The electrophysiological properties of the gap associated with the cavotricuspid isthmus (CTI) block line near the inferior vena cava (IVC) are not fully elucidated. Of 143 patients who underwent CTI ...block line ablation between September 2020 and April 2021, high-resolution CTI gap mapping was performed for 15 patients. Four patients were identified as having a gap near the IVC (IVC-side gap) despite wide double potentials (DPs) with > 90 ms intervals at the block line. Detailed gap mapping during coronary sinus ostial pacing was performed before and after touch-up ablation. CTI conduction delays caused by an IVC-side gap were classified into 3 patterns: (1) conduction delay at the IVC-side gap without detouring gap conduction, (2) detouring gap conduction due to intrinsic lower lateral right atrium (LLRA)-IVC functional block, and (3) detouring gap conduction due to LLRA-IVC conduction block created by lateral deviation of the CTI ablation line. In Pattern 2, IVC-side gap conduction traveled backward toward the crista terminalis below the LLRA-IVC junction and came back forward again above the border. One patient presented with a head-to-bottom activation pattern of the lateral right atrium (pseudo-CTI block). Pattern 3 was caused by lateral deviation of initial RF deliveries and presented with the same course as intrinsic LLRA-IVC functional block. All patients had wide DP intervals near the tricuspid annulus (mean, 112 ms) and just above the gap site (mean, 109 ms). An IVC-side gap associated with the CTI block line can present with various conduction delay patterns.
Interatrial conduction consists of various muscular bundles, including the Bachmann bundle. In this study, we investigated interatrial activation patterns using ultrahigh-resolution left atrial ...endocardial mapping. This study investigated 58 patients who underwent catheter ablation of atrial arrhythmia via an ultrahigh-resolution mapping system (Rhythmia) at our hospital from May 2020 to January 2021. Left atrial voltage maps and activation maps were acquired after the ablation procedure during right atrial appendage (RAA) pacing. We defined left atrial breakout sites (LABSs) as centrifugal activation patterns shown by the LUMIPOINT Activation Search Tool. The distance between each LABS in the left atrial anterior wall and the superior border of the interatrial septum (D
LABS-IAS
) was measured on the shell of the electroanatomical map, and anterior LABSs were divided equally into roof- and septal-side groups. Fifty-three (91%) patients underwent cryoballoon pulmonary vein isolation. Ultrahigh-resolution left atrial mapping was successfully performed in all patients (6831 ± 2158 points). A total of 82 LABSs were identified in left atrial anterior wall; 34 patients had single LABS and 24 patients had dual LABSs. The mean D
LABS-IAS
was 10.3 ± 9.6 mm. Seven patients also exhibited posterior LABS near the interatrial raphe below the right inferior pulmonary vein. Patients with a single roof-side LABS had significantly shorter left atrial activation times than those with a single septal-side LABS (81.6 ± 13.2 ms vs. 93.5 ± 13.7 ms,
p
< 0.05). Interatrial conduction patterns during RAA pacing varied between patients and affected the left atrial activation time.
Epicardial adipose tissue (EAT) induces inflammation in the atria and is associated with atrial fibrillation (AF). Several studies have examined the relationship between EAT volume (EAT-V) and ...density (EAT-D) and the presence of AF after catheter ablation. However, conclusions have been inconsistent. This study included 43 consecutive patients who underwent catheter ablation for AF and 30 control patients. EAT-V and EAT-D around the entire heart, entire atrium, left atrium (LA), and right atrium (RA) were measured in detail using reconstructed three-dimensional (3D) EAT images from dual-source computed tomography (CT). None of the measurements of EAT-V differed significantly between patients with AF and controls or between patients with recurrent AF and those without. On the other hand, all measurements of EAT-D were higher in patients with AF than in controls (entire atrium,
p
< 0.001; RA,
p
< 0.001; LA,
p
= 0.002). All EAT-D measurements were associated with the presence of AF. Among patients with AF who underwent ablation, all EAT-D measurements were higher in patients with recurrent AF than in those without. The difference was significant for EATRA-D (
p
= 0.032). All atrial EAT-D values predicted recurrent AF (EATRA-D: hazard ratio HR, 1.208; 95% confidence interval 95% CI, 1.053–1.387;
p
= 0.007; EATLA-D: HR, 1.108; 95% CI 1.001–1.225;
p
= 0.047; EATatrial-D: HR, 1.174; 95% CI 1.040–1.325;
p
= 0.010). The most sensitive cutoffs for predicting recurrent AF were highly accurate for EATRA-D (area under the curve AUC, 0.76;
p
< 0.01) and EATatrial-D (AUC = 0.75,
p
< 0.05), while the cutoff for EATLA-D had low accuracy (AUC, 0.65;
p
= 0.209). For predicting the presence of AF and recurrent AF after catheter ablation, 3D analysis of atrial EAT-D, rather than EAT-V, is useful.
Successful atrial fibrillation (AF) ablation can improve reduced left ventricular ejection fraction (LVEF) with AF, which is defined as arrhythmia-induced cardiomyopathy (AIC). However, it is ...difficult to pre-procedurally predict the presence of AIC. We aimed to explore the pre-procedural predictors of AIC in patients with AF and reduced LVEF. This study included 60 patients with a reduced LVEF (LVEF < 50%; 69.1 ± 8.8 years; 45 men) who underwent successful AF ablation. Responders were defined as patients whose LVEF post-procedurally improved to the normal range (≥ 50%). Multivariate analysis revealed that the log-transformed pre-procedural troponin I (TnI) levels (odds ratio OR = 0.059; 95% confidence interval CI = 0.0052–0.42,
p
= 0.003) and age (OR = 0.91; 95% CI = 0.82–1.00,
p
= 0.044) were independent predictors of post-procedural LVEF recovery; further, low TnI levels (< 11.1 pg/ml) predicted LVEF recovery (sensitivity, 79.1%; specificity, 76.5%; positive predictive value, 89.5%; and negative predictive value, 59.1%). There were no significant differences in TnI levels between the baseline and 1 month after the procedure. However, four patients with high baseline TnI levels showed
a
> 50% reduction in the TnI levels post-procedurally, with three of these patients showing LVEF recovery. Low pre-procedural TnI levels can predict LVEF recovery after successful AF ablation in patients with reduced LVEF.
Reported mapping procedures of left atrial (LA) low-voltage areas (LVAs) vary widely. This study aimed to compare the PentaRay
®
/CARTO
®
3 (PentaRay map) and Orion™/Rhythmia™ (Orion map) systems for ...LA voltage mapping. This study included 15 patients who underwent successful pulmonary vein isolation (PVI) for atrial fibrillation. After PVI, PentaRay and Orion maps created for all patients were compared. LVAs were defined as sites with ≥ 3 adjacent low-voltage points < 0.5 mV. LVAs were indicated in 8 (53%) among 15 patients, and the average values of the measured LVAs was comparable between the systems (PentaRay map = 5.4 ± 8.7 cm
2
; Orion map = 4.3 ± 6.4 cm
2
,
p
= 0.69). However, in 2 of 8 patients with LVAs, the Orion map indicated LVAs at the septum and posterolateral sites of the LA, respectively, whereas the PentaRay map indicated no LVAs. In those patients, sharp electrograms of > 0.5 mV were properly recorded at the septum and posterolateral sites during appropriate beats in the PentaRay map. The PentaRay map had a shorter procedure time than the Orion map (12 ± 3 min vs. 23 ± 8 min, respectively;
p
< 0.01). Our study results showed a discrepancy in the LVA evaluation between the PentaRay and Orion maps. In 2 of 15 patients, the Orion map indicated LVAs at the sites where > 0.5-mV electrograms were properly recorded in the PentaRay map.
Background
Few studies have examined whether catheter ablation for AF patients improves biomarkers other than serum levels of brain natriuretic peptide (BNP) and renal function. This study was to ...explore whether catheter ablation for atrial fibrillation (AF) patients affects uric acid (UA), glucose and lipid metabolism.
Methods and results
A total of 206 patients (66.6 ± 10.4 years; 132 men) who underwent initial AF ablation without changes to oral medications were included. Baseline BNP and UA levels significantly decreased at 1 year after ablation (
p
< 0.05 each). Changes in UA level correlated significantly with pre-procedural UA level (
r
= 0.57). In multivariable logistic regression modeling, pre-procedural UA level, persistent AF, and hemoglobin A1c (
p
< 0.05 each) were independent predictors of post-procedural UA level decline. Significant improvements in both persistent and paroxysmal AF patients were identified, and the magnitude of post-procedural serum UA level decline after ablation (ΔUA) was significantly greater in patients with persistent AF (0.8 ± 1.0 mg/dl) than in those with paroxysmal AF (0.2 ± 0.8 mg/dl,
p
< 0.001). Of the 48 patients with high UA level before procedure, 28 patients showed improvement in UA level to normal range.
Conclusions
Catheter ablation for AF patients significantly improved serum UA levels without obvious influences of heart failure, renal function, or inflammation, suggesting that AF ablation may be effective for AF patients with hyperuricemia.
Trial registration
The study was approved by the Research Ethics Committee of University of Fukui (no. 20210132) and clinical trial registration (UMIN000044669).
In patients with paroxysmal atrial fibrillation (PAF), 10%-15% of patients require repeat procedures after second-generation cryoballoon pulmonary vein isolation (CB-PVI). We sought to explore the ...mechanisms of recurrences after cryoballoon ablation.
The data of 122 PAF patients who underwent second procedures for recurrent arrhythmias 7.0 (4.0-12.0) months after the CB-PVI were analyzed. During second procedures, non-PV AF foci were explored with isoproterenol, adenosine, and repetitive cardioversions.
In total, 378/487 (77.6%) PVs remained isolated, and reconnections were not observed in any PVs in 59 (48.4%) patients. PV reconnections were associated with recurrences in 38 (31.1%) patients, of whom 33 (86.8%) had reconnections of at least 1 upper PV. In 6 (4.9%) patients, non-PV AF foci were identified in the upper PV antra where cryoballoons cannot isolate but within the circumferential radiofrequency PVI line. Non-PV AF foci were identified in the superior vena cava, right atrial body, left atrial body, and atrial septum in 28 (23.0%), 18 (14.7%), 4 (3.3%), and 5 (4.1%) patients, respectively. Twelve (9.8%) patients had multiple non-PV AF foci. Four (3.3%), 3 (2.4%), and 8 (6.5%) patients underwent second procedures for atrioventricular nodal reentrant tachycardia, atrial flutter, and atrial tachycardias. During 16.0 (8.0-24.0) months of follow-up, freedom from any atrial arrhythmia at 1 year and 2 years after the second procedure was 79.2% and 60.6%. Nineteen (15.5%) patients had antiarrhythmic drug therapy at the last follow-up.
Our study suggested that improvement in the upper PV PVI durability, eliminating arrhythmogenic superior vena cavae and coexisting atrial arrhythmias, and bonus cryoballoon applications at PV antra might improve the single procedure outcome in cryoballoon ablation.
Perimitral atrial tachycardias (PMATs) are common atrial tachycardias (ATs), yet their mechanisms vary.
The purpose of this study was to characterize clinical spontaneous PMATs using an ...ultra-high-resolution (UHR) mapping system.
The study included 32 consecutive PMATs in 31 patients who had undergone AT mapping/ablation using a UHR mapping system.
Six, 10, 11, and 5 PMATs occurred in cardiac intervention-naïve (group A), post-lateral/posterior mitral isthmus linear ablation (group B), post-atrial fibrillation ablation without mitral isthmus linear ablation (group C), and post-cardiac surgery (group D) patients, respectively. Group A patients tended to be older, more likely were female, and had sinus node or atrioventricular conduction disturbances more frequently. A 12-lead synchronous isoelectric interval was observed in 15 PMATs (46.9%). Coronary sinus activation was proximal to distal or distal to proximal except in 3 PMATs with straight patterns due to epicardial gaps. Left atrial anterior/septal wall (LAASW) low-voltage areas were smallest in group B. Slow conduction areas (SCAs) were identified in 26 PMATs (81.2%) and were located on the LAASW in all group A and group D patients. Conduction velocity in the SCAs was slowest in group B. In group B, all PMATs were terminated by single applications, and the gaps were located epicardially in 5 of 10 (50%). Anterior (n = 23) or lateral/posterior (n = 9) mitral isthmus linear block was successfully created without any complications in all. Twenty-five concomitant ATs among 18 patients (58.1%) also were eliminated. During a median of 20.0 (11.0-40.0) months of follow-up, 28 patients (90.3%) were free from any atrial tachyarrhythmias.
An UHR mapping-guided approach with identification of the individual tachycardia mechanism should be the preferred strategy given the distinct and complex arrhythmia mechanisms.
Few studies have examined the efficacy and safety of cardiac rehabilitation in patients with atrial fibrillation (AF) who underwent AF ablation. We explored the feasibility of additional cardiac ...rehabilitation after AF ablation in patients with a reduced left ventricular ejection fraction (LVEF). Fifty-four patients with heart failure (HF) and a reduced LVEF (HFrEF) (LVEF < 50%; 67.1 ± 11.6 years; 43 men) who underwent initial AF ablation procedures were included. Fourteen (25.9%) patients underwent cardiac rehabilitation (rehabilitation-group) and the remaining 40 (74.1%) did not (non-rehabilitation-group) after the procedure. The rehabilitation-group patients were relatively older, more likely female (
p
= 0.024), and had more likely a history of an HF hospitalization (
p
< 0.01) and cardiac device implantation (
p
= 0.041). The baseline LVEF was significantly lower (
p
= 0.043) and brain natriuretic peptide (BNP) (
p
< 0.01) and C-reactive protein (CRP) (
p
< 0.01) values were significantly higher in the rehabilitation-group. The 6-min walk distance significantly improved after 21.4 ± 11.5 days of cardiac rehabilitation during hospitalization (226.1 ± 155.9 vs. 398.1 ± 77.5 m,
p
= 0.016) without any adverse events. During an 18.9 ± 6.3 month follow-up period, the freedom from AF recurrence (
p
= 0.52) and re-hospitalizations due to HF (
p
= 0.63) were similar between the 2 groups. No death or strokes were observed. During the follow-up period, the LVEF significantly improved similarly in both groups, and the change in the BNP and CRP values significantly decreased in the rehabilitation-group. Despite the rehabilitation-group patients having a more severe HF status, the clinical outcomes and AF freedom were similar between the 2 groups, suggesting the favorable impact of cardiac rehabilitation after AF ablation in HFrEF patients.
Background
An acute cryothermal ablation lesion contains both reversible and irreversible elements. However, differences in lesions created with cryoballoon pulmonary vein isolation (PVI) between the ...acute and chronic phases have not been fully elucidated.
Methods
We retrospectively analyzed 23 consecutive patients with atrial fibrillation who underwent cryoballoon PVI during the initial procedure followed by a second ablation procedure. In all patients, cryoballoon PVI lesions were evaluated with high-resolution voltage mapping just after PVI (acute phase) and during the second session (chronic phase). We compared the area and width of the non-isolated left atrial posterior wall (NI-LAPW) with voltage ≥ 0.5 mV during both sessions.
Results
PVI was successfully achieved in all patients. Cryoballoon PVI lesions were re-evaluated at 11 2–17 months post-procedure. During the chronic phase, NI-LAPW width became significantly larger at the level of the roof (change, 5.8 ± 5.5 mm;
p
< 0.001) and at the level of the carina (change, 3.3 ± 7.0 mm;
p
< 0.05), and NI-LAPW area became significantly larger (change, 1.5 ± 1.9 cm
2
;
p
< 0.001) compared with the acute phase. Eight patients without any PV reconnections also had larger NI-LAPW areas (change, 1.3 ± 1.2 cm
2
;
p
< 0.05) during the chronic phase. Conduction resumption confined to the right carina was observed in 1 (4.3%) patient who presented with circumferential PVI that included the carina during the first session.
Conclusion
Acute cryoballoon PVI lesions significantly regressed during the chronic phase. PV reconnections and the isolation area should be carefully re-evaluated during the second procedure.
