Abstract Introduction Growing interest has emerged around cardiac autonomic nervous system driven by ablation approaches for the treatment of neurally-mediated syncope (NMS). Ganglionated-plexi (GPs) ...located in the epicardial fat pads are the main target of ablative therapies, but little is known about the finest method to track their location from the endocardium. Most current techniques rely on empirical research of signal fragmentation and/or vagal response at anatomical landmarks. A poor accuracy in targeting GPs may lead to the risk of incomplete or over-extensive ablation. Purpose We analyzed the atrial electrograms (EGMs) in healty subjects and their response to atropine to describe physiological fragmentation and the relationship with vagal output. Methods Study partecipants were selected from young patients without structural heart desease who underwent electrophysiological study (EPS) for standard indications. High-density mapping of right atrium was performed before and after administration of 2 mg atropine at the end of the planned procedure. Offline analyses were performed comparing the two maps of each patient focusing on the fragmentation of the atrial EGMs. Results The study cohort comprised 10 patients (mean age of 39±11 years, 6 males). The indication for EPS was: supraventricular tachycardia (SVT) ablation in 9 patients, syncope in 1 patient. High density three-dimensional electro-anatomic maps (EAM) were all obtained with a multipolar catheter during sinus rhythm (number of points: 8794±937 in basal maps and 9007±1296 after atropine, p=0,87). The response to atropine was documented by an increase in heart rate (mean increase 59 ± 19% of basal cycle length). All basal maps showed a similar pattern of fragmentation in the posterior-septal wall reflecting the anatomical distribution of right GPs. In particular, three main stations were identified in the supero-, mid- and infero-posterior regions. Fragmentation of EGMs was found to progress from the edge to the core of each area. After administration of atropine, a reduction in fractionated area was observed in all patients. Filtering the maps according to a cut-off of fragmentation ≥ 6 peaks allowed identification of the nucleus with the highest degree of variation after atropine injection (mean basal area = 0,89 ± 0,81 cm2 ; mean atropine area = 0,44 ± 0,56 cm2 p<0,001). Conclusion Fragmentation of atrial electrograms is a dynamic property related to vagal output. High density mapping with a high pass filter of 6 peaks allows to identify the smallest vagal sensitive area in the anatomical stations of the GPs.
Abstract Background Implantable Loop Recorder (ILR) has various indications for monitoring patients in different clinical settings. Most studies focus on a single indication without comprehensively ...evaluating the clinical impact of ILR. This study aims to retrospectively review a single experience regarding the actual role of ILR. Methods Patients were enrolled from March 2015 to April 2023 due to: syncope of unknown etiology, embolic stroke of undetermined source (ESUS), palpitation, monitoring of arrhythmias in Brugada syndrome (BrS), and following a pulmonary vein isolation (PVI). A change in the clinical course (cardiac implantable electrical devices (CIEDs) implantation, start of anticoagulation therapy, execution of an electrophysiologic study, ablation for tachyarrhythmias or PVI ablation) due to an ILR finding was considered as the primary endpoint. An unexpected result was defined as a different clinical finding from the expected for the cause of ILR implantation (ex. the finding of an atrioventricular block in a patient implanted for ESUS). Results 130 patients of which 58 (44%) were females with a mean age of 58 ± 6 years were enrolled. The indication for implant resulted to be ESUS (25/130, 19%), syncope (38/130, 29%), palpitation (18/130 14%), BrS (24/130 28%), or after PVI follow–up (25/130 20%). A change in clinical course was reached in 44 (33%) patients after 12 ± 8 months of follow–up. Ten (8%) patients had a double event. The change of the clinical course was more frequent in female sex than in males (26/58 45% vs. 18/72 25% patients, p =0.025). In patients with syncope, a CIED was implanted in 7 (24 %) patients but interestingly 7 tachyarrhythmias events (5 AF and 2 SVT) were incidentally detected. In the stroke group, 6 (24%) started anticoagulation therapy after AF detection, and 3 (12%) CIEDs were implanted due to bradyarrhythmia. ILR allowed the diagnosis of tachyarrhythmia in 4 (22%) patients implanted for palpitation. In the syncope and ESUS group, no difference between expected diagnosis and unexpected events was found (syncope 7/38 18% vs. 9/38 24%, p= 0.32; ESUS 3/25 12% vs. 6/25 24%, p = 0.55). Conclusions ILR impacted on clinical pathway in 33% of patients during 12 ± 8 months of follow–up. Despite the reason for its implantation, it remains a useful tool for diagnosing other arrhythmias and the consequent changing of therapeutical approach. ILR had more impact in changing the clinical course in females than in males.
Abstract Background The very high power short duration ablation by mean of the QDOT Micro catheter was demonstrated to be safe and effective to achieve pulmonary vein isolation (PVI) in atrial ...fibrillation (AF) patients. Data from large multicentric registries are still lacking. Purpose We sought to investigate whether different ablation approaches may impact procedural outcomes. First, the hybrid approach (Qmode+, 90 W for 4 sec, at the posterior wall of the left atrium and Qmode modality AI-guided at the anterior wall) was compared to the ablation performed exclusively with the Qmode+ modality. Second, we investigated the impact of the type of anesthesia. Methods The AIR HPSD registry is a multicentric real world data registry including patients undergoing AF ablation by mean of the QDOT Micro catheter. The ablation modality (hybrid/ Qmode+) and the type of anesthesia were left to operators’ preference. Results Overall, 330 patients were enrolled, 67% males, 71% had paroxysmal AF, the mean age was 61±11. Pulmonary vein isolation was reached in 100% regardless of the ablation modality or the anesthesia used. As for the first pass isolation (FPI) there was a trend toward higher rates in the hybrid group compared to the Qmode+ group (85% vs 74%, p=0.1). No differences in FPI were found between the general anesthesia/deep sedation group and the conscious sedation group (83% vs 81%, p=0.8), however when considering the Qmode+ group solely, the FPI was significantly higher in the general anesthesia/deep sedation group (84% vs 56%, p=0.006). As for the procedural time, this was significantly shorter in the general anesthesia/deep sedation compared to conscious sedation (82±21 vs 97±35 min, p<0.01), as well as in the Qmode+ group compared to the hybrid group (80±31 vs 102±30 min, p<0.01). Minor complications were observed in 1% of patients with no significant differences between groups. Conclusions The PVI can be safely and effectively obtained with both approaches, hybrid or Qmode+ solely, however the rate of FPI seems higher with the hybrid one. When adopting solely the Qmode+ modality the general anesthesia increases the rate of FPI.
Abstract
Background
Pulmonary vein isolation (PVI) with endoscopic laser balloon systems (ELBS) is an innovative option for catheter ablation of atrial fibrillation (AF). The third-generation ELBS ...has several structural improvements, including a novel feature (RAPID mode), potentially allowing a high-speed and precise circumferential PVI. Nevertheless, there is a need for large, multicentre studies on its use.
Objective
To assess the safety, efficiency, and efficacy of the third-generation ELBS in a multicentric, international cohort of patients.
Methods
We analyzed the data of all consecutive patients who underwent PVI using the third-generation ELBS between June 2019 and December 2022 in eight Italian and one German Hospital. For each pulmonary vein (PV), the maximum amount of laser delivery with the RAPID mode was attempted. When RAPID mode was not feasible, the operator used point-by-point laser delivery.
Results
We enrolled 429 patients (mean age 61.1±10.7 years, persistent atrial fibrillation 27.7%, female patients 27.7%). The operators isolated 1654 pulmonary veins. 93 (21.7%) patients had an anatomical variation of the left atrium, 60 of them had either a left or a right common trunk, and 33 had a middle PV. Mean total procedural and fluoroscopic times were 115.4±58.2 min and 19.3±12.8 min, respectively. Information on the use of RAPID mode was available for 336 patients: mean use of this feature was possible for 86±18.2 % of the PVs circumference. The operators could use the RAPID mode for at least 90% of all PVs circumference in 148 of 336 patients (44%), and ablation using only RAPID mode was possible in 79 of them (23%). 12 (2.8%) periprocedural complications occurred. There were 6 (1.4%) episodes of phrenic nerve palsy, of which only 1 (0.2%) did not completely resolve during follow up. 3 (0.7%) pericardial tamponades occurred, with a subsequent need for pericardiocentesis. Finally, there were 3 (0.7%) periprocedural transient ischaemic attacks (TIA), which resolved without sequelae. 219 patients were followed up for at least six months (mean follow-up 12.3 ± 6 months). Among these, 63 (28.8%) presented a clinical and/or subclinical recurrence after the blanking period.
Conclusion
This is the largest multicentre cohort of patients treated with the third-generation ELBS. In this multicentric international experience, the system proved to be safe, efficient and effective and the RAPID mode showed optimal applicability.
Abstract
Background
Marfan syndrome (MFS) is an autosomal dominant disorder of the connective tissue and it’s associated with an increased incidence of atrial fibrillation (AF), due to scar–mediated ...processes and sites of atrial ectopy. Limited data exist regarding ablation techniques in these patients. The frailty of atrial walls correlated to connective disease makes the ablation challenging with an increased risk of complications. Laser–balloon (LB) approach for pulmonary vein isolation (PVI) could be a promising strategy due to the possibility to ablate a large volume of tissue with a single application of energy, short procedure times, and real–time monitoring of balloon–tissue contact. We present a case in which LB technology was applied for PVI in an MFS patient
Clinical case
A 44–year–old woman with MFS and paroxysmal AF underwent PVI. The echocardiographic examination showed mild aortic and mitral valve regurgitation, the first due to a slight dilation of the aortic root, the latter associated with mitral valve prolapse. Atrial volume was normal. No other comorbidities were present. The procedure was executed in general anesthesia. A decapolar catheter was inserted in the coronary sinus and used later to stimulate the phrenic nerve during the ablation of the right pulmonary veins (Fig.1C). Left atria (LA) was reached after an ultrasound–guided transeptal puncture. High–density mapping of the LA was performed to assess the number and geometry of PVs (Fig.1A). A LB catheter was used to perform laser ablation at the level of PV antrum, delivering 13 W in automatic rapid mode in regions with optimal contact and 5.5 W in areas with more represented blood–tissue interface. LA mapping after ablation assessed the effective isolation of pulmonary veins (Fig.1B). No complications occurred during the procedure.
Conclusion
a laser–balloon approach for PVI in MFS patients seems feasible and safe. To our knowledge, this is the first application of this technology on MFS patients. Larger data are needed to confirm our findings.
Abstract
Background
Laser balloon ablation is a promising option for performing pulmonary vein isolation (PVI) which is the cornerstone of invasive atrial fibrillation (AF) treatment.
Purpose
We ...aimed to investigate the acute efficacy and safety of the novel third-generation of the laser balloon system in an initial multicenter experience.
Methods
First and consecutive patients who underwent PVI with LB3 for drug-resistant paroxysmal or persistent AF at 7 Italian sites were included in this analysis. Study endpoints were acute procedural efficacy, defined as successful isolation of all identified PVs without radiofrequency touch-up, total and fluoroscopy times, and periprocedural complications.
Results
Our population included 86 patients (81% males, mean age 60.6±9.5 years) who underwent a procedure of PVI using LB3 between June 2020 and March 2021.
Most patients had paroxysmal AF (74%) and were in sinus rhythm at the beginning of the procedure. The mean procedure time was 138±60 min; fluoroscopy time was 22±17 min and the mean ablation time was 44±40 min. Of the 313 targeted PVs, 311 (99.4%) could be isolated with first-pass LB3 application, while 2 (0.6%) required radiofrequency touchup. At the end of the procedure, all patients were in sinus rhythm and 26 (32%) received electrical cardioversion to achieve stable sinus rhythm.
The total rate of major compilations was 1.2% (1/82 patients): one pericardial tamponade requiring epicardial puncture. No surgical intervention was necessary, and the patient recovered without any sequalae. There were no vascular access complications or phrenic nervy palsy. Three pinhole balloon raptures (3.5%) were observed during energy applications that required replacement of the whole system but had no effect on patient safety.
Conclusions
In a first multicenter experience, the LB3 system for PVI was safe with excellent acute efficacy.
Funding Acknowledgement
Type of funding sources: None.
Abstract Background The optimal criteria for distinguishing microreentrant atrial tachycardias (mAT) from macroreentrant atrial arrhythmias (MAT) in clinical practice have not been definitively ...established. Recent advancements in ultra-high-density mapping featuring automated functionalities, has enhanced our understanding of mAT circuits and the precise localization of foci. Purpose Our intent was to observe the diagnostic support provided by high density mapping and Lumipoint algorithm in mAT as well as the ablation outcomes. Methods Consecutive patients eligible for atrial tachycardia (AT) ablation in 22 Italian centres were prospectively enrolled. all ATs were comprehensively mapped in either the left or right atrium utilizing the Rhythmia mapping system and the 64-pole Orion basket catheter. A mAT was defined as an AT characterized by slow, continuous, low fragmented potentials covering a minimum of 50% of the tachycardia cycle length (CL) within a confined area (defined as a circuit within < 1 cm2), enclosed by a couple of closed splines of the Orion catheter, and exhibiting a centrifugal activation pattern to the rest of the atria. The Lumipoint tool was systematically employed to confirm electrogram fragmentation within this defined area. Results Among 159 ATs analysed, 97 (61.0%) were identified as MAT, 50 (31.4%) as focal atrial tachycardias and 12 (7.5%) as mAT. Of these latter, 6 patients (50%) had a previous history of atrial ablation procedure. Concerning the mAT group, the predominant origin site was the left atrium (10 mAT, 83,3%); the targeted activity was localized in the anterior wall in 4 cases (33.3%), in proximity to PVs in 3 cases (25%), along the left ridge in 2 cases (16.6%) and at the roof in 1 case (8,3%). In the remaining right mAT, the foci were found in the free wall and along the CTI in 1 case (8.3% each). The electrical activity spanning the whole CL was detected by 2.7±1.8 pairs of close bipoles of the Orion catheter, was confined to a region of 0.36±0.3cm2 with the longest component of fractionated EGM per spline equal to 64.7±17% of the CL. Low voltage areas (<0.1 mV) were detected in all mAT cases and colocalized with the origin site. Voltage level was 0.2±0.1mV at the site of longest duration of the fragmented potential. A single shot RF delivery terminated each arrhythmia at targeted location. Consolidative RF ablations were then delivered in the adjacent area. Over a median of 288 248-349 days of follow-up, 5 (3.1%) patients suffered from an AT/AF arrhythmia recurrence and of these, 3 (3.1%) were in the MAT group, 1 (2%) in the focal AT and 1 (8.3%) in the mAT group. No complications were observed. Conclusions A novel automated algorithm for microreentrant atrial tachycardia identification, coupled with the identification of matched areas of electrogram fractionation by the Orion catheter, may restrict the extent of required ablation and result in a low arrhythmia recurrence.
Abstract Background Pulmonary vein isolation (PVI) with the use of an endoscopic laser balloon (ELB) is an alternative option for catheter ablation of atrial fibrillation (AF). The third-generation ...system has several improvements, including the novel RAPID mode (RM), potentially allowing a one-shot, continuous, circumferential laser lesion for PVI. Objective In an international, multicentric cohort, we assessed the third-generation ELB’s safety, efficacy, and long-term effectiveness. We also focused on the learning curve (LC) and the use of RM. Methods Between June 2019 and December 2022, we prospectively obtained data on all the patients who consecutively underwent ablation of AF using the third-generation ELB in eight Italian and one German hospital. Each operator attempted to use the RM to the maximum extent in every procedure. Follow-up (FU) visits were scheduled at 3, 6, 12 and 24 months and included a Holter-ECG of 24 hours or, if the patient was a carrier, a device interrogation (implantable loop recorder or two-chamber/three-chamber pacemaker/defibrillator). For FU analysis, we included patients with data available after the blanking period (the first 90 days after the procedure). We analysed the LC, comparing the outcomes of the first fifteen patients of each centre with the remaining patients. In addition, we investigated the impact of an extensive use of the RM (at least 90% of all PV circumferences) on the procedural and FU outcomes. Results we enrolled 427 patients. Of these, 328 had a FU >90 days. The mean total procedural and fluoroscopic times were 105 (66-150) and 17 (10-28) minutes, respectively. Serious adverse procedural events occurred in 11 patients (2.6 %) as follows: 3 periprocedural transient ischaemic attacks, 4 pericardial tamponades, 1 persistent phrenic nerve palsy and 3 severe vascular complications. The mean FU period was of 365 days (194-533). AF recurrence-free rate was 76.7% (95% CI, 70.8%-81.5%) at 12 months. Median RM use was 94% (81-100) of the PVs circumference. RM could be used for at least 90% of all PV circumferences in 188 (55.8%) patients, and the operators could perform an RM-only procedure in 82 (24.3%) patients. Patients treated after the LC or with extensive use of RM showed significantly reduced procedural times and rates of AF recurrence. In a multivariate analysis, the use of the RM was not an independent predictor of a lower recurrence rate at FU, demonstrating only a tendency toward significance (86.0% 77.3-91.6 vs 71.3% 61.3-79.2, HR 0.52, CI 0.26-1.07, p 0.075). Conclusion In this prospective, multicentre, international registry of patients treated with the third-generation ELB, the system proved efficient, safe, and effective. Completing the LC and using the RM reduced procedural time and arrhythmia recurrence. However, using RM was not an independent predictor of a lower recurrence rate.
Peristomal bullous pemphigoid Cecchi, R; Paoli, S; Giomi, A
Journal of the European Academy of Dermatology and Venereology,
07/2004, Letnik:
18, Številka:
4
Journal Article
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