Cryoballoon versus radiofrequency for pulmonary vein re-isolation after a failed initial ablation procedure in patients with paroxysmal atrial fibrillation.

AIM: Catheter ablation of paroxysmal atrial fibrillation (PAF) is associated with an important risk of early and late recurrence, necessitating repeat ablation procedures. The aim of this prospective randomized patient-blind study was to compare the efficacy and safety of cryoballoon (Cryo) versus radiofrequency (RF) ablation of PAF after failed initial RF ablation procedure. METHODS: Patients with a history of symptomatic PAF after a previous failed first RF ablation procedure were eligible for this study. Patients were randomized to Cryo or RF redo ablation. The primary endpoint of the study was recurrence of atrial tachyarrhythmia, including AF and left atrial flutter/tachycardia, after a second ablation procedure at 1 year of follow-up. All patients were implanted with a cardiac monitor (Reveal XT, Medtronic) to continuously track the cardiac rhythm. Patients with an AF burden (AF%) ≤ 0.5% were considered AF-free (Responders), while those with an AF% > 0.5% were classified as patients with AF recurrences (non-Responders). RESULTS: Eighty patients with AF recurrences after a first RF pulmonary vein isolation (PVI) were randomized to Cryo (N = 40) or to RF (N = 40). Electrical potentials were recorded in 77 mapped PVs (1.9 ± 0.8 per patient) in Cryo Group and 72 PVs (1.7 ± 0.8 per patient) in RF Group (P = 0.62), all of which were targeted. In Cryo group, 68 (88%) of the 77 PVs were re-isolated using only Cryo technique; the remaining 9 PVs were re-isolated using RF. In RF group, all 72 PVs were successfully re-isolated (P = 0.003 vs Cryo). By intention-to-treat, 23 (58%) RF patients were AF-free vs 17 (43%) Cryo patients on no antiarrhythmic drugs at 1 year (P = 0.06). Three patients had temporary phrenic nerve paralysis in the Cryo group; the RF group had no complications. Of the 29 patients who had only Cryo PVI without any RF ablation, 11 (38%) were AF-free vs 20 (59%) of the 34 patients who had RF only (P = 0.021). CONCLUSION: When patients require a redo pulmonary vein isolation ablation procedure for recurrent PAF, RF appears to be the preferred energy source relative to Cryo.

Ganglionated plexi ablation directed by high-frequency stimulation and complex fractionated atrial electrograms for paroxysmal atrial fibrillation.

BACKGROUND: The effectiveness of ganglionated plexi (GP) ablation in patients with atrial fibrillation (AF) is ambiguous. Some researchers had already suggested that additional identification of complex fractionated atrial electrograms (CFAE) around the areas with a positive reaction to high-frequency stimulation (HFS) might improve the accuracy of GP's boundaries location, then enhancing the success rate of ablation. The purpose of this study was to assess the safety and efficacy of GP ablation directed by HFS and CFAE in patients with paroxysmal AF (PAF). METHODS AND RESULTS: Sixty-two patients with PAF (age 57±8 years) underwent GP ablation. Ablation targets were the sites where vagal reflexes were evoked by HFS and additional extended ablation CFAE area around the areas where vagal reflexes were evoked. At 12 months, 71% of patients were free of symptomatic AF. At 3 months after ablation the root mean square successive differences and HF were significantly lower in patients without AF recurrence (P < 0.0001 and P = 0.004). The LF/HF ratio was significantly higher in patients without AF recurrence (P = 0.02). CONCLUSION: Enhanced GP ablation directed by HFS and CFAE can be safely performed and enables maintenance of sinus rhythm in the majority of patients with PAF for a 12-month period. Denervation of the intrinsic cardiac autonomic nervous system may be the preferable target of catheter ablation of AF.

Ablation of paroxysmal and persistent atrial fibrillation: 1-year follow-up through continuous subcutaneous monitoring.

BACKGROUND: The aim of this prospective observational study was to identify responders to ablation through continuous subcutaneous monitoring for 1 year after ablation in patients with paroxysmal atrial fibrillation (PAF) or persistent AF (PersAF). METHOD: Patients with symptomatic drug refractory AF were enrolled. Real-time three-dimensional (3D) left atrium maps were reconstructed by using a nonfluoroscopic navigation system (CARTO, Biosense-Webster Inc., Diamond Bar, CA, USA). The ipsilateral left and right pulmonary veins (PVs) were encircled in 1 lesion line by circumferential PV isolation. All patients were implanted with Reveal XT (Medtronic Inc.) for continuous AF monitoring and data collected every month during the 12-month follow-up. RESULTS: We enrolled 129 patients (56 ± 9 years, 102 males), all of whom were followed-up for 12 months after the last ablation procedure: 58 (45%) had a history of PersAF. After only 1 ablation procedure, 76 (59%) of the 129 patients were AF-free at 12-month: 48 out of 71 (68%) in the PAF group and 28 out of 58 (48%) in the PersAF group. After 1 or more ablation procedures, 94 (73%) of the 129 patients were AF-free 12 months after the last procedure: 57 out of 71 (80%) in the PAF group and 37 out of 58 (64%) in the PersAF group. CONCLUSION: Ablation is highly effective in treating AF, as assessed through detailed 1-year continuous monitoring: success rate is higher in PAF than in PersAF patients. The use of subcutaneous monitors is a valuable means of identifying responders and nonresponders, and can potentially guide antiarrhythmic and antithrombotic therapies.

Ganglionated plexi ablation for longstanding persistent atrial fibrillation.

AIMS: To study the potential efficacy of ganglionated plexi (GP) ablation in the setting of longstanding persistent atrial fibrillation (AF). METHODS AND RESULTS: Anatomic ablation at the areas of GP in the left atrium was performed in 89 patients with symptomatic, drug-refractory, persistent AF (71 men, 56 +/- 7 years of age). In 29 patients, a second procedure by means of circumferential pulmonary vein (PV) isolation was performed, and 5 of them were subjected to a third circumferential ablation. At 16 +/- 7 months after the final ablation procedure, 53 (59.6%) of the 89 patients were in sinus rhythm in the absence of antiarrhythmic drug therapy, 5 (5.6%) patients had permanent AF, and 31 (34.8%) patients had paroxysmal AF. The long-term success rate for patients who underwent a single ablation procedure with only GP ablation was 38.2% over a follow-up of 24 +/- 3 months. Independent predictors of later arrhythmia recurrences were left atrial diameter [HR 1.039 (1.00-1.07), P = 0.028] and duration of AF prior to ablation [HR 1.116 (1.02-1.22), P = 0.008]. CONCLUSION: Ganglionated plexi ablation in chronic AF results in long-term maintenance of sinus rhythm in 38.2% of cases. Repeat procedures with circumferential isolation of all PV offer a success rate of 59.6% over a follow-up of 16 +/- 7 months.

Left atrial ablation at the anatomic areas of ganglionated plexi for paroxysmal atrial fibrillation.

BACKGROUND: Modification of left atrial ganglionated plexi (GP) is a promising technique for the treatment of paroxysmal atrial fibrillation (AF) but its therapeutic efficacy is not established. This study aimed at evaluating the effectiveness of anatomic GP modification by means of an implantable arrhythmia monitoring device. METHODS: In 56 patients with paroxysmal AF, radiofrequency ablation at anatomic sites, where the main clusters of GP have been identified in the left atrium, was performed. In all patients, an electrocardiogram monitor (Reveal XT, Medtronic Inc., Minneapolis, MN, USA) was implanted before (n = 7) or immediately after (n = 49) AF ablation. RESULTS: Average duration of the procedure was 142 ± 18 min and average fluoroscopy time 20 ± 7 min. In total, 53-81 applications of RF energy were delivered (mean of 18.2 ± 3.8 at each of the four areas of GP ablation). Heart rate variability was assessed in 31 patients. Standard deviation of RR intervals over the entire analyzed period, the root mean square of differences between successive RR intervals, and high frequencies decreased, while HRmin, HRmean, and LF to HF ratio increased immediately postablation; these values returned to baseline 6 months after the procedure. At end of 12-month follow-up, 40 (71%) patients were free of arrhythmia recurrence. Ten patients had AF recurrence, two patients had left atrial flutter, and four patients had episodes of flutter as well as AF recurrence. Duration of episodes of AF after ablation gradually decreased over the follow-up period. CONCLUSIONS: Regional ablation at the anatomic sites of the left atrial GP can be safely performed and enables maintenance of sinus rhythm in 71% of patients with paroxysmal AF for a 12-month period.

Left atrial appendectomy after failed catheter ablation of a focal atrial tachycardia originating in the left atrial appendage.

This report describes a case of left atrial appendectomy after a failed endocardial catheter ablation of a continuous drug-refractory left atrial appendage (LAA) tachycardia in a 9-year-old boy. Electrophysiologic study showed atrial tachycardia (AT) originating in the LAA. Numerous radiofrequency applications with an irrigated-tip catheter were ineffective. During surgery, direct pressure on the apex of the LAA by forceps immediately terminated the AT and restored sinus rhythm. After a left atrial appendectomy, the patient remained free of any arrhythmias during a follow-up period of 18 months.

Successful epicardial catheter ablation of micro-reentrant ventricular tachycardia in a 14-year-old child.

The article describes successful epicardial catheter ablation of ventricular tachycardia using the transpericardial approach in a 14-year-old adolescent. Conventional mapping of endocardial surface revealed criteria consistent with subpericardial localization of arrythmogenic substrate. Epicardial mapping using a transpericardial approach enabled localization and successful elimination of the ventricular tachycardia on the lateral wall of the right ventricle.

Prophylactic pulmonary vein isolation during isthmus ablation for atrial flutter: the PReVENT AF Study I.

BACKGROUND: Although catheter ablation of isthmus-dependent atrial flutter (AFL) is successful at eliminating the target arrhythmia, many patients subsequently experience new-onset atrial fibrillation (AF). OBJECTIVE: The aim of this study was to determine whether AF can be prevented by prophylactic pulmonary vein ablation in patients with AFL. METHODS: A prospective, single-blind, randomized clinical trial in patients whose sole arrhythmia was AFL without AF was conducted. Patients were randomized to cavotricuspid isthmus ablation alone or with concomitant pulmonary vein isolation. All patients received an implantable cardiac monitor. RESULTS: Fifty patients completed the trial, and patients were well matched. Isthmus ablation was successful in all patients; pulmonary vein isolation was successful in 25 (100%) randomized patients. Procedure (P < .0001) and fluoroscopy (P < .0001) times were longer in the combined ablation group. More patients in the isthmus ablation-only group experienced new-onset AF during follow-up (52% vs. 12%; P = .003). The 1-year AF burden also favored the combined ablation group compared with the isthmus ablation-only group (8.3% vs. 4.0%; P = .034). In the isthmus ablation-only group, 8 (32%) patients subsequently underwent another ablation for AF. The performance of pulmonary vein isolation and male sex were independent predictors of freedom from AF. CONCLUSION: In the PREVENT-AF Study I randomized clinical trial of patients in whom only typical AFL had been observed clinically, the addition of pulmonary vein isolation to cavotricuspid isthmus ablation resulted in a marked reduction of new-onset AF during clinical follow-up as assessed with a continuous implantable cardiac monitor.

Renal denervation for improving outcomes of catheter ablation in patients with atrial fibrillation and hypertension: early experience.

BACKGROUND: The potential role of renal denervation (RD) in patients with AF and less severe hypertension is unknown. OBJECTIVE: The purpose of this study was to assess the potential role of RD as an adjunct to pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) and moderate resistant or severe resistant hypertension. METHODS: The data for this study were obtained from 2 different prospective randomized studies, analyzed by meta-analysis. Patients with paroxysmal AF or persistent AF and moderate resistant hypertension (office blood pressure BP ≥140/90 mm Hg and <160/100 mm Hg; first study; n = 48) or severe resistant hypertension (≥160/100 mm Hg; second study; n = 38) were randomized to PVI or PVI with RD. RESULTS: At 12 months, 26 of the 41 PVI with RD patients (63%) were AF-free vs 16 of the 39 patients (41%) in the PVI-only group (P = .014). In patients with severe hypertension, 11 of the 18 PVI with RD patients (61%) vs 5 of the 18 PVI-only patients (28%) were AF-free (P = .03). For moderate hypertension, the differences were less dramatic: 11 of 21 (52%) vs 15 of 23 (65%) when RD added (P = .19). The superior efficacy of adding RD was most apparent in persistent AF and severe hypertension (hazard ratio 0.25, confidence interval 0.09-0.72, P = .01). Duration of the procedure and fluoroscopy were nonsignificantly longer in the RD group. CONCLUSION: RD may improve the results of PVI in patients with persistent AF and/or severe resistant hypertension.

Ganglionated plexus ablation vs linear ablation in patients undergoing pulmonary vein isolation for persistent/long-standing persistent atrial fibrillation: a randomized comparison.

BACKGROUND: The optimal ablation technique for persistent and long-standing persistent atrial fibrillation (AF) is unclear. Both linear lesion (LL) and ganglionated plexus (GP) ablation have been used in addition to pulmonary vein isolation (PVI), but no direct comparison of the 2 methods exists. OBJECTIVE: The aim of this study is to assess the comparative safety and efficacy of 2 different ablation strategies-PVI+LL vs PVI+GP ablation -in patients with persistent or long-standing persistent AF. METHODS: Two hundred sixty-four consecutive patients with persistent/long-standing persistent AF were randomly assigned to 2 different ablation schemes: PVI+LL (n = 132) and PVI+GP (n = 132) ablation. Consistent sinus rhythm (SR) off antiarrhythmic drug was assessed after follow-up of at least 3 years with the use of an implanted monitoring device. RESULTS: All procedural end points were acutely achieved. At 12 months after a single procedure, 47% of the patients treated with PVI+LL were in SR compared to 54% of the patients treated with PVI+GP (P = .29). At 3 years, 34% of the patients with PVI+LL and 49% of the patients with PVI+GP maintained SR (P = .035). Atrial flutter was more frequent in the PVI+LL group than in PVI+GP group (18% vs 6%; P = .002). After a second procedure in 78 patients of the PVI+LL group and 55 patients of the PVI+GP group, the long-term overall success rate was 52% and 68%, respectively (P = .006). CONCLUSIONS: PVI+GP ablation confers superior clinical results with less ablation-related left atrial flutter and reduced AF recurrence compared to PVI+LL ablation at 3 years of follow-up.

Progression of atrial fibrillation after a failed initial ablation procedure in patients with paroxysmal atrial fibrillation: a randomized comparison of drug therapy versus reablation.

BACKGROUND: The aim of this prospective randomized study was to assess whether an early reablation was superior to antiarrhythmic drug (AAD) therapy in patients with previous failed pulmonary vein isolation. METHODS AND RESULTS: Patients with paroxysmal atrial fibrillation (AF) eligible for AAD therapy or reablation after a previously failed initial pulmonary vein isolation procedure were eligible for this study and were followed up for 3 years to assess rhythm by means of an implanted cardiac monitor. After the blanking period postablation, 154 patients had symptomatic AF recurrences and were randomized to AAD (n=77) or repulmonary vein isolation (n=77). At the end of follow-up, 61 (79%) patients in the AAD group and 19 (25%) patients in the reablation group demonstrated AF% progression (P<0.01). The AF% at 36 months was significantly greater in the AAD group compared with patients in the reablation group (18.8±11.4% versus 5.6±9.5%, respectively; P<0.01). In addition, 18 (23%) patients in the AAD group and 3 (4%) patients in the reablation group progressed to persistent AF (P<0.01). Furthermore, 45 (58%) of the 77 reablation group patients were free of AF/atrial tachycardia on no AADs; in contrast, in the AAD group, only 9 (12%) of the 77 patients were free of AF/atrial tachycardia (P<0.01) throughout follow-up. CONCLUSIONS: Redo AF ablation was substantially more effective than AAD in reducing the progression and prevalence of AF after the failure of an initial ablation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01709682.

A randomized comparison of pulmonary vein isolation with versus without concomitant renal artery denervation in patients with refractory symptomatic atrial fibrillation and resistant hypertension.

OBJECTIVES: The aim of this prospective randomized study was to assess the impact of renal artery denervation in patients with a history of refractory atrial fibrillation (AF) and drug-resistant hypertension who were referred for pulmonary vein isolation (PVI). BACKGROUND: Hypertension is the most common cardiovascular condition responsible for the development and maintenance of AF. Treating drug-resistant hypertension with renal denervation has been reported to control blood pressure, but any effect on AF is unknown. METHODS: Patients with a history of symptomatic paroxysmal or persistent AF refractory to ≥2 antiarrhythmic drugs and drug-resistant hypertension (systolic blood pressure >160 mm Hg despite triple drug therapy) were eligible for enrolment. Consenting patients were randomized to PVI only or PVI with renal artery denervation. All patients were followed ≥1 year to assess maintenance of sinus rhythm and to monitor changes in blood pressure. RESULTS: Twenty-seven patients were enrolled, and 14 were randomized to PVI only, and 13 were randomized to PVI with renal artery denervation. At the end of the follow-up, significant reductions in systolic (from 181 ± 7 to 156 ± 5, p < 0.001) and diastolic blood pressure (from 97 ± 6 to 87 ± 4, p < 0.001) were observed in patients treated with PVI with renal denervation without significant change in the PVI only group. Nine of the 13 patients (69%) treated with PVI with renal denervation were AF-free at the 12-month post-ablation follow-up examination versus 4 (29%) of the 14 patients in the PVI-only group (p = 0.033). CONCLUSIONS: Renal artery denervation reduces systolic and diastolic blood pressure in patients with drug-resistant hypertension and reduces AF recurrences when combined with PVI.

Use of an implantable monitor to detect arrhythmia recurrences and select patients for early repeat catheter ablation for atrial fibrillation: a pilot study.

BACKGROUND: Catheter ablation of atrial fibrillation (AF) has proved effective in curing highly symptomatic patients with paroxysmal AF. The aim of this prospective, randomized study was to identify the optimal treatment of patients with AF recurrences after the first ablation. METHODS AND RESULTS: Two hundred eighty-six patients with paroxysmal AF underwent ablation (circumferential pulmonary vein isolation with linear lesions) and were monitored with an implantable cardiac monitor (Reveal XT, Medtronic). Patients without AF recurrences during the 3-month postablation period were assigned to group 1; those with AF recurrences to group 2. Patients in group 2 were randomly assigned to group 3 or group 4. Group 3 patients were treated only with antiarrhythmic drugs for 6 weeks, with no early reablation during the 3-month postablation period. In the case of AF recurrence after the 3-month postablation period, patients underwent reablation. Group 4 patients were treated according to the onset mechanism of AF recurrences, as detected and stored by the implantable cardiac monitor: antiarrhythmic drug therapy, but no reablation if AF was not preceded by triggers; early reablation if premature atrial beats or atrial tachycardias or flutter triggered AF. All patients were followed up for 1 year to assess maintenance of sinus rhythm in each group. On 12-month follow-up examination, of the 119 (42%) patients in group 1, 112 (94%) had no AF recurrences. Among the 83 patients in group 3, only 27 (33%) had no recurrences. Of the 84 group 4 patients, 67 (80%) had no AF recurrences (P<0.0001 versus group 3). CONCLUSIONS: Patients with recurrences after the first AF ablation are likely to respond to a second early ablation when AF is triggered by supraventricular arrhythmias or premature contractions. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01164319.

Cardiac resynchronization therapy and bone marrow cell transplantation in patients with ischemic heart failure and electromechanical dyssynchrony: a randomized pilot study.

Most studies have confirmed the beneficial effects of autologous bone marrow mononuclear cell (BMMC) transplantation on angina, myocardial perfusion, regional wall motion, and LV ejection fraction (LVEF). Cardiac resynchronization therapy (CRT) has also shown a beneficial effect in patients with heart failure (HF) and electrical/mechanical dyssynchrony. However, the relative contribution of BMMC and CRT in patients with ischemic HF and electromechanical dyssynchrony has never been investigated. The aim of this study was to evaluate the benefit of combining BMMC transplantation with CRT in patients with severe ischemic HF, left bundle branch block (LBBB), and mechanical dyssynchrony. Patients with ischemic HF, LVEF < 35%, LBBB, and mechanical dyssynchrony underwent intramyocardial transplantation of BMMC and CRTD system implantation. This randomized, single-blind, crossover study compared clinical and echocardiographic parameters during two follow-up periods: 6 months of active CRT (BMMC + CRTact) and 6 months of inactive CRT (BMMC + CRTinact). Physical performance was assessed by means of a 6-min walking test. Myocardial perfusion was evaluated by SPECT. Quality of Life (QoL) was assessed through the Minnesota Living with HF Questionnaire (MLwHFQ). Twenty-six patients (64 ± 7 years) were enrolled in the study. The distance covered by the patients during the 6-min walking test significantly increased in the BMMC + CRTinact phase (BMMC therapy only) in comparison with the baseline (269 ± 68 vs 206 ± 51; p = 0.007) and in the BMMC + CRTact phase (BMMC therapy + CRT) in comparison with the BMMC + CRTinact (378 ± 59 vs 269 ± 68; p < 0.001). The summed rest and stress score (SPECT) decreased significantly in the BMMC + CRTact and BMMC + CRTinact phases in comparison with the baseline (p ≤ 0.03). Both phases showed equivalent myocardial perfusion in the segments into which BMMC had been injected. QoL score was significantly lower in the BMMC + CRTinact phase than at the baseline (44.1 ± 14 vs 64.8 ± 19; p < 0.001), and in the BMMC + CRTact phase than in the BMMC + CRTinact phase (26.4 ± 12 vs 44.1 ± 14; p = 0.004). BMMC and CRT seem to act independently on myocardial perfusion and electromechanical dyssynchrony, respectively. Combining these two complementary therapies can significantly improve LV performance in patients with severe HF and electromechanical dyssynchrony.

Percutaneous epicardial ablation of ventricular tachycardia after failure of endocardial approach in the pediatric population with arrhythmogenic right ventricular dysplasia.

BACKGROUND: Despite the high efficacy of catheter ablation of ventricular tachycardia (VT) in patients with arrhythmogenic right ventricular dysplasia (ARVD), in some patients, conventional endocardial ablation is ineffective. These failures could be explained by the presence of epicardial arrhythmogenic substrate. In these cases, a percutaneous epicardial ablation may be required. OBJECTIVE: This study sought to report the feasibility and results of epicardial VT ablation in a pediatric population of ARVD patients in whom endocardial ablation was unsuccessful. METHODS: Seventeen ARVD pediatric patients (mean age 14 ± 4 years) in whom a percutaneous epicardial radiofrequency ablation of VT was attempted were included in this retrospective analysis. A total of 20 mappable, hemodynamically stable, monomorphic VTs were induced (2 macroreentrant and 18 focal). All patients underwent right ventricular epicardial VT ablation. RESULTS: At the end of the procedure, 16 (94.1%) of the 17 patients had no inducible VT. Pericardial effusion occurred in 4 patients (23.5%), with 1 (5.9%) patient having tamponade that required percutaneous pericardial drainage. During a mean follow-up of 26 ± 15 (range 6 to 42) months, 12 (70.6%) patients remained free of any episodes of VT. All patients with successful RF ablation were free from any antiarrhythmic drugs. There were no deaths during the follow-up period. Recurrences of VT were recorded in 5 (29.4%) patients. CONCLUSION: Percutaneous epicardial catheter ablation is feasible and relatively safe in pediatric ARVD patients with recurrent VT in whom conventional endocardial ablation failed.

Efficiency of intramyocardial injections of autologous bone marrow mononuclear cells in patients with ischemic heart failure: a randomized study.

Intramyocardial transplantation of autologous bone marrow mononuclear cells (BMMC) is believed to be a promising method for the treatment of patients with chronic ischemic heart disease. The aim of this study was to evaluate long-term results of intramyocardial bone marrow cell transplantation in patients with severe ischemic heart failure. One hundred nine patients with chronic myocardial infarction and end-stage chronic heart failure were randomized into two groups: 55 patients received intramyocardial BMMC injection and 54 received optimal medical therapy. The NOGA system (Biosense-Webster) was used to administer 41 +/- 16 x 106 BMMC into the border zone of myocardial infarction. None of the patients developed periprocedural complications following BMMC injections. The injections led to improvement of CCS class (3.1 +/- 0.4 to 1.6 +/- 0.6 after 6 months and 1.6 +/- 0.4 after 12 months; p = 0.001) and NYHA functional class (3.3 +/- 0.2 to 2.3 +/- 0.2 after 6 months and 2.5 +/- 0.1 after 12 months; p = 0.006). Left ventricular ejection fraction increased significantly in the BMMC group (27.8 +/- 3.4% vs 32.3 +/- 4.1%; p = 0.04) while it tended to decrease in the control group (26.8 +/- 3.8% to 25.2 +/- 4.1%; p = 0.61). Summed rest score improved in the BMMC group after 12 months (30.2 +/- 5.6 to 27.8 +/- 5.1; p = 0.032). The improvement of stress score was more noticeable (34.5 +/- 5.4 to 28.1 +/- 5.2; p = 0.016). Neither stress nor rest score changed in patients numbers on medical therapy. In BMMC group 6 (10.9%) patients died at 12-month follow-up compared with 21 (38.9%) in control group (log-rank test, p = 0.0007). Intramyocardial bone marrow cell transplantation to patients with ischemic heart failure is safe and improved survival, clinical symptoms, and has beneficial effect on LV function.

Selective ganglionated plexi ablation for paroxysmal atrial fibrillation.

BACKGROUND: Selective ganglionated plexi (GP) ablation guided by high-frequency stimulation has been proposed for the treatment of paroxysmal atrial fibrillation (AF), but the efficacy of the method is not established. OBJECTIVE: This study sought to compare selective ablation of GP identified by high-frequency stimulation with extensive regional ablation targeting the anatomic areas of GP in patients with paroxysmal AF. METHODS: Eighty patients with paroxysmal AF (age 53 +/- 9 years) were randomized to undergo selective GP ablation or regional left atrial ablation at the anatomic sites of GP. For selective GP ablation (n = 40), ablation targets were the sites where vagal reflexes were evoked by high-frequency stimulation. Vagal reflexes were defined as prolongation of the R-R interval by >50% and a concomitant decrease in blood pressure (>20 mm Hg) during AF. The end point of the procedure was failure to reproduce vagal reflexes with repeated high-frequency stimulation. For anatomic ablation, lesions were delivered at the sites of GP clustering. RESULTS: At 13.1 +/- 1.9 months, 42.5% of patients with selective GP and 77.5% of patients with anatomic ablation were free of symptomatic paroxysmal AF (PAF) (P = .02). Parasympathetic denervation was more prominent in patients with anatomic than selective GP ablation, and in patients free of AF compared to these with AF recurrence immediately after ablation, but this trend was abolished at 6 months. CONCLUSION: Selective GP ablation directed by high-frequency stimulation does not eliminate paroxysmal AF in the majority of patients. An anatomic approach for regional ablation at the sites of GP confers better results.

Catheter ablation of left atrial ganglionated plexi for atrial fibrillation.

Radiofrequency ablation of pulmonary vein ostia does not provide complete and long-term elimination of atrial fibrillation. Combining this procedure with local radiofrequency application on sites with strong vagal reflexes results in partial parasympathetic denervation and increases the antiarrhythmic effect. A novel catheter-ablation technique to modify ganglionated plexi in the left atrium was assessed in 58 patients (mean age, 52.1 +/- 1.9 years, 67% male) with drug-refractory atrial fibrillation, which was chronic in 21 (36%; mean duration, 14.3 +/- 2.9 months; range, 5-39 months). The mean left atrial volume was 93.1 +/- 6.1 mL. The patients underwent ablation of 4 areas of ganglionated plexi in the left atrium, with no circumferential ablation of the pulmonary veins; atrial fibrillation ceased immediately in 94.1% of them. Transient vagal bradycardia was seen in 93% of patients. For 7.2 +/- 0.4 months after the procedure, 86.2% of them were free from arrhythmias, and no antiarrhythmic drugs were administered. Ganglionated plexi ablation is an efficient treatment for atrial fibrillation.