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1.
J Cardiovasc Electrophysiol ; 30(10): 1811-1818, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31310407

RESUMEN

BACKGROUND: We evaluated the association of P wave duration (PWD) with left atrial scar (LAS) in patients with paroxysmal atrial fibrillation (PAF). METHODS: Consecutive patients with PAF undergoing their first catheter ablation were screened and only those in sinus rhythm at baseline were included in the analysis. A standard 12-lead electrocardiogram (ECG) was performed in all and three-dimensional voltage mapping of the left atrium was generated for identification of low-voltage areas (≤0.2 mV) before the procedure. RESULTS: In total, 411 patients with PAF were included in this study of which 181 had LASs (scar group), while 230 had no scar (nonscar group). In the scar group, patients were older (65.5 ± 8.8 vs 59.7 ± 11.7 years; P < .001), the proportion of female was higher (47.5% vs 37.4%; P = .04) and left atrial (LA) diameter (4.1 ± 0.6 vs 3.9 ± 0.6 cm; P < .001) was larger compared with the nonscar group. There was no significant difference in terms of hypertension, sleep apnea, and diabetes between the two groups. When comparing ECG characteristics between the two groups, PWD was significantly longer in the scar group (122.9 ± 18.5 and 116.9 ± 28.0 ms; P = .01). A multivariate analysis was performed, after adjustment of age, sex, LA diameter, PWD ≥ 120 ms was found to be an independent predictor of LA scarring (OR: 1.69, p-value: 0.02). CONCLUSION: In the current series, prolonged PWD was found to be independently associated with LA scarring in PAF, even after adjustment for age, sex, and LA diameter.


Asunto(s)
Fibrilación Atrial/cirugía , Función del Atrio Izquierdo , Ablación por Catéter , Cicatriz/diagnóstico , Electrocardiografía , Atrios Cardíacos/cirugía , Frecuencia Cardíaca , Venas Pulmonares/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Remodelación Atrial , Ablación por Catéter/efectos adversos , Cicatriz/fisiopatología , Técnicas Electrofisiológicas Cardíacas , Femenino , Atrios Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Venas Pulmonares/fisiopatología , Recurrencia , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
2.
Heart Rhythm ; 16(5): 724-732, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-30503963

RESUMEN

BACKGROUND: The optimal site of ablation of idiopathic left ventricular outflow tract (LVOT) ventricular arrhythmias (VAs) is challenging as activation mapping can reveal similar activation times in different anatomical sites, suggesting an intramural origin. OBJECTIVE: We sought to assess whether in patients with intramural VAs and with multiple early activation sites (EASs), sequential ablation of all the early EASs could improve acute and long-term clinical outcomes. METHODS: A total of 116 patients undergoing catheter ablation for symptomatic LVOT VAs were enrolled in this study. Thirty-nine patients (34%) were referred for a redo procedure, whereas the remaining presented for a first procedure. Mapping was performed manually in 86 cases (74%) and with a magnetic robotic system (Niobe, Stereotaxis, St. Louis, MO) in the remainder of the cases. RESULTS: Of the 116 patients, 15 (13%) were found to have multiple sites of equally early activation. In patients with multiple EASs, the mean pre-QRS activation time was significantly less than in patients with a single EASs (-26 ± 3 ms vs -38 ± 6 ms; P < .005). Sequential ablation of all the EASs was possible in 14 patients (93%), resulting in complete arrhythmia suppression. After a mean follow-up of 21 ± 5 months, all patients with successful ablation of all multiple early EASs remained free from clinical VAs. CONCLUSION: Intramural LVOT VAs manifesting with multiple EASs require ablation at all sites to achieve acute and long-term success, particularly if none of the EASs is > -30ms pre-QRS activation time.


Asunto(s)
Ablación por Catéter , Técnicas Electrofisiológicas Cardíacas/métodos , Sistema de Conducción Cardíaco , Ventrículos Cardíacos/fisiopatología , Taquicardia Ventricular , Complejos Prematuros Ventriculares , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Ablación por Catéter/estadística & datos numéricos , Femenino , Sistema de Conducción Cardíaco/fisiopatología , Sistema de Conducción Cardíaco/cirugía , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/fisiopatología , Taquicardia Ventricular/cirugía , Estados Unidos , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/fisiopatología , Complejos Prematuros Ventriculares/cirugía
3.
Europace ; 20(10): 1566-1576, 2018 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-29697759

RESUMEN

Ablation of non-pulmonary vein (PV) triggers is an important step to improve outcomes in atrial fibrillation ablation. Non-pulmonary vein triggers typically originates from predictable sites (such as the left atrial posterior wall, superior vena cava, coronary sinus, interatrial septum, and crest terminalis), and these areas can be ablated either empirically or after observing significant ectopy (with or without drug challenge). In this review, we will focus on ablation of non-PV triggers, summarizing the existing evidence and our current approach for their mapping and ablation.


Asunto(s)
Fibrilación Atrial/cirugía , Tabique Interatrial/cirugía , Ablación por Catéter/métodos , Seno Coronario/cirugía , Atrios Cardíacos/cirugía , Vena Cava Superior/cirugía , Técnicas Electrofisiológicas Cardíacas , Humanos , Venas Pulmonares/cirugía , Resultado del Tratamiento
4.
Artículo en Inglés | MEDLINE | ID: mdl-29133380

RESUMEN

BACKGROUND: Obstructive sleep apnea (OSA) is associated with atrial remodeling, atrial fibrillation (AF), and increased incidence of arrhythmia recurrence after pulmonary vein (PV) isolation. We aimed to characterize the atrial substrate, including AF triggers in patients with paroxysmal AF and OSA. METHODS AND RESULTS: In 86 patients with paroxysmal AF (43 with ≥moderate OSA [apnea-hypopnea index ≥15] and 43 without OSA [apnea-hypopnea index <5]), right atrial and left atrial voltage distribution, conduction velocities, and electrogram characteristics were analyzed during atrial pacing. AF triggers were examined before and after PV isolation and targeted for ablation. Patients with OSA had lower atrial voltage amplitude (right atrial, P=0.0005; left atrial, P=0.0001), slower conduction velocities (right atrial, P=0.02; left atrial, P=0.0002), and higher prevalence of electrogram fractionation (P=0.0001). The areas of atrial abnormality were consistent among patients, most commonly involving the left atrial septum (32/43; 74.4%). At baseline, the PVs were the most frequent triggers for AF in both groups; however, after PV isolation patients with OSA had increased incidence of additional extra-PV triggers (41.8% versus 11.6%; P=0.003). The 1-year arrhythmia-free survival was similar between patients with and without OSA (83.7% and 81.4%, respectively; P=0.59). In comparison, control patients with paroxysmal AF and OSA who underwent PV isolation alone without ablation on extra-PV triggers had increased risk of arrhythmia recurrence (83.7% versus 64.0%; P=0.003). CONCLUSIONS: OSA is associated with structural and functional atrial remodeling and increased incidence of extra-PV triggers. Elimination of these triggers resulted in improved arrhythmia-free survival.


Asunto(s)
Fibrilación Atrial/etiología , Venas Pulmonares/fisiopatología , Apnea Obstructiva del Sueño/complicaciones , Potenciales de Acción , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Remodelación Atrial , Ablación por Catéter , Supervivencia sin Enfermedad , Técnicas Electrofisiológicas Cardíacas , Femenino , Frecuencia Cardíaca , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Venas Pulmonares/cirugía , Recurrencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos
5.
Europace ; 19(11): 1790-1797, 2017 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-28039211

RESUMEN

AIMS: Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF (PAF) and severe LA scarring identified by 3D mapping, undergoing pulmonary vein isolation (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI+ ablation of the non-PV triggers. METHODS AND RESULTS: Totally, 177 consecutive patients with PAF and severe LA scarring were included. Patients underwent PVAI only (n = 45, Group 1), PVAI+ scar homogenization (n = 66, Group 2) or PVAI+ ablation of non-PV triggers (n = 66, Group 3) based on operator's choice. Baseline characteristics were similar across the groups. After first procedure, all patients were followed-up for a minimum of 2 years. The success rate at the end of the follow-up was 18% (8 pts), 21% (14 pts), and 61% (40 pts) in Groups 1, 2, and 3, respectively. Cumulative probability of AF-free survival was significantly higher in Group 3 (overall log-rank P <0.01, pairwise comparison 1 vs. 3 and 2 vs. 3 P < 0.01). During repeat procedures, non-PV triggers were ablated in all. After average 1.5 procedures, the success rates were 28 (62%), 41 (62%), and 56 (85%) in Groups 1, 2, and 3, respectively (log-rank P< 0.001). CONCLUSIONS: In patients with PAF and severe LA scarring, PVAI+ ablation of non-PV triggers is associated with significantly better long-term outcome than PVAI alone or PVAI+ scar homogenization.


Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Cicatriz/cirugía , Venas Pulmonares/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Función del Atrio Izquierdo , Ablación por Catéter/efectos adversos , Cicatriz/diagnóstico , Cicatriz/fisiopatología , Supervivencia sin Enfermedad , Electrocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Fibrosis , Estudios de Seguimiento , Frecuencia Cardíaca , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Venas Pulmonares/fisiopatología , Recurrencia , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento
6.
J Cardiovasc Electrophysiol ; 28(1): 109-114, 2017 01.
Artículo en Inglés | MEDLINE | ID: mdl-27653802

RESUMEN

BACKGROUND: Contact-force (CF) sensing catheters are increasingly used in electrophysiological procedures due to their efficacy and safety profile. As data about the accuracy of fiberoptic CF technology are scarce, we sought to quantify it using in vitro experiments. METHODS AND RESULTS: A force sensor was built with a flexible membrane to allow exact reference force measurements for each set of experiments. A TactiCath Quartz (TCQ) ablation catheter was brought in contact with the force sensor membrane in order to compare the TCQ force measurements to sensor reference force measurements. Measurements were performed at different tip angles (0°/perpendicular contact, 45°, 90°/parallel contact), with fluid irrigation, different degrees of catheter deflection, and using a sheath. The accuracy of the TCQ force measurements was 0.9 ± 0.9 g (0°), 0.8 ± 0.8 g (45°) and 1.2 ± 1.3 g (90°), 0.8 ± 0.7 g (irrigation), 0.8 ± 0.8 g (deflection), and 0.8 ± 0.9 g (sheath); this was not significantly different among all experimental conditions. The precision was ≤3.8%. CONCLUSION: CF measurements using a fiberoptic sensing technology show a high level of accuracy and precision, without being significantly influenced by tip angle, fluid irrigation, catheter deflection or use of a sheath.


Asunto(s)
Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Técnicas Electrofisiológicas Cardíacas/instrumentación , Tecnología de Fibra Óptica/instrumentación , Transductores de Presión , Calibración , Cateterismo Cardíaco/normas , Catéteres Cardíacos/normas , Técnicas Electrofisiológicas Cardíacas/normas , Diseño de Equipo , Tecnología de Fibra Óptica/normas , Ensayo de Materiales , Estándares de Referencia , Reproducibilidad de los Resultados , Irrigación Terapéutica , Transductores de Presión/normas
7.
J Am Coll Cardiol ; 68(18): 1929-1940, 2016 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-27788847

RESUMEN

BACKGROUND: Longstanding persistent (LSP) atrial fibrillation (AF) is the most challenging type of AF. In addition to pulmonary vein isolation, substrate modification and triggers ablation have been reported to improve freedom from AF in patients with LSPAF. OBJECTIVES: This study sought to assess whether the empirical electrical isolation of the left atrial appendage (LAA) could improve success at follow-up. METHODS: This was an open-label, randomized study assessing the effectiveness of empirical electrical left atrial appendage isolation for the treatment of LSPAF. Patients were randomly assigned to undergo empirical electrical left atrial appendage isolation along with extensive ablation (group 1; n = 85) or extensive ablation alone (group 2; n = 88). Recurrence of atrial arrhythmias was the primary endpoint. Secondary endpoints included cardiac-related hospitalization, all-cause mortality, and stroke at follow-up. RESULTS: Major clinical characteristics were not different between the 2 groups. At 12-month follow-up, 48 (56%) patients in group 1 and 25 (28%) in group 2 were recurrence free after a single procedure (unadjusted hazard ratio [HR] for recurrence with standard ablation: 1.92; 95% confidence interval [CI]: 1.3 to 2.9; log-rank p = 0.001). After adjusting for age, sex, and left atrial size, standard ablation was predictive of recurrence (HR: 2.22; 95% CI: 1.29 to 3.81; p = 0.004). During repeat procedures, empirical electrical left atrial appendage isolation was performed in all patients. After an average of 1.3 procedures, cumulative success at 24-month follow-up was reported in 65 (76%) in group 1 and in 49 (56%) in group 2 (unadjusted HR: 2.24; 95% CI: 1.3 to 3.8; log-rank p = 0.003). CONCLUSIONS: This randomized study showed that both after a single procedure and after redo procedures in patients with LSPAF, empirical electrical isolation of the LAA improved long-term freedom from atrial arrhythmias without increasing complications. (Effect of Empirical Left Atrial Appendage Isolation on Long-term Procedure Outcome in Patients With Persistent or Longstanding Persistent Atrial Fibrillation Undergoing Catheter Ablation [BELIEF]; NCT01362738).


Asunto(s)
Apéndice Atrial , Fibrilación Atrial/cirugía , Ablación por Catéter , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Factores de Tiempo
8.
J Am Coll Cardiol ; 68(18): 1990-1998, 2016 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-27788854

RESUMEN

BACKGROUND: Scar homogenization improves long-term ventricular arrhythmia-free survival compared with standard limited-substrate ablation in patients with post-infarction ventricular tachycardia (VT). Whether such benefit extends to patients with nonischemic cardiomyopathy and scar-related VT is unclear. OBJECTIVES: The aim of this study was to assess the long-term efficacy of an endoepicardial scar homogenization approach compared with standard ablation in this population. METHODS: Consecutive patients with dilated nonischemic cardiomyopathy (n = 93), scar-related VTs, and evidence of low-voltage regions on the basis of pre-defined criteria on electroanatomic mapping (i.e., bipolar voltage <1.5 mV) underwent either standard VT ablation (group 1 [n = 57]) or endoepicardial ablation of all abnormal potentials within the electroanatomic scar (group 2 [n = 36]). Acute procedural success was defined as noninducibility of any VT at the end of the procedure; long-term success was defined as freedom from any ventricular arrhythmia at follow-up. RESULTS: Acute procedural success rates were 69.4% and 42.1% after scar homogenization and standard ablation, respectively (p = 0.01). During a mean follow-up period of 14 ± 2 months, single-procedure success rates were 63.9% after scar homogenization and 38.6% after standard ablation (p = 0.031). After multivariate analysis, scar homogenization and left ventricular ejection fraction were predictors of long-term success. During follow-up, the rehospitalization rate was significantly lower in the scar homogenization group (p = 0.035). CONCLUSIONS: In patients with dilated nonischemic cardiomyopathy, scar-related VT, and evidence of low-voltage regions on electroanatomic mapping, endoepicardial homogenization of the scar significantly increased freedom from any recurrent ventricular arrhythmia compared with a standard limited-substrate ablation. However, the success rate with this approach appeared to be lower than previously reported with ischemic cardiomyopathy, presumably because of the septal and midmyocardial distribution of the scar in some patients.


Asunto(s)
Cardiomiopatía Dilatada/cirugía , Ablación por Catéter , Cicatriz/cirugía , Taquicardia Ventricular/cirugía , Cardiomiopatía Dilatada/etiología , Cardiomiopatía Dilatada/fisiopatología , Enfermedades Cardiovasculares , Cicatriz/complicaciones , Cicatriz/etiología , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Estudios Prospectivos , Taquicardia Ventricular/etiología , Taquicardia Ventricular/fisiopatología
9.
Artículo en Inglés | MEDLINE | ID: mdl-27162030

RESUMEN

BACKGROUND: We report the outcome of pulmonary vein (PV) antrum isolation in paroxysmal atrial fibrillation (AF) patients over more than a decade of follow-up. METHODS AND RESULTS: A total of 513 paroxysmal AF patients (age 54±11 years, 73% males) undergoing catheter ablation at our institutions were included in this analysis. PV antrum isolation extended to the posterior wall between PVs plus empirical isolation of the superior vena cava was performed in all. Non-PV triggers were targeted during repeat procedure(s). Follow-up was performed quarterly for the first year and every 6 to 9 months thereafter. The outcome of this study was freedom from recurrent AF/atrial tachycardia. At 12 years, single-procedure arrhythmia-free survival was achieved in 58.7% of patients. Overall, the rate of recurrent arrhythmia (AF/atrial tachycardia) was 21% at 1 year, 11% between 1 and 3 years, 4% between 3 and 6 years, and 5.3% between 6 and 12 years. Repeat procedure was performed in 74% of patients. Reconnection in the PV antrum was found in 31% of patients after a single procedure and in no patients after 2 procedures. Non-PV triggers were found and targeted in all patients presenting with recurrent arrhythmia after ≥2 procedures. At 12 years, after multiple procedures, freedom from recurrent AF/atrial tachycardia was achieved in 87%. CONCLUSIONS: In patients with paroxysmal AF undergoing extended PV antrum isolation, the rate of late recurrence is lower than what previously reported with segmental or less extensive antral isolation. However, over more than a decade of follow-up, nearly 14% of patients developed recurrence because of new non-PV triggers.


Asunto(s)
Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Predicción , Sistema de Conducción Cardíaco/cirugía , Venas Pulmonares/cirugía , Taquicardia Paroxística/cirugía , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Técnicas Electrofisiológicas Cardíacas , Femenino , Estudios de Seguimiento , Sistema de Conducción Cardíaco/fisiopatología , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Venas Pulmonares/inervación , Recurrencia , Factores de Riesgo , Taquicardia Paroxística/diagnóstico , Taquicardia Paroxística/fisiopatología , Resultado del Tratamiento
10.
Heart Rhythm ; 13(6): 1197-202, 2016 06.
Artículo en Inglés | MEDLINE | ID: mdl-26994940

RESUMEN

BACKGROUND: Transesophageal echocardiography (TEE) is recommended in patients undergoing atrial fibrillation (AF) ablation, but use of this strategy is variable. OBJECTIVE: To evaluate whether TEE is necessary before AF ablation in patients treated with novel oral anticoagulants (NOACs). METHODS: We performed a prospective multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted NOACs (apixaban and rivaroxaban). All patients were on NOACs for at least 4 weeks before ablation. Heparin bolus was administered to all patients before transseptal catheterization to maintain a target activated clotting time above 300 seconds. A subset of 86 patients underwent brain diffuse magnetic resonance imaging (dMRI) to detect silent cerebral ischemia (SCI). RESULTS: A total of 970 patients (514 [53%] apixaban patients and 456 [47%] rivaroxaban patients) were enrolled for this study. The mean age was 69.5 ± 9.0 years, with 824 patients (85%) having nonparoxysmal AF, and 636 patients (65.6%) were male. The average CHA2DS2-VASc score was 3.01 ± 1.3 and CHADS2 score was ≥2 in 609 patients (62.8%). Intracardiac echocardiogram ruled out left atrial appendage thrombus in all patients whose left atrial appendage was visualized (692, 71%), and detected "smoke" in 407 patients (42%). SCI at postprocedure dMRI was detected in 2.3% (2/86). One thromboembolic event (transient ischemic attack) (0.10%) with positive dMRI occurred in a patient on uninterrupted rivaroxaban with longstanding persistent AF. CONCLUSION: Our study illustrates that performing AF ablation while on uninterrupted apixaban and rivaroxaban without TEE is feasible and safe. This finding has important clinical and economic relevance.


Asunto(s)
Apéndice Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Isquemia Encefálica , Ablación por Catéter , Ecocardiografía Transesofágica/métodos , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Rivaroxabán/uso terapéutico , Trombosis , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/epidemiología , Coagulación Sanguínea/efectos de los fármacos , Isquemia Encefálica/etiología , Isquemia Encefálica/prevención & control , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Inhibidores del Factor Xa/uso terapéutico , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Cuidados Preoperatorios/métodos , Sistema de Registros/estadística & datos numéricos , Trombosis/diagnóstico , Trombosis/etiología , Estados Unidos/epidemiología
11.
Heart Rhythm ; 13(1): 141-9, 2016 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-26304713

RESUMEN

BACKGROUND: Whether ablation of non-pulmonary vein (PV) triggers after pulmonary vein antrum isolation (PVAI) improves the long-term procedure outcome in patients with paroxysmal atrial fibrillation (PAF) and left ventricular systolic dysfunction is unknown. OBJECTIVE: We sought to evaluate whether a more extensive ablation procedure improves outcomes at follow-up. METHODS: Consecutive patients with PAF refractory to antiarrhythmic drugs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: patients with left ventricular ejection fraction (LVEF) ≤35% (group I; n = 175) and patients with LVEF ≥50% (group II; n = 545). Patients in group I were further divided according to whether additional ablation of non-PV triggers was performed (group IA; n = 88) or not (group IB; n = 87). Long-term ablation success off antiarrhythmic drugs after a single procedure was analyzed. RESULTS: Patients in group I had more non-PV triggers than did patients in group II (69.1% vs 26.6%; P < .001). During a follow-up of 15.8 ± 4.7 months, fewer patients in group I remained free from recurrences than those in group II (53.7% vs 81.7%; P < .001). Long-term ablation success was higher in group IA than in group IB (75.0% vs 32.2%; P < .001) and similar to that in group II (75.0% vs 81.7%; P = .44). In multivariate analysis, LVEF ≤35% (hazard ratio 1.68; P = .003) and non-PV triggers (hazard ratio 3.12; P < .001) were independent predictors of recurrences. CONCLUSION: In patients with PAF and left ventricular systolic dysfunction, ablation of non-PV triggers in addition to PVAI significantly improves their long-term procedure outcome.


Asunto(s)
Fibrilación Atrial , Ablación por Catéter , Efectos Adversos a Largo Plazo/prevención & control , Venas Pulmonares/cirugía , Disfunción Ventricular Izquierda , Anciano , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodos , Técnicas Electrofisiológicas Cardíacas/métodos , Femenino , Humanos , Efectos Adversos a Largo Plazo/diagnóstico , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Recurrencia , Volumen Sistólico , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/fisiopatología
12.
Methodist Debakey Cardiovasc J ; 11(2): 87-93, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26306125

RESUMEN

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and represents a major burden to health care systems. Atrial fibrillation is associated with a 4- to 5-fold increased risk of thromboembolic stroke. The pulmonary veins have been identified as major sources of atrial triggers for AF. This is particularly true in patients with paroxysmal AF but not always the case for those with long-standing persistent AF (LSPAF), in which other locations for ectopic beats have been well recognized. Structures with foci triggering AF include the coronary sinus, the left atrial appendage (LAA), the superior vena cava, the crista terminalis, and the ligament of Marshall. More than 30 studies reporting results on radiofrequency ablation of LSPAF have been published to date. Most of these are observational studies with very different methodologies using different strategies. As a result, there has been remarkable variation in short- and long-term success, which suggests that the optimal ablation technique for LSPAF is still to be elucidated. In this review we discuss the different approaches to LSPAF catheter ablation, starting with pulmonary vein isolation (PVI) through ablation lines in different left atrial locations, the role of complex fractionated atrial electrograms, focal impulses and rotor modulation, autonomic modulation (ganglionated plexi), alcohol ablation, and the future of epicardial mapping and ablation for this arrhythmia. A stepwise ablation approach requires several key ablation techniques, such as meticulous PVI, linear ablation at the roof and mitral isthmus, electrogram-targeted ablation with particular attention to triggers in the coronary sinus and LAA, and discretionary right atrial ablation (superior vena cava, intercaval, or cavotricuspid isthmus lines).


Asunto(s)
Técnicas de Ablación , Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Etanol/administración & dosificación , Sistema de Conducción Cardíaco/cirugía , Venas Pulmonares/cirugía , Técnicas de Ablación/efectos adversos , Potenciales de Acción , Animales , Apéndice Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Técnicas Electrofisiológicas Cardíacas , Etanol/efectos adversos , Sistema de Conducción Cardíaco/fisiopatología , Frecuencia Cardíaca , Humanos , Venas Pulmonares/fisiopatología , Factores de Tiempo , Resultado del Tratamiento
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