The Impact of Pulmonary Vein Anatomy on the Outcomes of Catheter Ablation for Atrial Fibrillation.

Background and Objectives: Prior studies have identified a number of predictors for Atrial fibrillation (AF) ablation success, including comorbidities, the type of AF, and left atrial (LA) size. Ectopic foci in the initiation of paroxysmal AF are frequently found in pulmonary veins. Our aim was to assess how pulmonary vein anatomy influences the recurrence of atrial fibrillation after radiofrequency catheter ablation. Materials and Methods: Eighty patients diagnosed with paroxysmal or persistent AF underwent radiofrequency catheter ablation (RFCA) between November 2016 and December 2017. All of these patients underwent computed tomography before AF ablation. PV anatomy was classified according to the presence of common PVs or accessory PVs. Several clinical and imagistic parameters were recorded. After hospital discharge, all patients were scheduled for check-up in an outpatient clinic at 3, 6, 9, and 12 months after RFCA to detect AF recurrence. Results: A total of 80 consecutive patients, aged 53.8 ± 9.6 years, 54 (67.5%) men and 26 (32.5%) women were enrolled. The majority of patients had paroxysmal AF 53 (66.3%). Regular PV anatomy (2 left PVs, 2 right PVs) was identified in 59 patients (73.7%), a left common trunk (LCT) was detected in 15 patients (18.7%), an accessory right middle pulmonary vein (RMPV) was found in 5 patients (6.25%) and one patient presented both an LCT and an RMPV. The median follow-up duration was 14 (12; 15) months. Sinus rhythm was maintained in 50 (62.5%) patients. Age, gender, antiarrhythmic drugs, and the presence of cardiac comorbidities were not predictive of AF recurrence. The diagnosis of persistent AF before RFCA was more closely associated with an increase in recurrent AF after RFCA than after paroxysmal AF (p = 0.01). Longer procedure times (>265 minutes) were associated with AF recurrence (p = 0.04). Patients with an LA volume index of over 48.5 (mL/m2) were more likely to present AF recurrence (p = 0.006). Multivariate analysis of recurrence risk showed that only the larger LA volume index and variant PV anatomy were independently associated with AF recurrence. Conclusion: The study demonstrated that an increased volume of the left atrium was the most important predictive factor for the risk of AF recurrence after catheter ablation. Variant anatomy of PV was the only other independent predictive factor associated with a higher rate of AF recurrence.

Atrial Fibrillation Ablation in a Patient with Cor Triatriatum Sinister and Left Common Pulmonary Vein: Impact of Left Atrium Anatomy on Ablation Approach.

Atrial fibrillation is the most common presentation in adult patients with cor triatriatum sinister. The key to successful and safe catheter ablation in these patients is an accurate exploration and thorough understanding of the left atrial anatomy, both before and during the procedure. Catheter manipulation is highly dependable on left atrial anatomy, including the interatrial septum, insertion of pulmonary veins and cor triatriatum membrane. Anatomical variants such as the left common pulmonary trunk may influence the ablation approach and outcome. We report the case of a 52-year-old patient with cor triatriatum sinister and the left common pulmonary vein variant who underwent successful high-power, short-duration catheter ablation for paroxysmal atrial fibrillation.

Value of Left Atrial Appendage Function Measured by Transesophageal Echocardiography for Prediction of Atrial Fibrillation Recurrence after Radiofrequency Catheter Ablation.

Atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA) remains a challenging issue. This study aims to explore the left atrial appendage function by transesophageal echocardiography (TEE) and assess its value in predicting AF recurrence following RFCA in paroxysmal AF patients. Eighty-one patients with paroxysmal AF that underwent RFCA were recruited. TEE was performed before ablation with the assessment of left atrial appendage emptying flow velocity (LAAeV). AF recurrence occurred in 24 patients (29.6%) within 12 months after RFCA. The left atrium diameter (LAD) and left atrium volume index (LAVI) were both significantly higher in the recurrence group compared to the non-recurrence group, while the LAAeV was significantly lower in the recurrence group. LAD, LAVi and LAAeV were univariately significant risk factors for AF recurrence after ablation. Based on receiver operating curve (ROC), LAAeV < 40.5 cm/s, LAVi > 40.5 mL and LAD > 41 mm were identified as cut-off values for predicting AF recurrence. In multivariate regression analysis LAAeV < 40.5 cm/s (HR 8.194, 95% CI 2.980-22.530, p < 0.001) was identified as the only statistically significant independent predictor of AF recurrence, as the statistical significance threshold was not achieved for LAVI > 40.5 mL and LAD > 41 mm (p = 0.319; p = 0.507, respectively). A low LAAeV was the only important independent predictor of AF recurrence within 1 year after first RFCA.

The role of intracardiac echocardiography in reducing radiation exposure during atrial fibrillation ablation.

AIMS: Intracardiac echocardiography (ICE) is a relatively young technique used during complex electrophysiology proce-dures, such as atrial fibrillation (AF) ablation. The aim of this study was to assess whether the use of ICE modifies the radia-tion exposure at the beginning of the learning curve in AF ablation. MATERIALS AND METHODS: In this retrospective study, 52 patients, in which catheter ablation for paroxysmal or persistent AF was performed, were included. For 26 patients we used ICE guidance together with fluoroscopy, whereas for the remaining 26 patients we used fluoroscopy alone, all supported by electroanatomical mapping. We compared total procedure time and radiation exposure, including fluoroscopy dose and time between the two groups and along the learning curve. RESULTS: Most of the patients included were suffering from paroxysmal AF (40, 76%), pulmonary vein isolation being performed in all patients, without secondary ablation sites. The use of ICE was associated with a lower fluoroscopy dose (11839.60±6100.6 vs. 16260.43±8264.5 mGy, p=0.041) and time (28.00±12.5 vs. 42.93±12.7 minutes, p=0.001), whereas the mean procedure time was similar between the two groups (181.54±50.3 vs 197.31±49.8 minutes, p=0.348). Radiation exposure was lower in the last 9 months compared to the first 9 months of the study (p<0.01), decreasing gradually along the learning curve. CONCLUSIONS: The use of ICE lowers radiation exposure in AF catheter ablation from the beginning of the learning curve, without any difference in terms of acute safety or efficacy. Aware-ness towards closest to zero radiation exposure during electrophysiology procedures should increase in order to achieve better protection for both patient and medical staff.

Impact of Three-Dimensional Strain on Major Adverse Cardiovascular Events after Acute Myocardial Infarction Managed by Primary Percutaneous Coronary Intervention-A Pilot Study.

BACKGROUND: Three-dimensional speckle-tracking echocardiography (3D-STE) allows simultaneous assessment of multidirectional components of strain. However, there are few data on its usefulness to predict prognosis in patients with acute myocardial infarction (AMI). The objective of our pilot study was to evaluate the prognostic value of four different 3D-STE parameters (global longitudinal strain (GLS-3D), global circumferential strain (GCS-3D), global radial strain (GRS-3D), and global area strain (GAS)) in AMI, after successful revascularization by primary PCI. METHODS: We enrolled 94 AMI patients (66 ± 13 years, 56% men) who underwent coronary angiography. All patients had been 3D-STE assessed and followed-up for 1 year for the occurrence of MACE. RESULTS: A total of 25 MACE were recorded over follow-up. Cut-off values of -17% for GAS (HR = 3.1, 95% CI: 1.39-6.92, p = 0.005), -12% for GCS-3D (HR = 3.06, 95% CI: 1.36-6.8, p = 0.006), -10% for GLS-3D (HR = 3.04, 95% CI: 1.36-6.78, p = 0.006), and 25% for GRS-3D (HR = 2.89, 95% CI: 1.29-6.46, p = 0.009) showed moderate accuracy in MACE prediction. Multivariate regression showed that GAS (HR = 1.1, 95% CI: 1.03-1.16), GLS-3D (HR = 1.13, 95% CI: 1.03-1.26), and GCS-3D (HR = 1.13, 95% CI: 1.03-1.23) remained independent predictors of MACE (HR = 1.07, 95% CI: 1.01-1.14 for GAS, and HR = 1.1, 95% CI: 1.01-1.2 for GCS-3D). However, post hoc power analysis indicated adequate sample size (power of 80%) only for GAS and GCS-3D for the ROC curve analysis and for GAS, GCS-3D, and GRS-3D for the log-rank test. CONCLUSION: Patients with AMI might benefit from early risk stratification with the aid of 3D-STE measurements, particularly GAS and GCS-3D, but larger studies are necessary to determine the optimal cut-off values to predict MACE.