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American Heart Journal Jun 2023In randomized studies, the strategy of pulmonary vein antral isolation (PVI) plus linear ablation has failed to increase success rates for persistent atrial fibrillation... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
In randomized studies, the strategy of pulmonary vein antral isolation (PVI) plus linear ablation has failed to increase success rates for persistent atrial fibrillation (PeAF) ablation when compared with PVI alone. Peri-mitral reentry related atrial tachycardia due to incomplete linear block is an important cause of clinical failures of a first ablation procedure. Ethanol infusion (EI) into the vein of Marshall (EI-VOM) has been demonstrated to facilitate a durable mitral isthmus linear lesion.
OBJECTIVE
This trial is designed to compare arrhythmia-free survival between PVI and an ablation strategy termed upgraded '2C3L' for the ablation of PeAF.
STUDY DESIGN
The PROMPT-AF study (clinicaltrials.gov 04497376) is a prospective, multicenter, open-label, randomized trial using a 1:1 parallel-control approach. Patients (n = 498) undergoing their first catheter ablation of PeAF will be randomized to either the upgraded '2C3L' arm or PVI arm in a 1:1 fashion. The upgraded '2C3L' technique is a fixed ablation approach consisting of EI-VOM, bilateral circumferential PVI, and 3 linear ablation lesion sets across the mitral isthmus, left atrial roof, and cavotricuspid isthmus. The follow-up duration is 12 months. The primary end point is freedom from atrial arrhythmias of >30 seconds, without antiarrhythmic drugs, in 12 months after the index ablation procedure (excluding a blanking period of 3 months).
CONCLUSIONS
The PROMPT-AF study will evaluate the efficacy of the fixed '2C3L' approach in conjunction with EI-VOM, compared with PVI alone, in patients with PeAF undergoing de novo ablation.
Topics: Humans; Atrial Fibrillation; Pulmonary Veins; Prospective Studies; Heart Atria; Ethanol; Catheter Ablation; Treatment Outcome; Recurrence
PubMed: 36813122
DOI: 10.1016/j.ahj.2023.01.019 -
IEEE Transactions on Bio-medical... Jan 2023Advancements in ablation techniques have paved the way towards the development of safer and more effective clinical procedures for treating various maladies such as...
Advancements in ablation techniques have paved the way towards the development of safer and more effective clinical procedures for treating various maladies such as atrial fibrillation (AF). AF is characterized by rapid, chaotic atrial activation and is commonly treated using radiofrequency applicators or laser ablation catheters. However, the lack of thermal lesion formation and temperature monitoring capabilities in these devices prevents them from measuring the treatment outcome directly. In addition, poor differentiation between healthy and ablated tissues leads to incomplete ablation, which reduces safety and causes complications in patients. Hence, a novel photoacoustic (PA)-guided laser ablation theranostic device was developed around a traditional phased-array endoscope. The proposed technology provides lesion formation, tissue distinguishing, and temperature monitoring capabilities. Our results have validated the lesion monitoring capability of the proposed technology through PA correlation maps. The tissue distinguishing capability of the theranostic device was verified by the measurable differences in the PA signal between pre-and post-ablated mice myocardial tissue. The increase in the PA signal with temperature variations caused by the ablation laser confirmed the ability of the proposed device to provide temperature feedback.
Topics: Animals; Mice; Precision Medicine; Endoscopy; Heart Atria; Atrial Fibrillation; Laser Therapy; Treatment Outcome; Catheter Ablation; Pulmonary Veins
PubMed: 35724291
DOI: 10.1109/TBME.2022.3184495 -
The American Journal of Cardiology Sep 2023Atrial myocardial degeneration predisposes to atrial fibrillation (AF), ischemic stroke, and heart failure. Studies suggest the presence of gender differences in atrial... (Observational Study)
Observational Study
Atrial myocardial degeneration predisposes to atrial fibrillation (AF), ischemic stroke, and heart failure. Studies suggest the presence of gender differences in atrial myocardial degeneration. This study aimed to delineate gender differences in the prevalence, predictors, and prognostic impact of left atrial low-voltage areas (LVAs). This observational study included 1,488 consecutive patients who underwent initial ablation for AF. Voltage mapping was performed after pulmonary vein isolation during sinus rhythm. LVAs were defined as regions where bipolar peak-to-peak voltage was <0.50 mV. LVA prevalence was higher in women (38.7%) than in men (16.0%). High age, persistent form of AF, diabetes mellitus, and a large left atrium were shown to be common predictors in both gender categories. Heart failure and history of stroke/thromboembolic events were men-specific predictors of LVA existence. Women experienced more AF recurrence than men (31.1% vs 25.7%, p = 0.027). LVA existence was significantly associated with increased AF recurrence in each gender category, with a respective hazard ratio, 95% confidence interval, and p value of 2.45, 1.87 to 3.22, and <0.0001 in men and 1.82, 1.33 to 2.49, and <0.0001 in women. In conclusion, LVA was more frequent in women than men, and predicted frequent AF recurrence irrespective of gender category.
Topics: Male; Humans; Female; Atrial Fibrillation; Sex Factors; Heart Atria; Fibrosis; Catheter Ablation; Cardiomyopathies; Pulmonary Veins; Heart Failure; Recurrence; Treatment Outcome
PubMed: 37481810
DOI: 10.1016/j.amjcard.2023.07.001 -
JACC. Clinical Electrophysiology Feb 2020
Topics: Atrial Appendage; Atrial Fibrillation; Catheter Ablation; Cicatrix; Heart Atria; Humans
PubMed: 32081216
DOI: 10.1016/j.jacep.2019.12.006 -
The Journal of Thoracic and... Nov 2022Stand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few...
OBJECTIVES
Stand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few reports of late outcomes after stand-alone surgical ablation exist using comprehensive follow-up with strict definitions of success. This study examined our late outcomes of the stand-alone Cox-Maze IV procedure.
METHODS
Between January 2003 and December 2019, 236 patients underwent a stand-alone Cox-Maze IV for refractory atrial fibrillation. Freedom from atrial tachyarrhythmias was assessed by electrocardiography, Holter, or pacemaker interrogation for up to 10 years, with a mean follow-up of 4.8 ± 3.5 years. Rhythm outcomes were compared in multiple subgroups. Factors associated with recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.
RESULTS
The majority of patients (176/236, 75%) had nonparoxysmal atrial fibrillation. Median duration of preoperative atrial fibrillation was 6.2 years (interquartile range, 3-11). Fifty-nine percent of patients (140/236) failed 1 or more prior catheter-based ablation. Thirteen patients (6%) experienced a major complication. There was no 30-day mortality. Freedom from atrial tachyarrhythmias was 94% (187/199), 89% (81/91), and 77% (24/31) at 1, 5, and 10 years, respectively. There was no difference in freedom from atrial tachyarrhythmias between patients with paroxysmal atrial fibrillation versus nonparoxysmal atrial fibrillation (P > .05) or those undergoing sternotomy versus a minimally invasive approach (P > .05). Increased left atrial size and number of catheter ablations were associated with late atrial fibrillation recurrence. For patients who experienced any atrial tachyarrhythmia recurrence, the median number of recurrences was 1.5 (1.0-3.0).
CONCLUSIONS
The stand-alone Cox-Maze IV had excellent late efficacy at maintaining sinus rhythm in patients with symptomatic, refractory atrial fibrillation, with low morbidity and no mortality. The Cox-Maze IV, in contrast to catheter-based ablation, was equally effective in patients with paroxysmal and nonparoxysmal atrial fibrillation.
Topics: Atrial Fibrillation; Catheter Ablation; Electrocardiography; Heart Atria; Humans; Recurrence; Treatment Outcome
PubMed: 34045056
DOI: 10.1016/j.jtcvs.2021.03.109 -
JACC. Clinical Electrophysiology Dec 2020
Topics: Atrial Fibrillation; Catheter Ablation; Heart Atria; Humans
PubMed: 33334440
DOI: 10.1016/j.jacep.2020.05.040 -
Cardiology Journal 2022Atrial fibrosis can promote atrial fibrillation (AF). Electroanatomic mapping (EAM) can provide information regarding local voltage abnormalities that may be used as a...
BACKGROUND
Atrial fibrosis can promote atrial fibrillation (AF). Electroanatomic mapping (EAM) can provide information regarding local voltage abnormalities that may be used as a surrogate marker for fibrosis. Specific voltage cut-off values have been reproduced accurately to identify fibrosis in the ventricles, but these values are not well defined in atrial tissue.
METHODS
This study is a prospective single-center study. Patients with persistent AF referred for ablation were included. EAM was performed before ablation. We recorded bipolar signals, first in AF and later in sinus rhythm (SR). Two thresholds delimited low-voltage areas (LVA), 0.5 and 0.3 mV. We compared LVA extension between maps in SR and AF in each patient.
RESULTS
A total of 23 patients were included in the study. The percentage of points with voltage lower than 0.5 mV and 0.3 mV was significantly higher in maps in AF compared with maps in SR: 38.2% of points < 0.5 mV in AF vs. 22.9% in SR (p < 0.001); 22.3% of points < 0.3 mV in AF vs. 14% in SR (p < 0.001). Areas with reduced voltage were significantly larger in maps in AF (0.5 mV threshold, mean area in AF 41.3 ± 42.5 cm2 vs. 11.7 ± 17.9 cm2 in SR, p < 0.001; 0.3 mV threshold, mean area in AF 15.6 ± 22.1 cm2 vs. 6.2 ± 11.5 cm2 in SR, p < 0.001).
CONCLUSIONS
Using the same voltage thresholds, LVA extension in AF is greater than in SR in patients with persistent AF. These findings provide arguments for defining a different atrial fibrosis threshold based on EAM rhythm.
Topics: Atrial Fibrillation; Catheter Ablation; Electrophysiologic Techniques, Cardiac; Fibrosis; Heart Atria; Humans; Prospective Studies
PubMed: 34642920
DOI: 10.5603/CJ.a2021.0125 -
Heart Rhythm Jan 2023The sinoatrial node (SAN) is the primary pacemaker of the human heart. It is a single, elongated, 3-dimensional (3D) intramural fibrotic structure located at the... (Review)
Review
The sinoatrial node (SAN) is the primary pacemaker of the human heart. It is a single, elongated, 3-dimensional (3D) intramural fibrotic structure located at the junction of the superior vena cava intercaval region bordering the crista terminalis (CT). SAN activation originates in the intranodal pacemakers and is conducted to the atria through 1 or more discrete sinoatrial conduction pathways. The complexity of the 3D SAN pacemaker structure and intramural conduction are underappreciated during clinical multielectrode mapping and ablation procedures of SAN and atrial arrhythmias. In fact, defining and targeting SAN is extremely challenging because, even during sinus rhythm, surface-only multielectrode mapping may not define the leading pacemaker sites in intramural SAN but instead misinterpret them as epicardial or endocardial exit sites through sinoatrial conduction pathways. These SAN exit sites may be distributed up to 50 mm along the CT beyond the ∼20-mm-long anatomic SAN structure. Moreover, because SAN reentrant tachycardia beats may exit through the same sinoatrial conduction pathway as during sinus rhythm, many SAN arrhythmias are underdiagnosed. Misinterpretation of arrhythmia sources and/or mechanisms (eg, enhanced automaticity, intranodal vs CT reentry) limits diagnosis and success of catheter ablation treatments for poorly understood SAN arrhythmias. The aim of this review is to provide a state-of-the-art overview of the 3D structure and function of the human SAN complex, mechanisms of SAN arrhythmias and available approaches for electrophysiological mapping, 3D structural imaging, pharmacologic interventions, and ablation to improve diagnosis and mechanistic treatment of SAN and atrial arrhythmias.
Topics: Humans; Sinoatrial Node; Heart Conduction System; Atrial Fibrillation; Vena Cava, Superior; Heart Atria
PubMed: 36113768
DOI: 10.1016/j.hrthm.2022.08.039 -
Journal of Cardiovascular... Aug 2022Transseptal left atrial catheterization is routinely used for many common catheter-based interventions. Tools for transseptal catheterization have advanced over the... (Review)
Review
Transseptal left atrial catheterization is routinely used for many common catheter-based interventions. Tools for transseptal catheterization have advanced over the recent years. Such tools include imaging advances with intracardiac echocardiology as well as an array of needles, wires, and dilators to achieve transseptal access with greater ease and safety. This study will discuss the contemporary tools for transseptal catheterization and guidance for difficult cases.
Topics: Atrial Appendage; Cardiac Catheterization; Catheter Ablation; Heart Atria; Heart Septum; Humans; Punctures
PubMed: 35229417
DOI: 10.1111/jce.15428 -
Europace : European Pacing,... Mar 2024Pulmonary vein isolation (PVI) for catheter ablation of atrial fibrillation (AF) is a time-demanding procedure. High-power short-duration (HPSD) ablation protocols and...
AIMS
Pulmonary vein isolation (PVI) for catheter ablation of atrial fibrillation (AF) is a time-demanding procedure. High-power short-duration (HPSD) ablation protocols and high-density mapping catheters have recently been introduced to clinical practice. We investigated the impact of high-density mapping and HPSD ablation protocols on procedural timing, efficacy, and safety by comparing different standardized set-ups.
METHODS AND RESULTS
Three electrophysiology (EP) laboratory set-ups were analysed: (i) circular catheter for mapping and HPSD ablation with 30/35 W guided by an ablation index (AI); (ii) pentaspline catheter for mapping an HPSD ablation with 50 W guided by an AI; and (iii) pentaspline catheter for mapping and HPSD ablation with 90 W over 4 s using a novel ablation catheter. All patients underwent PVI without additional left atrial ablation strategies. Procedural data and operating intervals in the EP laboratory were systematically analysed. Three hundred seven patients were analysed (30/35 W AI: n = 102, 50 W AI: n = 102, 90 W/4 s: n = 103). Skin-to-skin times [105.3 ± 22.7 (30/35 W AI) vs. 81.4 ± 21.3 (50 W AI) vs. 69.5 ± 12.2 (90 W/4 s) min, P ≤ 0.001] and total laboratory times (132.8 ± 42.1 vs. 107.4 ± 25.7 vs. 95.2 ± 14.0 min, P < 0.001) significantly differed among the study groups. Laboratory interval analysis revealed significant shortening of mapping and ablation times. Arrhythmia-free survival after 12 months was not different among the study groups (log-rank P = 0.96).
CONCLUSION
The integration of high-density mapping and HPSD protocols into an institutional AF ablation process resulted in reduced procedure times without compromising safety or efficacy.
Topics: Humans; Atrial Fibrillation; Workflow; Heart Atria; Atrial Appendage; Catheter Ablation; Pulmonary Veins; Treatment Outcome; Recurrence
PubMed: 38516791
DOI: 10.1093/europace/euae067