Background:The aim of this study was to identify the ECG features that might differentiate between anterior interventricular vein (AIV) and distal great cardiac vein (d-GCV) outflow tract-ventricular ...arrhythmias (OT-VAs).Methods and Results:Radiofrequency catheter ablation was performed in 13 of 375 patients (3.5%) for AIV or d-GCV OT-VAs. We grouped the 13 patients by the origin, d-GCV (n=9) or AIV (n=4), and compared their ECGs and electrophysiological data. The OT-VA ECGs had S waves in lead I in all 13 patients. The voltage in the inferior lead III and peak deflection index showed no significant between-group differences (2.3±0.7 vs. 2.5±0.3 mV and 0.65±0.04 vs. 0.68±0.04 mV, respectively) for the d-GCV and AIV groups. There were also no significant between-group differences in the QaVL/QaVR, where Q denotes the amplitude of the Q wave in the suffix lead. However, the R/S ratio in V1 (1.7±1.0 n=5 vs. 0.2±0.05, P=0.04), and QRS duration (149±16.6 vs. 123±3.8 ms, P=0.012) were greater in the d-GCG group than in the AIV group. There were no significant between-group differences in the activation time or pace mapping score at the optimal ablation sites.Conclusions:A low R/S ratio in V1 and shorter QRS duration may help identify AIV sites of epicardial OT-VA origin. (Circ J 2015; 79: 2335–2344)
It is unclear whether the electrocardiogram amplitude in the inferior leads (Amp-I) can always predict the height of the origin of right ventricular outflow tract arrhythmias (RVOT-VAs). We analyzed ...patients who received catheter ablation of multiple RVOT-VAs in the same session in our hospital from 2011 to 2016. Two distinguished RVOT-VAs, those with anatomically higher origins (HOs) and lower origins (LOs), were identified and compared to measure the longitudinal distance. Amp-I was uniquely determined for each OTVA as the highest amplitude in leads II, III, and aVF and compared between the HO-VAs and LO-VAs. In total, out of 187 patients who underwent catheter ablation of RVOT-VAs, 9 (4.8%) had multiple right OTVAs successfully treated. Four cases (Group A) had HO-VAs (10.8 ± 5.3 mm from an LO) with a lower Amp-I (1.28 ± 0.46 mV) than the LO-VAs (1.81 ± 0.59 mV), whereas the other 4 patients (Group B) had HO-VAs with a higher Amp-I (1.91 ± 0.23 mV) than the LO-VAs (1.26 ± 0.35 mV). In Group A, all HO-VAs originated from the lateral free wall and had notched R waves in the inferior leads, whereas all LOs with higher Amp-Is were located on the septum. In one patient, the HO and LO were at almost the same height, while a VA from a lateral origin had lower notched R waves in the inferior leads. A divided excitation from high lateral origins may result in not only QRS notching, but also a reduction in the QRS amplitude. In patients harboring multiple RVOT-VAs, VAs arising from the high lateral free wall could have lower Amp-Is than VAs from low septal origins.
Background
The reported incidence of phrenic nerve injury (PNI) varies owing to different definitions, balloon generations, balloon size, freezing regimen, and protective maneuvers. We evaluated the ...incidence, predictors, and outcome of PNI during cryoballoon pulmonary vein isolation in a large population.
Methods and Results
Five hundred fifty atrial fibrillation patients underwent pulmonary vein isolation using one 28‐mm second‐generation cryoballoon and single 3‐minute freeze strategy under diaphragmatic compound motor action potential (CMAP) monitoring. A total of 34 (6.2%) patients experienced PNI during the right superior and inferior pulmonary vein ablation in 30 and 4 patients, respectively. Applications were interrupted using double‐stop techniques after 136 104–158 second applications, and a pulmonary vein isolation was already achieved in all but one case. The baseline CMAP amplitude and timing of deflation (CMAPdef) were 0.75±0.30 and 0.17±0.17 mV, respectively. Persistent atrial fibrillation, larger right superior pulmonary vein ostia, and deeper balloon positions were associated with higher incidences of PNI. The CMAPdef predicted a PNI recovery delay, and the best cutoff value for predicting PNI recovery by the next day was 0.20 mV (sensitivity 57.1%, specificity 100%). Among 6 patients undergoing second procedures 8.5 (6.7–15.0) months later, the right superior pulmonary vein was durable in 3 with >120 second applications. Despite active balloon deflation, no significant pulmonary vein stenosis was observed in 15 right superior pulmonary veins evaluated 6 (5–9) months later. No patients had symptoms, and the PNI recovered 1 day and 1 month postprocedure in 21 and 4 patients, respectively.
Conclusions
PNI resulting from cryoballoon ablation was reversible. The double‐stop technique is safe, and immediate active deflation following a CMAP decrease appears to be essential for faster PNI recovery.
Background:Deep sedation or general anesthesia is generally used during atrial fibrillation (AF) ablation. The aim of this study was to report the safety and feasibility of minimal sedation during AF ...ablation.Methods and Results:One thousand and fifty-two AF ablation procedures in 819 patients (62±11 years, 621 men, 506 paroxysmal) were included. Boluses of intravenous hydroxyzine pamoate and pentazocine were administered, with a maximal dose of 100 mg of hydroxyzine and 60 mg of pentazocine in response to pain. If the pain was intolerable or patients requested deeper sedation, moderate sedation using dexmedetomidine or propofol was introduced. Among 819 consecutive first procedures, the procedure was completed under minimal sedation in 795 (97.1%) patients without inotropic drugs or respiratory support, whereas in 20 (2.4%) patients, anesthesia was switched to moderate sedation due to pain. Patients requiring a switch to moderate sedation were significantly younger than those without (53.6±2.3 vs. 62.6±10.4, P<0.01). No procedures were abandoned due to adverse effects of sedation. Significant intra-procedural blood pressure decreases requiring inotropic drugs were not observed in any patients. Among 233 patients who underwent repeat procedures, 6 (2.6%) requested moderate sedation before the procedure. The mean procedure time was 151±54 min. Cardiac tamponade, unrelated to sedation, was observed in 7 (0.66%) procedures.Conclusions:Minimal sedation might be acceptable anesthesia in the vast majority of AF ablation procedures performed in electrophysiological laboratories. (Circ J 2015; 79: 346–350)
We investigated the electrocardiographic (ECG) and electrophysiologic characteristics of ventricular tachycardia (VT) originating within the pulmonary artery (PA).
Radiofrequency catheter ablation ...(RFCA) is routinely applied to the endocardial surface of the right ventricular outflow tract (RVOT) in patients with idiopathic VT of left bundle branch block morphology. It was recently reported that this arrhythmia may originate within the PA.
Activation mapping and ECG analysis were performed in 24 patients whose VTs or ventricular premature contractions (VPCs) were successfully ablated within the PA (PA group) and in 48 patients whose VTs or VPCs were successfully ablated from the endocardial surface of the RVOT (RV-end-OT group).
R-wave amplitudes on inferior ECG leads, aVL/aVR ratio of Q-wave amplitude, and R/S ratio on lead V2were significantly larger in the PA group than in the RV-end-OT group. On intracardiac electrograms, atrial potentials were more frequently recorded in the PA group than in the RV-end-OT group (58% vs. 12%; p < 0.01). The amplitude of local ventricular potentials recorded during sinus rhythm within the PA was significantly lower than that recorded from the RV-end-OT (0.62 ± 0.56 mV vs. 1.55 ± 0.88 mV; p < 0.01).
Ventricular tachycardia originating within the PA has different electrocardiographic and electrophysiologic characteristics from that originating from the RV-end-OT. When mapping the RVOT area, the catheter may be located within the PA if a low-voltage atrial or local ventricular potential of <1-mV amplitude is recorded. Heightened attention must be paid if RFCA is required within the PA.
Persistent iatrogenic atrial septal defects (iASDs) can be observed after intervention requiring a left atria (LA) access, including pulmonary vein isolation (PVI) of atrial fibrillation (AF). We ...investigated the incidence of iASDs post-second-generation cryoballoon ablation and the pre-procedural predictors. Eighty-three paroxysmal AF patients underwent PVI using second-generation cryoballoons. The LA was accessed with single 15-Fr steerable sheaths following a radiofrequency transseptal puncture, and the iASD was evaluated with transthoracic echocardiography (TTE), a median of 9.3 (7.1–13.3) months post-procedure. All patients underwent pre-procedural contrast-enhanced multi-detector computed tomography (CT) to evaluate the LA and PV anatomy. iASDs were detected by TTE in 7 (8.4%) patients, a median of 15.5 (6.8–17.3) months post-procedure. Patients with iASDs had significantly larger LA volumes and smaller atrial septal angles, defined as the angle between the atrial septum and sagittal line on the horizontal section at the height of the fossa ovalis, which could be the transseptal puncture site measured on CT, and more likely hypertension than those without. Multivariate analyses revealed that the atrial septal angle was the sole predictor of iASDs odds ratio 0.764, 95% confidence interval (CI) 0.624–0.935,
p
= 0.009, and the optimal cut-off value was 57.5° (sensitivity 85.7%, specificity 88.2%, 95% CI 0.873–0.995,
p
< 0.0001). Patients with iASDs were asymptomatic and had no adverse clinical events during a 17.7 (14.4–25.8) month median follow-up. iASDs were still detectable in 8.4% of patients a median of 15.5 months after the second-generation CB ablation, and the atrial septal angle might aid in predicting persistent iASDs.
Background: The prevalence, gender- and age-related differences, ablation success rate and inter-relationship between the origins of the idiopathic ventricular arrhythmias (I-VA) have not been ...clarified. Methods and Results: A total of 625 consecutive patients with symptomatic, drug resistant I-VA (315 males and 310 females; mean age, 54±17 years; 218 ventricular tachycardias, 407 premature ventricular contractions) who underwent catheter ablation were studied. The patients were divided into 5 groups based on the VA origin: (1) outflow tract (OT)-VA, consisting of right ventricular (RV) OT-VA and left ventricular (LV) OT-VA; (2) inflow tract (IT)-VA, consisting of tricuspid annulus (TA)-free wall (FW)-VA, IT-septum-VA, and mitral (MA)-FW-VA; (3) LV-inferoseptum-VA; (4) LV-other-VA; and (5) RV-other-VA. RVOT-VA in women were 1.5 times more frequent than in men, while LVOT-VA were more frequent in men. The prevalence of LVOT origin I-VA increased with age compared to that for the RVOT. The mean age of MA-FW-VA patients (62±14 years) was higher than that of TA-FW-VA patients (51±18 years; P=0.03). The ablation success rate for RVOT-VA (88%) was higher than that for LVOT-VA (58%; P<0.0001). A multivariate analysis revealed that the patient age was one of the valuable predictors of a successful ablation (odds ratio=0.97; 95% confidence interval: 0.95-0.99; P=0.007). Conclusions: Distinct gender and age differences were found in the incidence of I-VA according to their site of origin. (Circ J 2011; 75: 1585-1591)
Background:Clinical outcomes after atrial fibrillation (AF) ablation are evaluated using standard 24-h Holter monitoring, and the large spontaneous variability of AF episodes and incidence of silent ...AF are major limitations. Further, symptoms generally decrease after AF ablation.Methods and Results:Newly developed extended external auto-trigger loop recorders (ELR) were used for 14-day consecutive monitoring to detect atrial tachyarrhythmia (ATa). Continuous tracings were stored for the initial 24h. Among 500 examinations after AF ablation in 342 patients, 40 ATa episodes were manually detected in 25 patients during the initial 24h. All episodes including 27 asymptomatic episodes (67.5%) were successfully identified using ELR. Recurrent ATa after AF ablation were detected in 83 patients, and a median monitoring duration of 4.0 days (IQR, 1.0–7.75 days) was required to detect the first episode of recurrence. The sensitivity of 24-h monitoring in detecting arrhythmia recurrence was 27.7% relative to the 14-day monitoring. The diagnostic yield gradually improved with longer monitoring duration regardless of the period after the ablation procedure. Longer follow-up, however, was required to obtain similar diagnostic yield >1 year after as compared to <1 year after the procedure.Conclusions:Twenty-four-hour monitoring detected a part of the ATa recurrences after ablation procedures. Extended ELR enabled arrhythmia monitoring for longer, with higher diagnostic yield of recurrence, regardless of patient symptoms. (Circ J 2014; 78: 2637–2642)
•Flexible irrigation-tip catheter is superior than rigid-tip catheter in CTI ablation.
Clinical utility of irrigation-tip ablation catheters for cavo-tricuspid isthmus (CTI) ablation is established. ...Recently, new-generation enhanced-cooling irrigation-tip catheters were introduced into clinical use. This study compared the performance of different types of novel irrigation-tip catheters in CTI ablation.
One hundred patients undergoing CTI ablation with novel irrigated-tip catheters were included. Ablation was performed with a power output of 30–35W using either 4-mm flexible tip catheters FlexAbility (FAs) St. Jude Medical, St. Paul, MN, USA or 3.5-mm enhanced-cooling ring-tip catheters without ThermoCool SurroundFlow (SFs), Biosense Webster, Diamond Bar, CA, USA and with contact force sensing ThermoCool SmartTouch SurroundFlow (STSFs), Biosense Webster in 32, 34, and 34 patients, respectively.
The successful CTI block creation rate was significantly higher for FAs than SFs/STSFs 32/32 (100%), 30/34 (88.2%), and 27/34 (79.4%), p=0.006. In all 11 failed procedures, block was created by additional 5 (2–7) applications with 8-mm tip catheters. The radiofrequency (RF) application number (p=0.001) and energy (p=0.021) were significantly lower, and total RF time (p=0.005) and procedure time (p=0.036) significantly shorter in the FA than SF/STSF groups. The FA catheter was associated with significantly higher tip temperature readings (34.9°C vs. 32.0/33.0°C, p<0.001) and lower initial impedances than SF/STSF catheters (both p<0.001). The tip temperature reached the maximum temperature setting in 15/295 (5.1%) FA catheter applications among 11 (34.3%) patients, 0/521 (0%) ST applications, and 0/448 (0%) STSF applications. The mean RF power achieved during RF applications was significantly lower for FA than SF/STSF catheters (28.6W vs. 30.4/30.8W, p<0.001). Audible steam pops were detected in 1/448 applications in only the STSF group.
In human CTI ablation, flexible irrigation-tip catheters showed a significantly better performance than rigid enhanced-cooling irrigation-tip catheters.
PDF
