Because the left atrium (LA) and esophagus are adjacent to each other, collateral damage to the periesophageal vagal nerve after ablation of atrial fibrillation (AF) is not uncommon. 1 The left vagal ...nerve branches form a plexus anterior to the esophagus and control the esophageal and gastric motility, maintain a lower esophageal sphincter tone, and induce pyloric relaxation. The exact pathophysiologic mechanisms of vagal nerve injury are not well understood. Besides the direct thermic effects on neural action potentials, edema and hematomas (disruption of vessels supplying the esophageal wall and giving rise to necrosis) may cause local pressure on vagal nerve branches. ...in some cases, the esophageal probe itself may serve as an RF “antenna” and promote esophageal thermal injury.
Background:The number of patients undergoing cardiac resynchronization therapy has increased. Consequently, there is increased frequency in the removal and reimplantation of coronary venous (CV) ...leads due to infection or malfunction.Methods and Results:A total of 345 consecutive patients referred for lead(s) extraction were reviewed. Of these, 34 patients who underwent a CV lead removal were investigated. The indications for CV leads removal were device-related infections in 29 patients and lead malfunctions in 5 patients. The average duration of the CV leads was 4.1±3.8 years. All CV leads were successfully removed without any major complications, except for 1 in-hospital death. Successful CV lead removal by simple traction (ST) was achieved in 21 patients (62%), whereas extraction tools were required in 13 patients (38%). Local infection and CV lead dwell time were significantly associated with successful ST (P=0.04 and P=0.014, respectively). CV lead re-implantation was successfully performed in 25 patients; however, a right-side approach was required in 92%, and occlusion/stenosis of the previous CV was observed in 80% of the patients.Conclusions:CV lead removal is relatively successful and safe. The presence of local infection and a shorter lead duration may enable successful ST of a CV lead. However, the re-implantation procedure should be well prepared for the complexity related to the right-side approach and occlusion/stenosis of the previous CV.
Purpose
To determine the efficacy and identify the relevant factors for durable lesion creation in pulmonary vein isolation (PVI) using a high-power short-duration (HPSD) strategy.
Methods
Thirty-two ...consecutive patients who underwent PVI using HPSD (50 W) (HP group: HP-G) were compared with 32 controls using normal power (25–40 W) (conventional group: C-G). The segments were divided into 12 segments per group; thus, there were 768 segments for analysis. Radiofrequency (RF) ablation (RFA) was mainly performed under guidance with a unipolar electrogram at the distal tip of the ablation catheter in both groups. The high-power strategy reduced radiofrequency energy (
P
< 0.0001), RFA time (
P
< 0.0001), acute pulmonary vein reconnection (PVR) segments (
P
= 0.02), and several three-dimensional-mapping-related indices except for minimum impedance drop (Imp-min).
Results
There was a significant difference only in Imp-min between the subjects with acute PVR and those without in the HP-G (
P
= 0.002). Multivariate analysis revealed Imp-min to be the only independent predictor of the absence of PVR after adjusting for maximum inter-lesion distance and minimum ablation index (odds ratio OR 1.22, 95% confidence interval CI 1.07–1.39,
P
= 0.001). In the region-specific analysis, this was attenuated in posterior segments, where the HP strategy independently predicted the absence of PVR (OR 2.80 95% CI 1.32–6.30,
P
= 0.007).
Conclusion
The HPSD strategy reduced RF time, RF energy, and three-dimensional mapping-related indices but also improved the acute outcome. The HP strategy may be a sophisticated strategy under guidance with the impedance drop rather than the ablation index.
Introduction
Negative component abolition of the unipolar signal (unipolar signal modification USM) reflects the lesion transmurality. The purpose of this study was to compare the procedural safety ...and outcome between high‐power and conventional‐power atrial radiofrequency applications during a pulmonary vein isolation (PVI) using USM as a local endpoint.
Methods and Results
High‐power (50 W) and conventional‐power (25‐40 W) applications were compared among 120 consecutive patients with paroxysmal atrial fibrillation who underwent a USM‐guided PVI. The first 60 patients were treated with conventional‐power (CP) group and last 60 with high‐power (HP) group. The atrial radiofrequency applications lasted for 5 to 10 seconds (CP group) or 3 to 5 seconds (HP group) after the USM. All procedures were performed using 3D mapping systems with image integration and esophageal temperature monitoring. The baseline characteristics were similar between the two groups. The HP group had fewer acute PV reconnections (62% vs 78%; P = .046) and a reduced procedure time (119.3 ± 28.1 vs 140.1 ± 51.2 minutes; P = .04). Freedom from recurrence after a single ablation procedure without any antiarrhythmic drugs was higher in the HP group than CP group (88.3% vs 73.3% at 12‐months after the procedure, log‐rank; P = .0423). There were no major complications that required any intervention.
Conclusions
The high‐power PVI guided by USM decreased the procedural time and may improve the procedural outcomes without compromising the safety.
Atrial fibrillation (AF) ablation can improve left ventricular ejection fraction (LVEF) and renal function and can even reduce mortality in patients with impaired LVEF. However, the effect of ...post-ablation cardiorenal dysfunction on the prognosis of patients with impaired LVEF who underwent AF ablation remains unclear. Of the 1243 consecutive patients undergoing AF ablation, the prognosis of 163 non-dialysis patients who underwent AF ablation with < 50% LVEF was evaluated. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, and a need for modification of the treatment for heart failure. During the median follow-up of 4.2 years after the first AF ablation procedure, the primary outcome occurred in 30 of 163 patients (18%). The receiver operating characteristic curve analysis demonstrated that the post-LVEF (LVEF within 1 year after the procedure, and before the occurrence of primary outcome) had larger areas under the curve (0.70) than the pre-LVEF (LVEF before the procedure), and the most optimal cutoff value was LVEF ≤ 42%. Multivariate analysis demonstrated that patients with post-LVEF ≤ 42% and worsening renal function (WRF; an absolute increase in serum creatinine SCr ≥ 0.3 mg/dL compared with the SCr at baseline within 1 year after the procedure and before the occurrence of primary outcome) had a 3.4- to 4.3-fold and 3.4- to 3.7-fold higher risk of the primary outcome compared with those without these predictors, respectively. Patients were categorized using post-LVEF ≤ 42% and WRF as follows: group 1 (post-LVEF > 42% without WRF), group 2 (post-LVEF ≤ 42% without WRF), group 3 (post-LVEF > 42% with WRF), and group 4 (post-LVEF ≤ 42% with WRF). Group 4 had a 15.8-fold (
P
= 0.0001) higher risk of the primary outcome compared with group 1 after adjusting for pre-procedural factors. In patients with impaired LVEF undergoing AF ablation, post-LVEF ≤ 42% and WRF were independent predictors of poor prognosis. The combination of post-LVEF ≤ 42% and WRF is strongly associated with a poor prognosis in patients with AF undergoing ablation, who with these post-ablation cardiorenal dysfunction may have to be treated more intensively after AF ablation.
There are some cases that are difficult to cure with only circumferential pulmonary vein isolation (CPVI) of persistent atrial fibrillation (PerAF). Recently, prolonged interatrial conduction times ...(IACTs), which seem to be associated with progressive remodeled atria, have been reported as a predictor of new-onset AF. This study aimed to investigate the prognostic value of a prolonged IACT for predicting AF recurrences after CPVI of PerAF. One hundred thirteen patients who underwent CPVI without an empirical substrate modification of PerAF were retrospectively analyzed. The IACT was defined as the interval from the earliest P-wave onset on the ECG to the latest activation in the coronary sinus and was measured after achieving the CPVI and conversion to sinus rhythm. During a mean 22.7-month follow-up after the initial procedure, 56 patients (50%) had AF recurrences. Patients with AF recurrence had a longer IACT than those without AF recurrence (
p
< 0.001). The best discriminative cut-off value for the IACT was 123 ms (sensitivity 53%, specificity 85%). In a Cox multivariate analysis, a prolonged IACT of ≥ 123 ms was the only independent predictor (hazard ratio: 2.38; 95% confidence interval: 1.36–4.16,
p
= 0.002) of being associated with the incidence of an AF recurrence. Even after multiple CPVI procedures, patients with an IACT ≥ 123 ms had a higher AF recurrence rate than those with an IACT < 123 ms (
p
= 0.002). In conclusion, a prolonged IACT of ≥ 123 ms may be a useful marker for predicting AF recurrences after both initial and multiple CPVI procedures for PerAF.
•Cardiac resynchronization therapy (CRT) upgrade from right ventricular pacing in patients with mid-range left ventricular ejection fraction (LVEF) has not been established.•We evaluated the ...responses after CRT in mild heart failure patients with atrioventricular (AV) block.•The de novo CRT implantation improved left ventricular end systolic volume (LVESV) and LVEF in patients with reduced LVEF.•The CRT upgrade improved both LVESV and LVEF even in patients with mid-range LVEF.•CRT upgrade in AV block patients with mid-range LVEF can be an acceptable option.
Indication for de novo cardiac resynchronization therapy (CRT) has been recommended in mild heart failure (HF) patients with left ventricular (LV) ejection fraction (LVEF) <50% and atrioventricular block (AVB). In contrast, the indication of CRT upgrade from right ventricular pacing (RVP) has been limited to severe HF patients with LVEF≤35% and AVB. This study examined LV volumetric responses and clinical outcomes in mild HF patients with AVB who underwent CRT upgrade, compared with those of de novo CRT patients.
This retrospective study focused on patients with CRT due to AVB, mild HF at New York Heart Association class II and LVEF<50%. A total of 58 patients were divided into two groups: (1) 27 patients with CRT upgrade from RVP>40% (Upgrade group, UG), and (2) 31 patients with de novo CRT implantation (De novo group, DG). The echocardiographic assessment was performed at baseline and six months after CRT. The study endpoint was a combined endpoint with total mortality, HF hospitalization, or ventricular tachyarrhythmia events.
At six months after CRT, the LV end-systolic volume (LVESV) was significantly reduced in both groups (from 144.3±39.4 mL to 111.1±33.5 mL in UG, p<0.01; from 134.5±36.6 mL to 123.5±45.6 mL in DG, p<0.05); however, a significant improvement in LVEF was obtained in UG but not in DG (from 31.7±6.8% to 39.7±8.5% in UG, p<0.01; from 34.2±7.3% to 36.0±9.7% in DG, p=0.15). Consequently, the changes in LVESV and LVEF were significantly greater in UG than in DG. During the follow-up of 989 days, the survival rate for the composite events were similar between both groups (p=0.18).
LV reverse remodeling was significantly greater in UG than DG, and the incidence of clinical composite events at mid-term follow-up was equivalent between UG and DG. CRT upgrade could be an acceptable indication in mild HF patients dependent on RVP.
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The safety and efficacy of an empiric superior vena cava isolation (SVCI) in addition to circumferential pulmonary vein isolation (CPVI) in patients with paroxysmal atrial fibrillation (PAF) have not ...been clarified. A total of 186 consecutive patients who underwent catheter ablation of PAF were included. All patients underwent a CPVI. Patients in the first half underwent an additional SVCI only if SVC-triggered AF or rapid SVC activity was observed during the procedure (n = 93, as-needed SVCI, group I), and those in the second half underwent an empirical SVCI after the CPVI (n = 93, empiric SVCI, group II). The CPVI was successfully performed in all patients. An SVCI was performed in 8 of 93 patients (9%) in group I and 81 of the 93 patients (87%) in group II. In the remaining 12 patients in group II, an SVCI was not performed because of the lack of SVC potentials. During a mean follow-up of 27 ± 12 months, the atrial tachyarrhythmia recurrence rate after a single ablation procedure in the patients in group II was lower than that in group I (44% vs 23%, p = 0.035). A Cox regression multivariate analysis demonstrated that an empiric SVCI was an independent predictor of an atrial tachyarrhythmia recurrence after a single ablation procedure (odds ratio: 0.57, 95% confidence interval 0.31 to 0.999; p = 0.049). Neither sinus node injury nor any injury to the phrenic nerve was observed. In conclusion, an empiric SVCI in addition to the CPVI improved the outcome of AF ablation in patients with PAF without any additional adverse effects.
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