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Journal of Cardiovascular... Dec 2021Atrial fibrillation (AF) recurrence after catheter ablation is associated with worse outcomes and quality of life. Left atrial (LA) structural remodeling provides the... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Atrial fibrillation (AF) recurrence after catheter ablation is associated with worse outcomes and quality of life. Left atrial (LA) structural remodeling provides the essential substrate for AF perpetuation. Baseline extent and the progression of LA fibrosis after ablation are strong predictors of postprocedural AF recurrence. Dronedarone is an antiarrhythmic drug proven to efficiently maintain sinus rhythm.
OBJECTIVE
We sought to investigate the effect of the antiarrhythmic drug Dronedarone in decreasing LA fibrosis progression and AF recurrence after ablation of AF patients.
METHODS
EDORA (NCT04704050) is a multicenter, prospective, randomized controlled clinical trial. Patients with persistent or paroxysmal AF undergoing AF ablation will be randomized into Dronedarone versus placebo/standard of care. The co-primary outcomes are the recurrence of atrial arrhythmias (AA) within 13 months of follow-up after ablation and the progression of left atrial fibrosis postablation. All patients will receive a late-gadolinium enhancement magnetic resonance imaging at baseline, 3- and 12-month follow-up for the quantification of LA fibrosis and ablation-related scarring. AA recurrence and burden will be assessed using a 30-day ECG patch every 3 months with daily ECG recordings in between. Quality of life improvement is assessed using the AFEQT and AFSS questionnaires.
CONCLUSION
EDORA will be the first trial to assess the progression of LA structural remodeling after ablation and its association with Dronedarone treatment and ablation success in a randomized controlled fashion. The trial will provide insight into the pathophysiology of AF recurrence after ablation and may provide potential therapeutic targets to optimize procedural outcomes.
Topics: Atrial Fibrillation; Catheter Ablation; Contrast Media; Dronedarone; Fibrosis; Gadolinium; Heart Atria; Humans; Prospective Studies; Quality of Life; Recurrence; Treatment Outcome
PubMed: 34664772
DOI: 10.1111/jce.15274 -
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 -
Arquivos Brasileiros de Cardiologia Jun 2019
Topics: Atrial Appendage; Atrial Fibrillation; Cardiomyopathies; Catheter Ablation; Heart Atria; Humans
PubMed: 31188957
DOI: 10.5935/abc.20190087 -
JACC. Clinical Electrophysiology Sep 2017The study examined the frequency in which a right coronary artery (RCA) anomaly resulting in intra-atrialization of the vessel might increase risk of RCA damage during... (Observational Study)
Observational Study
OBJECTIVES
The study examined the frequency in which a right coronary artery (RCA) anomaly resulting in intra-atrialization of the vessel might increase risk of RCA damage during routine radiofrequency ablation in the right atrium even with low power or temperature.
BACKGROUND
Right coronary artery (RCA) injury with endocardial RF ablation of the right atrium is a rare complication.
METHODS
This prospective observational study comprised an analysis of coronary artery anatomies in 331 patients who underwent autopsies at our institution from 2005 to 2014. The presence of intra-atrial RCA including the number and length of intra-atrial RCA segments with accompanying atherosclerosis and coronary anomalies were evaluated.
RESULTS
The authors report a case series of 6 of 331 (1.8%) patients in whom autopsies showed evidence of an intra-atrial RCA. The patients were all men (average 69 ± 12 years of age). They observed 3 variations of the intra-atrial RCA course. In 2 similar variations, the RCA entered the anterolateral aspect of the right atrium, returning to its normal distribution to supply the distal RCA (case 4 of 6) and the atrioventricular nodal artery (case 1 of 6). In the sixth case, the atrialized artery was an anterior branch of the RCA, in which the artery similarly coursed across the pectinate muscles, extending to the region of the anterior crista terminalis, before diving into the muscle.
CONCLUSIONS
The prevalence and variants of the intra-atrial RCA have not been reported before. In the presence of an intra-atrial artery, RCA damage may occur due to direct injury rather than collateral injury due to transmural extension of an ablation lesion.
Topics: Aged; Aged, 80 and over; Autopsy; Catheter Ablation; Coronary Artery Disease; Heart Atria; Humans; Male; Middle Aged; Prospective Studies; Treatment Outcome
PubMed: 29759708
DOI: 10.1016/j.jacep.2017.02.025 -
Europace : European Pacing,... Aug 2023The amount of fibrosis in the left atrium (LA) predicts atrial fibrillation (AF) recurrence after catheter ablation (CA). We aim to identify whether regional variations... (Randomized Controlled Trial)
Randomized Controlled Trial
AIMS
The amount of fibrosis in the left atrium (LA) predicts atrial fibrillation (AF) recurrence after catheter ablation (CA). We aim to identify whether regional variations in LA fibrosis affect AF recurrence.
METHODS AND RESULTS
This post hoc analysis of the DECAAF II trial includes 734 patients with persistent AF undergoing first-time CA who underwent late gadolinium enhancement magnetic resonance imaging (LGE-MRI) within 1 month prior to ablation and were randomized to MRI-guided fibrosis ablation in addition to standard pulmonary vein isolation (PVI) or standard PVI only. The LA wall was divided into seven regions: anterior, posterior, septal, lateral, right pulmonary vein (PV) antrum, left PV antrum, and left atrial appendage (LAA) ostium. Regional fibrosis percentage was defined as a region's fibrosis prior to ablation divided by total LA fibrosis. Regional surface area percentage was defined as an area's surface area divided by the total LA wall surface area before ablation. Patients were followed up for a year with single-lead electrocardiogram (ECG) devices. The left PV had the highest regional fibrosis percentage (29.30 ± 14.04%), followed by the lateral wall (23.23 ± 13.56%), and the posterior wall (19.80 ± 10.85%). The regional fibrosis percentage of the LAA was a significant predictor of AF recurrence post-ablation (odds ratio = 1.017, P = 0.021), and this finding was only preserved in patients receiving MRI-guided fibrosis ablation. Regional surface area percentages did not significantly affect the primary outcome.
CONCLUSION
We have confirmed that atrial cardiomyopathy and remodelling are not a homogenous process, with variations in different regions of the LA. Atrial fibrosis does not uniformly affect the LA, and the left PV antral region has more fibrosis than the rest of the wall. Furthermore, we identified regional fibrosis of the LAA as a significant predictor of AF recurrence post-ablation in patients receiving MRI-guided fibrosis ablation in addition to standard PVI.
Topics: Humans; Atrial Fibrillation; Contrast Media; Gadolinium; Heart Atria; Fibrosis; Catheter Ablation; Recurrence; Pulmonary Veins; Treatment Outcome
PubMed: 37428891
DOI: 10.1093/europace/euad199 -
Journal of Cardiovascular... Feb 2021The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood.
BACKGROUND
The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood.
OBJECTIVES
To examine short- and long-term associations of AF catheter ablation with LA function using cardiac magnetic resonance (CMR).
METHODS
Fifty-one AF patients (mean age 56 ± 8 years) underwent CMR at baseline, 1 day (n = 17) and 11 ± 2 months after ablation (n = 38). LA phasic volumes, emptying fractions (LAEF), and longitudinal strain were measured using feature-tracking CMR. LA fibrosis was quantified using late gadolinium enhancement (LGE).
RESULTS
There were no acute changes in volume; however, active, total LAEF, and peak LA strain decreased significantly compared to the baseline. During long-term follow-up, there was a decrease in maximum but not minimum LA volume (from 99 ± 5.2 ml to 89 ± 4.7 ml; p = .009) and a decrease in total LAEF (from 43 ± 1.8% to 39 ± 2.0%; p = .001). In patients with AF recurrence, LA volumes were unchanged. However, total LAEF decreased from 38 ± 3% to 33 ± 3%; p = .015. Patients without AF recurrence had no changes in LA functional parameters during follow-up. The amount of LA LGE at long-term follow-up was higher compared to the baseline, however, was significantly less compared to immediately post-procedure (37 ± 1.9% vs. 47 ± 2.8%; p = .015). A higher increase in LA LGE extent compared to the baseline was associated with a greater decrease in total LAEF (r = -.59; p < .001).
CONCLUSIONS
LA function is impaired acutely following AF catheter ablation. However, long-term changes of LA function are associated positively with the successful restoration of sinus rhythm and inversely with increased LA LGE.
Topics: Atrial Fibrillation; Catheter Ablation; Contrast Media; Gadolinium; Heart Atria; Humans; Magnetic Resonance Imaging; Magnetic Resonance Spectroscopy; Middle Aged
PubMed: 33350536
DOI: 10.1111/jce.14842 -
Journal of the American Heart... Jul 2021Background We assessed the impact of preprocedural plasma levels of MRproANP (midregional N-terminal pro-atrial natriuretic peptide) and sST2 (soluble suppression of... (Comparative Study)
Comparative Study Observational Study
Impact of Midregional N-Terminal Pro-Atrial Natriuretic Peptide and Soluble Suppression of Tumorigenicity 2 Levels on Heart Rhythm in Patients Treated With Catheter Ablation for Atrial Fibrillation: The Biorhythm Study.
Background We assessed the impact of preprocedural plasma levels of MRproANP (midregional N-terminal pro-atrial natriuretic peptide) and sST2 (soluble suppression of tumorigenicity 2) on recurrence of atrial fibrillation (AF) at 1 year after catheter ablation of AF. Methods and Results This was a prospective, multicenter, observational study including patients undergoing catheter ablation of AF. MRproANP and sST2 were measured in a peripheral venous blood preprocedure, and MRproANP was assessed in the right and left atrial blood during ablation. The primary end point was recurrent AF between 3 and 12 months postablation, defined as a documented (>30 seconds) episode of AF, flutter, or atrial tachycardia. We included 106 patients from December 2017 to March 2019; 105 had complete follow-up, and the mean age was 63 years with 74.2% males. Overall, 34 patients (32.1%) had recurrent AF. In peripheral venous blood, MRproANP was significantly higher in patients with recurrent AF (median, 192.2; [quartile 1-quartile 3, 155.9-263.9] versus 97.1 [60.9-150.7] pmol/L; <0.0001), as was sST2 (median, 30.3 [quartile 1-quartile 3, 23.3-39.3] versus 23.4 [95% CI, 17.4-33.0] ng/mL; =0.0033). In the atria, MRproANP was significantly higher than in peripheral blood and was higher during AF than during sinus rhythm. Receiver operating characteristic curve analysis identified a threshold of MRproANP>107.9 pmol/L to predict AF recurrence at 1 year and a threshold of >26.7 ng/mL for sST2. By multivariate analysis, MRproANP>107.9 pmol/L was the only independent predictor of recurrent AF (OR, 24.27; 95% CI, 4.23-139.18). MRproANP<107.9 pmol/L identified subjects at very low risk of recurrence (negative predictive value >95%). Conclusions Elevated MRproANP level independently predicts recurrent AF, whereas sST2 levels do not appear to have any prognostic value in assessing the risk of recurrence of AF up to 1 year after catheter ablation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03351816.
Topics: Aged; Atrial Fibrillation; Atrial Natriuretic Factor; Biomarkers; Catheter Ablation; Female; France; Heart Atria; Heart Rate; Humans; Interleukin-1 Receptor-Like 1 Protein; Male; Middle Aged; Predictive Value of Tests; Prospective Studies; Recurrence; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Up-Regulation
PubMed: 34187182
DOI: 10.1161/JAHA.121.020917 -
JACC. Clinical Electrophysiology Apr 2019The goal of this study was to characterize, in detail, focal atrial tachycardia (AT) arising from the crista terminalis to investigate associations with other atrial...
OBJECTIVES
The goal of this study was to characterize, in detail, focal atrial tachycardia (AT) arising from the crista terminalis to investigate associations with other atrial arrhythmia and to define long-term ablation outcomes.
BACKGROUND
The crista terminalis is known to be the most common site of origin for focal AT, but it is not well characterized.
METHODS
This study retrospectively identified a total of 548 ablation procedures for AT performed at a single center over a 16-year period, of which 171 were arising from the crista terminalis.
RESULTS
Compared with patients with other AT sites of origin, crista terminalis AT patients were older (57.3 vs. 47.3 years), more commonly female (72.9% vs. 59.1%), were more commonly associated with coexistent atrioventricular nodal re-entry tachycardia (17.1% vs. 9.7%), and were more likely to be inducible with programmed stimulation (81.5% vs. 58.9%). There was preferential conduction in the superior-inferior axis along the crista terminalis. Acute ablation success rate was high (92.2%) and improved significantly when three-dimensional mapping was used (98.5%). Recurrence in the first 12 months after a successful ablation was 9.7%. Only 2 patients developed atrial fibrillation over the long-term follow-up of >7 years.
CONCLUSIONS
This large series characterized the clinical and electrophysiological features and immediate and long-term ablation outcomes for AT originating from the crista terminalis. Features of the tachycardia suggest that age-related localized remodeling of the crista terminalis causes a superficial endocardial zone of conduction slowing leading to re-entry. Ablation outcomes were good, with long-term freedom from atrial arrhythmia.
Topics: Atrial Fibrillation; Catheter Ablation; Electrocardiography; Female; Heart Atria; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Tachycardia; Treatment Outcome
PubMed: 31000098
DOI: 10.1016/j.jacep.2019.01.014 -
The Journal of Thoracic and... Feb 2022Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical...
OBJECTIVE
Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV).
METHODS
Between May 2003 and March 2018, 853 patients underwent either biatrial CMP-IV (n = 765) or a left-sided CMP-IV (n = 88) lesion set with complete isolation of the posterior left atrium. Freedom from atrial tachyarrhythmia (ATA) was assessed for up to 10 years. Rhythm outcomes were compared in multiple subgroups. Predictors of recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.
RESULTS
The majority of patients (513/853, 60%) had nonparoxysmal AF. Twenty-four percent of patients (201/853) had not responded to at least 1 catheter-based ablation. Prolonged monitoring was used in 76% (647/853) of patients during their follow-up. Freedom from ATA was 92% (552/598), 84% (213/253), and 77% (67/87) at 1, 5, and 10 years, respectively. By competing risk analysis, incidence of first ATA recurrence was 11%, 23%, and 35% at 1, 5, and 10 years, respectively. On Fine-Gray regression, age, peripheral vascular disease, nonparoxysmal AF, left atrial size, early postoperative ATAs, and absence of sinus rhythm at discharge were the predictors of first ATA recurrence over 10 years of follow-up.
CONCLUSIONS
The CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence.
Topics: Action Potentials; Aged; Atrial Fibrillation; Atrial Function, Left; Databases, Factual; Female; Heart Atria; Heart Rate; Humans; Male; Maze Procedure; Middle Aged; Recurrence; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 32563577
DOI: 10.1016/j.jtcvs.2020.04.100 -
Minerva Cardioangiologica Apr 2004Pulmonary veins have been shown to play an important role in the initiation and maintenance of paroxysmal atrial fibrillation. Seg-mental ostial isolation of the... (Review)
Review
Pulmonary veins have been shown to play an important role in the initiation and maintenance of paroxysmal atrial fibrillation. Seg-mental ostial isolation of the pulmonary veins results in cure in about 2/3 of the patients. This approach does not address non-pulmonary venous triggers of atrial fibrillation or the importance of the left atrium itself. Left atrial circumferential ablation has also been shown to be efficacious in patients with paroxysmal atrial fibrillation. This approach seems to address not only the various triggers of atrial fibrillation but also the left atrial substrate. Recently, a randomized study compared the 2 strategies and showed that left atrial ablation is superior to segmental ostial isolation. This review will highlight the anatomy and electrophysiology of the pulmonary veins, and the possible mechanisms by which they initiate and maintain paroxysms of atrial fibrillation. Segmental ostial isolation of the pulmonary veins and left atrial ablation will be compared as well.
Topics: Adult; Atrial Fibrillation; Catheter Ablation; Electrocardiography; Heart Atria; Heart Conduction System; Humans; Middle Aged; Myocardium; Postoperative Care; Postoperative Complications; Pulmonary Veins; Randomized Controlled Trials as Topic; Recurrence; Tachycardia; Treatment Outcome
PubMed: 15194991
DOI: No ID Found