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AIMS: Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse. METHODS AND RESULTS: This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0-60) days and 21 (15, 29.5; range: 2-63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0-42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001]. CONCLUSION: Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.
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Fibrilación Atrial , Ablación por Catéter , Fístula Esofágica , Humanos , Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Fibrilación Atrial/diagnóstico , Resultado del Tratamiento , Incidencia , Factores de Riesgo , Fístula Esofágica/epidemiología , Fístula Esofágica/etiología , Fístula Esofágica/diagnóstico , Pronóstico , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodosRESUMEN
INTRODUCTION: Procedural atrial fibrillation (AF) termination is considered as a predictor of long-term success after catheter ablation for persistent AF (persAF). However, some patients remain free of arrhythmia recurrences despite failure to achieve AF termination. The objective of this study was to assess long-term outcome and prognostic factors in patients undergoing complex ablation without procedural AF termination. METHODS AND RESULTS: This study comprised 419 patients (63.8 ± 10.2 years, 63.4% male) undergoing complex ablation for persAF. Patients without procedural AF termination (n = 137, 64.2 ± 9.7 years, 63.5% male) were categorized into patients who remained in sinus rhythm (SR) in long-term outcome (SR-group) and patients with recurrence of AF or atrial tachycardia (AT) (AR-group). During a follow-up (FU) of 19.6 ± 14.6 months, the SR-group consisted of 65 (47.5%) and the AR-group of 69 (50.4%) patients. Three patients (2.2%) were lost to FU. Left atrial appendage (LAA) flow velocity and left atrium volume index (LAVI) could be identified as predictors for long-term success. LAA flow velocity and baseline AF cycle length (AFCL) were significantly associated with the type of arrhythmia recurrence (AF vs AT), ie, higher values of both are predictive for AT rather than AF recurrences. Patients with a LAVI < 34.4 mL/m² and significant AFCL increase during the ablation procedure had rather AT than AF recurrences. CONCLUSION: Patients with an arrhythmia-free outcome despite failure of procedural AF termination during complex ablation for persAF are characterized by specific morphological and functional properties that are easy to obtain.
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Fibrilación Atrial/cirugía , Ablación por Catéter , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/fisiopatología , Función del Atrio Izquierdo , Ablación por Catéter/efectos adversos , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Supervivencia sin Progresión , Recurrencia , Factores de Riesgo , Taquicardia Supraventricular/etiología , Taquicardia Supraventricular/fisiopatología , Factores de TiempoAsunto(s)
Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Taquicardia Supraventricular , Humanos , Atrios Cardíacos/cirugía , Taquicardia , Ablación por Catéter/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Resultado del Tratamiento , Venas Pulmonares/cirugíaRESUMEN
BACKGROUND: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as an alternative to transvenous systems for prevention of sudden cardiac death. However, concerns have been raised regarding its efficacy and safety in obese individuals. OBJECTIVE: The purpose of this study was to perform a meta-analysis to evaluate the efficacy and safety of the S-ICD in patients with obesity by assessing the relationship between body mass index (BMI) and clinical outcomes. METHODS: A comprehensive search of multiple databases was conducted for English-language peer-reviewed studies reporting clinical outcomes in S-ICD recipients with (BMI ≥30 kg/m2) and without obesity (BMI <30 kg/m2). Data on preimplantation screening failure, defibrillation testing, complications, appropriate and inappropriate shocks, and survival were analyzed using standard, random-effects, meta-analytical techniques. RESULTS: Twenty-nine studies involving 20,486 patients were included. There was no statistically significant difference in mean BMI values of patients with failed or successful preimplantation screening (mean difference -0.60 kg/m2; 95% confidence interval [CI] -2.06 to 0.86). Obesity was associated with higher rates of failed defibrillation testing at ≤65 J (odds ratio [OR] 2.16; 95% CI 1.39-3.35), and malpositioning/suboptimal positioning occurred more frequently in obese compared to nonobese patients (OR 3.37; 95% CI 1.76-6.44). Increased BMI as a continuous variable (per increase in 1 kg/m2 BMI) was associated with elevated defibrillation thresholds (OR 1.05; 95% CI 1.03-1.08); higher risk of complications (hazard ratio [HR] 1.04; 95% CI 1.02-1.05); a trend toward an increased number of appropriate shocks (HR 1.02; 95% CI 1.00-1.04); and no significant increase in the risk of inappropriate shocks (HR 1.01; 95% CI 0.99-1.03). CONCLUSION: This meta-analysis underscores the importance of considering obesity in S-ICD implantation decisions. Although S-ICD remains effective in obese patients, attention to potential technical challenges and higher complication rates is warranted.
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Background: The automated NavX Ensite Precision latency-map (LM) algorithm aims to identify atrial tachycardia (AT) mechanisms. However, data on a direct comparison of this algorithm with conventional mapping are scarce. Methods: Patients scheduled for AT ablation were randomized to mapping with the LM- algorithm (LM group) or to conventional mapping (conventional only group: ConvO), using entrainment and local activation mapping techniques. Several outcomes were exploratively analyzed. Primary endpoint was intraprocedural AT Termination. If AT termination with only automated 3D-Mapping failed, additional conventional methods were applied (conversion). Results: A total of 63 patients (mean 67 years, 34 % female) were enrolled. In the LM group (n = 31), the correct AT mechanism was identified in 14 patients (45 %) using the algorithm alone compared to 30 patients (94 %) with conventional methods. Time to termination of the first AT was not different between groups (LM group 34 ± 20 vs. ConvO 43.1 ± 28.3 min; p = 0.2). However, when AT termination did not occur with LM algorithm, time to termination prolonged significantly (65 ± 35 min; p = 0.01). After applying conventional methods (conversion), procedural termination rates did not differ between LM group (90 %) vs. ConvO (94 %) (p = 0.3). During a follow-up time of 20 ± 9 months, no differences were observed in clinical outcomes. Conclusion: In this small prospective, randomized study, the use of the LM algorithm alone may lead to AT termination, but less accurate than conventional methods.
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BACKGROUND: Complex ablation for persistent atrial fibrillation (AF) aims to modify the arrhythmogenic substrates to become incapable to perpetuate the arrhythmia. Ablation-associated determinants of atrial tachycardia (AT) rather than AF recurrences are unknown. The aim of the study was to evaluate the association between the type of arrhythmia recurrence and electrophysiological findings during redo procedures. METHODS: A total number of 384 consecutive patients with persistent AF underwent complex ablation consisting of PV isolation (PVI), biatrial electrogram-guided ablation, and linear ablation with the desired procedural endpoint of AF termination. Electrophysiological findings during redo procedures and its relation to AR type are the subject of this study. RESULTS: Overall, 177 (46%) patients underwent a second procedure. Patients with AT recurrences had significantly more often persistent PVI (47 vs. 25%; P = 0.002). Moreover, a higher number of recovered PVs were associated with AF recurrence (3 PVs recovered, AF = 16.1% vs. AT = 5.2%; P = 0.02; 4 PVs recovered, AF = 18.5% vs. AT = 6.3%; P = 0.01), regardless of the extent of substrate ablation during the first procedure. CONCLUSIONS: Durable PV isolation but not the extent of atrial substrate ablation determines the type of arrhythmia recurrence. Thus, the PVs may represent dominant perpetuators (and not only triggers) of persistent AF even in the presence of a significantly modified atrial substrate.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Taquicardia Supraventricular , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Humanos , Venas Pulmonares/cirugía , Recurrencia , Taquicardia Supraventricular/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: We aimed at assessing the safety and efficacy of a systematic transradial approach for left ventricular endomyocardial biopsy using a new hydrophilic sheathless guiding catheter. METHODS AND RESULTS: Forty-two consecutive patients were included. The transradial success rate was 98% (41 of 42). In one case, cross over to femoral access due to irreversible spasm of the right radial artery was necessary. No radial spasm was observed in the other 41 patients. Depending on the indication, several other procedures, such as coronary angiography or ventricular angiography, were additionally performed through the same transradial access site. Median fluoroscopy time was 7.9 min. The mean dose area product was 1867 cGy × cm(2). All biopsy samples were graded as good or excellent quality. No patient had any complications. Immediate post-procedural ambulation could be achieved in all patients. Radial artery patency was confirmed by duplex sonography 24 h after removal of the guide. CONCLUSION: The present study demonstrates safety and efficacy of a systematic transradial access for left ventricular EMB using a highly hydrophilic sheathless guiding catheter. This is of clinical importance since this new technique may overcome critical limitations of the common approach.
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Biopsia , Cardiomiopatías/patología , Cateterismo Periférico , Ventrículos Cardíacos/patología , Miocardio/patología , Arteria Radial , Adulto , Anciano , Anciano de 80 o más Años , Biopsia/efectos adversos , Biopsia/instrumentación , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/instrumentación , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Arteria Radial/diagnóstico por imagen , Radiografía Intervencional , Factores de Riesgo , Ultrasonografía Doppler Dúplex , Dispositivos de Acceso VascularRESUMEN
INTRODUCTION: Atrial tachycardia in virtually all areas of both atria has become more important in the clinical management of patients with previous complex atrial fibrillation ablation. Accurate interpretation of surface electrocardiogram (ECG) characteristics is of paramount importance to localize the origin of atrial tachycardia, particularly for planning interventional treatment. This article highlights the ECG features of different types of right and left atrial tachycardia. DEFINITION: Typical right atrial flutter through the cavotricuspid isthmus conducts septally in a cranial direction and demonstrates sawtooth-like flutter waves which start negative in II, III and aVF and then show a steep slope upwards to the isoelectric line. The flutter rate typically ranges between 240-250 beats/min. In contrast, right atrial flutter in a clockwise rotation, flutter around the vena cava inferior or superior and around a scar (e.g. after cardiac surgery) show positive or biphasic flutter waves (lower or upper loop reentry). Left atrial flutter waves (e.g. around the mitral valve or around the pulmonary veins) are very heterogeneous and are typically positive in V1 as the left atrium is located in the posterior mediastinum. CONCLUSION: Specific knowledge of flutter wave morphology in surface ECG facilitates planning and performance of the ablation strategy.