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INTRODUCTION: Carina breakthrough (CB) at the right pulmonary vein (RPV) can occur after circumferential pulmonary vein isolation (PVI) due to epicardial bridging or transient tissue edema. High-power short-duration (HPSD) ablation may increase the incidence of RPV CB. Currently, the surrogate of ablation parameters to predict RPV CB is not well established. This study investigated predictors of RPV CB in patients undergoing ablation index (AI)-guided PVI with HPSD. METHODS: The study included 62 patients with symptomatic atrial fibrillation (AF) who underwent AI-guided PVI using HPSD. Patients were categorized into two groups based on the presence or absence of RPV CB. Lesions adjacent to the RPV carina were assessed, and CB was confirmed through residual voltage, low voltage along the ablation lesions, and activation wavefront propagation. RESULTS: Out of the 62 patients, 21 (33.87%) experienced RPV CB (Group 1), while 41 (66.13%) achieved first-pass RPV isolation (Group 2). Despite similar AI and HPSD, patients with RPV CB had lower contact force (CF) at lesions adjacent to the RPV carina. Receiver operating characteristic (ROC) curve analysis identified CF < 10.5 g as a predictor of RPV CB, with 75.7% sensitivity and 56.2% specificity (area under the curve: 0.714). CONCLUSION: In patients undergoing AI-guided PVI with HPSD, lower CF adjacent to the carina was associated with a higher risk of RPV CB. These findings suggest that maintaining higher CF during ablation in this region may reduce the occurrence of RPV CB.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Humanos , Venas Pulmonares/cirugía , Ablación por Catéter/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Resultado del Tratamiento , RecurrenciaRESUMEN
BACKGROUND: The aim of this study was to build an auto-segmented artificial intelligence model of the atria and epicardial adipose tissue (EAT) on computed tomography (CT) images, and examine the prognostic significance of auto-quantified left atrium (LA) and EAT volumes for AF. METHODSâANDâRESULTS: This retrospective study included 334 patients with AF who were referred for catheter ablation (CA) between 2015 and 2017. Atria and EAT volumes were auto-quantified using a pre-trained 3-dimensional (3D) U-Net model from pre-ablation CT images. After adjusting for factors associated with AF, Cox regression analysis was used to examine predictors of AF recurrence. The mean (±SD) age of patients was 56±11 years; 251 (75%) were men, and 79 (24%) had non-paroxysmal AF. Over 2 years of follow-up, 139 (42%) patients experienced recurrence. Diabetes, non-paroxysmal AF, non-pulmonary vein triggers, mitral line ablation, and larger LA, right atrium, and EAT volume indices were linked to increased hazards of AF recurrence. After multivariate adjustment, non-paroxysmal AF (hazard ratio [HR] 0.6; 95% confidence interval [CI] 0.4-0.8; P=0.003) and larger LA-EAT volume index (HR 1.1; 95% CI 1.0-1.2; P=0.009) remained independent predictors of AF recurrence. CONCLUSIONS: LA-EAT volume measured using the auto-quantified 3D U-Net model is feasible for predicting AF recurrence after CA, regardless of AF type.
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Tejido Adiposo , Fibrilación Atrial , Ablación por Catéter , Estudios de Factibilidad , Pericardio , Recurrencia , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Femenino , Ablación por Catéter/métodos , Tejido Adiposo/diagnóstico por imagen , Estudios Retrospectivos , Pericardio/diagnóstico por imagen , Anciano , Tomografía Computarizada por Rayos X , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Valor Predictivo de las Pruebas , Tejido Adiposo EpicárdicoRESUMEN
INTRODUCTION: Ventricular arrhythmia (VA) commonly originate from the left ventricular summit (LVS) and results in left ventricular (LV) dysfunction in some patients; however, factors related to LV cardiomyopathy have not been well elucidated. Therefore, this study aimed to investigate the risk factors for LV cardiomyopathy and the outcomes of patients with LVS VA. METHODS: Between 2013 and 2018, a total of 139 patients (60.7% men; mean age 53.2 ± 13.9 years old) underwent catheter ablation for LVS VA in two centers. Detailed patient demographics, electrocardiograms, electrophysiological characteristics, and clinical outcomes were analyzed. LV cardiomyopathy was defined as left ventricular ejection fraction (LVEF) <50%. RESULTS: Acute procedural success was achieved in 92.8% of patients. There were 40 patients (28.8%) with LV cardiomyopathy, and the mean LVEF improved from 37.5 ± 9.3% to 48.5 ± 10.2% after ablation (p < .001). After multivariate analysis, the independent factors of LV dysfunction were wider QRS duration (QRSd) of the VA (odds ratio [OR] 1.02; 95% confidence interval [CI]: 1.00-1.04; p = .046) and the absolute earliest activation time discrepancy (AEAD) between epicardium and endocardium (OR 1.05; 95% CI: 1.00-1.09; p = .048). After ablation, the LV function was completely recovered in 20 patients (50%). The factors for LV dysfunction without recovery included wider premature ventricular complex (PVC) QRSd (OR 1.09; 95% CI: 1.02-1.17; p = .012) and poorer LVEF (OR 0.85; 95% CI: 0.74-0.97; p = .020). CONCLUSION: In patients with VA from the LVS, PVC QRSd and AEAD are factors associated with deteriorating LV systolic function. Catheter ablation can reverse LV remodeling. Narrower QRSd and better LVEF are associated with better recovery of LV function after ablation.
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Cardiomiopatías , Ablación por Catéter , Disfunción Ventricular Izquierda , Complejos Prematuros Ventriculares , Masculino , Humanos , Adulto , Persona de Mediana Edad , Anciano , Femenino , Función Ventricular Izquierda , Volumen Sistólico/fisiología , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/cirugía , Complejos Prematuros Ventriculares/complicaciones , Resultado del Tratamiento , Electrocardiografía/métodos , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/etiología , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodosRESUMEN
INTRODUCTION: Despite undergoing an index ablation, some patients progress from paroxysmal atrial fibrillation (PAF) to persistent AF (PersAF), and the mechanism behind this is unclear. The aim of this study was to investigate the predictors of progression to PersAF after catheter ablation in patients with PAF. METHODS: This study included 400 PAF patients who underwent an index ablation between 2015 and 2019. The patients were classified into three groups based on their outcomes: Group 1 (PAF to sinus rhythm, n = 226), Group 2 (PAF to PAF, n = 146), and Group 3 (PAF to PersAF, n = 28). Baseline and procedural characteristics were collected, and predictors for AF recurrence and progression were evaluated. RESULTS: The mean age of the patients was 58.4 ± 11.1 years, with 272 males. After 3 years of follow-up, 7% of the PAF cases recurred and progressed to PersAF despite undergoing an index catheter ablation. In the multivariable analysis, a larger left atrial (LA) diameter and the presence of non-pulmonary vein (PV) triggers during the index procedure independently predicted recurrence. Moreover, a larger LA diameter, the presence of non-PV triggers, and a history of thyroid disease independently predicted AF progression. CONCLUSION: The progression from PAF to PersAF after catheter ablation is associated with a larger LA diameter, history of thyroid disease, and the presence of non-PV triggers. Meticulous preprocedural evaluation, patient selection, and comprehensive provocation tests during catheter ablation are recommended.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Enfermedades de la Tiroides , Masculino , Humanos , Persona de Mediana Edad , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Resultado del Tratamiento , Venas Pulmonares/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , RecurrenciaRESUMEN
AIMS: Investigations on non-VKA oral anticoagulants (NOACs) for atrial fibrillation (AF) patients without taking any oral anticoagulants (OACs) or staying well on warfarin were limited. We aimed to investigate the associations between stroke prevention strategies and clinical outcomes among AF patients who were previously well without taking any OACs or stayed well on warfarin for years. METHODS AND RESULTS: The retrospective analysis included a total of 54 803 AF patients who did not experience an ischaemic stroke or intra-cranial haemorrhage (ICH) for years after AF was diagnosed. Among these patients, 32 917 patients who did not receive OACs were defined as the 'original non-OAC cohort' (group 1), and 8007 patients who continuously received warfarin were defined as the 'original warfarin cohort' (group 2). In group 1, compared to non-OAC, warfarin showed no significant difference in ischaemic stroke (aHR 0.979, 95%CI 0.863-1.110, P = 0.137) while those initiated NOACs were associated with lower risk (aHR 0.867, 95%CI 0.786-0.956, P = 0.043). When compared to warfarin, the composite of 'ischaemic stroke or ICH' and 'ischaemic stroke or major bleeding' was significantly lower in the NOAC initiator with an aHR of 0.927 (95%CI 0.865-0.994; P = 0.042) and 0.912 (95%CI 0.837-0.994; P < 0.001), respectively. In group 2, when compared to warfarin, those shifted to NOACs were associated with a lower risk of ischaemic stroke (aHR 0.886, 95%CI 0.790-0.993, P = 0.002) and major bleeding (aHR 0.849, 95%CI 0.756-0.953, P < 0.001). CONCLUSIONS: The NOACs should be considered for AF patients who were previously well without taking OACs and those who were free of ischaemic stroke and ICH under warfarin for years.
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BACKGROUND: Circumferential pulmonary vein isolation (CPVI) has supplanted segmental PVI (SPVI) as standard procedure for atrial fibrillation (AF). However, there is limited evidence examining the efficacy of these strategies in redo ablations. In this study, we investigated the difference in recurrence rates between SPVI and CPVI in redo ablations for PV reconnection.MethodsâandâResults: This study retrospectively enrolled 543 patients who had undergone AF ablation between 2015 and 2017. Among them, 167 patients (30.8%, including 128 male patients and 100 patients with paroxysmal AF) underwent redo ablation for recurrent AF. Excluding 26 patients without PV reconnection, 141 patients [90 patients of SPVI (Group 1) and 51 patients of CPVI (Group 2)] were included. The AF-free survival rates were 53.3% and 56.9% in Group 1 and Group 2, respectively (P=0.700). The atrial flutter (AFL)-free survival rates were 90% and 100% in Group 1 and Group 2, respectively (P=0.036). The ablation time was similar between groups, and there no major complications were observed. CONCLUSIONS: For redo AF ablation procedures, SPVI and CPVI showed similar outcomes, except for a higher AFL recurrence rate for SPVI after long-term follow-up (>2 years). This may be due to a higher probability of residual PV gaps causing reentrant AFL.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Humanos , Masculino , Fibrilación Atrial/cirugía , Venas Pulmonares/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Recurrencia , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodosRESUMEN
BACKGROUND: High-power short-duration (HPSD) and cryoballoon ablation (CBA) has been used for pulmonary vein isolation (PVI). OBJECTIVE: We aimed to compare the efficacy of PVI between CBA and HPSD ablation in patients with paroxysmal atrial fibrillation (PAF). METHODS: We retrospectively analyzed 251 consecutive PAF patients from January 2018 to July 2020. Of them, 124 patients (mean age 57.2 ± 10.1 year) received HPSD and 127 patients (mean age 59.6 ± 9.4 year) received CBA. In HPSD group, the radiofrequency energy was set as 50 W/10 s at anterior wall and 40 W/10 s at posterior wall. In CBA group, 28 mm s generation cryoballoon was used for PVI according the guidelines. RESULTS: There was no significant difference in baseline characteristics between these 2 groups. The time to achieve PVI was significantly shorter in cryoballoon ablation group than in HPSD group (20.6 ± 1.7 min vs 51.8 ± 36.3, P = 0.001). The 6-month overall recurrence for atrial tachyarrhythmias was not significantly different between the two groups (HPSD:14.50% vs CBA:11.0%, P = 0.40). There were different types of recurrent atrial tachyarrhythmia between these 2 groups. Recurrence as atrial flutter was significantly more common in CBA group compared to HPSD group (57.1% vs 12.5%, P = 0.04). CONCLUSION: In PAF patients, CBA and HPSD had a favourable and comparable outcome. The recurrence pattern was different between CBA and HPSD groups.
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INTRODUCTION: Dynamic display of real-time wavefront activation pattern may facilitate the recognition of reentrant circuits, particularly the diastolic path of ventricular tachycardia (VT). OBJECTIVE: We aimed to evaluate the feasibility of LiveView Dynamic Display for mapping the critical isthmus of scar-related reentrant VT. METHODS: Patients with mappable scar-related reentrant VT were selected. The characteristics of the underlying substrates and VT circuits were assessed using HD grid multielectrode catheter. The VT isthmuses were identified based on the activation map, entrainment, and ablation results. The accuracy of the LiveView findings in detecting potential VT isthmus was assessed. RESULTS: We studied 18 scar-related reentrant VTs in 10 patients (median age: 59.5 years, 100% male) including 6 and 4 patients with ischemic and nonischemic cardiomyopathy, respectively. The median VT cycle length was 426 ms (interquartile range: 386-466 ms). Among 590 regional mapping displays, 92.0% of the VT isthmus sites were identified by LiveView Dynamic Display. The accuracy of LiveView for isthmus identification was 84%, with positive and negative predictive values of 54.8% and 97.8%, respectively. The area with abnormal electrograms was negatively correlated with the accuracy of LiveView Dynamic Display (r = -.506, p = .027). The median time interval to identify a VT isthmus using LiveView was significantly shorter than that using conventional activation maps (50.5 [29.8-120] vs. 219 [157.5-400.8] s, p = .015). CONCLUSION: This study demonstrated the feasibility of LiveView Dynamic Display in identifying the critical isthmus of scar-related VT with modest accuracy.
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Cardiomiopatías , Ablación por Catéter , Taquicardia Ventricular , Cardiomiopatías/cirugía , Ablación por Catéter/métodos , Cicatriz/diagnóstico , Cicatriz/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiología , Taquicardia Ventricular/cirugíaRESUMEN
Arrhythmogenic cardiomyopathy (ACM) is a group of arrhythmogenic disorders of the myocardium that are not caused by ischemic, hypertensive, or valvular heart disease. The clinical manifestations of ACMs may overlap those of dilated cardiomyopathy, complicating the differential diagnosis. In several ACMs, ventricular tachycardia (VT) has been observed at an early stage, regardless of the severity of the disease. Therefore, preventing recurrences of VT can be a clinical challenge. There is a wide range of efficacy and side effects associated with the use of antiarrhythmic drugs (AADs) in the treatment of VT. In addition to AADs, patients with ACM and ventricular tachyarrhythmias may benefit from catheter ablation, especially if they are drug-refractory. The differences in pathogenesis between the various types of ACMs can lead to heterogeneous distributions of arrhythmogenic substrates, non-uniform ablation strategies, and distinct ablation outcomes. Ablation has been documented to be effective in eliminating ventricular tachyarrhythmias in arrhythmogenic right ventricular dysplasia (ARVC), sarcoidosis, Chagas cardiomyopathy, and Brugada syndrome (BrS). As an entity that is rare in nature, ablation for ventricular tachycardia in certain forms of ACM may only be reported through case reports, such as amyloidosis and left ventricular noncompaction. Several types of ACMs, including ARVC, sarcoidosis, Chagas cardiomyopathy, BrS, and left ventricular noncompaction, may exhibit diseased substrates within or adjacent to the epicardium that may be accountable for ventricular arrhythmogenesis. As a result, combining endocardial and epicardial ablation is of clinical importance for successful ablation. The purpose of this article is to provide a comprehensive overview of the substrate characteristics, ablation strategies, and ablation outcomes of various types of ACMs using endocardial and epicardial approaches.
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AIMS: For patients with typical and atypical atrial flutter (AFL) but without history of atrial fibrillation (AF), the long-term cardiovascular (CV) outcomes after catheter ablation for AFL remain unclear. We compared the long-term all-cause mortality and CV outcomes in patients with AFL receiving catheter ablation compared with the results with medical therapy. METHODS AND RESULTS: Atrial flutter patients receiving catheter ablation for typical AFL were identified using the Health Insurance Database, and constituted the 'AFL ablation group'. Patients with typical and atypical AFL but without ablation (AFL without ablation group) were propensity matched to the AFL ablation group. Patients with prior AF diagnosis were excluded. Primary outcomes included all-cause and CV mortality, heart failure (HF) hospitalization, and stroke. The multivariable cox hazards regression model was used to evaluate the hazard ratio (HR) for study outcomes. A total of 3784 AFL patients (1892 patients in each group) was studied. Their mean follow-up durations were 7.85 ± 2.57 years (AFL without ablation group) and 8.31 ± 4.53 years (AFL ablation group). Atrial flutter with ablation patients had lower risks of all-cause mortality (HR: 0.68, P < 0.001), CV deaths (HR: 0.78, P = 0.001), HF hospitalization (HR: 0.84, P = 0.01), and stroke (HR: 0.80, P = 0.01). CONCLUSIONS: Catheter ablation for AFL in patients without prior AF was associated with lower risks of all-cause mortality and CV events compared with AFL patients without ablation during long-term follow-ups.
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Fibrilación Atrial , Aleteo Atrial , Ablación por Catéter , Accidente Cerebrovascular , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Aleteo Atrial/diagnóstico , Aleteo Atrial/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Humanos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: Radiofrequency catheter ablation (RFCA) is commonly performed in patients with non-paroxysmal atrial fibrillation (AF), but because very long-term follow-up results of RFCA are limited, we investigated the 10-year RFCA outcomes of non-paroxysmal AF.MethodsâandâResults: We retrospectively enrolled 100 patients (89 men, mean age 53.5±8.4years) with drug-refractory symptomatic non-paroxysmal AF who underwent 3D electroanatomic-guided RFCA. Procedural characteristics at index procedures and clinical outcomes were investigated. In the index procedures, all patients had pulmonary vein isolation, 56 (56.0%), 48 (48.0%), and 32 (32.0%) underwent additional linear, complex fractionated atrial electrogram (CFAE) and non-pulmonary vein (NPV) foci ablations, respectively. After 124.1±31.7 months, 16 (16%) patients remained in sinus rhythm after just 1 procedure (3 with antiarrhythmic drugs [AAD]) and after multiple (2.1±1.3) procedures in 53 (53.0%) patients (22 with AAD). Left atrial (LA) diameter (hazard ratio HR 1.061; 95% confidence interval (CI) 1.020 to 1.103; P=0.003), presence of NPV triggers (HR 1.634; 95% CI 1.019 to 2.623; P=0.042) and undergoing CFAE ablation (HR 2.003; 95% CI 1.262 to 3.180; P=0.003) in the index procedure were independent predictors for recurrent atrial tachyarrhythmia. CONCLUSIONS: The 10-year outcomes of single RFCA in non-paroxysmal AF were unsatisfactory. Enlarged LA, presence of NPV triggers, and undergoing CFAE ablation in the index procedure independently predicted single-procedure recurrence. Multiple procedures are required to achieve adequate rhythm control.
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Apéndice Atrial , Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Masculino , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Atrios Cardíacos , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Antiarrítmicos/uso terapéutico , Venas Pulmonares/cirugía , Recurrencia , Resultado del TratamientoRESUMEN
Background: Left atrial appendage (LAA) is the main source of thrombus formation, and occlusion of this structure decreases the risk of stroke in patients with atrial fibrillation. Objectives: We aimed to describe the feasibility, safety and outcomes of percutaneous LAA closure using an occluder device, and to evaluate residual LAA contrast leak detected on computed tomography (CT) imaging in patients who underwent implantation in our institution. Methods: Consecutive patients of Taipei Veterans General Hospital who underwent percutaneous implantation of an LAA occluder (LAAO) were retrospectively collected and analyzed. Results: A total of 23 patients were included with a median age of 67 years (42-87) and median CHA2DS2-VASc score of 4 (1-7). The most frequent indication for intervention was bleeding while on oral anticoagulation treatment. After a mean follow-up of 31.17 ± 25.10 months, successful device implantation was achieved in 95.7% of the patients. There was no occurrence of death, stroke, device embolization, acute ST elevation myocardial infarction, major bleeding requiring invasive treatment or blood transfusion, inguinal hematoma or major bleeding related to antiplatelet therapy. One patient had cardiac tamponade, 1 had intra-procedural thrombus formation, 1 had impingement of mitral valve leaflet, and 1 had device-related thrombosis. Of 12 patients who underwent CT post- implantation, 6 had residual contrast leak into the LAA, one third of those who had peri-device leak. Conclusions: Percutaneous implantation of an LAAO appeared to be feasible with a low risk of major complications.
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Background: The presence of ventricular tachycardia (VT) is associated with higher mortality. The annual incidence of VT after a diagnosis of amyloidosis and the associated cardiovascular (CV) outcomes have not been well assessed in a large cohort. Methods: A total of 12,139 amyloidosis patients were identified from the Taiwan National Health Insurance Research Database. Non-amyloidosis group was matched 1:1 for age, gender, hypertension, and diabetes mellitus (DM) to the amyloidosis group using a propensity score. Analysis of the risk of CV outcomes was conducted. We also analyzed the incidence of cardiac amyloidosis (CA). Results: The incidence rates of amyloidosis and CA were 6.54 and 0.61 per 100,000 person-years, respectively. Multivariable analysis revealed that the risk of VT was higher in both the amyloidosis [hazard ratio (HR): 7.90; 95% confidence interval (CI): 4.49-13.9] and CA (HR: 153.3, 95% CI: 54.3-432.7) groups. In the amyloidosis group, the risk of heart failure (HF)-related hospitalization, CV death, and all-cause death was also higher. Amyloidosis was associated with a higher CV mortality rate following VT (HR: 1.50; 95% CI: 1.07-2.12). The onset of a new VT event in patients with amyloidosis was associated with HF, DM, chronic liver disease, and anti-arrhythmic drug use. Conclusions: In this nationwide cohort study, the incidence rates of amyloidosis and CA were 6.54 and 0.61 per 100,000 person-years, respectively. The long-term risks of VT and CV mortality were higher in the patients with amyloidosis and CA. The patients with amyloidosis had a poorer prognosis following VT events, highlighting the importance of continuous monitoring in these patients.
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INTRODUCTION: Identifying the critical isthmus (CI) in scar-related macroreentrant atrial tachycardia (AT) is challenging, especially for patients with cardiac surgery. We aimed to investigate the electrophysiological characteristics of scar-related macroreentrant ATs in patients with and without cardiac surgery. METHODS: A prospective study of 31 patients (mean age 59.4 ± 9.81 years old) with scar-related macroreentrant ATs were enrolled for investigation of substrate properties. Patients were categorized into the nonsurgery (n = 18) and surgery group (n = 13). The CIs were defined by concealed entrainment, conduction velocity less than 0.3 m/s, and the presence of local fractionated electrograms. RESULTS: Among the 31 patients, a total of 65 reentrant circuits and 76 CIs were identified on the coherent map. The scar in the surgical group is larger than the nonsurgical group (18.81 ± 9.22 vs. 10.23 ± 5.34%, p = .016). The CIs in surgical group have longer CI length (15.27 ± 4.89 vs. 11.20 ± 2.96 mm, p = .004), slower conduction velocity (0.46 ± 0.19 vs. 0.69 ± 0.14 m/s, p < .001), and longer total activation time (45.34 ± 9.04 vs. 38.24 ± 8.41%, p = .016) than those in the nonsurgical group. After ablation, 93.54% of patients remained in sinus rhythm during a follow-up of 182 ± 19 days. CONCLUSION: The characteristics of the isthmus in macroreentrant AT are diverse, especially for surgical scar-related AT. The identification of CIs can facilitate the successful ablation of scar-related ATs.
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Procedimientos Quirúrgicos Cardíacos , Ablación por Catéter , Taquicardia Supraventricular , Anciano , Cicatriz/diagnóstico , Cicatriz/etiología , Cicatriz/patología , Técnicas Electrofisiológicas Cardíacas , Sistema de Conducción Cardíaco/patología , Sistema de Conducción Cardíaco/cirugía , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Taquicardia Supraventricular/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: A drug provocation test (DPT) is important for the diagnosis of Brugada syndrome (BrS). The link, however, between dynamic changes of electrocardiography (ECG) features after DPT and unstable ventricular arrhythmia (VA) in BrS remains unknown. METHODS: Between 2014 and 2019, we assessed 27 patients with BrS (median age: 37.0 [interquartile range, IQR: 22.0-51.0] years; 25 men), including 9 (33.3%) with a history of unstable VA and 18 (66.7%) without. All patients in the study presented with Brugada-like ECG features before DPT. The ECG parameters and dynamic changes (∆) in 12-lead ECGs recorded from the second, third, and fourth intercostal spaces (ICS) before and at 1, 6, 12, 18, and 24 h after DPT (oral flecainide 400 mg) were analyzed. RESULTS: The total amplitude of V1 at the third ICS 18 and 24 h after DPT was significantly lower in patients with a history of unstable VA than in those without. Patients with BrS and unstable VAs had a significantly larger ∆ amplitude of V1 at the second ICS 12 h after DPT than in those without unstable VAs (0.28 [0.18-0.41] mV vs. 0.08 [0.01-0.15] mV, p = .01). A multivariate analysis revealed that the amplitude of V1 at the third ICS 18 and 24 h after DPT and the ∆ amplitude of V1 at the second ICS 12 h after DPT were associated with a history of unstable VA. CONCLUSION: Nonuniform changes and spatiotemporal differences in precordial ECG features after DPT were observed in patients with BrS and these may be surrogate markers for risk stratification.
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Síndrome de Brugada , Flecainida , Adulto , Síndrome de Brugada/diagnóstico , Electrocardiografía , Flecainida/efectos adversos , Humanos , MasculinoRESUMEN
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy caused by defective desmosomal proteins. The typical histopathological finding of ARVC is characterized by progressive fibrofatty infiltration of the right ventricle due to the dysfunction of cellular adhesion molecules, thus, developing arrhythmogenic substrates responsible for the clinical manifestation of ventricular tachycardia/fibrillation (VT/VF). Current guidelines recommend implantable cardiac defibrillator (ICD) implantation to prevent sudden cardiac death (SCD) in ARVC, especially for those experiencing VT/VF or aborted SCD, while antiarrhythmic drugs, despite their modest effectiveness and several undesirable adverse effects, are frequently used for those experiencing episodes of ICD interventions. Given the advances in mapping and ablation technologies, catheter ablation has been implemented to eliminate drug-refractory VT in ARVC. A better understanding of the pathogenesis, underlying arrhythmogenic substrates, and putative VT isthmus in ARVC contributes to a significant improvement in ablation outcomes through comprehensive endocardial and epicardial approaches. Regardless of ablation strategies, there is a diversity of arrhythmogenic substrates in ARVC, which could partly explain the nonuniform ablation outcome and long-term recurrences and reflect the role of potential factors in the modification of disease progression and triggering of arrhythmic events.
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Displasia Ventricular Derecha Arritmogénica , Ablación por Catéter , Taquicardia Ventricular , Displasia Ventricular Derecha Arritmogénica/diagnóstico , Displasia Ventricular Derecha Arritmogénica/terapia , Ablación por Catéter/efectos adversos , Muerte Súbita Cardíaca/etiología , Muerte Súbita Cardíaca/prevención & control , Humanos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/etiología , Taquicardia Ventricular/cirugía , Resultado del Tratamiento , Fibrilación Ventricular/etiologíaRESUMEN
AIMS: J-wave syndrome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has been linked to an increased risk of ventricular arrhythmia. We investigated the significance of J waves with respect to substrate manifestations and ablation outcomes in patients with ARVC. METHODS AND RESULTS: Forty-five patients with ARVC undergoing endocardial/epicardial mapping/ablation were studied. Patients were classified into two groups: 13 (28.9%) and 32 (71.1%) patients with and without J waves, respectively. The baseline characteristics, electrophysiological features, ventricular substrate, and recurrent ventricular tachycardia/fibrillation (VT/VF) were compared. Among the 13 patients with J waves, only the inferior J wave was observed. More ARVC patients with J waves fulfilled the major criteria of ventricular arrhythmias (76.9% vs. 21.9%, P = 0.003). Similar endocardial and epicardial substrate characteristics were observed between the two groups. However, patients with J waves had longer epicardial total activation time than those without (224.7 ± 29.9 vs. 200.8 ± 21.9 ms, P = 0.005). Concordance of latest endo/epicardial activation sites was observed in 29 (90.6%) patients without J waves and in none among those with J waves (P < 0.001). Complete elimination of endocardial/epicardial abnormal potentials resulted in the disappearance of the J wave in 8 of 13 (61.5%) patients. The VT/VF recurrences were not different between ARVC patients with and without J waves. CONCLUSION: The presence of J waves was associated with the discordance of endocardial/epicardial activation pattern in terms of transmural depolarization discrepancy in patients with ARVC.
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Displasia Ventricular Derecha Arritmogénica , Ablación por Catéter , Taquicardia Ventricular , Displasia Ventricular Derecha Arritmogénica/diagnóstico , Displasia Ventricular Derecha Arritmogénica/cirugía , Endocardio/cirugía , Mapeo Epicárdico , Humanos , Estudios Retrospectivos , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/cirugíaRESUMEN
PURPOSE: Left atrial appendage (LAA) closure decreases atrial natriuretic peptide (ANP) levels, which indirectly increases the risk of arrhythmogenicity. We aimed to determine the effect of a combined angiotensin receptor-neprilysin inhibitor (ARNi) on arrhythmogenicity following LAA closure in an animal model. METHODS: Twenty-four rabbits were randomized into four groups: (1) control, (2) LAA closure (LAAC), (3) heart failure (HF)-LAAC, and (4) HF-LAAC with sacubitril/valsartan (+ARNi). HF models were developed in the HF-LAAC and HF-LAAC+ARNi groups. Epicardial LAA exclusion was performed in the LAAC, HF-LAAC, and HF-LAAC+ARNi groups. ANP levels were measured. An electrophysiological study was performed. The myocardium was harvested for histopathological analysis. RESULTS: The ANP level decreased in the LAAC group (785 ± 103 pg/mL, p = 0.03), failed to increase in the HF-LAAC group (917 ± 172 pg/mL, p = 0.3), and increased in the HF-LAAC+ARNi group (1524 ± 126 pg/mL, p < 0.01) compared to that in the control group (1014 ± 56 pg/mL). The atrial effective refractory period (ERP) was prolonged in the HF-LAAC group and restored to baseline in the HF-LAAC+ARNi group. Ventricular ERP was the longest in the HF-LAAC group. The atrial fibrillation window of vulnerability (AF WOV) was elevated in the LAAC, HF-LAAC, and HF-LAAC+ARNi groups, with the latter group having lower AF WOV than the two former groups. Ventricular fibrillation (VF) inducibility was the highest in the HF-LAAC group (51 ± 5%, p < 0.001), followed by the LAAC group (30 ± 4%, p = 0.006) and the HF-LAAC+ARNi group (25 ± 5%, p = 0.11) when compared to the control group (18 ± 4%). Atrial and ventricular fibrosis were noted in all groups except the control group. CONCLUSION: LAA closure decreased ANP, which in turn increased AF and VF inducibility. Atrial and ventricular arrhythmogenicity was suppressed by ARNi.
Asunto(s)
Aminobutiratos/farmacología , Arritmias Cardíacas , Apéndice Atrial/cirugía , Factor Natriurético Atrial/metabolismo , Compuestos de Bifenilo/farmacología , Atrios Cardíacos/cirugía , Neprilisina/antagonistas & inhibidores , Valsartán/farmacología , Antagonistas de Receptores de Angiotensina/farmacología , Animales , Arritmias Cardíacas/etiología , Arritmias Cardíacas/prevención & control , Combinación de Medicamentos , Modelos Animales , Conejos , Dispositivo Oclusor Septal , Resultado del TratamientoRESUMEN
INTRODUCTION: The efficacy of stereotactic body radiation therapy (SBRT) as an alternative treatment for recurrent ventricular tachycardia (VT) is still unclear. This study aimed to report the outcome of SBRT in VT patients with nonischemic cardiomyopathy (NICM). METHODS: The determination of the target substrate for radiation was based on the combination of CMR results and electroanatomical mapping merged with the real-time CT scan image. Radiation therapy was performed by Flattening-filter-free (Truebeam) system, and afterward, patients were followed up for 13.5 ± 2.8 months. We analyzed the outcome of death, incidence of recurrent VT, ICD shocks, anti-tachycardia pacing (ATP) sequences, and possible irradiation side-effects. RESULTS: A total of three cases of NICM patients with anteroseptal scar detected by CMR. SBRT was successfully performed in all patients. During the follow-up, we found that VT recurrences occurred in all patients. In one patient, it happened during a 6-week blanking period, while the others happened afterward. Re-hospitalization due to VT only appeared in one patient. Through ICD interrogation, we found that all patients have reduced VT burden and ATP therapies. All of the patients died during the follow-up period. Radiotherapy-related adverse events did not occur in all patients. CONCLUSIONS: SBRT therapy reduces the number of VT burden and ATP sequence therapy in NICM patients with VT, which had a failed previous catheter ablation. However, the efficacy and safety aspects, especially in NICM cases, remained unclear.
Asunto(s)
Cardiomiopatías/radioterapia , Radiocirugia/métodos , Taquicardia Ventricular/radioterapia , Anciano , Anciano de 80 o más Años , Cardiomiopatías/diagnóstico por imagen , Cicatriz/radioterapia , Mapeo Epicárdico , Femenino , Humanos , Masculino , Dosificación Radioterapéutica , Taquicardia Ventricular/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: Accurate identification of slow conducting regions in patients with scar-related atrial tachycardia (AT) is difficult using conventional electrogram annotation for cardiac electroanatomic mapping (EAM). Estimating delays between neighboring mapping sites is a potential option for activation map computation. We describe our initial experience with CARTO 3 Coherent Mapping (Biosense Webster Inc,) in the ablation of complex ATs. METHODS: Twenty patients (58 ± 10 y/o, 15 males) with complex ATs were included. We created three-dimensional EAMs using CARTO 3 system with CONFIDENSE and a high-resolution mapping catheter (Biosense Webster Inc). Local activation time and coherent maps were used to aid in the identification of conduction isthmus (CI) and focal origin sites. System-defined slow or nonconducting zones and CI, defined by concealed entrainment (postpacing interval < 20 ms), CV < 0.3 m/s and local fractionated electrograms were evaluated. RESULTS: Twenty-six complex ATs were mapped (mean: 1.3 ± 0.7 maps/pt; 4 focal, 22 isthmus-dependent). Coherent mapping was better in identifying CI/breakout sites where ablation terminated the tachycardia (96.2% vs 69.2%; P = .010) and identified significantly more CI (mean/chamber 2.0 ± 1.1 vs 1.0 ± 0.7; P < .001) with narrower width (19.8 ± 10.5 vs 43.0 ± 23.9 mm; P < .001) than conventional mapping. Ablation at origin and CI sites was successful in 25 (96.2%) with long-term recurrence in 25%. CONCLUSIONS: Coherent mapping with conduction velocity vectors derived from adjacent mapping sites significantly improved the identification of CI sites in scar-related ATs with isthmus-dependent re-entry better than conventional mapping. It may be used in conjunction with conventional mapping strategies to facilitate recognition of slow conduction areas and critical sites that are important targets of ablation.