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INTRODUCTION: Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C. METHODS AND RESULTS: Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-three out of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patients Kansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula. CONCLUSION: Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.
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Fibrilación Atrial , Ablación por Catéter , Úlcera , Humanos , Femenino , Masculino , Persona de Mediana Edad , Úlcera/diagnóstico por imagen , Úlcera/etiología , Úlcera/diagnóstico , Resultado del Tratamiento , Anciano , Medición de Riesgo , Factores de Riesgo , Ablación por Catéter/efectos adversos , Fibrilación Atrial/cirugía , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Enfermedades del Esófago/etiología , Enfermedades del Esófago/diagnóstico , Factores de Tiempo , Atrios Cardíacos/fisiopatología , Atrios Cardíacos/cirugía , Atrios Cardíacos/diagnóstico por imagen , Endoscopía del Sistema Digestivo/efectos adversos , Estudios Retrospectivos , Esófago/lesionesRESUMEN
BACKGROUND: Previous clinical studies on pulmonary vein isolation (PVI) with a radiofrequency balloon (RFB) reported safe and effective procedures using Conventional ablation settings with 20/60-second RF delivery via posterior/anterior (PST/ANT) electrodes. The latest evidence suggests that reducing the application time to 15 seconds (s) on the posterior wall when facing the esophageal region is as effective as applying 20 s. OBJECTIVE: To prospectively assess whether reducing RF time on PST/ANT segments to 15/45 s can ensure sufficient quality of lesion metrics and compare the new Shortened ablation settings with the Conventional one in terms of safety, and effectiveness at 1-year. METHODS: A total of 641 patients from 7 European centers were enrolled in a collaborative registry, with 374 in the conventional RF delivery group and 267 in the shortened RF delivery group. Procedural outcomes, lesion metrics, and safety profiles were assessed and compared between the groups. RESULTS: Freedom of any atrial tachycarrythmias at one year were 85.4% and 88.2% in the SHRT and CONV groups, respectively. The shortened RF delivery strategy was associated with significantly shorter procedure times (median 63.5 vs. 96.5 minutes, P < 0.001) and shortened fluoroscopy exposure (median 10.0 vs. 14.0 minutes, P < 0.001) compared to conventional delivery. Efficacy metrics, including first-pass isolation rates and time to isolation, were comparable between groups. Shortened RF delivery was associated with a lower incidence of procedural complications (1.4% vs. 5.3%, P = 0.04) and optimized thermal characteristics. CONCLUSION: Analyses from the COLLABORATE Registry demonstrate that shortening RF energy delivery times to 15/45s (PST/ANT) during PVI with the RFB resulted in comparable freedom from recurrent atrial tachyarrhythmia compared to conventional delivery times with comparable efficiency and safety.
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AIMS: Cryoballoon (CB) ablation is the mainstay of single-shot pulmonary vein isolation (PVI). A radiofrequency balloon (RFB) catheter has recently emerged as an alternative. However, these two technologies have not been compared. This study aims to evaluate the freedom from atrial tachyarrhythmias (ATas) at 1â year: procedural characteristics, efficacy, and safety of the novel RFB compared with CB for PVI in patients with paroxysmal atrial fibrillation (AF). METHODS AND RESULTS: This prospective multi-centre study included consecutive patients with symptomatic drug-resistant paroxysmal AF who underwent PVI with RFB or CB between July 2021 and January 2022 from three European centres. A total of 375 consecutive patients were included, 125 in the RFB group and 250 in the CB. Both groups had comparable clinical characteristics. At 12.33 ± 4.91â months, ATas-free rates were 83.20% and 82.00% in the RFB and CB groups, respectively (P > 0.05). Compared with the CB group, the RFB group showed a shorter procedure time [59.91 (45.80-77.12) vs. 77.0 (35.13-122.71)â min (P < 0.001)], dwell time [19.59 (14.41-30.24) vs. 27.03 (17.11-57.21)â min (P = 0.04)], time to isolation, and thermal energy delivery in all pulmonary veins (P < 0.001). First-pass isolation was comparable. No major complications occurred in either group, with no stroke, atrio-oesophageal fistula, or permanent phrenic nerve injury. Transient phrenic nerve palsy occurred more frequently with CB than RFB (7.20% vs. 3.20%; P = 0.02). Oesophageal temperature rise occurred in 21 (16.8%) patients in the RFB group, and gastroscopy showed erythema in two of them with complete recovery after 30â days. CONCLUSIONS: The RFB appears to have a safety and efficacy profile similar to that of the CB for PVI. Shorter procedural times appear to be driven by shorter left atrial dwell and thermal delivery times.
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Apéndice Atrial , Fibrilación Atrial , Fístula Esofágica , Venas Pulmonares , Humanos , Estudios ProspectivosRESUMEN
AIMS: Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. METHODS AND RESULTS: Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63 years (CHA2DS2VASc 1 [1-3], left atrium diameter 41 ± 6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (P = 0.011). Diagnosis-to-ablation time ≥1 year was associated with a nearly two-fold increased risk for developing AF recurrence. CONCLUSION: The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Venas Pulmonares/cirugía , Calidad de Vida , Recurrencia , Resultado del TratamientoRESUMEN
AIMS: "CLOSE"-guided pulmonary vein isolation (PVI) is based on contiguous (≤6 mm) and optimized radiofrequency (RF) ablation lesions (ablation index [AI] ≥ 400 posteriorly and ≥ 550 anteriorly]. However, the optimal RF power to reach the desired AI is unknown. Therefore we evaluated the efficiency of an ablation strategy using higher power (40 W) during a first "CLOSE"-guided PVI. METHODS: Eighty consecutive patients undergoing "CLOSE"-guided PVI for symptomatic paroxysmal atrial fibrillation were ablated with 40 W (group A). Results were compared with 105 consecutive patients enrolled in the "CLOSE to CURE"-study and were ablated using the same protocol with 35 W (group B). RESULTS: In group A, ablation was associated with shorter ablation procedure time (91 vs 111 minutes; P < .001), shorter fluoroscopy time (5 vs 11 minutes; P < .001), shorter PVI time (48 vs 64 minutes; P < .001), shorter RF time (20 vs 28 minutes; P < .001), lower RF time per application (22 vs 29 seconds; P < .001), less RF applications (52 vs 58; P < .001), and less catheter dislocations (1 vs 2; P = .002). The impedance drop (12 vs 13 Ω; P = .192), first-pass isolation rate (99% vs 93%; P = .141) and acute reconnection rate (6% vs 4%; P > .733) were similar in both groups (groups A and B, respectively). No complications occurred. In group A, a gastroscopy-performed in five patients with esophageal temperature rise more than 42°C-did not reveal any esophageal lesion. Postprocedural recurrence of atrial tachyarrhythmia at 1 year was not significantly different between both groups. CONCLUSIONS: Using the "CLOSE"-protocol, increased power increases the efficiency of PVI without compromising patients' safety.
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Fibrilación Atrial/cirugía , Ablación por Catéter , Venas Pulmonares/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Proyectos Piloto , Complicaciones Posoperatorias/etiología , Venas Pulmonares/fisiopatología , Recurrencia , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: Despite recent advances in catheter ablation for atrial fibrillation (AF), pulmonary vein reconnection (PVR), and AF recurrence remain significantly high. Ablation index (AI) is a new method incorporating contact force, time, and power that should optimize procedural outcomes. We aimed to evaluate the efficacy and safety of AI-guided catheter ablation compared to a non-AI-guided approach. METHODS AND RESULTS: A systematic search was performed on MEDLINE (via PubMED), EMBASE, COCHRANE, and European Society of Cardiology (ESC) databases (from inception to 1 July 2019). We included only studies that compared AI-guided with non-AI-guided catheter ablation of AF. Eleven studies reporting on 2306 patients were identified. Median follow-up period was 12 months. Ablation index-guided ablation had a significant shorter procedural time (141.0 vs. 152.8 min, P = 0.01; I2 = 90%), ablation time (21.8 vs. 32.0 min, P < 0.00001; I2 = 0%), achieved first-pass isolation more frequently [odds ratio (OR) = 0.09, 95%CI 0.04-0.21; 93.4% vs. 62.9%, P < 0.001; I2 = 58%] and was less frequently associated with acute PVR (OR = 0.37, 95%CI 0.18-0.75; 18.0% vs 35.0%; P = 0.006; I2 = 0%). Importantly, atrial arrhythmia relapse post-blanking was significantly lower in AI compared to non-AI catheter ablation (OR = 0.41, 95%CI 0.25-0.66; 11.8% vs. 24.9%, P = 0.0003; I2 = 35%). Finally, there was no difference in complication rate between AI and non-AI ablation, with the number of cardiac tamponade events in the AI group less being numerically lower (OR = 0.69, 95%CI 0.30-1.60, 1.6% vs. 2.5%, P = 0.39; I2 = 0%). CONCLUSIONS: These data suggest that AI-guided catheter ablation is associated with increased efficacy of AF ablation, while preserving a comparable safety profile to non-AI catheter ablation.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Humanos , Venas Pulmonares/cirugía , Recurrencia , Resultado del TratamientoRESUMEN
BACKGROUND: Primary mitral valve regurgitation (MR) is a comprehensive term that mostly comprises mitral valve prolapse (MVP), while other causes of degenerative MR are often not considered. We describe the echocardiographic characteristics of degenerative nonprolapse mitral regurgitation (DMR) and assess the outcome at medium-term follow-up using the novel average pixel intensity (API) method. METHODS: Of 126 patients with any nonprolapse DMR were consecutively included. MR was graded according to all guideline-recommended parameters and with the API method. MR flow dynamics in DMR were compared to MVP-MR and functional MR (FMR). RESULTS: DMR is associated with moderate-to-severe calcifications of the mitral valve apparatus, and a low event rate was observed at a mean follow-up of 27 months. The API grading method had a higher feasibility (94%) compared to proximal isovelocity surface area (PISA) (60%) method and vena contracta width (VCW) (71%) for assessing MR. The API method was predictive for events. The API method also provides insights into DMR flow dynamics: A triphasic pattern was observed with a midsystolic nadir for both API and PISA-EROA, which is similar to the dynamic flow pattern described in FMR, but distinct from holosystolic MVP-MR. Compared to FMR and MVP-MR patients, DMR is less severe and patients with DMR are generally older than MVP-MR patients. CONCLUSIONS: DMR is a distinct MR pathology and conveys a relatively low event rate. MR grading was feasible with the API method, and flow dynamics demonstrated a similar triphasic pattern compared to FMR but distinct from holosystolic MVP-MR.
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Insuficiencia de la Válvula Mitral , Prolapso de la Válvula Mitral , Ecocardiografía , Humanos , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/diagnóstico por imagenRESUMEN
INTRODUCTION: Recent studies have characterized drivers in persistent atrial fibrillation using automated algorithm detection with panoramic endocardial mapping by means of basket catheters. We aimed to identify repetitive atrial activation patterns (RAAPs) during ongoing atrial fibrillation (AF) based upon automated annotation of unipolar electrograms (EGMs) recorded with a high-density regional endocardial contact mapping catheter. METHODS: In 14 persistent AF patients, high-resolution EGMs were recorded for 30 seconds at sequential PentaRay (Biosense Inc) positions covering the entire biatrial surface. All recordings were reviewed off-line with dedicated software allowing automated annotation of the local activation time of the unipolar fibrillatory EGMs (CARTOFINDER; Biosense Inc). RAAPs were defined as a consistent activation pattern (for ≥3 consecutive beats) of either focal activity with centrifugal spread (RAAPfocal ) or rotational activity across the PentaRay splines spanning the AF cycle length (RAAProtational ). RESULTS: A total of 498 PentaRay recordings were analyzed (35.6 ± 7.6 per patient). The number of PentaRay recordings displaying RAAP was 9.8 ± 3.1 per patient (range = 3-15), of which 2.4 ± 2.4 RAAProtational (range = 0-7), and 7.4 ± 4.4 RAAPfocal (range = 1-13). 77% of RAAPs portrayed focal firing. The median number of repetitions per 30 second recording was 11 (range = 3-225) per recording. RAAPs were observed both in the right atrium (RA) (35%) and left atrium (LA) (65%), with the majority being near the left PVs/appendage (35% of all RAAPs) and the superior vena cava/right appendage (23% of all RAAPs). CONCLUSION: High-resolution, sequential endocardial EGM-based mapping allows identification of RAAPs in persistent AF. In our series, focal firing was the most frequently observed pattern.
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Potenciales de Acción , Fibrilación Atrial/diagnóstico , Cateterismo Cardíaco , Técnicas Electrofisiológicas Cardíacas , Atrios Cardíacos/fisiopatología , Frecuencia Cardíaca , Anciano , Fibrilación Atrial/fisiopatología , Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Técnicas Electrofisiológicas Cardíacas/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reconocimiento de Normas Patrones Automatizadas , Valor Predictivo de las Pruebas , Procesamiento de Señales Asistido por Computador , Factores de TiempoRESUMEN
AIMS: We sought to evaluate the efficacy and the safety of a simple technique for stabilizing the ablation catheter during anterior pulmonary vein (PV) encirclement in patients ablated for paroxysmal atrial fibrillation. This consisted of bending the ablation catheter in the left atrium, creating a loop that was cautiously advanced together with the long sheath at the ostium and then within the left superior PV. The curve was then progressively released to reach a stable contact with the anterior part of the left PVs. METHODS AND RESULTS: Eighty consecutive patients (age 64 ± 11 years, left atrial diameter 43 ± 8 mm) undergoing 'CLOSE'-guided PV isolation were prospectively randomized into two groups depending on whether the loop technique was used or not. When using the loop technique, the encirclement of the left PVs was shorter [20 min (interquartile range, IQR 17-24) vs. 26 min (IQR 18-33), P < 0.01] with a high rate of first pass isolation [(100%) vs. (97%), P = 0.9] and adenosine proof isolation [(93%) vs. (95%), P = 0.67]. Most specifically, at the anterior part of the left PVs, there were less dislocations [0 (IQR 0-0) vs. 1 (IQR 0-4), P < 0.001], radiofrequency duration was shorter (272 ± 85 s vs. 378 ± 122 s, P < 0.001), force-time integral was higher [524 gs (IQR 427-687) vs. 398 gs (IQR 354-451), P < 0.001], average contact force was higher [20 g (IQR 13-27) vs. 11g (IQR 9-16), P < 0.001], and impedance drop was higher [12 Ω (IQR 9-19) vs. 10 Ω (IQR 7-14), P < 0.001]. CONCLUSION: This study describes a simple technique to facilitate catheter stability at the anterior part of the left PVs, resulting in more efficient left PV encirclement without compromising safety.
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Fibrilación Atrial , Ablación por Catéter/métodos , Atrios Cardíacos , Venas Pulmonares/cirugía , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Catéteres Cardíacos , Técnicas Electrofisiológicas Cardíacas , Femenino , Atrios Cardíacos/patología , Atrios Cardíacos/fisiopatología , Sistema de Conducción Cardíaco/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Recurrencia , Resultado del TratamientoRESUMEN
Aims: Catheter ablation is indicated in patients with symptomatic paroxysmal atrial fibrillation (AF) resistant to antiarrhythmic drug therapy (ADT). We investigated whether continued use of previously ineffective ADT beyond the post-ablation blanking period reduces recurrence of atrial tachyarrhythmia within the 1st year after ablation. Methods and results: This was a multicentre, randomized controlled study in patients undergoing contact force-guided pulmonary vein isolation (PVI) for paroxysmal AF in whom previously ineffective ADT was continued during a blanking period of 3 months. If free of AF at the end of the blanking period, patients were randomly assigned in the ratio of 1:1 to continue ADT (ADT ON group, n = 77) or discontinue ADT (ADT OFF group, n = 76). Patients were followed up until 1 year after PVI, with clinical visits, Holter monitoring, and quality-of-life (QOL) questionnaires at 6 and 12 months post-procedure. Analysis of the primary endpoint (any documented atrial tachyarrhythmia lasting >30 s) was performed according to the modified intention-to-treat principle. Secondary endpoints included repeat ablation, unscheduled visits, and QOL score. Baseline clinical characteristics and initial ablation procedure characteristics were comparable between both groups. Three patients were lost to follow-up in each arm. The primary endpoint was observed in 2 of 74 (2.7%) patients in the ADT ON group vs. 16 of 73 (21.9%) patients in the ADT OFF group (P < 0.001). The ADT ON group had a lower rate of repeat ablation [1.4% vs. 19.2%, hazard ratio (HR) = 0.053; 95% confidence interval (CI) 0.007-0.399; P < 0.01) and less unscheduled arrhythmia-related health care visits (2.7% vs. 20.5%, HR = 0.055, 95% CI 0.007-0.410; P < 0.01). Quality-of-life scores were similar in both groups. Conclusion: In patients free of AF at the end of 3 months of post-ablation blanking period, continued use of previously ineffective ADT significantly reduces the recurrence of atrial tachyarrhythmia in the 1st year after PVI.
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Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Ablación por Catéter , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Terapia Combinada , Femenino , Humanos , Masculino , Persona de Mediana Edad , RecurrenciaRESUMEN
BACKGROUND: High-density automated mapping of regular atrial tachycardias (ATs) requires accurate assessment of local activation times (LATs). OBJECTIVE: To evaluate high-density mapping of ATs and compare the accuracy of different automated LAT annotation algorithms. METHODS: Fifteen patients underwent AT ablation guided by the automated ConfiDENSEÛ high-density mapping module (Carto 3 v4) allowing manual reannotation (edited maps). For each AT, unedited automated maps were reconstructed offline by three algorithms: maximum unipolar slope (LATSlope ), bipolar peak (LATPeak ), and a new hybrid annotation algorithm (LATHybrid ). Five blinded experts were asked to define the (1) tachycardia mechanism, (2) ablation target, and (3) level of difficulty of these unedited maps. RESULTS: Twenty-one ATs (cycle length 300 ± 46 ms, activation points 955 ± 421) were successfully ablated using LATHybrid guided ablation with manual editing in a small number of points. At 6 months, 14 (93%) of the patients were free of AT recurrences. Unedited LATHybrid maps showed the highest accuracy in defining the tachycardia mechanism (LATHybrid : 49% vs. LATPeak : 27% vs. LATSlope : 28%, P < 0.001) and ablation target (LATHybrid : 65% vs. LATPeak : 39% vs. LATSlope : 31%, P < 0.001). Overall, LATHybrid -annotated maps were graded as "easier to interpret" by the experts (difficulty score 2.3 ± 0.9) versus LATPeak (2.8 ± 1) and LATSlope (3.2 ± 0.8) (P < 0.001). Only 12% of the LATHybrid maps were annotated as uninterpretable compared to 31% of LATSlope and 45% of the LATPeak maps (P < 0.001). CONCLUSION: Automated LATHybrid annotation allows better and easier recognition of the tachycardia mechanism compared to automated LATPeak and LATSlope algorithms, although fully automated mapping still requires further improvements.
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Potenciales de Acción , Técnicas Electrofisiológicas Cardíacas/métodos , Atrios Cardíacos/fisiopatología , Frecuencia Cardíaca , Procesamiento de Señales Asistido por Computador , Taquicardia Supraventricular/diagnóstico , Anciano , Algoritmos , Automatización de Laboratorios , Ablación por Catéter , Femenino , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Taquicardia Supraventricular/fisiopatología , Taquicardia Supraventricular/cirugía , Factores de TiempoRESUMEN
Aims: We have recently shown that a contact force (CF)-guided ablation protocol respecting region-specific criteria of lesion contiguity and lesion depth ('CLOSE' protocol) is associated with high incidence of acute durable pulmonary vein (PV) isolation (PVI) and a high single-procedure arrhythmia-free survival at 1 year. In the present study, we compared efficiency, safety, and efficacy of 'CLOSE'-guided PVI to conventional CF-guided PVI (CONV-CF). Methods and results: Fifty consecutive paroxysmal atrial fibrillation (AF) patients underwent PV encircling using a CF-sensing catheter targeting an interlesion distance (ILD) ≤6 mm and ablation index (AI) ≥400 and ≥550 at posterior and anterior wall ('CLOSE' group). Results were compared to the last 50 patients undergoing 'CONV-CF'. All patients underwent adenosine testing after PVI. Arrhythmia recurrence was defined as any atrial tachyarrhythmia (ATA) >30 s on Holter at 3, 6, and 12 months. Clinical characteristics did not differ. Contact force variability was comparable in between both groups (proportion of applications with intermittent contact 2% in 'CLOSE' vs. 1% in CONV-CF, P = 0.67). In the 'CLOSE' group, procedure time and radiofrequency (RF) time per circle were shorter (respectively 149 ± 33 min vs. 192 ± 42 min, P < 0.0001 and 18 ± 4 min vs 28 ± 7.5 min, P < 0.0001) and incidence of adenosine-proof isolation was higher (97% vs. 82%, P < 0.001). No complications were observed in the 'CLOSE' group, one tamponade in the 'CONV-CF' group. At 12 months, single-procedure freedom from ATA was 94% in 'CLOSE' vs. 80% in 'CONV-CF' group (P < 0.05). In both groups, the majority of reconnections at repeat were associated with either ILD > 6 mm and/or AI < 400/550 (100% vs. 83%, P = 0.99). Conclusion: 'CLOSE'-guided PVI improves procedural and 1 year outcome in CF-guided PVI while shortening procedure time. Improvement cannot be explained by differences in CF variability and is most likely due to the strict application of criteria for contiguity and ablation index. A randomized controlled trial is needed to exclude the possible contribution of a learning curve.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Venas Pulmonares/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Catéteres Cardíacos , Ablación por Catéter/efectos adversos , Ablación por Catéter/instrumentación , Bases de Datos Factuales , Electrocardiografía Ambulatoria , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Supervivencia sin Progresión , Venas Pulmonares/fisiopatología , Recurrencia , Factores de Riesgo , Factores de Tiempo , Transductores de PresiónRESUMEN
Aims: Achieving block across linear lesions is challenging. We prospectively evaluated radiofrequency (RF) linear ablation at the roof and mitral isthmus (MI) using point-by-point contiguous and optimized RF lesions. Methods and results: Forty-one consecutive patients with symptomatic persistent AF underwent stepwise contact force (CF)-guided catheter ablation during ongoing AF. A single linear set of RF lesions was delivered at the roof and posterior MI according to the 'Atrial LINEar' (ALINE) criteria, i.e. point-by-point RF delivery (up to 35 W) respecting strict criteria of contiguity (inter-lesion distance ≤ 6 mm) and indirect lesion depth assessment (ablation index ≥550). We assessed the incidence of bidirectional block across both lines only after restoration of sinus rhythm. After a median RF time of 7 min [interquartile range (IQR) 5-9], first-pass block across roof lines was observed in 38 of 41 (93%) patients. Final bidirectional roof block was achieved in 40 of 41 (98%) patients. First-pass block was observed in 8 of 35 (23%) MI lines, after a median RF time of 8 min (IQR 7-12). Additional endo- and epicardial (54% of patients) RF applications resulted in final bidirectional MI block in 28 of 35 (80%) patients. During a median follow-up of 396 (IQR 310-442) days, 12 patients underwent repeat procedures, with conduction recovery in 4 of 12 and 5 of 10 previously blocked roof lines and MI lines, respectively. No complications occurred. Conclusion: Anatomical linear ablation using contiguous and optimized RF lesions results in a high rate of first-pass block at the roof but not at the MI. Due to its complex 3D architecture, the MI frequently requires additional endo- and epicardial RF lesions to be blocked.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Atrios Cardíacos/cirugía , Válvula Mitral/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Femenino , Atrios Cardíacos/fisiopatología , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/fisiopatología , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Current guidelines select patients for cardiac resynchronization therapy (CRT) mainly on electrocardiographic parameters like QRS duration and left bundle branch block (LBBB). However, among those LBBB patients, heterogeneity in mechanical dyssynchrony occurs and might be a reason for nonresponse to CRT. This study assesses the relation between electrocardiographic characteristics and presence of mechanical dyssynchrony among LBBB patients. METHODS: The study included patients with true LBBB (including mid-QRS notching) on standard 12-lead electrocardiograms. Left bundle branch block-induced mechanical dyssynchrony was assessed by the presence of septal flash on two-dimensional echocardiography. Previously reported electro- and vectorcardiographic dyssynchrony markers were analyzed: global QRS duration (QRSDLBBB ), left ventricular activation time (QRSDLVAT ), time to intrinsicoid deflection (QRSDID ), and vectorcardiographic QRS areas in the 3D vector loop (QRSA3D ). RESULTS: The study enrolled 545 LBBB patients. Septal flash (SF) is present in 52% of patients presenting with true LBBB. Patients with SF are more frequent female, have less ischemic heart disease and smaller left ventricular dimensions. In multivariate analysis longer QRSDLBBB , QRSDLVAT and larger QRSA3D were independently associated with SF. Of all parameters, QRSA3D has the best accuracy to predict SF, although overall accuracy remains moderate (59% sensitivity, 58% specificity). The predictive value of QRSA3D remained constant in both sexes, irrespective of ischemic heart disease, ejection fraction and even when categorizing for QRSDLBBB . CONCLUSION: In LBBB patients, large QRS areas correlate better with mechanical dyssynchrony compared to wide QRSD intervals. However, the overall accuracy to predict mechanical dyssynchrony by electrocardiographic dyssynchrony markers, even when using complex vectorcardiographic parameters, remains low.
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Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatología , Bloqueo de Rama/fisiopatología , Terapia de Resincronización Cardíaca/métodos , Electrocardiografía/métodos , Anciano , Arritmias Cardíacas/terapia , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Factores Sexuales , Vectorcardiografía/métodosRESUMEN
INTRODUCTION: Vectorcardiographic (VCG) QRS area of left bundle branch block (LBBB) predicts acute hemodynamic response in cardiac resynchronization therapy (CRT) patients. We hypothesized that changes in QRS area occurring with biventricular pacing (BV) might predict acute hemodynamic CRT response (AHR). METHODS AND RESULTS: VCGs of 624 BV paced electrocardiograms (25 LBBB patients with 35 different pacing configurations) were calculated according to Frank's orthogonal lead system. Maximum QRS vector amplitudes (XAmpl , YAmpl , ZAmpl , and 3DAmp ) and QRS areas (XArea , YArea , ZArea , and 3DArea ) in the orthogonal leads (X, Y, and Z) and in 3-dimensional projection were measured. Volume of the 3D vector loop and global QRS duration (QRSD) on the surface electrocardiogram were assessed. Differences (Δ) in VCG parameters between BV paced and LBBB QRS complexes were calculated. An increase of 10% in dP/dt max was considered as AHR. LBBB conduction is characterized by a large ZArea (109 µVs, interquartile range [IQR]:75;135), significantly larger than XArea (22 µVs, IQR:10;57) and YArea (44 µVs, IQR:32;62, P < 0.001). Overall, QRS duration, amplitudes, and areas decrease significantly with BV pacing (P < 0.001). Of all VCG parameters, 3DAmpl , Δ3DAmpl , ZArea, ΔZArea , Δ3DArea , and ΔQRSD differentiate AHR response from nonresponse (P < 0.05). ΔZArea predicted best positive AHR (area under the curve = 0.813) and outperformed any other VCG parameter or QRSD measurement. CONCLUSION: Of all VCG parameters, reduction in QRS area, calculated in Frank's Z lead, predicts acute hemodynamic response best. This method might be an easy, noninvasive tool to guide CRT implantation and optimization.
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Potenciales de Acción , Bloqueo de Rama/terapia , Terapia de Resincronización Cardíaca , Electrocardiografía , Frecuencia Cardíaca , Anciano , Área Bajo la Curva , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/fisiopatología , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medio Oriente , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Vectorcardiografía , Función Ventricular IzquierdaRESUMEN
AIMS: In patients with systolic heart failure and left bundle branch block (LBBB), septal flash (SF) movement has been described by echocardiography. We evaluated the prevalence of SF in LBBB and non-LBBB patients and evaluated whether specific electrocardiographic (ECG) characteristics within LBBB are associated with the presence of SF on echocardiography. METHODS AND RESULTS: One hundred and four patients with probable LBBB on standard 12-lead ECG were selected, 40 patients with non-LBBB served as controls. Left bundle branch block and non-LBBB were defined, according to the most recent guidelines. The presence of SF was assessed by echocardiography. Strict LBBB criteria were met in 93.3% of the patients. Septal flash was present in 45.2% of LBBB patients and was not present in non-LBBB patients. This was more prevalent in patients without anterior ischaemic cardiomyopathy (ICMP) compared with those with anterior ICMP (P = 0.008). The duration of QRS was longer in SF patients compared with that of non-SF patients (P < 0.05). The presence of a mid-QRS notching in more than two consecutive leads was a good predictor for the presence of SF (P = 0.01), and when combined with an absent R-wave in lead V1, the presence of SF is very likely (P = 0.001). CONCLUSION: Our data show that SF is present in 45.2% of LBBB patients, whereas it was absent in patients with non-LBBB. Patients with SF fulfilled more LBBB criteria compared with LBBB patients without SF. Our findings raise the provocative question of whether the presence of SF identifies patients with 'true LBBB' and whether this echocardiographic finding might be considered as a selection parameter in cardiac resynchronization therapy.
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Bloqueo de Rama/diagnóstico , Ecocardiografía , Electrocardiografía , Insuficiencia Cardíaca Sistólica/diagnóstico , Tabique Interventricular/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Bélgica/epidemiología , Bloqueo de Rama/diagnóstico por imagen , Bloqueo de Rama/epidemiología , Bloqueo de Rama/fisiopatología , Estudios de Casos y Controles , Bases de Datos Factuales , Femenino , Insuficiencia Cardíaca Sistólica/diagnóstico por imagen , Insuficiencia Cardíaca Sistólica/epidemiología , Insuficiencia Cardíaca Sistólica/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica , Variaciones Dependientes del Observador , Valor Predictivo de las Pruebas , Prevalencia , Reproducibilidad de los Resultados , Función Ventricular Izquierda , Tabique Interventricular/fisiopatologíaRESUMEN
BACKGROUND: Verification of pulmonary vein isolation (PVI) can be challenging due to the coexistence of pulmonary vein potentials and far-field potentials. This study aimed to prospectively validate a novel algorithm for automated verification of PVI in radiofrequency (RF)-guided and cryoballoon (CB)-guided ablation strategies. METHODS: A data set of 620 (RF: 516 EGMs and CB: 104 EGMs) bipolar electrograms (EGM), recorded by circular mapping catheter placed at the left atrium-pulmonary vein (PV) junction, were prospectively analyzed by a two-step algorithm. The algorithm differentiates isolated from nonisolated EGMs based on typology and specific parameters of the bipolar EGMs. EGMs were recorded at baseline and after proven isolation in RF- and CB-guided procedures. Additionally, in the RF group, EGMs during encircling of the PVs were analyzed. RESULTS: In the RF and CB group, the algorithm correctly identifies EGMs as isolated or nonisolated with respectively 93% and 96% sensitivity and 86% and 90% specificity. In the RF subgroups of (1) baseline and proven isolated EGMs, (2) EGMs during encircling, and (3) EGMs in redo procedures sensitivity was 96%, 88%, and 100%, respectively, with specificity of 81%, 91%, and 100%. Fourteen out of 14 (100%) reconnected PVs were correctly identified as containing PVPs. Eleven out of 12 (92%) failed freeze attempts were correctly identified as being nonisolated. CONCLUSION: We validated a two-step algorithm for automated PVI verification, applicable both for RF- and CB-guided PVI. The algorithm automatically differentiates isolated from nonisolated PVs with high accuracy and without the need for pacing maneuvers.
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Algoritmos , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Criocirugía/métodos , Venas Pulmonares/cirugía , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Ondas de Radio , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
BACKGROUND: Measurements of QRS duration (QRSD) in patients undergoing cardiac resynchronization therapy (CRT) are not standardized. We hypothesized that both the measurement of QRSD and its predictive value on CRT response are sensitive to the method by which QRSD is measured. METHODS: Electrocardiograms (ECGs) pre- and post-CRT from 52 CRT patients (66 ± 12 years, 65% male) were retrospectively analyzed. Custom-made software was developed to measure global QRSD (QRSDglobal ) and lead-specific QRSD (QRSDI,II,III,aVR,aVL,aVF,V1,V2,V3,V4,V5,V6 ). QRSD was also assessed automatic by a routinely used ECG device. For each method we measured QRSD pre- and post-CRT and shortening of QRSD (∆QRSD). Response to CRT at 6 months was defined as an improvement of ≥1 class in New York Heart Association classification and an increase by >7.5% in left ventricular ejection fraction. RESULTS: The CRT response rate was 77% (n = 40). Different methods to measure QRSD show divergent nominal values before (median range 152-172 ms, P < 0.001) and after CRT (130-152 ms, P < 0.001). The predictive value of QRSD measurements for CRT response also varies significantly according to the method used (range AUC pre-CRT QRSD 0.400-0.580, P < 0.05; AUC post-CRT QRSD 0.447-0.768, P < 0.05; AUC ΔQRSD 0.540-0.858, P < 0.05). Global QRSD measurements revealed lower variability compared to lead-specific QRSD. CONCLUSION: Different methods to measure QRSD yield not only different nominal values but also influence the value of QRSD in predicting CRT response. Measuring QRSD by a global method can help to standardize QRSD measurements in future studies.
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Terapia de Resincronización Cardíaca , Electrocardiografía , Sistema de Conducción Cardíaco/fisiopatología , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/terapia , Anciano , Ecocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Programas InformáticosRESUMEN
BACKGROUND: Delayed medical attendance is a leading cause of death in patients with ST elevation myocardial infarction (STEMI). METHODS: We aimed to introduce, develop, and validate a novel method (RELF method) for detection of transmural ischemia based on a new and easy-to-use 3-lead configuration and orthonormalization of ST reference vectors (STDVN). The study included 60 patients undergoing coronary artery occlusion (CAO) during balloon inflation and 30 healthy subjects. RESULTS: STDVN was significantly different and an optimal discriminator between CAO patients and healthy subjects (respectively 8.00±4.50 vs. 1.90±0.86 normalized units, p<0.001). Compared to the 12-lead ECG, the RELF method was sensitive (90 vs. 73%, p=0.13) and more specific (91 vs. 75%, p<0.001). CONCLUSIONS: The RELF method is highly accurate for early detection of acute occlusion related ischemia and it outperforms the conventional 12-lead ECG criteria for STEMI. This method provides a platform for self-detection of CAO with handheld devices or smart phones.
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Estenosis Coronaria/diagnóstico , Diagnóstico por Computador/métodos , Electrocardiografía/métodos , Isquemia Miocárdica/diagnóstico , Autocuidado/métodos , Telemedicina/métodos , Adulto , Anciano , Algoritmos , Estenosis Coronaria/complicaciones , Diagnóstico por Computador/instrumentación , Electrocardiografía/instrumentación , Electrodos , Femenino , Humanos , Masculino , Aplicaciones Móviles , Isquemia Miocárdica/etiología , Reproducibilidad de los Resultados , Autocuidado/instrumentación , Sensibilidad y Especificidad , Telemedicina/instrumentaciónRESUMEN
Aims: Pulsed field ablation (PFA) is a promising ablation technique for pulmonary vein isolation (PVI) with appealing advantages over radiofrequency (RF) including speed, tissue selectivity, and the promise of enhanced durability. In this study, we determine the procedural performance, efficacy, safety, and durability of PFA and compare its performance with a dataset of optimized RF ablation. Methods and results: After propensity score matching, we compared 161 patients who received optimized RF-guided PVI in the PowerPlus study (CLOSE protocol) with 161 patients undergoing PFA-guided PVI for paroxysmal or persistent atrial fibrillation (AF; pentaspline basket catheter). The median age was 65 years with 78% paroxysmal AF in the PFA group (comparable characteristics in the RF group). Pulsed field ablation-guided PVI was obtained in all patients with a procedure time of 47â min (vs. 71â min in RF, P < 0.0001) and a fluoroscopy time of 15â min (vs. 11â min in RF, P < 0.0001). One serious adverse event [transient ischaemic attack] occurred in a patient with thrombocytosis (0.6 vs. 0% in RF). During the 6-month follow-up, 24 and 27 patients experienced a recurrence with 20 and 11 repeat procedures in the PFA and the RF groups, respectively (P = 0.6 and 0.09). High-density mapping revealed a status of 4 isolated veins in 7/20 patients in the PFA group and in 2/11 patients in the RF group (35 vs. 18%, P = 0.3). Conclusion: Pulsed field ablation fulfils the promise of offering a short and safe PVI procedure, even when compared with optimized RF in experienced hands. Pulmonary vein reconnection is the dominant cause of recurrence and tempers the expectation of a high durability rate with PFA.