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Interactive Cardiovascular and Thoracic... Nov 2021Atrio-oesophageal fistula is a rare but serious complication of radiofrequency catheter ablation of atrial fibrillation. Therapeutic options are surgery, oesophageal...
OBJECTIVES
Atrio-oesophageal fistula is a rare but serious complication of radiofrequency catheter ablation of atrial fibrillation. Therapeutic options are surgery, oesophageal stenting and conservative treatment (antibiotics and anticoagulation). However, there are no guidelines available. Since no article dwells on the technical considerations of this surgery, we aim to present here our experience and share our surgical approach.
METHODS
Between January 2012 and March 2020, all consecutive patients treated for atrio-oesophageal fistula following radiofrequency catheter ablation of atrial fibrillation at our institution were analysed retrospectively. The diagnosis was made on a set of clinical and radiological signs. All patients benefitted from a combined approach involving both digestive and cardiac surgeons. Femoro-femoral peripheral cardiopulmonary by-pass was used. The surgical approach was a right posterolateral thoracotomy. Atrial repair was done on fibrillating heart without cross-clamping, using a left atriotomy. Digestive management consisted of a total oesophagectomy.
RESULTS
We identified 6 patients with this complication. The median age was 53 [34-72] years. Symptoms were neurological symptoms, fever and chest pain. Diagnostic modalities were cerebral imaging, chest CT and transthoracic echocardiogram. Atrial repair consisted in a suture of the atrium or by using a pericardial patch. With a median follow-up of 3.1 [0.1-7.7] years, only one patient died during the follow-up.
CONCLUSIONS
Our experience shows that an aggressive surgery with a large resection of the oesophagus and left atrial repair by right thoracotomy in the same time provides good results. The ability to involve simultaneously both experienced digestive and cardiac surgical teams is the key for this strategy.
Topics: Adult; Aged; Atrial Fibrillation; Catheter Ablation; Esophageal Fistula; Heart Atria; Heart Diseases; Humans; Middle Aged; Retrospective Studies
PubMed: 34313300
DOI: 10.1093/icvts/ivab202 -
Kardiologia Polska 2021Transesophageal echocardiography (TEE) allows detailed characterization of atrial fibrillation (AF) substrate and could be valuable for predicting pulmonary vein...
BACKGROUND
Transesophageal echocardiography (TEE) allows detailed characterization of atrial fibrillation (AF) substrate and could be valuable for predicting pulmonary vein isolation (PVI) procedure outcomes.
AIMS
We aimed at assessing the value of TEE-derived left atrial (LA) and LA appendage (LAA) features as prognostic markers for AF recurrence after cryoballoon-based ablation.
METHODS
Patients were enrolled using a prospective database of consecutive PVI procedures performed over a 7-year period. The following TEE-derived parameters were investigated: LAA emptying flow velocity (LAA-FV), the presence of patent foramen ovale (PFO), LA spontaneous echo contrast, and mitral regurgitation. Diagnosis of AF recurrence was based on scheduled and symptoms triggered ECG monitoring. The Cox's regression model and Kaplan-Meier survival curves were applied for statistical analysis.
RESULTS
A total of 417 consecutive patients who underwent their first PVI using cryoballoon were analyzed (mean age: 59 years). AF recurrence was noted in 25.7% of patients (median follow-up of 24 months). Four TEE-derived variables had predictive values for AF recurrence: LAA-FV <45 cm/s, presence of PFO at resting state, LA spontaneous echo contrast, and mitral regurgitation. In the multivariable model, apart from the transthoracic echocardiography-derived LA size, two TEE-derived features (LAA-FV <45 cm/s and the presence of PFO) remained as independent predictors.
CONCLUSIONS
This study proposed a novel TEE-derived AF recurrence risk factor - the presence of PFO - and confirmed the prognostic value of LAA flow velocity in patients undergoing cryoballoon-based AF ablation. These risk factors could be useful in the global assessment of AF recurrence risk and potentially helpful in planning the ablation strategy.
Topics: Atrial Appendage; Atrial Fibrillation; Echocardiography, Transesophageal; Foramen Ovale, Patent; Heart Atria; Humans; Middle Aged
PubMed: 34002841
DOI: 10.33963/KP.a2021.0004 -
Current Cardiology Reviews 2016In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population.... (Review)
Review
In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population. The advent of sophisticated devices and well-designed equipment has made the management of many congenital cardiac lesions more efficient and safer, while providing more comfort to the patient. Nowadays, a large variety of heart diseases are managed with transcatheter techniques, such as patent foramen ovale, atrial and ventricular septal defects, valve stenosis, patent ductus arteriosus, aortic coarctation, pulmonary artery and vein stenosis and arteriovenous malformations. Moreover, hybrid procedures and catheter ablation have opened new paths in the treatment of complex cardiac lesions and arrhythmias, respectively. In this article, the main therapeutic utilities of cardiac catheterization in children are discussed.
Topics: Aortic Coarctation; Cardiac Catheterization; Catheter Ablation; Child; Ductus Arteriosus, Patent; Equipment Design; Heart Atria; Heart Defects, Congenital; Heart Septal Defects, Atrial; Heart Valve Diseases; Humans; Pulmonary Artery; Stenosis, Pulmonary Vein; Vascular Diseases
PubMed: 26926291
DOI: 10.2174/1573403x12666160301121253 -
Circulation Journal : Official Journal... Jan 2022
Topics: Atrial Fibrillation; Catheter Ablation; Heart Atria; Humans
PubMed: 34937826
DOI: 10.1253/circj.CJ-21-0975 -
Europace : European Pacing,... May 2023Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized...
AIMS
Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF.
METHODS AND RESULTS
Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50-67), fluoroscopy time was 43 s (IQR 20-71), and radiofrequency (RF) time was 16.5 min (IQR 14.3-18.4). The median AI tailored to the local LAWT was 387 (IQR 360-410) for the anterior wall and 335 (IQR 300-375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up.
CONCLUSION
In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).
Topics: Humans; Male; Middle Aged; Aged; Female; Atrial Fibrillation; Pulmonary Veins; Prospective Studies; Catheter Ablation; Heart Atria; Treatment Outcome
PubMed: 37125968
DOI: 10.1093/europace/euad118 -
Computers in Biology and Medicine Jan 2024The visualization and comparison of electrophysiological information in the atrium among different patients could be facilitated by a standardized 2D atrial mapping....
The visualization and comparison of electrophysiological information in the atrium among different patients could be facilitated by a standardized 2D atrial mapping. However, due to the complexity of the atrial anatomy, unfolding the 3D geometry into a 2D atrial mapping is challenging. In this study, we aim to develop a standardized approach to achieve a 2D atrial mapping that connects the left and right atria, while maintaining fixed positions and sizes of atrial segments across individuals. Atrial segmentation is a prerequisite for the process. Segmentation includes 19 different segments with 12 segments from the left atrium, 5 segments from the right atrium, and two segments for the atrial septum. To ensure consistent and physiologically meaningful segment connections, an automated procedure is applied to open up the atrial surfaces and project the 3D information into 2D. The corresponding 2D atrial mapping can then be utilized to visualize different electrophysiological information of a patient, such as activation time patterns or phase maps. This can in turn provide useful information for guiding catheter ablation. The proposed standardized 2D maps can also be used to compare more easily structural information like fibrosis distribution with rotor presence and location. We show several examples of visualization of different electrophysiological properties for both healthy subjects and patients affected by atrial fibrillation. These examples show that the proposed maps provide an easy way to visualize and interpret intra-subject information and perform inter-subject comparison, which may provide a reference framework for the analysis of the atrial fibrillation substrate before treatment, and during a catheter ablation procedure.
Topics: Humans; Atrial Fibrillation; Heart Atria; Atrial Appendage; Catheter Ablation
PubMed: 38039895
DOI: 10.1016/j.compbiomed.2023.107755 -
Chinese Medical Journal Dec 2023
Topics: Humans; Atrial Fibrillation; Left Atrial Appendage Closure; Heart Atria; Catheter Ablation; Atrial Appendage; Treatment Outcome
PubMed: 37365140
DOI: 10.1097/CM9.0000000000002746 -
Clinical Cardiology Jan 2021Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the most common procedures used to treat refractory atrial fibrillation (AF) and are performed through... (Observational Study)
Observational Study
BACKGROUND
Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the most common procedures used to treat refractory atrial fibrillation (AF) and are performed through pulmonary vein isolation (PVI). Studies have shown that CBA can approximately match the therapeutic effects of RFA against AF. However, few studies have investigated the difference between CBA and RFA of the effects on left atrial remodeling for paroxysmal AF.
OBJECTIVE
Atrial remodeling is considered pivotal to the occurrence and development of AF, therefore we sought to assess the influence of atrial remodeling in patients with paroxysmal AF after CBA and RFA in this study.
METHODS
In this nonrandomized retrospective observational study, we enrolled 328 consecutive patients who underwent CBA or RFA for refractory paroxysmal AF in May 2014 to May 2017 in our hospital. After propensity score matching, 96 patients were included in the CBA group, and 96 were included in the RFA group. Patients were asked to undergo a 12-lead electrocardiogram, a 24-h Holter monitor, and an echocardiogram and to provide their clinical history and symptoms at 6 months and 1, 2, and 3 years postprocedurally. Electrical remodeling of the left atrium was assessed by P wave dispersion (Pdis); structural remodeling was assessed by the left atrium diameter (LAD) and left atrial volume index (LAVI) during scheduled visits.
RESULTS
As of January 2020, compared with baseline, at 1 year, 2 years, and 3 years after ablation, the average changes in Pdis (∆Pdis), LAD (∆LAD), and LAVI (∆LAVI) were significant in both the CBA and RFA groups. Six months after ablation, ∆Pdis, ∆LAD, and ∆LAVI were greater in the CBA group than in the RFA group. There was no significant difference between the two groups in AF/flutter recurrence, but the AF/flutter-free survival time of CBA group may be longer than RFA group after 2 years after ablation. A higher ∆Pdis, ∆LAD, or ∆LAVI at 1 year after ablation may increase AF/flutter-free survival.
CONCLUSIONS
Although CBA and RFA are both effective in left atrial electrical and structural reverse-remodeling in paroxysmal AF, CBA may outperform RFA for both purposes 6 months after ablation. However, during long-term follow-up, there was no significant intergroup difference.
Topics: Atrial Fibrillation; Atrial Function, Left; Atrial Remodeling; Catheter Ablation; Cryosurgery; Echocardiography; Female; Heart Atria; Humans; Male; Middle Aged; Retrospective Studies; Tachycardia, Paroxysmal; Treatment Outcome
PubMed: 33205849
DOI: 10.1002/clc.23507 -
Heart Rhythm Jul 2021Although atrial fibrillation ablation is increasingly used for rhythm control therapy, antiarrhythmic drugs (AADs) are commonly used, either alone or in combination with...
BACKGROUND
Although atrial fibrillation ablation is increasingly used for rhythm control therapy, antiarrhythmic drugs (AADs) are commonly used, either alone or in combination with ablation. The effectiveness of AADs is highly variable. Previous work from our group suggests that alterations in atrial resting membrane potential (RMP) induced by low Pitx2 expression could explain the variable effect of flecainide.
OBJECTIVE
The purpose of this study was to assess whether alterations in atrial/cardiac RMP modify the effectiveness of multiple clinically used AADs.
METHODS
The sodium channel blocking effects of propafenone (300 nM, 1 μM), flecainide (1 μM), and dronedarone (5 μM, 10 μM) were measured in human stem cell-derived cardiac myocytes, HEK293 expressing human Na1.5, primary murine atrial cardiac myocytes, and murine hearts with reduced Pitx2c.
RESULTS
A more positive atrial RMP delayed I recovery, slowed channel inactivation, and decreased peak action potential (AP) upstroke velocity. All 3 AADs displayed enhanced sodium channel block at more positive atrial RMPs. Dronedarone was the most sensitive to changes in atrial RMP. Dronedarone caused greater reductions in AP amplitude and peak AP upstroke velocity at more positive RMPs. Dronedarone evoked greater prolongation of the atrial effective refractory period and postrepolarization refractoriness in murine Langendorff-perfused Pitx2c hearts, which have a more positive RMP compared to wild type.
CONCLUSION
Atrial RMP modifies the effectiveness of several clinically used AADs. Dronedarone is more sensitive to changes in atrial RMP than flecainide or propafenone. Identifying and modifying atrial RMP may offer a novel approach to enhancing the effectiveness of AADs or personalizing AAD selection.
Topics: Action Potentials; Animals; Anti-Arrhythmia Agents; Atrial Fibrillation; Disease Models, Animal; Dronedarone; Female; Flecainide; Heart Atria; Male; Membrane Potentials; Mice; Propafenone; Sodium; Voltage-Gated Sodium Channel Blockers
PubMed: 33737232
DOI: 10.1016/j.hrthm.2021.03.016 -
Active esophageal cooling during radiofrequency ablation of the left atrium: data review and update.Expert Review of Medical Devices Dec 2022Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the... (Review)
Review
INTRODUCTION
Radiofrequency (RF) ablation of the left atrium of the heart is increasingly used to treat atrial fibrillation (AF). Unfortunately, inadvertent thermal injury to the esophagus can occur during this procedure, potentially creating an atrioesophageal fistula (AEF) which is 80% fatal. The ensoETM (Attune Medical, Chicago, IL), is an esophageal cooling device that has been shown to reduce thermal injury to the esophagus during RF ablation.
AREAS COVERED
This review summarizes growing evidence related to active esophageal cooling during RF ablation for the treatment of AF. The review presents data demonstrating improved outcomes related to patient safety and procedural efficiency and suggests directions for future research.
EXPERT OPINION
The use of active esophageal cooling during RF ablation reduces esophageal injury, reduces or eliminates fluoroscopy requirements, reduces procedure duration and post-operative pain, and increases long-term freedom from arrhythmia. These effects in turn increase patient same-day discharge rates, decrease operator cognitive load, and reduce cost. These findings are likely to further accelerate the adoption of active esophageal cooling.
Topics: Humans; Catheter Ablation; Heart Atria; Esophagus; Atrial Fibrillation; Radiofrequency Ablation
PubMed: 36413154
DOI: 10.1080/17434440.2022.2150930