrial Research Fund.
Abstract Background Delayed medical attendance is a leading cause of death in patients with ST elevation myocardial infarction (STEMI). Methods We aimed to introduce, develop, and validate a novel ...method (RELF method) for detection of transmural ischemia based on a new and easy-to-use 3-lead configuration and orthonormalization of ST reference vectors (STDVN ). The study included 60 patients undergoing coronary artery occlusion (CAO) during balloon inflation and 30 healthy subjects. Results STDVN was significantly different and an optimal discriminator between CAO patients and healthy subjects (respectively 8.00 ± 4.50 vs. 1.90 ± 0.86 normalized units, p < 0.001). Compared to the 12-lead ECG, the RELF method was sensitive (90 vs. 73%, p = 0.13) and more specific (91 vs. 75%, p < 0.001). Conclusions The RELF method is highly accurate for early detection of acute occlusion related ischemia and it outperforms the conventional 12-lead ECG criteria for STEMI. This method provides a platform for self-detection of CAO with handheld devices or smart phones.
This study sought to evaluate the safety and the acute and 1 year outcomes of an ablation protocol aiming to enclose the PV with a contiguous and optimized RF circle by targeting region-specific ...criteria for lesion depth assessed by ablation index and interlesion distance.
Reconnections after pulmonary vein (PV) isolation are explained by insufficient lesion depth and/or discontiguity of radiofrequency (RF) lesions.
A total of 130 consecutive patients with paroxysmal atrial fibrillation (AF) underwent PV encircling using a contact force-sensing catheter. RF was delivered targeting interlesion distance ≤6 mm and ablation index ≥400 at posterior wall and ≥550 at anterior wall. Recurrence was defined as any AF, atrial tachycardia (AT), or atrial flutter (AFL) (AF/AT/AFL >30 s) on Holter electrocardiographs at 3, 6, and 12 months.
Procedure and RF time per circle were 155 ± 28 min and 17 ± 5 min, respectively. Incidence of first-pass and adenosine-proof isolation were 98% and 98%, respectively. One short-lived transient ischemic attack was observed. At 12 months, single-procedure freedom from AF/AT/AFL was 91.3% in those 104 patients off antiarrhythmic drug therapy and 96.2% in those 26 patients on antiarrhythmic drug therapy. Single-procedure freedom from both AF/AT/AFL and antiarrhythmic drug therapy was 73.1%.
This study suggests that an ablation protocol respecting strict criteria for lesion depth and contiguity results in acute durable PV isolation followed by a high single-procedure arrhythmia-free survival at 1 year. A prospective, multicenter trial is ongoing.
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