Background Left atrial appendage flow velocity (LAAFV) is a predictor of thromboembolism in atrial fibrillation (AF) patients, as well as CHA2 DS2 -VASc score. However, little is known about LAAFV in ...sinus rhythm (SR) after catheter ablation. The aim of this study was to determine clinical predictors of low LAAFV in patients in whom stable SR had been maintained after catheter ablation for persistent AF. Methods The study comprised 104 patients with persistent AF (median AF duration 24 months) in whom SR had been achieved and maintained for at least 6 months after the final ablation procedure. Transesophageal echocardiography was performed to assess LAAFV during SR after ablation. Lower LAAFV was defined as ≤40 cm/s. Results Mean LAAFV before ablation was 29 ± 11 cm/s (range 10-67 cm/s). In 23 (22%) patients, LAAFV remained low even after being in SR for at least 6 months. Multiple logistic regression analysis showed that CHA2 DS2 -VASc scores of ≥2 (odds ratio 2.18, 95% CI 1.19-3.99, P = .012) was an independent predictor of lower LAAFV after successful ablation. Seventeen (74%) of the 23 patients with low LAAFV during SR presented CHA2 DS2 -VASc scores of ≥2 complicated by spontaneous echo contrast during AF. Conclusions Long-term maintenance of SR after catheter ablation for persistent AF does not guarantee LAAFV recovery. The CHA2 DS2 -VASc score appears to predict poor recovery of LAAFV. Further studies are necessary to confirm the usefulness of LAAFV during SR as a surrogate marker predicting thromboembolism in patients after AF ablation.
Abstract Background Cardiac computed tomography (CT) provides accurate imaging of the pulmonary vein (PV) and left atrial (LA) anatomy. This study aimed to evaluate the prevalence and morphological ...characteristics of anatomical variants that could influence atrial fibrillation (AF) ablation procedures. Methods and results One thousand forty consecutive patients (62 ± 10 years, 243 female, 644 paroxysmal AF) undergoing pre-procedural imaging with a 320-row CT and their first AF ablation procedure were analyzed. A total of 194 (18.7%) patients had anatomical variants. Left, right, and inferior common PVs were observed in 118, 5, and 6 patients, respectively. Three right and left PVs were observed in 44 and 4 patients, respectively. Three patients had remnants of PVs after lobectomies, and significant PV stenosis was observed in one. Supernumerary PVs that drained into the LA and diverticula were observed in eight patients. One patient had a string-like structure connecting the LA septum and posterior LA, and the others had membranous structures incompletely compartmentalizing the LA. Three patients had persistent left superior vena cavae, two strong deviations of the LA and PVs, and one dexiocardia. All patients underwent successful PV isolation during the index procedure. Conclusions Patients referred for AF ablation often have anatomical variants, which could influence the procedure. This information might aid in planning procedural strategies, and reducing unexpected procedural complications in AF ablation.
Bilateral Diaphragmatic CMAPs During Cryoablation
Background
Left phrenic nerve injury (PNI) can occur during cryoballoon ablation of the left pulmonary veins (PVs). This study aimed to evaluate the ...feasibility of monitoring the bilateral phrenic nerve function during cryoballoon ablation of atrial fibrillation (AF).
Methods
Fifty consecutive paroxysmal AF patients undergoing cryoballoon ablation using one 28‐mm second‐generation balloon were prospectively enrolled. Bilateral diaphragmatic compound motor action potentials (CMAPs) were obtained from modified surface electrodes by pacing from the bilateral subclavian veins, and monitored during 3‐minute cryoballoon applications at the ipsilateral PVs.
Results
One hundred ninety of 202 PVs were successfully isolated exclusively using 28‐mm cryoballoons. CMAPs could be obtained in all except 3 cases with catheter inaccessibility in the left subclavian vein. The left and right CMAP amplitudes were similar at baseline (1.04 ± 0.41 mV vs. 1.01 ± 0.43 mV, P = 0.49). Among 105 left and 132 right PV applications while monitoring CMAPs, 2 (1.9%) and 13 (9.8%) applications were interrupted for a decreased CMAP amplitude (P = 0.01). Among them, CMAPs decreased due to right PNI in 4 applications/patients and to catheter dislodgement in the remaining applications. PNI remained in 1 and recovered in the remaining 3 patients one day after the procedure. Applications without requiring interruptions exhibited no significant CMAP amplitude changes throughout the applications, and the time‐course pattern was similar between the bilateral CMAPs (P = 0.292).
Conclusions
A stable bilateral diaphragmatic CMAP could be similarly obtained during cryoballoon applications in the vast majority of patients. Monitoring CMAPs might be useful to anticipate not only right but also left PNI during cryoballoon ablation.
An 18‐year‐old man without organic heart disease underwent catheter ablation for frequent monomorphic ventricular ectopic beats(VEBs). The origin of the VEB was presumed located on the left coronary ...cusp(LCC) regarding his electrocardiography. Local activation in the right ventricular outflow tract was not so early. On the LCC, four different prepotentials were obtained by slight relocation of the catheter. Finally, on the site with positive discrete prepotential recorded on the distal electrodes, an application of radiofrequency current immediately eliminated the VEB. Although LCC is considered as a small structure, detailed mapping may be important to find the most optimal ablation site.
Background
Pacemaker positioning on the right ventricular (RV) septum during implantation is conventionally conducted utilizing two fixed fluoroscopy angles, a 45° left anterior oblique (LAO) and 35° ...right anterior oblique projection. However, placement location can be suboptimal, especially for leadless pacemakers (LPMs).
Objective
To evaluate the safety and ease of LPM implantation using individualized LAO projection.
Methods
Consecutive patients undergoing LPM implantation were prospectively included. The angle of the RV septum was recorded for each patient by studying the angle at which an RV pigtail catheter (RV‐PC) could be seen edge on. This was then used as the preferred LAO projection angle for that patient. We evaluated the success rate and safety of this method. We also compared the RV septum angle as measured by this method versus that measured by chest CT.
Results
Of the 31 patients (mean age 80.6 ± 7.0 years, 15 females), LPM implantation was successful in 30. The pacemaker was implanted on the RV septum in 29 and on the free wall in one. LPM implantation was abandoned for anatomical reasons in one. Complications were limited to a groin arteriovenous fistula and one deep vein thrombosis. The angle of RV septum as measured by pigtail catheter and chest CT was not significantly different (CT: 54.8 ± 6.0°, RV pigtail catheter: 52.9 ± 6.1°, P = .07).
Conclusions
Using an RV‐PC to determine the preferred angle of LAO projection facilitates differentiation between the RV septum and free wall, which in turn facilitates optimal LPM placement.
In our study, we used a pigtail catheter to orient radiographic angle during leadless pacemaker implantation such that the interventricular septum would be on edge in the LAO projection. Employing this angle made it very easy for even our cardiology fellows in training to implant leadless pacemakers at the optimal site on the septum. To the best of our knowledge, this is the first time a right ventricular pigtail catheter has ever been used in this manner, and we feel that both physicians and patients would benefit from this simple maneuver, which we found to be safe and effective.
Abstract Background Chromosome 4q25 has been repeatedly identified as atrial fibrillation (AF)-sensitive locus in multiple genome-wide association studies (GWAS) and is considered to hold some clues ...to AF pathogenesis. We aimed to investigate the clinical utilities in Japanese and to unveil the function of the 4q25 locus in affecting transcription of adjacent genes. Methods We conducted AF GWAS in Japanese population (1382 AF cases and 1478 controls) and the replication panel (1666 AF cases and 1229 controls) with detailed clinical information which showed the acceleration of AF onset. Stepwise investigations with linkage disequilibrium analysis, histone code patterns, and reporter assay in the 4q25 locus were performed. Results The AF GWAS confirmed a significant association of rs4611994 and rs1906617 in chromosome 4q25 with AF. In the clinical analysis, AF onset of the individuals with risk allele accelerated 2.5 years compared with those with protective allele ( p = 0.00012). Next, in the functional analysis, three single nucleotide polymorphisms (SNPs) in the variant group selected by linkage disequilibrium analysis were identified as candidates for the cis -regulatory element toward adjacent genes in chromatin immunoprecipitation assay. Among them, rs4611994 and rs72900144 regions showed higher effects on the transcriptional activity of luciferase gene in the risk alleles than those in the protective alleles ( p < 0.0001, p < 0.005, respectively). Conclusions AF GWAS in Japanese confirmed the association with 4q25 locus and indicated that its SNP affected the acceleration of AF onset. The candidate regions of the causative SNPs, rs4611994 and rs72900144, could alter the adjacent gene expression level.
Background
The precise details of atrial activation around the triangle of Koch (ToK) remain unknown. We evaluated the relationship between the atrial‐activation pattern around the ToK and success ...sites for slow‐pathway (SP) modification ablation in slow‐fast atrioventricular reentrant tachycardia (AVNRT).
Methods
Thirty patients with slow‐fast AVNRT who underwent successful ablation were enrolled. Atrial activation around the ToK during sinus rhythm was investigated using ultra‐high‐density mapping pre‐ablation. The relationships among features of atrial‐activation pattern and success sites were examined.
Results
Of 30 patients (22 cryoablation; 8 radiofrequency ablation), 26 patients had a collision site of two wavefronts of delayed atrial activation within ToK, indicating a success site. The activation‐search function of Lumipoint software, which highlights only atrial activation with a spatiotemporal consistency, showed non‐highlighted area on the tricuspid‐annulus side of ToK. In 23 of the patients, a spiky potential was recorded at that collision site outside the Lumipoint‐highlighted area. Fifteen cryoablation patients with a success site coincident with a collision site outside the Lumipoint‐highlighted area had significantly more frequent disappearances of SP after initial cryoablation (46.7% vs. 0%, p = .029), fewer cryoablations (3.7 ± 1.8 vs. 5.3 ± 1.3, p = .045), and shorter procedure times (170 ± 57 vs. 228 ± 91 min, p = .082) compared to the seven cryoablation patients without such sites. Four patients had transient AV block by ablation inside the Lumipoint‐highlighted area with fractionated signals, but no patient developed permanent AV block or recurrence post‐procedure (median follow‐up: 375 days).
Conclusions
SP modification ablation at the collision site of atrial activation of the tricuspid‐annulus side along with a spiky potential could provide a better outcome.
Slow pathway modification ablation at the collision site of atrial‐activation pattern around the triangle of Koch along with a spiky potential could provide a better outcome in slow‐fast AVNRT.
Background: Although pulmonary vein (PV) antrum isolation is an established therapy for drug-resistant paroxysmal atrial fibrillation (PAF), long-term (>5 years) follow-up data are limited. This ...study investigated long-term clinical outcome of catheter ablation. Methods and Results: From September 2003 to August 2006, 161 patients (mean age, 60±9 years; 119 male) with symptomatic drug-refractory PAF who underwent extensive encircling PV isolation (EEPVI) with a double Lasso technique were included. Right-sided and left-sided circular lesions encircling the ipsilateral PVs were created. The procedure endpoint was electrical isolation of the PV antrum. Patients with recurrent atrial tachyarrhythmia (ATa) had their previous lesions assessed and consolidated. Trigger ablation was added if necessary. EEPVI was successfully performed at the initial procedure. During a median follow-up of 6.4 years (25th–75th percentile, 5.8–7.1 years), 86 patients (53.4%) had recurrent ATa. Among 78, 15 and 4 patients undergoing 2nd, 3rd and 4th procedures, PV reconnections were observed in 68, 10 and 2, respectively. During a median follow-up of 6.0 years (25th–75th percentile, 5.2–6.9 years) after a mean of 1.6±0.7 procedures per patient, 144 patients (89.4%) were free from ATa. No progression toward persistent AF was observed in any patients. Conclusions: The vast majority of drug-resistant PAF could be controlled by EEPVI without an additional atrial substrate modification. No progression toward persistent AF was observed during a median follow-up of 6 years. (Circ J 2013; 77: 2722–2727)
We report a rare case of a mobile ectopic calcification in the left atrium requiring surgical excision 9 years after multiple atrial fibrillation ablations. (Level of Difficulty: Intermediate.)
...Display omitted
PDF
