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INTRODUCTION: Catheter ablation of ectopy originating from the vicinity of the His bundle can be challenging. METHODS AND RESULTS: We report a case of a 33-year-old man with narrow QRS ectopy with preferential conduction from a para-Hisian origin to the proximal left fascicles, which was successfully eliminated by radiofrequency ablation in the right coronary cusp, guided by ultrahigh-resolution mapping of the His bundle, bundle branch, and fascicular electrograms. CONCLUSION: Some narrow QRS ectopy may originate from the vicinity of the conduction system, instead of the "true" conduction system, and have concealed connections from its origin to the conduction system.
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Potenciais de Ação , Fascículo Atrioventricular , Ablação por Cateter , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Frequência Cardíaca , Humanos , Masculino , Adulto , Fascículo Atrioventricular/fisiopatologia , Fascículo Atrioventricular/cirurgia , Resultado do Tratamento , Valor Preditivo dos TestesRESUMO
INTRODUCTION: The optimal slow pathway (SP) ablation site in cases with an inferiorly located His bundle (HIS) remains unclear. METHODS AND RESULTS: In 45 patients with atrioventricular nodal reentrant tachycardia, the relationship between the HIS location and successful SP ablation site was assessed in electroanatomical maps. We assessed the location of the SP ablation site relative to the bottom of the coronary sinus ostium in the superior-to-inferior (SPSI), anterior-to-posterior (SPAP), and right-to-left (SPRL) directions. The HIS location was assessed in the same manner. The HIS location in the superior-to-inferior direction (HISSI), SPSI, SPAP, and SPRL were 17.7 ± 6.4, 1.7 ± 6.4, 13.6 ± 12.3, and -1.0 ± 13.0 mm, respectively. The HISSI was positively correlated with SPSI (R2 = 0.62; P < .01) and SPAP (R2 = 0.22; P < .01), whereas it was not correlated with SPRL (R2 = 0.01; P = .65). The distance between the HIS and SP ablation site was 17.7 ± 6.4 mm and was not affected by the location of HIS. The ratio of the amplitudes of atrial and ventricular potential recorded at the SP ablation site did not differ between the high HIS group (HISSI ≥ 13 mm) and low HIS group (HISSI < 13 mm) (0.10 ± 0.06 vs. 0.10 ± 0.06; P = .38). CONCLUSION: In cases with an inferiorly located HIS, SP ablation should be performed at a lower and more posterior site than in typical cases.
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Taquicardia por Reentrada no Nó Atrioventricular , Septo Interventricular , Humanos , Fascículo Atrioventricular/cirurgia , Taquicardia por Reentrada no Nó Atrioventricular/cirurgia , Ventrículos do Coração , Átrios do CoraçãoRESUMO
A 50-year-old woman underwent catheter ablation for atrial fibrillation. Preoperative computed tomography revealed a left-sided variant of the right top pulmonary vein (PV) and a persistent left superior vena cava. The right top PV was successfully isolated through a wide antral circumferential ablation line simultaneously with the right PVs.
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We report a case of an ischemic stroke after a successful catheter ablation of atrial fibrillation (AF) and continuous oral anticoagulation therapy with direct oral anticoagulants (DOACs), which was the trigger for diagnosing antiphospholipid syndrome (APS). A 68-year-old woman underwent catheter ablation of persistent AF and continued oral anticoagulation with edoxaban at a dose of 30 mg once daily after the ablation procedure. An asymptomatic intracerebral hemorrhage was detected by brain computed tomography and magnetic resonance imaging one month post-ablation. Oral anticoagulation with dabigatran at 110 mg twice daily was continued thereafter due to a high stroke risk profile of a CHA2D2-VASc score of 3. Eight months after the procedure, the patient had multiple acute cerebral infarctions despite no apparent recurrence of atrial tachyarrhythmias and continuation of the DOAC. A blood examination revealed the presence of anti-cardiolipin-beta2-glycoproteion complex antibodies and lupus anticoagulants, and the patient was diagnosed with primary APS. The DOAC was changed to warfarin. The patient has remained free from any ischemic or hemorrhagic cerebral events for 11 months after the oral anticoagulants were changed. The ischemic stroke in the present case appeared to be associated with APS rather than AF. A diagnosis of APS may be extremely crucial in AF patients who have new-onset ischemic strokes under continuous administration of DOACs, because vitamin K antagonists are more effective for the prevention of APS-related ischemic strokes than DOACs.
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Síndrome Antifosfolipídica/diagnóstico , Fibrilação Atrial/terapia , Ablação por Cateter , Inibidores do Fator Xa/uso terapêutico , AVC Isquêmico/etiologia , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Idoso , Síndrome Antifosfolipídica/complicações , Fibrilação Atrial/complicações , Feminino , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/prevenção & controleRESUMO
The sympathetic nervous system plays an important role in life-threatening ventricular arrhythmias (VAs). Bilateral cardiac sympathetic denervation (BCSD) is performed for refractory VAs. We sought to assess our institutional experience with BCSD in managing treatment-resistant monomorphic ventricular tachycardia (MMVT) in heart failure patients with a reduced ejection fraction (HFrEF).Four patients with HFrEF (EF 30.0 ± 8.2%, New York Heart Association [NYHA] class IV 1) underwent BCSD for MMVT (VT storm 3, repetitive VT requiring implantable cardioverter defibrillator [ICD] therapy 1) refractory to antiarrhythmic drugs, catheter ablation and ICD therapy. BCSD was effective for suppressing VT in 3 patients for whom deep sedation was effective for suppressing VT. One patient remained alive after 14 months of follow-up without episodes of VT. One patient died of acute myocardial infarction before discharge and 1 patient died from unknown cause at 3 days post-discharge. In contrast, BCSD was completely ineffective for suppressing VT in a patient with NYHA class IV for whom deep sedation and stellate ganglion block were ineffective. This patient died on the 10th post-CSD day, despite left ventricular assist device implantation. In all cases, BCSD was successfully performed without procedure-related complications.Despite the limited number of cases, our results showed that BCSD in patients with HFrEF suppressed refractory MMVT in acute-phase except for a patient with NYHA class IV; however, the prognoses were not good. BCSD may be a treatment option at an earlier stage of NYHA and a bridge to orthotopic heart transplantation, even if BCSD is effective for suppressing VAs.
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Ablação por Cateter , Desfibriladores Implantáveis , Insuficiência Cardíaca , Taquicardia Ventricular , Assistência ao Convalescente , Arritmias Cardíacas/complicações , Ablação por Cateter/métodos , Desfibriladores Implantáveis/efeitos adversos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/cirurgia , Humanos , Alta do Paciente , Volume Sistólico , Simpatectomia/métodos , Resultado do TratamentoRESUMO
INTRODUCTION: Local impedance (LI) drops during radiofrequency ablation can predict lesion formation. Some conduction gaps during pulmonary vein isolation (PVI) can be associated with nonendocardial connections. This study aimed to investigate the incidence, characteristics, and predictors of endocardial and nonendocardial conduction gaps during an LI-guided PVI. METHODS AND RESULTS: We prospectively enrolled 157 consecutive patients undergoing an initial LI-guided extensive PVI of atrial fibrillation (AF). After the first-pass encirclement, the residual conduction gaps and reconnected gaps were mapped using Rhythmia (Boston Scientific) and a mini-basket catheter. Right and left PV (RPV/LPV) gaps were observed in 22.3% and 18.5% of the patients, respectively: 27 endocardial and 49 nonendocardial gaps. The carina regions were common sites for the gaps (51 carina-related vs. 25 noncarina-related). The carina-related gaps consisted of more nonendocardial gaps than endocardial gaps (RPVs: 90.0% vs. 10.0%, p = .001; LPVs: 76.2% vs. 23.8%, p < .001). A univariate analysis revealed that paroxysmal AF and the left atrial (LA) volume index for RPV endocardial gaps (odds ratio [OR]: 8.640 and 0.946; p = .043 and 0.009), minor right inferior PV diameter for RPV nonendocardial gaps (OR: 1.165; p = .028), and major left inferior PV diameter for LPV endocardial gaps (OR: 1.233; p = .028) were significant predictors. CONCLUSIONS: During the LI-guided PVI, approximately two-thirds of the conduction gaps were nonendocardial. The carina regions had more conduction gaps than noncarina regions, which was due to the presence of nonendocardial connections. Paroxysmal AF, a lower LA volume index, and larger inferior PV diameters may increase the risk of conduction gaps.
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Fibrilação Atrial , Ablação por Cateter , Veias Pulmonares , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/epidemiologia , Ablação por Cateter/efeitos adversos , Impedância Elétrica , Humanos , Prevalência , Veias Pulmonares/diagnóstico por imagem , Veias Pulmonares/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: The difference in the incidence and characteristics of silent cerebral events (SCEs) after radiofrequency-based atrial fibrillation (AF) ablation between the different mapping catheters and indices used for guiding radiofrequency ablation remains unclear. This study aimed to compare the incidence and characteristics of postablation SCEs between the following two groups: Group C, Ablation Index-guided ablation using two circular mapping catheters with CARTO (Biosense Webster); Group R, local impedance-guided ablation using one mini-basket catheter and one circular mapping with Rhythmia (Boston Scientific). METHODS AND RESULTS: Of 211 consecutive patients who underwent an AF ablation and brain magnetic resonance (MR) imaging after the ablation, 120 patients (each group, n = 60) were selected by propensity score matching. SCEs were detected in 37 patients (30.8%). Group R had a higher incidence of SCEs (51.7% vs. 10.0%; p < .001) and more SCEs per patient (median, 3 vs. 1, p = .028) than Group C. A multivariate analysis demonstrated that nonparoxysmal AF and being Group R were independent positive predictors of SCEs (odds ratios, 6.930 and 15.464; both p < .001). On the follow-up MR imaging, all SCEs in Group C and 87.9% of the SCEs in Group R disappeared (p = .537). CONCLUSIONS: Group R had a significantly higher incidence of SCEs than Group C. Most probably the use of a complexly designed basket mapping catheter is the reason for the difference in the incidence of SCEs but further validation is needed. A nonparoxysmal form of AF may also increase the risk of SCEs during these ablation procedures.
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Fibrilação Atrial , Ablação por Cateter , Embolia Intracraniana , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/epidemiologia , Boston , Ablação por Cateter/efeitos adversos , Catéteres , Humanos , Incidência , Pontuação de Propensão , Resultado do TratamentoRESUMO
BACKGROUND: Air bubble intrusion through transseptal sheaths during left atrial (LA) catheter ablation can cause cerebral embolisms, especially when using complex-shape catheters. This study aimed to compare the incidence of silent cerebral events (SCEs) after atrial fibrillation (AF) catheter ablation using a mini-basket catheter (IntellaMap Orion; Boston Scientific) between the following groups: group SP, strict prevention of LA air intrusion and group CP, conventional air intrusion prevention. METHODS: We enrolled 123 consecutive AF patients (group SP, n = 61 and group CP, n = 62) who underwent brain magnetic resonance imaging after a local-impedance-guided ablation using one mini-basket catheter and one circular mapping catheter. The preventive strategy in group SP included (a) the insertion of the mini-basket catheter into the transseptal sheaths in a container filled with heparinized saline and (b) no exchange of all catheters over the sheaths. RESULTS: SCEs were detected in 67 patients (54.5%), and the incidence of SCEs did not significantly differ between groups SP and CP (55.7% vs 53.2%; P = .780). A multivariate analysis demonstrated that an older age, non-paroxysmal AF, and radiofrequency (RF) power output were independent positive predictors of SCEs (odds ratios: 1.079, 5.613, and 1.405; P = .005, <.001, and .012). On the follow-up MR imaging, 83.5% of the SCEs in group SP and 87.7% in group CP disappeared (P = .398). CONCLUSIONS: Strict prevention of LA air intrusion may have no additional effect for reducing the incidence of SCEs after local impedance-guided AF ablation using a mini-basket catheter. An older age, non-paroxysmal AF, and high-power RF applications may increase the risk of SCEs.
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Cateterismo Cardíaco/instrumentação , Ablação por Cateter/métodos , Embolia Aérea/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Idoso , Ablação por Cateter/instrumentação , Desenho de Equipamento , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Estudos RetrospectivosRESUMO
The aim of this study was to evaluate the impact of the size of the isolated surface area and non-ablated left atrial posterior area after extensive encircling pulmonary vein isolation (EEPVI) for non-paroxysmal atrial fibrillation (AF) on arrhythmia recurrence. This study included 132 consecutive persistent AF patients who underwent EEPVI guided by Ablation Index (AI). The isolated antral surface area (IASA) excluding the pulmonary veins, the non-ablated left atrial (LA) posterior wall surface area (PWSA), the ratio of IASA to LA surface area (IASA/LA ratio), and the ratio of PWSA to LA surface area (PWSA/LA ratio) were assessed using CARTO3 and the association with AF and atrial tachycardia (AT) recurrence was examined. At a mean follow-up of 13.2 ± 7.3 months, sinus rhythm was maintained in 115 (87%) patients. In the univariate Cox regression analysis, the factors that significantly predicted AT/AF recurrence were a history of heart failure, a higher CHA2DS2-VASc score, a larger LA diameter, and a larger PWSA/LA ratio. Multivariate Cox regression analysis revealed that the independent predictors of AT/AF recurrence were LA diameter [hazard ratio (HR) 1.120 per 1 mm increase; 95% confidence interval (CI) 1.006-1.247; P = 0.039] and PWSA/LA ratio (HR 1.218 per 1% increase; 95% CI 1.041-1.425; P = 0.014). Receiver operating characteristics curve analysis yielded an optimal cut-off value of 8% for the PWSA/LA ratio. The Kaplan-Meier survival curve showed that patients with a larger PWSA/LA ratio had poorer clinical outcomes (Log-rank P = 0.001). A larger PWSA/LA ratio was associated with a high AT/AF recurrence rate in patients with non-paroxysmal atrial fibrillation.
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Fibrilação Atrial , Ablação por Cateter , Veias Pulmonares , Fibrilação Atrial/cirurgia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Humanos , Veias Pulmonares/diagnóstico por imagem , Veias Pulmonares/cirurgia , Recidiva , Resultado do TratamentoRESUMO
We respond to a letter by Dr. A. Goyal. If the tachycardia were junctional ectopic tachycardia (JET), the occurrence of the ventriculoatrial block following an atrial premature depolarization could not be explained. Therefore, we conclude that atrioventricular nodal reentrant tachycardia was more likely than JET.
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A newly developed pesticide, flupentiofenox, has a unique trifluoroethyl phenylsulfoxide structure, and it powerfully affects spider mites, including those with resistance to multiple commercial acaricides. To clarify the mode of action of flupentiofenox, we investigated its effect on mitochondrial energy generation. We observed that flupentiofenox decreased adenosine triphosphate (ATP) levels in two-spotted spider mites (Tetranychus urticae) at a practical dose. Flupentiofenox potently inhibited mitochondrial oxygen consumption under conditions of palmitoyl-carnitine or octanoic acid supply, but not under conditions of pyruvate supply. These results show that flupentiofenox inhibits the mitochondrial fatty acid metabolic pathway between the uptake of long-chain acylcarnitine or medium-chain fatty acid and the synthesis of acetyl-CoA by ß-oxidation, resulting in suppressed mitochondrial energy generation. Our investigations have led us to conclude that flupentiofenox is a pesticide with a novel mode of action.
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Acaricidas , Ácidos Graxos , Mitocôndrias , Oxirredução , Tetranychidae , Animais , Acaricidas/farmacologia , Acaricidas/química , Acaricidas/metabolismo , Ácidos Graxos/metabolismo , Ácidos Graxos/química , Mitocôndrias/metabolismo , Mitocôndrias/efeitos dos fármacos , Tetranychidae/efeitos dos fármacos , Tetranychidae/metabolismo , Trifosfato de Adenosina/metabolismoRESUMO
BACKGROUND: Epicardial connections from surrounding structures to the right pulmonary vein (PV) antrum impede PV isolation. OBJECTIVE: This study aimed to evaluate the efficacy of an ablation approach targeting epicardial connections for right PV isolation. METHODS: We prospectively enrolled 124 patients with atrial fibrillation undergoing initial PV isolation. We identified the activation breakthrough into the right PV antrum (BT-RPV) on the activation map created during high right atrial pacing before PV isolation. BT-RPV sites were targeted when right PV isolation was not achieved by wide antral circumferential ablation (WACA). RESULTS: BT-RPV was observed in 83 cases (67%). PV isolation was achieved by WACA in all 41 cases without BT-RPV. Among cases with BT-RPV, PV isolation was achieved by WACA in 48 cases when all BT-RPV sites were covered by the PV isolation line. Conversely, PV isolation was completed by WACA in only 5 out of 35 cases when not all BT-RPV sites were covered. In cases where WACA failed, 35 sites were targeted for BT-RPV ablation. Initial BT-RPV ablation led to PV isolation at 20 sites, while the remaining 15 BT-RPV sites required repeat BT-RPV ablation. The ablated area of successful BT-RPV ablation was 0.9 [0.6-1.2] cm2, corresponding to the area activated within 15 [14-16] ms after BT-RPV emergence. Ablating the area activated within 14 ms after BT-RPV emergence was associated with successful PV isolation (sensitivity 91% and specificity 100%). CONCLUSION: Ablation targeting BT-RPV sites is effective for right PV isolation. Extensive ablation is required to eliminate BT-RPV.
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Background: Periesophageal vagal nerve injury (PNI) is an unpredictable and serious complication of atrial fibrillation (AF) ablation. We aimed to identify the factors associated with symptomatic PNI. Methods: This study included 1391 patients who underwent ablation index-guided pulmonary vein isolation (PVI) using the CARTO system. The target ablation index was set at 550, except for the left atrial (LA) posterior wall near the esophagus, where radiofrequency (RF) power and duration were limited. Ten patients (0.72%) were diagnosed with symptomatic PNI. We randomly selected 40 patients without PNI (1:4 ratio) matched based on age, sex, body mass index, LA diameter, type of AF, and esophageal location. We measured the shortest distance from the RF lesions to the esophagus (LED) and classified the RF lesions according to the LED into four groups: 0-5, 5-10, 10-15, and 15-20 mm. We conducted a comparative analysis of classified RF lesions between patients with PNI (n = 10) and those without (n = 40). Results: The contact force at LED 0-5 mm was significantly higher in patients with PNI than in those without (14.6 ± 1.7 vs. 12.0 ± 2.9 g; p = .01). Multivariate logistic analysis revealed that the independent factor for PNI was contact force at an LED of 0-5 mm (odds ratio: 1.506; 95% confidence interval: 1.053-2.153; p = .025). Conclusions: The symptomatic PNI was significantly associated with a higher contact force near the esophagus. Strategies for regulating contact force near the esophagus may aid in the prevention of PNI.
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Flupentiofenox, which has a unique chemical structure, is a novel acaricide that has been developed by the Kumiai Chemical Industry Co., Ltd. Flupentiofenox exerted significant acaricidal activities against spider mites Tetranychus urticae and Panonychus citri at all developmental stages even at extremely low concentrations, as compared with its practical concentration (80 ppm) for use in mites and was effective against spider mite populations that are resistant to widely used commercial acaricides. These results suggested that flupentiofenox could be used effectively for the control and prevention of spider mite infestation. Additionally, flupentiofenox had a more rapid effect than acetyl CoA carboxylase inhibitors, but it had a relatively slower effect than mitochondrial electron transport inhibitors and glutamate-gated chloride channel modulators. Overall, flupentiofenox is assumed to have a new mode of action.
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We present an atypical response to single atrial premature depolarization (APD) in a long RP' tachycardia. APD advanced the His-bundle potential immediately after it and resulted in a VA block; however, tachycardia persisted and consequently exhibited an A-V-V-A response. We propose the mechanism for an A-V-V-A response to APD in a long RP' tachycardia.
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PURPOSE: The left atrial posterior wall (LAPW) can be a target for atrial fibrillation (AF) catheter ablation but is sometimes difficult to completely isolate due to the presence of endocardial-epicardial connections. We aimed to investigate the incidence and distribution of epicardial residual connections (epi-RCs) and the electrogram characteristics at epi-RC sites during an initial LAPW isolation. METHODS: We retrospectively studied 102 AF patients who underwent LAPW mapping before and after a first-pass linear ablation along the superior and inferior LAPW (pre-ablation and post-ablation maps) using an ultra-high-resolution mapping system (Rhythmia, Boston Scientific). RESULTS: Epi-RCs were observed in 41 patients (40.2%) and were widely distributed in the middle LAPW area and surrounding it. The sites with epi-RCs had a higher bipolar voltage amplitude and greater number of fractionated components than those without (median, 1.09 mV vs. 0.83 mV and 3.9 vs. 3.4 on the pre-ablation map and 0.38 mV vs. 0.27 mV and 8.5 vs. 4.2 on the post-ablation map, respectively; P < 0.001). Receiver operating characteristic analyses demonstrated that the number of fractionated components on the post-ablation map had a larger area under the curve of 0.847 than the others, and the sensitivity and specificity for predicting epi-RCs were 95.4% and 62.1%, respectively, at an optimal cutoff of 5.0. CONCLUSIONS: Among the patients with epi-RCs after a first-pass LAPW linear ablation, areas with a greater number of fractionated components (> 5.0 on the post-ablation LAPW map) may have endocardial-epicardial connections and may be potential targets for touch-up ablation to eliminate the epi-RCs.
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PURPOSE: Symptomatic intracerebral hemorrhages (ICHs) are a rare complication after atrial fibrillation (AF) catheter ablation, while the incidence of asymptomatic ICHs detected by magnetic resonance (MR) imaging remains unclear. This study aimed to investigate the incidence, characteristics, and predictors of new-onset ICHs on MR imaging after AF ablation. METHODS: We retrospectively studied 1257 consecutive AF ablation procedures in 1201 patients who underwent MR imaging on the day after the procedure. Repeat MR imaging within 3 months post-ablation was available in 352 procedures. RESULTS: Old ICHs on the initial MR imaging were observed in 28 procedures (2.2%). Post-ablation new ICHs were observed in 14 procedures (4.0%), including one symptomatic (0.3%) and 13 (3.7%) asymptomatic ICHs. One patient had a new ICH on the initial MR imaging, while the remaining 13 had such on the repeat MR imaging. A univariate analysis revealed that a previous ischemic stroke or transient ischemic attack (TIA) and the CHA2DS2-VASc score were positive predictors of new ICHs (odds ratios, 5.502 and 1.435; P = 0.004 and 0.044). The lesion diameter did not significantly differ between the old and new ICHs (median, 6.1 mm vs. 8.0 mm, P = 0.281), while the predominant location differed (lobar areas, 22.6% vs. 53.3%; cerebellum, 22.6% vs. 20.0%; others, 54.8% vs. 26.7%; P = 0.026). CONCLUSIONS: A few asymptomatic ICHs may occur after AF ablation. Most of the post-ablation new ICHs occurred a few days or later after the procedure. A previous ischemic stroke/TIA and the CHA2DS2-VASc score may be risk factors for post-ablation ICHs.
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Fibrilação Atrial , Ablação por Cateter , Ataque Isquêmico Transitório , AVC Isquêmico , Acidente Vascular Cerebral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/etiologia , Humanos , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Imageamento por Ressonância Magnética/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
A 66-year-old male had an atrial tachycardia (AT) during a first extensive pulmonary vein (PV) isolation (PVI) of persistent atrial fibrillation. Activation mapping during the AT using Rhythmia (Boston Scientific, Marlborough, MA, USA) exhibited a centrifugal pattern with the earliest activation at the left-sided carina, and conduction towards the inferior left atrium (LA) over the left PVI line. The post-pacing interval was similar to the tachycardia cycle length (TCL) upon entrainment from the LA roof, left-sided carina, and anterior, inferior, and septal LA, but was longer than the TCL upon entrainment from the left superior PV and lateral and posterior LA. These findings suggested the presence of a macroreentrant AT circuit with epicardial conduction from the roof toward the inferior LA via the left-sided carina over the PVI line and propagation to the anterior LA through the septum. A radiofrequency application at the left-sided carina terminated the AT. This case suggested a rare type of PV-gap reentrant AT with multiple epicardial conduction gaps by high-resolution activation mapping and entrainment pacing, which may have been associated with non-transmural radiofrequency lesions along the PVI line. Further, the origin of the residual epicardial gaps may have been subepicardial myocardial strands or the Marshall ligament.
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BACKGROUND: Left atrial tachycardias (ATs) often occur after left atrial ablation. The incidence of symptomatic and silent cerebral embolism after radiofrequency catheter ablation of left ATs and the impact of the type of 3-dimensional electroanatomic mapping (3D-EAM) system on the incidence of cerebral embolism remain unclear. OBJECTIVES: This study aimed to investigate the incidence of cerebral embolism after a 3D-EAM system-guided left AT ablation procedure and compare that between the different 3D-EAM systems. METHODS: We prospectively enrolled 59 patients who underwent left AT ablation and brain magnetic resonance imaging after the procedure: 30 were guided by the Rhythmia system (Boston Scientific, Marlborough, MA) and 29 by the CARTO system (Biosense Webster, Diamond Bar, CA) (groups R and C, respectively). RESULTS: One transient ischemic attack occurred in group R, and no symptomatic embolism occurred in group C. Silent cerebral ischemic lesions (SCILs) were observed in 35 patients (59.3%), and group R had a significantly higher incidence of SCILs than did group C (86.2% vs 33.3%; P < .001). In multivariate analysis, group R and left atrial linear ablation were independent positive predictors of SCILs (odds ratio 12.822 and 8.668; P = .001 and P = .005). The incidence of bleeding complications was comparable between groups R and C (0% vs 3.3%; P = .508). CONCLUSION: Group R exhibited a higher incidence of postablation cerebral embolism than did group C. The use of the high-resolution 3D-EAM system with a mini-basket catheter to guide radiofrequency ablation of left atrial macroreentrant tachycardias may markedly increase the risk of silent cerebral embolism. The present results require further validation in a randomized study.