RESUMEN
INSTRUCTION: We hypothesized that real-time simultaneous amplitude frequency electrogram transform (SAFE-T) during sinus rhythm (SR) is able to identify and characterize the drivers of atrial fibrillation (AF) in nonparoxysmal (NP) AF. METHODS: Twenty-one NPAF patients (85.71% males, mean age 52 years old) underwent substrate mapping during SR (SAFE-T and voltage) and during AF (complex fractionated atrial electrograms [CFAE] and similarity index [SI]). After pulmonary veins isolation, extensive substrate ablation was performed with the endpoint of procedural termination or elimination of all SI sites (>63% similarities). Sites with procedural termination and non-termination sites were tagged for postablation SR analysis using SAFE-T. RESULTS: In 74 CFAE sites identified (average of 3 ± 2 sites per person), 28 (37.84%) were identified as termination sites demonstrating a high SI compared with the non-termination sites (80.11 ± 9.57% vs. 45.96 ± 13.38%, p < .001) during AF. During SR, these termination sites have high SAFE-T values and harbor a highly resonant, localized, repetitive high frequency components superimposed in the low frequency components compared with non-termination sites (5.70 ± 3.04 vs. 1.49 ± 1.66 Hz·mV, p < .001). In the multivariate analysis, the termination sites have higher SAFE-T and SI value (p < .001). CONCLUSION: AF procedural termination sites harbored signal characteristics of repetitive, high frequency component of individualized electrogram during SR, which can be masked by the low frequency fractionated electrogram and are difficult to see from the bipolar electrogram. Thus, SAFE-T mapping is feasible in identifying and characterizing sites of AF drivers.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Masculino , Humanos , Persona de Mediana Edad , Femenino , Fibrilación Atrial/cirugía , Técnicas Electrofisiológicas Cardíacas , Venas Pulmonares/cirugía , Análisis MultivarianteAsunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter , Técnicas Electrofisiológicas Cardíacas , Venas Pulmonares/cirugía , Potenciales de Acción , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Frecuencia Cardíaca , Humanos , Valor Predictivo de las Pruebas , Venas Pulmonares/fisiopatología , Recurrencia , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: The presence of bipolar low-voltage zone (LVZ) is a predictor of AF recurrence after PV isolation (PVI). However, changes of wavefront and bipole directions may cause different electrogram characteristics. We aimed to investigate whether using omnipolar maximum voltage (Vmax) map derived from high density (HD) Grid mapping catheter could assess LVZ and AF ablation outcome accurately. METHODS: Fifty paroxysmal AF patients (27 males, 57.8 ± 9.5 years old) who underwent 3D mapping guided PVI were enrolled. Left atrial voltage mapping during sinus rhythm before ablation was performed. The significant LVZ (<0.5 mV with area > 5 cm2) were defined as sites by omnipolar Vmax, bipolar HD wave map, conventional bipolar electrograms acquired from electrode pairs along to and across to the catheter shaft. The primary end point was the first documented recurrence of any AF during follow-ups. RESULTS: PVI was performed in all patients, and there were 2 patients (4%) who also received additional non-PV triggers ablation. After a follow-up of 11.4 ± 5.4 months, recurrence of AF occurred in 12 patients (24%). The presence of a significant LVZ was less detected by omnipolar Vmax map, compared to HD wave map (24.0% vs. 58.0%, p = 0.001). LVZ detected by omnipolar Vmax map independently predicted the AF recurrence (odds ratio 16.91; 95% CI, 3.17-90.10; p = 0.001). CONCLUSION: LVZ detected by omnipolar Vmax map accurately predicts the AF recurrence following ablation in paroxysmal AF, compared to conventional bipolar and HD wave maps, suggesting the omnipolar Vmax map can precisely define the atrial substrate property.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Técnicas Electrofisiológicas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Venas Pulmonares/cirugía , Recurrencia , Resultado del TratamientoRESUMEN
BACKGROUND: Atrial fibrillation (AF) prevalence increases with age. Aging affects the substrate properties of the left atrium (LA) and the outcomes of catheter ablation for treating AF. We investigated the AF trigger distribution and catheter ablation outcomes in patients of different ages with AF. METHODS: 1585 patients with AF (1181 paroxysmal and 404 non- paroxysmal AF) who had undergone catheter ablation were enrolled. The patients were divided into young (20-40 year-old, n = 175), middle-aged (41-64 year-old, n = 1134), and old (≥ 65 year-old, n = 276) groups. Electrophysiological characteristics and AF trigger sites were recorded. RESULT: The incidence of AF with only non-pulmonary vein (non-PV) foci was higher in the young group than in the other groups (8.6% vs. 3.6% vs. 3.3%, p < 0.01). Non-PV foci were more commonly located in the superior vena cava (SVC) in the young group than in the other groups (13.1% vs. 7.8% vs. 6.5%, p = 0.03). The left atrium (LA) mean voltage was higher and the incidence of very late recurrence after AF ablation was lower in the young group than in the other groups. However, the final AF recurrence rate after multiple procedures and complication rates were similar among all the groups at a mean follow-up of 5.6 years. CONCLUSION: The young patients with AF had a higher incidence of only non-PV foci, mostly located in SVC, than the middle-aged and old patients. Our study highlights the importance of identifying the non-PV foci in catheter ablation of young patients with AF.
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Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Adulto , Factores de Edad , Anciano , Técnicas Electrofisiológicas Cardíacas , Femenino , Atrios Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , RecurrenciaRESUMEN
BACKGROUND: Transmural lesion creation is essential for effective atrial fibrillation (AF) ablation. Lesion characteristics between conventional energy and high-power short-duration (HPSD) setting in contact force-guided (CF) ablation for AF remained unclear. METHODS: Eighty consecutive AF patients who received CF with conventional energy setting (power control: 25-30 W, force-time integral = 400 g s, n = 40) or with HPSD (power control: 40-50 W, 10 s, n = 40) ablation were analyzed. Of them, 15 patients in each conventional and HPSD group were matched by age and gender respectively for ablation lesions analysis. Type A and B lesions were defined as a lesion with and without significant voltage reduction after ablation, respectively. The anatomical distribution of these lesions and ablation outcomes among the 2 groups were analyzed. RESULTS: 1615 and 1724 ablation lesions were analyzed in the conventional and HPSD groups, respectively. HPSD group had a higher proportion of type A lesion compared to conventional group (P < 0.01). In the conventional group, most type A lesions were at the right pulmonary vein (RPV) posterior wall (50.2%) whereas in the HPSD group, most type A lesions were at the RPV anterior wall (44.0%) (P = 0.04). The procedure time and ablation time were significantly shorter in the HPSD group than that in the conventional group (91.0 ± 12.1 vs. 124 ± 14.2 min, P = 0.03; 30.7 ± 19.2 vs. 57.8 ± 21 min, P = 0.02, respectively). At a mean follow-up period of 11 ± 1.4 months, there were 13 and 7 patients with recurrence in conventional and HPSD group respectively (P = 0.03). CONCLUSION: Optimal ablation lesion characteristics and distribution after conventional and HPSD ablation differed significantly. HPSD ablation had shorter ablation time and lower recurrence rate than did conventional ablation.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Venas Pulmonares/lesiones , Factores de Edad , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Estudios de Casos y Controles , Ablación por Catéter/instrumentación , Ablación por Catéter/estadística & datos numéricos , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Venas Pulmonares/fisiopatología , Recurrencia , Factores Sexuales , Materiales Inteligentes , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter , Técnicas Electrofisiológicas Cardíacas , Modelos Cardiovasculares , Modelación Específica para el Paciente , Reconocimiento de Normas Patrones Automatizadas , Periodicidad , Procesamiento de Señales Asistido por Computador , Potenciales de Acción , Fibrilación Atrial/fisiopatología , Toma de Decisiones Clínicas , Frecuencia Cardíaca , Humanos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
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: 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.
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Potenciales de Acción , Cicatriz/complicaciones , Técnicas Electrofisiológicas Cardíacas , Sistema de Conducción Cardíaco/fisiopatología , Frecuencia Cardíaca , Taquicardia Supraventricular/diagnóstico , Anciano , Algoritmos , Ablación por Catéter , Cicatriz/diagnóstico , Femenino , Sistema de Conducción Cardíaco/cirugía , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Procesamiento de Señales Asistido por Computador , Taquicardia Supraventricular/etiología , Taquicardia Supraventricular/fisiopatología , Taquicardia Supraventricular/cirugía , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background and Purpose- In the daily practice, low-dose nonvitamin K antagonist oral anticoagulants are commonly used among Asian patients with atrial fibrillation (AF). The aim of the present study was to compare the risks of ischemic stroke, intracranial hemorrhage, and net clinical benefit of Asian patients with AF treated with off-label low-dose and on-label dosing rivaroxaban. Methods- A total of 2214 patients with AF aged ≥20 years treated with rivaroxaban at a tertiary medical center in Taiwan were studied. Patients were categorized into 2 groups: (1) on-label dose (n=1630): ROCKET-AF or J-ROCKET dosage criteria; and (2) off-label low-dose (10 mg/d for patients with an estimated glomerulus filtration rate >50 mL/min, n=584). The risks of ischemic stroke and intracranial hemorrhage were compared between 2 groups. Results- Compared with the on-label dose group, off-label low-dose rivaroxaban was associated with an increased risk of ischemic stroke with an adjusted hazard ratio of 2.75; 95% CI =1.62-4.69; P<0.001). The risk intracranial hemorrhage did not differ significantly between the on-label and off-label low-dosing groups (adjusted hazard ratio =0.62; 95% CI =0.32-1.20; P=0.213). Compared with off-label low-dose group, on-label dosing rivaroxaban was associated with a positive net clinical benefit in different weighted models. The results were consistent among the propensity-matched cohort. Conclusions- Off-label low-dosing rivaroxaban should be avoided for Asian patients with AF giving the higher risk of ischemic stroke without risk reduction in intracranial hemorrhage compared with on-label dosing.
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Fibrilación Atrial/tratamiento farmacológico , Inhibidores del Factor Xa/uso terapéutico , Hemorragias Intracraneales/etiología , Rivaroxabán/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Inhibidores del Factor Xa/efectos adversos , Femenino , Humanos , Hemorragias Intracraneales/inducido químicamente , Masculino , Persona de Mediana Edad , Factores de Riesgo , Rivaroxabán/efectos adversos , Accidente Cerebrovascular/complicaciones , Warfarina/uso terapéuticoAsunto(s)
Potenciales de Acción , Aleteo Atrial/diagnóstico , Técnicas Electrofisiológicas Cardíacas , Frecuencia Cardíaca , Venas Pulmonares/fisiopatología , Taquicardia Supraventricular/diagnóstico , Aleteo Atrial/fisiopatología , Aleteo Atrial/cirugía , Ablación por Catéter , Femenino , Humanos , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Venas Pulmonares/cirugía , Taquicardia Supraventricular/fisiopatología , Taquicardia Supraventricular/cirugía , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Adjunctive driver-guided ablation in addition to pulmonary vein isolation has been proposed as a strategy to improve procedural success and outcomes for various populations with atrial fibrillation (AF). First, this study aimed to evaluate the different mapping techniques for driver/rotor identification and second to evaluate the benefits of driver/rotor-guided ablation in patients with paroxysmal and persistent AF (PerAF). METHODS: We searched the electronic database in PubMed using the keywords "atrial fibrillation," "rotor," "rotational driver," "atrial fibrillation source," and "drivers" for both randomized controlled trials and observational controlled trials. Clinical studies reporting efficacy or safety outcomes of driver-guided ablation for paroxysmal AF or (PerAF) were identified. We performed subgroup analyses comparing different driver mapping methods in patients with PerAF. The odds ratios (ORs) with random effects were analyzed. RESULTS: Out of 175 published articles, seven met the inclusion criteria, of which two were randomized controlled trials, one was quasiexperimental study, and four observational studies (three case-controlled studies and one cross-sectional study). Overall, adjunctive driver-guided ablation was associated with higher rates of acute AF termination (OR: 4.62, 95% confidence interval [CI]: 2.12-10.08; P < 0.001), lower recurrence of any atrial arrhythmia (OR: 0.44, 95% CI: 0.30-0.065; P < 0.001), and comparable complication incidence. CONCLUSIONS: Adjunctive driver-guided catheter ablation suggested an increased freedom from AF/AT relative to conventional strategies, irrespective of the mapping techniques. Furthermore, phase mapping appears to be superior to electrogram-based driver mapping in PerAF ablation.
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Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Técnicas Electrofisiológicas Cardíacas/métodos , Humanos , Estudios Observacionales como Asunto , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Intracardiac electrogram recording is influenced by the electrode size and inter-electrode spacing. Smaller electrodes with a closer inter-electrode spacing may improve the mapping resolution and outcome. METHODS: Substrate mapping of the left atrium and residual pulmonary vein (PV) potentials during sinus rhythm was sequentially performed using a 3.5-mm electrode tip catheter and a 1-mm electrode multielectrode catheter in 33 patients (Group 1) that underwent repeat atrial fibrillation (AF) procedures. PV gap identification and electrophysiological characteristics were compared. Arrhythmia freedom was compared with a propensity matched (1:2) control group (66 patients, Group 2) undergoing repeat AF procedures guided by wide inter-electrode spacing catheter. RESULTS: In the Group 1 patients, the total area of residual PV potentials measured using the 1-mm catheter was larger than that measured by the 3.5-mm catheter. Overall 1.97⯱â¯0.59 (1-3) and 1.49⯱â¯0.62 (1-3) PVs were identified by the 1-mm electrode and 3.5â¯mm catheters, respectively (Pâ¯=â¯0.02). The gaps not identified by the 3.5â¯mm catheter had a smaller width and lower voltage. Radiofrequency catheter ablation in the areas with residual PV potentials identified by the 1-mm catheter resulted in complete electrical isolation of the PVs. Arrhythmia freedom at one year of follow-up was achieved in 26 of 33 (78.8%) patients in Group 1, which was significantly higher than the matched control group (33/66 [50%], Pâ¯<â¯0.05). CONCLUSION: In the patients with a previous PV isolation, mapping with small, closely spaced electrodes can increase the detection rate of residual PV potentials and improve the outcome.
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Ablación por Catéter/instrumentación , Electrocardiografía/instrumentación , Técnicas Electrofisiológicas Cardíacas/instrumentación , Venas Pulmonares/diagnóstico por imagen , Venas Pulmonares/cirugía , Anciano , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Angiografía por Tomografía Computarizada/instrumentación , Angiografía por Tomografía Computarizada/métodos , Electrocardiografía/métodos , Técnicas Electrofisiológicas Cardíacas/métodos , Femenino , Humanos , Masculino , Microelectrodos , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
INTRODUCTION: Cigarette smoking contributes to the development of atrial fibrosis via nicotine. The impact of smoking on ablation results in persistent atrial fibrillation (AF) is unknown. We aimed to investigate the triggers and long-term outcome between smokers and nonsmokers in the patients with persistent AF after catheter ablation. METHODS: This study included 201 (177 males, 53 ± 10 years old) patients who received index catheter ablation, including pulmonary vein isolation (PVI) and complex fractionated atrial electrograms (CFAEs) ablation for persistent AF, retrospectively. Electrophysiological characteristics at the index procedure and long-term outcome were investigated to determine the differences between smokers and nonsmokers. RESULTS: Baseline characteristics were similar between two groups. Pulmonary vein (PV) triggers were found in all patients in the two groups. There was a higher incidence of nonpulmonary vein (NPV) triggers in smokers than in nonsmokers (61% vs. 31%, P < 0.05). There were no differences of the long-term ablation outcomes between smokers and nonsmokers in Kaplan-Meier analysis. Smokers with PV plus right atrial NPV (RA-NPV) triggers had a higher incidence of recurrence (log-rank P < 0.05) than those without RA-NPV triggers, but not in nonsmokers, after a mean follow-up of 31 ± 25 months. CONCLUSIONS: Smoking increases the incidence of NPV triggers in patients with persistent AF. Smokers who have RA-NPV triggers during index procedure do have a worse outcome after catheter ablation, indicating the harmful effects of nicotine to right atrium.
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Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Venas Pulmonares/cirugía , Fumar/efectos adversos , Potenciales de Acción , Adulto , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Técnicas Electrofisiológicas Cardíacas , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Nicotina/efectos adversos , Agonistas Nicotínicos/efectos adversos , No Fumadores , Venas Pulmonares/fisiopatología , Recurrencia , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Fumadores , Fumar/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Aims: Whether the distribution of scar in arrhythmogenic right ventricular cardiomyopathy (ARVC) plays a role in predicting different types of ventricular arrhythmias is unknown. This study aimed to investigate the prognostic value of scar distribution in patients with ARVC. Methods and results: We studied 80 consecutive ARVC patients (46 men, mean age 47 ± 15 years) who underwent an electrophysiological study with ablation. Thirty-four patients receive both endocardial and epicardial mapping. Abnormal endocardial substrates and epicardial substrates were characterized. Three groups were defined according to the epicardial and endocardial scar gradient (<10%: transmural, 10-20%: intermediate, >20%: horizontal, as groups 1, 2, and 3, respectively). Sinus rhythm electrograms underwent a Hilbert-Huang spectral analysis and were displayed as 3D Simultaneous Amplitude Frequency Electrogram Transformation (SAFE-T) maps, which represented the arrhythmogenic potentials. The baseline characteristics were similar between the three groups. Group 3 patients had a higher incidence of fatal ventricular arrhythmias requiring defibrillation and cardiac arrest during the initial presentation despite having fewer premature ventricular complexes. A larger area of arrhythmogenic potentials in the epicardium was observed in patients with horizontal scar. The epicardial-endocardial scar gradient was independently associated with the occurrence of fatal ventricular arrhythmias after a multivariate adjustment. The total, ventricular tachycardia, and VF recurrent rates were higher in Group 3 during 38 ± 21 months of follow-up. Conclusion: For ARVC, the epicardial substrate that extended in the horizontal plane rather than transmurally provided the arrhythmogenic substrate for a fatal ventricular arrhythmia circuit.
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Displasia Ventricular Derecha Arritmogénica/complicaciones , Endocardio/fisiopatología , Pericardio/fisiopatología , Fibrilación Ventricular/etiología , Potenciales de Acción , Adulto , Displasia Ventricular Derecha Arritmogénica/diagnóstico por imagen , Displasia Ventricular Derecha Arritmogénica/fisiopatología , Ablación por Catéter , Muerte Súbita Cardíaca/etiología , Electrocardiografía Ambulatoria , Técnicas Electrofisiológicas Cardíacas , Endocardio/diagnóstico por imagen , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Pericardio/diagnóstico por imagen , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Fibrilación Ventricular/diagnóstico , Fibrilación Ventricular/fisiopatología , Fibrilación Ventricular/cirugíaRESUMEN
BACKGROUND: Septal ventricular outflow tract ventricular arrhythmias (OT-VAs) are defined as septal origin VAs from the right ventricular or left ventricular OT. Patients with septal OT-VAs may require a sequential bilateral OT ablation. This study aimed to evaluate the electrophysiological characteristics and ablation outcome in patients with septal OT-VAs. METHODS: We retrospectively analyzed the electrocardiography and electrophysiological parameters in 96 patients (mean age 49 ± 15 years, 49 male) undergoing bilateral activation mapping before catheter ablation of idiopathic septal OT-VAs. The patients were categorized into three groups based on the successful ablation sites, including the right ventricular outflow tract (RVOT), RVOT/left ventricular outflow tract (LVOT), and LVOT. RESULTS: Mapping in the three groups demonstrated a gradually decreasing and increasing trend in the earliest activation time obtained from the RVOT and LVOT, respectively. The absolute earliest activation time discrepancy (AEAD) of ≤18 milliseconds could predict the requirement for a sequential bilateral ablation with a sensitivity and specificity of 100.0% and 93.7%, respectively. The small AEAD (≤21 milliseconds) was associated with a higher recurrence rate in patients receiving a successful unilateral ablation, while patients with a longer distance between the bilateral OT earliest activation sites (DEA > 26 mm) increased future recurrences after an initially successful sequential bilateral ablation. CONCLUSIONS: The application of bilateral OT-VA activation mapping and the measurement of the AEAD and DEA provided not only pivotal information for the ablation strategy, but also prognostic implications for recurrences in patients with septal OT-VAs.
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Ablación por Catéter/métodos , Técnicas Electrofisiológicas Cardíacas , Taquicardia Ventricular/cirugía , Tabique Interventricular/cirugía , Potenciales de Acción , Adulto , Anciano , Ablación por Catéter/efectos adversos , Electrocardiografía , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda , Función Ventricular Derecha , Tabique Interventricular/fisiopatologíaRESUMEN
PURPOSE OF REVIEW: Pulmonary vein (PV) isolation is the cornerstone of atrial fibrillation (AF) ablation. However, the long-term procedural outcome remains suboptimal and there is a frequent need for repeat ablation procedure, especially in patients with non-paroxysmal AF. The review article summarizes the rationales, recent evidences, and strategies of ablation of extra-PV sites and its clinical outcomes. RECENT FINDINGS: It is a consensus that durable PV isolations are a definite therapy in patients with paroxysmal AF. In non-paroxysmal AF, many laboratories still believe that adequate substrate ablation outside PVs is definitely required. Empirical linear ablation is not recommended because of difficulty in achieving complete linear block, unless macro-reentry atrial tachycardia developed during procedure. Most of laboratories applied complex fractionated atrial electrogram (CFAE) ablation after PV isolation in non-paroxysmal AF, but the efficacy is limited in the long-term follow-up studies. A combined approach using CFAE, non-linear similarity, and phase mapping strategy to identify rotors or focal sources for substrate modification increases the ablation outcome, when compared to CFAE ablation alone. Provocative test with mapping of non-PV triggers is also recommended in all patients to improve long-term ablation success. Ablation beyond PV isolation is important, especially in non-paroxysmal AF patients, to modify the diseased atrial substrate and eliminate the non-PV triggers, which in turn improve the ablation outcome.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Venas Pulmonares , Técnicas Electrofisiológicas Cardíacas , Humanos , Resultado del TratamientoRESUMEN
PURPOSE: Differentiation between idiopathic left posterior fascicular ventricular arrhythmias (LPF-VAs) and posterior papillary muscle (PPM) VAs is of clinical value. This study aimed to develop an algorithm to distinguish PPM-VAs from LPF-VAs. METHODS: This study enrolled 73 consecutive cases, including 31 with PPM-VAs and 42 with LPF-VAs, undergoing successful ablation by using 3D mapping and intracardiac echography to confirm the origin of the VAs. Electrocardiographic and electrophysiological parameters were compared between two groups. RESULTS: The 12-lead electrocardiography of the PPM-VAs was characterized by a longer QRS duration than that in LPF-VAs (154.4 ± 14.5 vs. 132.3 ± 13.1 ms, P < 0.001). A QRS duration ≥133 ms was observed in all patients (100%) with PPM-VAs and 13/42 (31.0%) patients with LPF-VAs. The conduction duration from the earliest left ventricular activation site of the VA to the proximal right bundle branch (VA-RBB) was longer in patients with PPM-VAs than LPF-VAs (51.3 ± 12.2 vs. 23.6 ± 7.7 ms, P < 0.001). Based on the ROC analysis, a VA-RBB >36 ms was recognized in 28/31 patients with PPM-VAs (90.3%) and 2/42 with LPF-VAs (4.8%). An algorithm incorporating a QRS duration of ≥133 ms with a conduction duration of a VA-RBB of >36 ms could yield a sensitivity of 90.3% and specificity of 100% for discriminating PPM-VAs from LPF-VAs. CONCLUSIONS: The novel algorithm incorporating a QRS duration of ≥133 ms with a conduction duration of the VA-RBB of >36 ms could be useful in differentiating PPM-VAs from LPF-VAs.
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Bloqueo de Rama/cirugía , Ablación por Catéter/métodos , Electrocardiografía/métodos , Músculos Papilares/fisiopatología , Taquicardia Ventricular/diagnóstico por imagen , Taquicardia Ventricular/cirugía , Adulto , Bloqueo de Rama/diagnóstico por imagen , Estudios de Cohortes , Ecocardiografía/métodos , Técnicas Electrofisiológicas Cardíacas , Femenino , Sistema de Conducción Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/cirugía , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Curva ROC , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la EnfermedadRESUMEN
The incidence of acute myocarditis complicated with ventricular tachycardia (VT) is unknown. This study aimed to investigate the association between myocarditis and the incidence of VT and mortality. We also aimed to determine the independent predictors that increased the VT risk in those patients. From 2000 to 2004, 13,250 patients with a history of myocarditis were identified from the Taiwan National Health Insurance Research Database. The same number of individuals without heart disease with a matched sex and underlying diseases were selected as the control group. The long-term risks of life-threatening ventricular arrhythmias and mortality in patients with a history of myocarditis were investigated by an adjusted Cox proportional hazards regression. After a mean follow-up of 10.4â±â2.94 years (interquartile range: 12, 10.19-12), the myocarditis patients showed a higher incidence of new onset VT events compared with healthy controls (5.4% [519 per 100,000 person-year] in the myocarditis group vs, 0.47% [43 per 100,000 person-year] in the healthy controls; adjusted hazard ratio [HR]: 16.1, 95% confidence interval [CI]: 12.4-20.9; Pâ<â.001). A higher incidence of cardiovascular death was noted in the myocarditis group than healthy controls (6.52% vs 3.18%; HR: 2.42, 95% CI: 2.14-2.73; Pâ<â.001) after adjusting for the multivariate confounders including sex, age, underlying comorbidities, and medications. The results of this study suggested that there was higher incidence of life-threatening VT and mortality during the very long-term follow-up in patients with a history of myocarditis. Future work should focus on an in-depth risk stratification of VT in myocarditis patients.
Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Miocarditis/mortalidad , Taquicardia Ventricular/mortalidad , Adulto , Bases de Datos Factuales , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Estimación de Kaplan-Meier , Masculino , Programas Nacionales de Salud , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Riesgo , Taiwán/epidemiologíaRESUMEN
INTRODUCTION: The signal characteristics of intracardiac bipolar electrograms at the origin of idiopathic RVOT-VT during sinus rhythm remain unclear. OBJECTIVE: The study sought to develop a novel real-time/online technique, simultaneous amplitude frequency electrogram transformation (SAFE-T), to quantify and localize the diseased ventricular substrate in idiopathic RVOT-VT. METHODS: We retrospectively investigated the intracardiac bipolar recordings in 70 consecutive patients (26% male, mean age 42±12 years) who underwent successful radiofrequency catheter ablation of idiopathic RVOT-VT. We quantified the extent of the frequency fraction of ventricular potentials during sinus rhythm or ventricular pacing using a novel formula, the product of instantaneous amplitude and frequency, and showed that in a 3D geometry as an online SAFE-T map. RESULTS: The characteristics of the HHT spectra of electrograms derived from VT origins demonstrated high frequency components (>70 Hz), which were independent of the rhythm. The density of the abnormal potentials at the VT origins were higher (VT origins, 7.5±2.3 sites/cm2 vs. surrounding myocardium, 1.5±1.3 sites/cm2, p<0.001), and were significantly decreased after ablation (0.7±0.6 sites/cm2, p<0.001). A small region of abnormal potentials were observed in the VT origins (mean area of 1.5±0.8 cm2). The SAFE-T maps predicted the VT origins with 92% sensitivity, 78% specificity with optimal cut-off value of >3.0 Hz·mV. CONCLUSION: The online SAFE-T map was feasible for quantifying the diseased ventricular substrate, irrespective of the rhythm of activation, and can be used to identify the optimal ablation targets for idiopathic RVOT-VT. We found a limited region of abnormal potentials where the RVOT-VT origins were successfully ablated.
Asunto(s)
Ventrículos Cardíacos/fisiopatología , Taquicardia Ventricular/fisiopatología , Adulto , Área Bajo la Curva , Ablación por Catéter , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Curva ROC , Estudios Retrospectivos , Procesamiento de Señales Asistido por Computador , Taquicardia Ventricular/metabolismo , Taquicardia Ventricular/terapiaRESUMEN
BACKGROUND: Fever is associated with the manifestation of Brugada phenotype and ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with Brugada syndrome (BrS). The thermal effect on the pathogenesis of functional substrates in BrS remains unknown. OBJECTIVE: This study aimed to elucidate the thermal effect on BrS phenotype, VT/VF, and electrophysiological characteristics of epicardial functional substrates in BrS. METHODS: We consecutively studied 15 patients with BrS receiving radiofrequency catheter ablation for drug-refractory ventricular tachyarrhythmias. Baseline characteristics, electrocardiographic features, and changes in epicardial functional substrates before and after epicardial warm water instillation (n = 6) were recorded and analyzed. RESULTS: A total of 15 male patients (mean age 41.3 ± 10.3 years) with type 1 BrS presenting with ventricular tachyarrhythmias were consecutively enrolled. Epicardial mapping in 11 patients demonstrated a significantly larger epicardial scar/low-voltage zone (LVZ) area within the right ventricular outflow tract and anterior right ventricular free wall than within the endocardium (6.32 ± 12.74 cm2 vs 52.91 ± 45.25 cm2; P = .007). Epicardial warm water instillation in 6 patients led to a significant enlargement of the functional scar/LVZ area (123.83 ± 35.26 cm2 vs 63.53 ± 40.57 cm2; P = .03), accelerated conduction velocity of the endocardium and epicardium without scar/LVZ area, and increased VT/VF inducibility (16.7% vs 100%; P = .02). Ablation by targeting premature ventricular complexes and/or epicardial abnormal substrates rendered noninducibility of VT/VF and prevented the recurrences of VT/VF. CONCLUSION: Epicardial warm water instillation enhanced functional epicardial substrates, which contributed to the increased inducibility of ventricular tachyarrhythmias in BrS. Ablation by targeting the triggers and abnormal epicardial substrates provided an effective strategy for preventing ventricular tachyarrhythmia recurrences in BrS.