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BACKGROUND: Idiopathic epicardial premature ventricular contractions (PVCs) originating from the left ventricular summit are difficult to eliminate. OBJECTIVE: The purpose of this study was to describe the feasibility and procedural safety of monopolar biphasic focal pulsed field ablation (F-PFA) from within the great cardiac vein (GCV) for treatment of idiopathic epicardial PVCs. METHODS: In 4 pigs, F-PFA (Centauri, CardioFocus) was applied from within the GCV followed by macroscopic gross analysis. In 4 patients with previously failed radiofrequency ablation, electroanatomic mapping was used to guide F-PFA from within the GCV and the ventricular outflow tracts. Coronary angiography and optical coherence tomography (OCT) were performed in 2 patients. RESULTS: In pigs, F-PFA from within the GCV (5 mm away from the coronary arteries) resulted in myocardial lesions with a maximal depth of 4 mm, which was associated with nonobstructive transient coronary spasms. In patients, sequential delivery of F-PFA in the ventricular outflow tracts and from within the GCV eliminated the PVCs. During F-PFA delivery from within the GCV with prophylactic nitroglycerin application, coronary angiography showed no coronary spasm when F-PFA was delivered >5 mm away from the coronary artery and a transient coronary spasm without changes in a subsequent OCT, when F-PFA was delivered directly on the coronary artery. Intracardiac echocardiography and computed tomography integration was used to monitor F-PFA delivery from within the GCV. There were no immediate or short-term complications. CONCLUSION: Sequential mapping-guided F-PFA from endocardial ventricular outflow tracts and from within the GCV is feasible with a favorable procedural safety profile for treatment of epicardial PVCs.
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BACKGROUND: Dark-blood late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) has better correlation with bipolar voltage (BiV) to define ablation scar in the left atrium (LA) compared to conventional bright-blood LGE CMR. OBJECTIVES: This study sought to determine the optimal signal intensity threshold of dark-blood LGE CMR to identify LA ablation scar. METHODS: In 54 patients scheduled for atrial fibrillation ablation, image intensity ratios (IIRs) were derived from preprocedural dark-blood LGE CMR. In 26 patients without previous ablation, the upper limit of normal was derived from the 95th and 98th percentiles of pooled IIR values. In 28 patients with previous atrial fibrillation ablation, BiV was compared with the corresponding IIR. Receiver-operating characteristics analyses were employed to determine the optimal IIR threshold (ie, the point with the smallest distance to the upper left corner of the receiver-operating characteristics) for LA ablation scar (BiV ≤0.15 mV). RESULTS: Upper limit of normal corresponded to IIR values 1.16 and 1.21, yielding low sensitivities of 0.32 and 0.09 to detect LA ablation scar. Receiver-operating characteristics analysis of IIR and BiV comparison achieved a median area under the curve of 0.77. Median optimal IIR threshold for LA ablation scar was 1.09, with an average sensitivity of 0.73, specificity of 0.75, and accuracy of 0.71. Median IIR thresholds of 1.00 and 1.10 corresponded to 80% sensitivity and 80% specificity, respectively. There was considerable interpatient variability: optimal IIR thresholds per patient ranged from 1.01 to 1.22. CONCLUSIONS: The optimal IIR threshold to identify LA ablation scar by dark-blood LGE CMR is 1.09. Because of interpatient variability, the investigators recommend using a lower (1.00) and upper (1.10) threshold to prevent over- or underestimation of ablation scar.
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AIMS: Pulmonary vein isolation (PVI) is the corner stone of modern rhythm control strategies in patients with atrial fibrillation (AF). Sleep-disordered breathing (SDB) is prevalent in more than 50% of patients undergoing AF ablation, and studies have indicated a greater recurrence rate after PVI in patients with SDB. Herein, we study the effect of catheter-based PVI on AF in a pig model for SDB. METHODS AND RESULTS: In 11 sedated spontaneously breathing pigs, obstructive apnoeas were simulated by 75â s of intermittent negative upper airway pressure (INAP) applied by a negative pressure device connected to the endotracheal tube. Intermittent negative upper airway pressures were performed before and after PVI. AF-inducibility and atrial effective refractory periods (aERPs) were determined before and during INAP by programmed atrial stimulation. Pulmonary vein isolation prolonged the aERP by 48 ± 27â ms in the right atrium (RA) (P < 0.0001) and by 40 ± 34â ms in the left atrium (LA) (P = 0.0004). Following PVI, AF-inducibility dropped from 28 ± 26% to 0% (P = 0.0009). Intermittent negative upper airway pressure was associated with a transient aERP-shortening (ΔaERP) in both atria, which was not prevented by PVI (INAP indued ΔaERP after PVI in the RA: -57 ± 34â ms, P = 0.0002; in the LA: -42 ± 24â ms, P < 0.0001). Intermittent negative upper airway pressure was associated with a transient increase in AF-inducibility (from 28 ± 26% to 69 ± 21%; P = 0.0008), which was not attenuated by PVI [INAP-associated AF-inducibility after PVI: 58 ± 33% (P = 0.5)]. CONCLUSION: Transient atrial arrhythmogenic changes related to acute obstructive respiratory events are not prevented by electrical isolation of the pulmonary veins, which partially explains the increased AF recurrence in patients with SDB after PVI procedures.
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Fibrilação Atrial , Ablação por Cateter , Modelos Animais de Doenças , Veias Pulmonares , Animais , Veias Pulmonares/cirurgia , Veias Pulmonares/fisiopatologia , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Fibrilação Atrial/prevenção & controle , Fibrilação Atrial/diagnóstico , Suínos , Ablação por Cateter/métodos , Apneia Obstrutiva do Sono/fisiopatologia , Falha de Tratamento , Frequência Cardíaca , Átrios do Coração/fisiopatologia , Átrios do Coração/cirurgiaRESUMO
AIM: To evaluate changes in healthcare utilisation and comprehensive packages of care activities and procedures (referred in the Netherlands to as 'diagnose-behandelcombinatie (DBC) care products) during the implementation of the TeleCheck-AF approach (teleconsultation supported by app-based heart rate/rhythm monitoring) in a Dutch atrial fibrillation (AF) clinic. METHODS AND RESULTS: In the Maastricht University Medical Centre+ AF Clinic, data on healthcare utilisation and DBC care products for patients consulted by both a conventional approach in 2019 and the TeleCheck-AF approach in 2020 were analysed. A patient experience survey was performed. Thirty-seven patients (median age 68 years; 40% women) were analysed. With the conventional approach, 35 face-to-face consultations and 0 teleconsultations were conducted. After the implementation of TeleCheck-AF, the number of face-to-face consultations dropped by 80% (pâ¯< 0.001) and teleconsultations increased to 45 (pâ¯< 0.001). While 42 electrocardiograms (ECGs) and 25 Holter ECGs or echocardiograms were recorded when using the conventional approach, the number of ECGs decreased by 71% (pâ¯< 0.001) and Holter ECGs or echocardiograms by 72% (pâ¯< 0.001) with the TeleCheck-AF approach. The emergency department patient presentations showed no statistically significant change (pâ¯= 0.33). Overall, 57% of medium-weight DBC care products were changed to light-weight ones during implementation of the TeleCheck-AF approach. Patient satisfaction with the TeleCheck-AF approach was high. CONCLUSION: The implementation of TeleCheck-AF led to a change in healthcare utilisation, a change from medium-weight to light-weight DBC care products and a reduction in patient burden. These results created the basis for a new reimbursement code for the TeleCheck-AF approach in the Netherlands.
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Fibrilação Atrial , Remodelamento Atrial , Humanos , Remodelação Ventricular , Coração , Átrios do CoraçãoRESUMO
Background: In atrial fibrillation (AF) patients, presence of expiratory airflow limitation may negatively impact treatment outcomes. AF patients are not routinely screened for expiratory airflow limitation, but existing examinations can help identify at-risk individuals. We aimed to assess the diagnostic value of repurposing existing assessments from the pre-ablation work-up to identify and understand the characteristics of affected patients. Methods: We screened 110 consecutive AF patients scheduled for catheter ablation with handheld spirometry. Routine pre-ablation work-up included cardiac computed tomographic angiography (CCTA), transthoracic echocardiography and polygraphy. CCTA was analyzed qualitatively for emphysema and airway abnormalities. Multivariate logistic regression analysis was performed to determine predictors of expiratory airflow limitation. Results: We found that 25 % of patients had expiratory airflow limitation, which was undiagnosed in 86 % of these patients. These patients were more likely to have pulmonary abnormalities on CCTA, including emphysema (odds ratio [OR] 4.2, 95 % confidence interval [CI] 1.12-15.1, p < 0.05) and bronchial wall thickening (OR 2.6, 95 % CI 1.0-6.5, p < 0.05). The absence of pulmonary abnormalities on CCTA accurately distinguished patients with normal lung function from those with airflow limitation (negative predictive value: 85 %). Echocardiography and polygraphy did not contribute significantly to identifying airflow limitation. Conclusions: In conclusion, routine pre-ablation CCTA can detect pulmonary abnormalities in AF patients with airflow limitation, guiding further pulmonary assessment. Future studies should investigate its impact on ablation procedure success.
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Background: The combination of information obtained from pre-procedural cardiac imaging and electro-anatomical mapping (EAM) can potentially help to locate new ablation targets. In this study we developed and evaluated a fully automated technique to align left atrial (LA) anatomies obtained from CT- and MRI-scans with LA anatomies obtained from EAM. Methods: Twenty-one patients scheduled for a pulmonary vein (PV) isolation with a pre-procedural MRI were enrolled. Additionally, a recent computed tomography (CT) scan was available in 12 patients. LA anatomies were segmented from MRI-scans using ADAS-AF (Galgo Medical, Barcelona) and from the CT-scans using Slicer3D. MRI and CT anatomies were aligned with the EAM anatomy using an iterative closest plane-to-plane algorithm. Initially, the algorithm included the PVs, LA appendage and mitral valve anulus as they are the most distinctive landmarks. Subsequently, the algorithm was applied again, excluding these structures, with only three iterative steps to refine the alignment of the true LA surface. The result of the alignments was quantified by the Euclidian distance between the aligned anatomies after excluding PVs, LA appendage and mitral anulus. Results: Our algorithm successfully aligned 20/21 MRI anatomies and 11/12 CT anatomies with the corresponding EAM anatomies. The average median residual distances were 1.9 ± 0.6 mm and 2.5 ± 0.8 mm for MRI and CT anatomies respectively. The average LA surface with a residual distance less than 5.00 mm was 89 ± 9% and 89 ± 10% for MRI and CT anatomies respectively. Conclusion: An iterative closest plane-to-plane algorithm is a reliable method to automatically align pre-procedural cardiac images with anatomies acquired during ablation procedures.
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BACKGROUND: Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated. METHODS: Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter. RESULTS: 25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up. CONCLUSIONS: LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF.
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Background: The 'double fire' (DF) atrioventricular (AV) nodal response is a rare mechanism of two ventricular electrical activations following a single atrial beat due to dual AV node physiology. DF AV nodal response is often misdiagnosed and may lead to unnecessary invasive procedures. Case summary: We describe a series of three cases with distinct clinical manifestations of DF AV nodal response: Patient 1 remained symptomatic after slow pathway modification for common AV nodal re-entry tachycardia. Patient 2 was misdiagnosed as having junctional bigeminy and developed heart failure with reduced left ventricle ejection fraction. Patient 3 was misdiagnosed as having atrial fibrillation (AF) and underwent two pulmonary vein isolation (PVI) procedures, without clinical improvement. All patients underwent an electrophysiological study (EPS) during which DF AV nodal response was confirmed and treated with radiofrequency ablation of the slow pathway. All patients were afterwards relieved from their symptoms. Discussion and conclusion: DF AV nodal response is a rare electrophysiological phenomenon which can be clinically misinterpreted as other common arrhythmias, such as premature junctional bigeminy or AF and can contribute to tachycardia induced cardiomyopathy. Typical electrocardiogram- and EPS-derived findings can be indicative for DF AV nodal response. DF AV nodal response can be easily and effectively treated by slow pathway ablation.
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Aim: To propose a standardized workflow for 3D-electroanatomical mapping guided pulmonary vein isolation in pigs. Materials and methods: Danish female landrace pigs were anaesthetized. Ultrasound-guided puncture of both femoral veins was performed and arterial access for blood pressure measurement established. Fluoroscopy- and intracardiac ultrasound-guided passage of the patent foramen ovale or transseptal puncture was performed. Then, 3D-electroanatomical mapping of the left atrium was conducted using a high-density mapping catheter. After mapping all pulmonary veins, an irrigated radiofrequency ablation catheter was used to perform ostial ablation to achieve electrical pulmonary vein isolation. Entrance- and exit-block were confirmed and re-assessed after a 20-min waiting period. Lastly, animals were sacrificed to perform left atrial anatomical gross examination. Results: We present data from 11 consecutive pigs undergoing pulmonary vein isolation. Passage of the fossa ovalis or transseptal puncture was uneventful and successful in all animals. Within the inferior pulmonary trunk 2-4 individual veins as well as 1-2 additional left and right pulmonary veins could be cannulated. Electrical isolation by point-by-point ablation of all targeted veins was successful. However, pitfalls including phrenic nerve capture during ablation, ventricular arrhythmias during antral isolation close to the mitral valve annulus and difficulties in accessing right pulmonary veins were encountered. Conclusion: Fluoroscopy- and intracardiac ultrasound-guided transseptal puncture, high-density electroanatomical mapping of all pulmonary veins and complete electrical pulmonary vein isolation can be achieved reproducibly and safely in pigs when using current technologies and a step-by-step approach.
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BACKGROUND: Although catheter ablation (CA) is successful for the treatment of paroxysmal atrial fibrillation (AF), results are less satisfactory in persistent AF. Hybrid ablation (HA) results in better outcomes in patients with persistent atrial fibrillation (persAF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure. OBJECTIVES: The purpose of this study was to compare the effectiveness and safety of HA with CA in a prospective, superiority, unblinded, randomized controlled trial. METHODS: Forty-one ablation-naive patients with (long-standing)-persAF were randomized to HA (n = 19) or CA (n = 22) and received pulmonary vein isolation, posterior left atrial wall isolation and, if needed, a cavotricuspid isthmus ablation. The primary efficacy endpoint was freedom from any atrial tachyarrhythmia >5 minutes off antiarrhythmic drugs after 12 months. The primary and secondary safety endpoints included major and minor complications and the total number of serious adverse events. RESULTS: After 12 months, the freedom of atrial tachyarrhythmias off antiarrhythmic drugs was higher in the HA group compared with the CA group (89% vs 41%, P = 0.002). There was 1 pericarditis requiring pericardiocentesis and 1 femoral arteriovenous-fistula in the HA group. In the CA arm, 1 bleeding from the femoral artery occurred. There were no deaths, strokes, need for pacemaker implantation, or conversions to sternotomy, and the number of (serious) adverse events was comparable between groups (21% vs 14%, P = 0.685). CONCLUSIONS: Hybrid AF ablation is an efficacious and safe procedure and results in better outcomes than catheter ablation for the treatment of patients with persistent AF. (Hybrid Versus Catheter Ablation in Persistent AF [HARTCAP-AF]; NCT02441738).
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Fibrilação Atrial , Ablação por Cateter , Humanos , Resultado do Tratamento , Estudos Prospectivos , Antiarrítmicos/uso terapêutico , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodosRESUMO
BACKGROUND: Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF. AIM: We aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection. METHODS: Consecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea-hypopnoea index (AHI) of ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening. RESULTS: Of 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573-0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672-0.805) in the overall population. CONCLUSION: AF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies. TRIAL REGISTRATION NUMBER: ISOLATION was registered NCT04342312, 13-04-2020.