Permanent His-bundle pacing using distal His-bundle electrogram-guided approach in patients with atrioventricular block.

BACKGROUND: Permanent His-bundle pacing (HBP) is effective and safe; however, the success rate of HBP is low, especially in patients with infranodal block. This study aimed to assess the efficacy and feasibility of HBP implantation using an electrophysiological guided approach targeting a distal His-bundle electrogram (HBE) in patients with atrioventricular block (AVB). METHODS: Thirty-four consecutive patients with AVB (infranodal block in 28 patients) who underwent HBP were enrolled. During implantation, we attempted to target the distal part of the HBE (distal HBE) beyond the block site based on unipolar mapping. The His-capture threshold was evaluated for 1 year after implantation. RESULTS: HBP was achieved in 26 patients and in 21 patients (75%) with infranodal block. Detection of distal HBE was significantly higher in the successful HBP group than in the HBP failure group (65.4% vs. 0%, p = .001). Among 15 patients with intra-Hisian block, 14 patients (93%) successfully achieved HBP with distal HBE detection. During the 1-year follow-up period, an increase in His-capture threshold by ≥1.0 V at 1.0 ms occurred in five (19.2%) of 26 patients. The increased His-capture threshold group exhibited significantly less detection of distal HBE (20% vs. 76.2%; odds ratio 0.078, 95% confidence interval 0.07-0.87, p = .038) and a higher His-capture threshold at implantation (2.0 ± 1.1 V vs. 1.1 ± 0.9 V; odds ratio 1.702, 95% confidence interval 1.025-2.825, p = 0.04) than the non-increased His-capture threshold group. CONCLUSION: HBP implantation guided by distal HBE approach may be feasible with subsequent stable pacing in patients with intra-Hisian and atrioventricular nodal block.

Acute improvement of left ventricular relaxation as a predictor of volume reduction after cardiac resynchronization therapy: a pilot study assessing the value of left ventricular hemodynamic parameter.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves cardiac function, but CRT recipients with advanced heart failure (HF) do not always respond well. Because the best parameters for the prediction of CRT response are not established, we investigated whether improvement of invasive left ventricular (LV) hemodynamic diastolic parameters could identify CRT responders. METHODS: A total of 34 consecutive patients (age, 69 ± 9 years; 70% men) who received CRT devices for HF were assessed as to whether acute invasive hemodynamic parameters with and without CRT function could predict LV volume responders. RESULTS: These patients demonstrated an improvement in LV dP/dtmax (11.1 ± 11.7%), LV dP/dtmin (4.6 ± 12.1%), and tau (3.7 ± 11.6%) by biventricular pacing. Nineteen patients (55%) were classified as CRT responders, which was defined by a >15% decrease in LV end-systolic volume (ESV) at the 6-month follow-up evaluation. The area under the receiver operator characteristic curve to detect CRT volume response was 0.93 for the shortening of tau, which was superior to any other hemodynamic parameter. The multivariate analysis revealed that this improvement in tau was the strongest predictive factor for identifying CRT volume responders. Of note, the magnitude of tau shortening during biventricular pacing was significantly correlated with the reduction in LVESV at the 6-month follow-up evaluation. CONCLUSIONS: The extent of acute improvement in LV isovolumic relaxation time, as assessed by tau, was associated with favorable response to CRT. The assessment of invasive diastolic function could provide valuable information about CRT volume response.

Idiopathic ventricular arrhythmias originating from the aortic root prevalence, electrocardiographic and electrophysiologic characteristics, and results of radiofrequency catheter ablation.

OBJECTIVES: This study investigated the prevalence and electrocardiographic and electrophysiologic characteristics of aortic root ventricular arrhythmias (VAs). BACKGROUND: Idiopathic VAs originating from the ostium of the left ventricle may be ablated at the base of the aortic cusps. METHODS: We studied 265 patients with idiopathic VAs with an inferior QRS-axis morphology. RESULTS: The successful ablation site was within (or below) the aortic cusps in 44 patients (16.6%). The site of the origin was the left coronary cusp (LCC) in 24 (54.5%), the right coronary cusp (RCC) in 14 (31.8%), the noncoronary cusp (NCC) in 1 (2.3%), and at the junction between the LCC and RCC (L-RCC) in 5 (11.4%) cases. The maximum amplitude of the R-wave in the inferior leads was significantly greater with an LCC than with an RCC origin (p < 0.05). The ratio of the R-wave amplitude in leads II and III was significantly greater with an LCC than with an RCC origin (p < 0.01) and was significantly smaller in the NCC than in the other sites (p < 0.0001). The ventricular deflection in the His bundle electrogram was significantly later relative to the surface QRS with an LCC or L-RCC origin than with an RCC or NCC origin (p < 0.0001). The ratio of the atrial-to-ventricular deflection amplitude was significantly greater in the NCC than in the other sites (p < 0.0001). No other factors predicted the site of origin. CONCLUSIONS: Idiopathic VAs are more common in the LCC than in the RCC and rarely arise from the NCC. The electrocardiogram is useful for differentiating the site of origin.

Efficacy of electroanatomic mapping in the catheter ablation of premature ventricular contractions originating from the right ventricular outflow tract.

BACKGROUND: Mapping of premature ventricular contractions (PVCs) originating from the right ventricular outflow tract (RVOT) sometimes is not easy because of an unstable incidence and multiple foci of the PVCs. The aim of this study was to evaluate the effectiveness of electroanatomic mapping in catheter ablation of those PVCs. METHODS AND RESULTS: One hundred patients with 134 RVOT origin PVCs were randomly allotted to undergo either conventional (group I; 50 patients with 65 PVCs) or electroanatomic mapping (group II; 50 patients with 69 PVCs). In group II, electroanatomic mapping of the RVOT was performed using auto-freeze maps in patients with frequent PVCs, and pace mapping was performed marking the pacing sites on the remap which was made by extracting the anatomic frame out of the baseline map during sinus rhythm in patients with infrequent PVCs. Successful ablation was achieved in 44 (88%) group I patients and 48 (96%) group II patients (p = 0.14). The fluoroscopy and procedure times and those per PVC morphology were all significantly shorter in group II than group I overall (p < 0.0001 for all comparisons), and in each patient group with infrequent PVCs, frequent PVCs or unstable PVCs (p < 0.05-0.0001). The number of RF applications and that per PVC was significantly smaller in group II than group I (5.3 +/- 1.8 vs 6.2 +/- 2.4, and 4.4 +/- 1.2 vs 5.2 +/- 2.1; p < 0.05). CONCLUSIONS: The use of electroanatomic mapping may reduce the fluoroscopy and procedure times in the ablation of RVOT PVCs, but there is no evidence that it improves the overall efficacy of the procedure.

Preferential conduction across the ventricular outflow septum in ventricular arrhythmias originating from the aortic sinus cusp.

OBJECTIVES: The purpose of this study was to examine the relationship between the origin and breakout site of idiopathic ventricular tachycardia (VT) or premature ventricular contractions (PVCs) originating from the myocardium around the ventricular outflow tract. BACKGROUND: The myocardial network around the ventricular outflow tract is not well known. METHODS: We studied 70 patients with idiopathic VT (n = 23) or PVCs (n = 47) with a left bundle branch block and inferior QRS axis morphology. Electroanatomical mapping was performed in both the right ventricular outflow tract (RVOT) and aortic sinus cusp (ASC) during VT or PVCs. RESULTS: The earliest ventricular activation (EVA) was recorded in the RVOT in 55 patients (group R) and in the ASC in 15 (group A). In all group R patients, the closest pace map and successful ablation were achieved at the EVA site. Although a successful ablation was achieved at the EVA site in all group A patients, the closest pace map was obtained at the EVA site in 8 and RVOT in 7 (with an excellent pace map in 4). The stimulus to QRS interval was 0 ms during pacing from the RVOT and 36 +/- 8 ms from the ASC. The distance between the EVA and perfect pace map sites in those 4 patients was 11.9 +/- 3.0 mm. CONCLUSIONS: Ventricular arrhythmias originating from the ASC often show preferential conduction to the RVOT, which may render pace mapping or some algorithms using the electrocardiographic characteristics less reliable. In some of those cases, an insulated myocardial fiber across the ventricular outflow septum may exist.

Plasma brain natriuretic peptide level after radiofrequency catheter ablation of paroxysmal, persistent, and permanent atrial fibrillation.

AIMS: The aim of this study was to investigate the change in plasma brain natriuretic peptide (BNP) level after pulmonary vein isolation (PVI) in paroxysmal (PAF), persistent (Pers-AF), and permanent atrial fibrillation (AF) (Perm-AF) patients. METHODS AND RESULTS: In 96 lone AF patients (PAF=65, Pers-AF=17, and Perm-AF=14), BNP was measured before and 3 months after successful PVIs. At baseline, in all patients, BNP was elevated and was significantly greater in Pers-AF and Perm-AF patients than PAF patients (P<0.05). After 3 months of follow-up following multiple PVIs, AF recurred in 12 (18%) PAF, 7 (41%) Pers-AF, and 8 (57%) Perm-AF patients. In Pers-AF and Perm-AF patients, BNP at baseline did not predict AF recurrence. After the PVIs, BNP significantly decreased in PAF and Pers-AF patients (P=0.005) but not in Perm-AF patients. An elevated BNP at baseline decreased to within-normal limits in all Pers-AF and Perm-AF patients without AF recurrences. In all seven (23%) patients, whose AF type improved after the PVIs, BNP decreased. CONCLUSION: The reduction in the BNP level after the PVI seemed to be a marker for a good outcome in AF post-ablation patients.

Incidence, location, and cause of recovery of electrical connections between the pulmonary veins and the left atrium after pulmonary vein isolation.

AIMS: The aim of this study was to reveal the incidence, location, and cause of recovery of the electrical connections (ECs) between the left atrium and the pulmonary veins (PVs) after the segmental ostial PV isolation (PVI). METHODS AND RESULTS: Pulmonary vein mapping and successful PVI were performed using a computerized three-dimensional mapping system (QMS2trade mark) with a basket catheter in 167 PVs in 53 consecutive patients with atrial fibrillation (AF). In 14 patients with recurrent AF after PVI, the same PV mapping and isolation as in the first procedure were performed, and the PV potential maps constructed by QMS2 in two different procedures were compared. Forty-nine recovered ECs were observed in 27 PVs, and all were eliminated by a few local radiofrequency (RF) applications. Thirty-four (69%) of those ECs recovered at the edge of original ECs, and another 15 (31%) recovered at the mid-portion of the continuous broad original ECs. CONCLUSION: Electrical connection recovery occurred most commonly at the edges of original ECs and occasionally at the mid-portion of continuous broad original ECs after PVI probably due to tissue oedema neighbouring the segmental RF lesions. Further RF lesions at the edge of original ECs and linear ablation to the continuous broad ECs may help reduce AF recurrence.

Electrophysiological pulmonary vein antrum isolation with a multielectrode basket catheter is feasible and effective for curing paroxysmal atrial fibrillation: efficacy of minimally extensive pulmonary vein isolation.

BACKGROUND: How extensive should an appropriate pulmonary vein (PV) ablation be is a matter of controversy. OBJECTIVE: The study's aim was to investigate the efficacy of minimally extensive PV ablation for isolating the PV antrum (PVA) with the guidance of electrophysiological parameters. METHODS: Fifty-five consecutive symptomatic paroxysmal atrial fibrillation (PAF) patients underwent PV mapping with a multielectrode basket catheter (MBC). A 31-mm MBC was deployed in 3-4 PVs as proximally as possible without dislodgement, and the longitudinal PV mapping enabled us to recognize single sharp potentials formed by the total fusion of the PV and left atrial potentials around the PV ostium or the transverse activation patterns that were observed. Those potentials were defined as PVA potentials. Radiofrequency ablation was performed circumferentially targeting PVA potentials with the end point being their elimination. RESULTS: After circumferential PVA ablation, electrical disconnection was achieved in 77% and residual PVA conduction gaps were observed in 23% of all targeted PVs. Those residual conduction gaps were mainly located at the border between ipsilateral PVs (42%) and between the left PVs and left atrial appendage (33%) and were eliminated by a mean of 3 +/- 2 minutes of local radiofrequency deliveries. During the follow-up period (11 +/- 5 months), 46 (84%) patients were free of symptomatic PAF without any anti-arrhythmic drugs. No PV stenosis or spontaneous left atrial flutter occurred. CONCLUSIONS: Electrophysiological PVA ablation with an MBC is feasible and effective for curing PAF because this minimally extensive PVA isolation technique targets the optimal sites, achieving both high efficacy and safety.

Simple and accurate catheter mapping technique to predict atrial fibrillation foci in the pulmonary veins or posterior right atrium.

OBJECTIVES: The purpose of this study was to investigate the efficacy of a novel catheter mapping technique for predicting atrial fibrillation (AF) foci. BACKGROUND: Most AF originates from pulmonary veins (PVs), but some originate from the right atrium. METHODS: We developed an algorithm by correlating the cardiac recordings obtained from multielectrode catheters placed in the posterior right atrium (RA) and esophagus during pacing from the PVs and superior vena cava (SVC) or crista terminalis (CT) in 10 AF patients. We tested the algorithm's accuracy prospectively in 46 AF patients. RESULTS: During pacing from the left PVs, the esophageal potentials preceded all other potentials. During pacing from both the right PVs and SVC-CT, the first component (FP) of the double potential (DP) recorded in the posterior RA preceded all other potentials. The amplitude of the FP was higher than that of the second DP component during pacing from the SVC-CT, whereas the reverse occurred from the right PVs. The activation sequence of the FPs and esophageal potentials was from superior to inferior during pacing from the superior PVs, whereas the reverse occurred from the inferior PVs. The accuracy of predicting 34 foci in the right PVs, 28 foci in left PVs, and 6 foci in SVC-CT was 100% for all, respectively. The accuracy of discriminating foci in the superior PVs from those in the inferior PVs was 97% in the right PVs and 96% in the left PVs. CONCLUSIONS: The technique using mapping catheters placed in the posterior RA and esophagus is feasible and effective for mapping and ablating AF.