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Journal of Interventional Cardiac... Sep 2023We describe our initial experience using a multipolar pulsed-field ablation catheter for the treatment of left atrial (LA) reentry tachycardia.
BACKGROUND
We describe our initial experience using a multipolar pulsed-field ablation catheter for the treatment of left atrial (LA) reentry tachycardia.
METHODS
We included all patients with LA reentry tachycardia treated with PFA at our institution between September 2021 and March 2022. The tachycardia mechanism was identified using 3D electro-anatomical mapping (3D-EAM). Subsequently, a roof line, anterior line, or mitral isthmus line was ablated as appropriate. Roof line ablation was always combined with LA posterior wall (LAPW) ablation. Positioning of the PFA catheter was guided by a 3D-EAM system and by fluoroscopy. Bidirectional block across lines was verified using standard criteria. Additional radiofrequency ablation (RFA) was used to achieve bidirectional block as necessary.
RESULTS
Among 22 patients (median age 70 (59-75) years; 9 females), we identified 27 LA reentry tachycardia: seven roof dependent macro-reentries, one posterior-wall micro-reentry, twelve peri-mitral macro-reentries, and seven anterior-wall micro-reentries. We ablated a total of 20 roof lines, 13 anterior lines, and 6 mitral isthmus lines. Additional RFA was necessary for two anterior lines (15%) and three mitral isthmus lines (50%). Bidirectional block was achieved across all roof lines, 92% of anterior lines, and 83% of mitral isthmus lines. We observed no acute procedural complications.
CONCLUSION
Ablation of a roof line and of the LAPW is feasible, effective, and safe using this multipolar PFA catheter. However, the catheter is less suited for ablation of the mitral isthmus and the anterior line. A focal pulsed-field ablation catheter may be more effective for ablation of these lines. This study shows the feasibility to ablate linear lesions with a multipolar pulsed-field ablation catheter. 27 left atrial reentry tachycardia were treated in 22 patients.
Topics: Female; Humans; Aged; Atrial Fibrillation; Treatment Outcome; Catheter Ablation; Heart Atria; Tachycardia
PubMed: 36496543
DOI: 10.1007/s10840-022-01436-1 -
The Journal of International Medical... Apr 2022A man in his early 40s developed palpitations brought on by swallowing and was found to have short runs of atrial tachycardia induced by swallowing solid food. Atrial...
A man in his early 40s developed palpitations brought on by swallowing and was found to have short runs of atrial tachycardia induced by swallowing solid food. Atrial tachycardia during swallowing was documented on electrocardiography and 24-hour Holter monitoring. No structural heart disease or esophageal disorders were found by echocardiography. The patient then underwent an electrophysiological study and catheter ablation. We mapped the left atrium with a multipolar mapping catheter while the patient swallowed bread and found that the earliest endocardial breakthrough was on the left anterior superior atrium, where the left superior ganglionated plexus was located. We successfully eliminated the paroxysmal atrial tachycardia at this site. Interestingly, in the process of ablation, atrioventricular node reentrant tachycardia was triggered. After the slow-pathway ablation procedure, no further tachycardia was induced.
Topics: Catheter Ablation; Deglutition; Electrocardiography; Heart Atria; Humans; Male; Tachycardia; Tachycardia, Atrioventricular Nodal Reentry
PubMed: 35441549
DOI: 10.1177/03000605211070755 -
PloS One 2018Compared with left atrial (LA) dimension, LA emptying fraction (LAEF) has received less emphasis as a predictor of atrial fibrillation (AF) recurrence after...
BACKGROUND
Compared with left atrial (LA) dimension, LA emptying fraction (LAEF) has received less emphasis as a predictor of atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA). In addition, patients experiencing post-RFCA AF recurrence may respond to previously ineffective antiarrhythmic drugs (AADs). Classifying these patients into a third RFCA outcome category is recommended.
OBJECTIVE
To identify predictors of RFCA outcome classified into three categories, and to build proportional odds logistic regression models for clinical applicability to predict AF recurrence.
METHODS
Data were retrospectively collected from 483 consecutive patients with drug-refractory AF undergoing RFCA (328 men; age 58.4 ± 11.5 years; 383 paroxysmal). Patients were classified into 3 groups based on the last RFCA outcome: group 1, free from AF without AADs; group 2, free from AF with AADs; and group 3, recurrence of AADs-refractory atrial tachyarrhythmia.
RESULTS
After a mean follow-up duration of 64.5 ± 43.2 months and mean ablation procedure number of 1.37 ± 0.68, the RFCA outcome showed 76.0%, 9.5% and 14.5% of patients in groups 1, 2, and 3, respectively. In multivariate analysis, LAEF was the most stable and important predictor of AF recurrence, followed by body mass index, stroke, AF duration, mitral regurgitation, and LA linear ablation. For patients undergoing repeat RFCA, LAEF was the only independent predictor (cutoffs: 43% and 35% for groups 1 and 3, respectively).
CONCLUSION
LAEF provides optimal prognostic information regarding the risk stratification of AF patients undergoing RFCA.
Topics: Aged; Anti-Arrhythmia Agents; Atrial Fibrillation; Atrial Function, Left; Catheter Ablation; Echocardiography; Female; Heart Atria; Humans; Logistic Models; Male; Middle Aged; Predictive Value of Tests; Prognosis; Recurrence; Retrospective Studies; Treatment Outcome
PubMed: 29364912
DOI: 10.1371/journal.pone.0191196 -
Cardiovascular Ultrasound Jan 2021Left atrial (LA) and left atrial appendage (LAA) dysfunction has been demonstrated to contribute to atrial fibrillation (AF)-related stroke. However, usefulness of LA... (Comparative Study)
Comparative Study
BACKGROUND
Left atrial (LA) and left atrial appendage (LAA) dysfunction has been demonstrated to contribute to atrial fibrillation (AF)-related stroke. However, usefulness of LA and LAA mechanics has not been fully compared. We sought to investigate the association of LA and LAA mechanics with stroke and to compare their diagnostic values in the risk stratification of stroke in patients with nonvalvular AF.
METHODS
A total of 208 consecutive patients with AF (63.58 ± 10.37 years, 63.9% male,57.7% persistent AF) who underwent echocardiography before catheter ablation were prospectively enrolled. Speckle-tracking was used to measure LA and LAA global longitudinal strain (GLS). LA and LAA mechanical dispersions (MD) were defined as the standard deviation (SD) of time to peak positive strain corrected by the R-R interval.
RESULTS
Patients with prior stroke/ transient ischemic attack (TIA) (n = 31) had significantly higher LA and LAA MD than those without (n = 177) (11.56 ± 4.38% vs. 8.43 ± 3.44%, 15.15 ± 5.46% vs. 10.94 ± 4.40%, both P < 0.01). In multivariable analysis, LA and LAA MD were independently associated with stroke/TIA (odds ratio, 1.18-1.29, 1.19-1.22, respectively, both P < 0.01), providing incremental values over clinical and standard echocardiographic parameters. In a subgroup analysis, LA MD was more useful than LAA MD in patients with normal LA volumes, while LAA MD was superior to LA MD in patients with LA enlargement.
CONCLUSIONS
Higher LA and LAA mechanical dispersion are independently associated with stroke/TIA in AF patients and had incremental values over clinical and conventional echocardiographic parameters. What's more, priorities of dispersion assessment are different depending on patients' LA size.
Topics: Aged; Atrial Appendage; Atrial Fibrillation; Atrial Function, Left; China; Cross-Sectional Studies; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Humans; Incidence; Male; Middle Aged; Prospective Studies; Risk Assessment; Risk Factors; Stroke
PubMed: 33422087
DOI: 10.1186/s12947-020-00232-z -
Trends in Cardiovascular Medicine Jan 2017Although there have been great technological advances in the treatment of atrial fibrillation (AF), current therapies remain limited due to a narrow understanding of AF... (Review)
Review
Although there have been great technological advances in the treatment of atrial fibrillation (AF), current therapies remain limited due to a narrow understanding of AF mechanisms in the human heart. This review will highlight our recent studies on explanted human hearts where we developed and employed a novel functional-structural mapping approach by integrating high-resolution simultaneous endo-epicardial and panoramic optical mapping with 3D gadolinium-enhanced MRI to define the spatiotemporal characteristics of AF drivers and their structural substrates. The results allow us to postulate that the primary mechanism of AF maintenance in human hearts is a limited number of localized intramural microanatomic reentrant AF drivers anchored to heart-specific 3D fibrotically insulated myobundle tracks, which may remain hidden to clinical single-surface electrode mapping. We suggest that ex vivo human heart studies, by using an integrated 3D functional and structural mapping approach, will help to reveal defining features of AF drivers as well as validate and improve clinical approaches to detect and target these AF drivers in patients with cardiac diseases.
Topics: Action Potentials; Atrial Fibrillation; Catheter Ablation; Contrast Media; Fibrosis; Heart Atria; Heart Conduction System; Heart Rate; Humans; Imaging, Three-Dimensional; Isolated Heart Preparation; Magnetic Resonance Imaging; Predictive Value of Tests; Risk Factors; Voltage-Sensitive Dye Imaging
PubMed: 27492815
DOI: 10.1016/j.tcm.2016.05.008 -
JACC. Clinical Electrophysiology Aug 2017Recently, studies using late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) to identify structural changes of atrial tissue have contributed significantly... (Review)
Review
Recently, studies using late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) to identify structural changes of atrial tissue have contributed significantly to understanding the pathophysiology and progression of atrial fibrillation (AF). Moreover, imaging of atrial fibrosis using MRI has evolved to be a tool to improve clinical outcome of AF ablation procedures by allowing a patient-specific individualized management approach. LGE-MRI has been shown to predict AF ablation outcome based on pre-procedural imaging to define the extent of atrial fibrosis. The results of the ongoing DECAAF II (Delayed-Enhancement MRI Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation) trial might extend ablation strategies from pulmonary vein isolation alone to a substrate-based approach. Furthermore, an improved understanding of the underlying mechanisms of atrial structural remodeling is crucial in order to reduce the occurrence of AF-associated complications (e.g., ischemic stroke and heart failure). This review article provides current methodology of atrial fibrosis imaging using LGE-MRI and delineates actual clinical implications and future directions for this imaging approach.
Topics: Atrial Fibrillation; Fibrosis; Gadolinium; Heart Atria; Humans; Magnetic Resonance Imaging; Radiofrequency Ablation
PubMed: 29759774
DOI: 10.1016/j.jacep.2017.07.004 -
Journal of Interventional Cardiac... Jun 2023Short runs of atrial tachycardias (ATs) and infrequent premature atrial contractions (PACs) are difficult to map and ablate using sequential electrophysiology mapping...
BACKGROUND
Short runs of atrial tachycardias (ATs) and infrequent premature atrial contractions (PACs) are difficult to map and ablate using sequential electrophysiology mapping techniques. The AcQMap mapping system allows for highly accurate mapping of a single atrial activation.
OBJECTIVES
We aimed to test the value of a novel dipole charge density-based high-resolution mapping technique (AcQMap) in the treatment of brief episodes of ATs and PACs.
METHODS
Data of all patients undergoing catheter ablation (CA) using the AcQMap mapping system were reviewed.
RESULTS
Thirty-one out of 219 patients (male n = 8; female n = 23) had short runs of ATs (n = 23) and PACs (n = 8). The mean procedural time was 155.3 ± 46.6 min, with a mean radiation dose of 92.0 (IQR 37.0-121.0) mGy. Total radiofrequency application duration 504.0 (271.0-906.0) s. Left atrial localization of ATs and PACs was identified in 45.1% of the cases, right atrium localization in 45.1%, and septal origins in 9.8% of the cases. Acute success was achieved in 30/31 (96.8%), and recurrence during the follow-up developed in six patients (19.4%), including four patients with PACs and two patients with short-lived ATs. One patient presented procedure-related groin hematoma as minor complication.
CONCLUSION
Brief episodes of highly symptomatic ATs and infrequent PACs can be mapped using charge density mapping and successfully ablated with high acute and long-term success rates.
Topics: Humans; Male; Female; Atrial Premature Complexes; Treatment Outcome; Electrophysiologic Techniques, Cardiac; Tachycardia, Supraventricular; Heart Atria; Catheter Ablation; Atrial Fibrillation
PubMed: 36282368
DOI: 10.1007/s10840-022-01405-8 -
Current Cardiology Reviews 2015Focal atrial tachycardias arise preferentially from specific locations within the atria. Careful analysis of the P wave can provide useful information about the chamber... (Review)
Review
Focal atrial tachycardias arise preferentially from specific locations within the atria. Careful analysis of the P wave can provide useful information about the chamber and likely site of origin within that chamber. Macro-reentrant atrial flutter also tends to occur over a limited number of potential circuits. In this case, the ECG usually gives a guide to the chamber of origin, but unless it shows a specific morphology it is less useful in delineating the circuit involved. Nonetheless, prior knowledge of the likely chamber of origin helps to plan the ablation strategy.
Topics: Algorithms; Atrial Flutter; Catheter Ablation; Electrocardiography; Heart Atria; Humans; Tachycardia
PubMed: 25308814
DOI: 10.2174/1573403x10666141013121252 -
Europace : European Pacing,... Nov 2021Pulsed field ablation (PFA), a non-thermal ablative modality, may show different effects on the myocardial tissue compared to thermal ablation. Thus, this study aimed to...
AIMS
Pulsed field ablation (PFA), a non-thermal ablative modality, may show different effects on the myocardial tissue compared to thermal ablation. Thus, this study aimed to compare the left atrial (LA) structural and mechanical characteristics after PFA vs. thermal ablation.
METHODS AND RESULTS
Cardiac magnetic resonance was performed pre-ablation, acutely (<3 h), and 3 months post-ablation in 41 patients with paroxysmal atrial fibrillation (AF) undergoing pulmonary vein (PV) isolation with PFA (n = 18) or thermal ablation (n = 23, 16 radiofrequency ablations, 7 cryoablations). Late gadolinium enhancement (LGE), T2-weighted, and cine images were analysed. In the acute stage, LGE volume was 60% larger after PFA vs. thermal ablation (P < 0.001), and oedema on T2 imaging was 20% smaller (P = 0.002). Tissue changes were more homogeneous after PFA than after thermal ablation, with no sign of microvascular damage or intramural haemorrhage. In the chronic stage, the majority of acute LGE had disappeared after PFA, whereas most LGE persisted after thermal ablation. The maximum strain on PV antra, the LA expansion index, and LA active emptying fraction declined acutely after both PFA and thermal ablation but recovered at the chronic stage only with PFA.
CONCLUSION
Pulsed field ablation induces large acute LGE without microvascular damage or intramural haemorrhage. Most LGE lesions disappear in the chronic stage, suggesting a specific reparative process involving less chronic fibrosis. This process may contribute to a preserved tissue compliance and LA reservoir and booster pump functions.
Topics: Atrial Fibrillation; Catheter Ablation; Contrast Media; Fibrosis; Gadolinium; Heart Atria; Humans; Magnetic Resonance Imaging
PubMed: 34240134
DOI: 10.1093/europace/euab155 -
Journal of Cardiovascular... May 2023Structural changes in the left atrium (LA) modestly predict outcomes in patients undergoing catheter ablation for atrial fibrillation (AF). Machine learning (ML) is a...
BACKGROUND
Structural changes in the left atrium (LA) modestly predict outcomes in patients undergoing catheter ablation for atrial fibrillation (AF). Machine learning (ML) is a promising approach to personalize AF management strategies and improve predictive risk models after catheter ablation by integrating atrial geometry from cardiac computed tomography (CT) scans and patient-specific clinical data. We hypothesized that ML approaches based on a patient's specific data can identify responders to AF ablation.
METHODS
Consecutive patients undergoing AF ablation, who had preprocedural CT scans, demographics, and 1-year follow-up data, were included in the study for a retrospective analysis. The inputs of models were CT-derived morphological features from left atrial segmentation (including the shape, volume of the LA, LA appendage, and pulmonary vein ostia) along with deep features learned directly from raw CT images, and clinical data. These were merged intelligently in a framework to learn their individual importance and produce the optimal classification.
RESULTS
Three hundred twenty-one patients (64.2 ± 10.6 years, 69% male, 40% paroxysmal AF) were analyzed. Post 10-fold nested cross-validation, the model trained to intelligently merge and learn appropriate weights for clinical, morphological, and imaging data (AUC 0.821) outperformed those trained solely on clinical data (AUC 0.626), morphological (AUC 0.659), or imaging data (AUC 0.764).
CONCLUSION
Our ML approach provides an end-to-end automated technique to predict AF ablation outcomes using deep learning from CT images, derived structural properties of LA, augmented by incorporation of clinical data in a merged ML framework. This can help develop personalized strategies for patient selection in invasive management of AF.
Topics: Humans; Male; Female; Atrial Fibrillation; Retrospective Studies; Treatment Outcome; Heart Atria; Tomography, X-Ray Computed; Catheter Ablation; Machine Learning; Recurrence; Pulmonary Veins
PubMed: 36934383
DOI: 10.1111/jce.15890