Safety and efficacy of contemporary catheter ablation for atrial fibrillation patients with a history of cardioembolic stroke in the era of direct oral anticoagulants.

BACKGROUND: The safety and efficacy of the contemporary atrial fibrillation (AF) ablation in patients with a recent or previous history of cardioembolic stroke (CS) or transient ischemic attack (TIA) remain to be established. METHODS: A total of 447 patients who underwent first-ever contact force (CF)-guided AF ablation with circumferential pulmonary vein isolation were included. Of these, 17 had CS or TIA within 6 months before ablation (Group 1), 30 more than 6 months before ablation (Group 2), and the other 400 without CS or TIA (Group 3). Procedural complications and recurrence of AF and atrial tachyarrhythmias were compared among the 3 groups. RESULTS: The mean age was 71±7, 66±9, and 61±11 years in Groups 1, 2, and 3, respectively (p<0.05, Group 1 versus Group 3). The oral anticoagulants were warfarin (n=108, 24.1%), dabigatran (n=101, 22.6%), rivaroxaban (n=147, 32.9%), apixaban (n=87, 19.5%), and edoxaban (n=4, 0.9%), and did not differ among the 3 groups. Median follow-up period was 14 [IQR 12-22], 13 [12-14], and 12 [10-16] months, respectively. One episode of cardiac tamponade, 2 episodes of arteriovenous fistula, and some minor complications occurred in Group 3, but no complications occurred in Groups 1 and 2 in the periprocedural period. Although one episode of CS occurred 11 days after the procedure in Group 3, there were no periprocedural CS, TIA, or major bleedings in Groups 1 and 2. AF recurrence-free rate after the procedure was 76.5%, 86.7%, and 79.1% in Groups 1, 2, and 3, respectively, and there was no difference in Kaplan-Meier curves among the 3 groups. CONCLUSION: The safety and efficacy of CF-guided AF ablation in the era of direct oral anticoagulants in patients with a recent or previous history of CS or TIA are similar to those in patients without it.

Long Postpacing Interval After Entrainment of Tachycardia Including a Slow Conduction Zone Within the Circuit.

BACKGROUNDS: Postpacing interval (PPI) measured after entrainment pacing describes the distance between pacing site and reentrant circuit. However, the influential features to PPI remain to be elucidated. METHODS AND RESULTS: This study included 22 cases with slow/fast atrioventricular (AV) nodal reentrant tachycardia (AVNRT), 14 orthodromic AV reciprocating tachycardia (AVRT) using an accessary pathway, 22 typical atrial flutter (AFL), and 18 other macroreentrant atrial tachycardia (atypical AFL). Rapid pacing at a pacing cycle length (PCL) 5% shorter than tachycardia cycle length (TCL) was done from a site on or close to the reentry circuit. Pacing sites included the coronary sinus ostium in AVNRT, earliest atrial activation site in AVRT, and cavotricuspid isthmus in typical AFL. In atypical AFL, tachycardia circuit was determined on the basis of CARTO mapping, and then the pacing site was. TCL was significantly longer in AVNRT and AVRT than in typical AFL and atypical AFL (both P < 0.05). PCL minus TCL value was similar among the 4 groups. PPI minus TCL value (milliseconds) was significantly longer in AVNRT (median, 40 [IQR, 29-60.8]) and AVRT (34 [20-47]) than in typical AFL (0 [0-4]) and atypical AFL (3.5 [0-8]) (both P < 0.05). Furthermore, PPI minus TCL was prolonged with shortening of PCL in AVNRT and AVRT (both P < 0.05), whereas it was unchanged in typical AFL (P = 0.50). CONCLUSION: PPI after concealed entrainment is prolonged compared with TCL when the reentry circuit involves a slow conduction zone with a decremental conduction property such as the AV node.

High correlation of estimated local conduction velocity with natural logarithm of bipolar electrogram amplitude in the reentry circuit of atrial flutter.

BACKGROUND: Low conduction velocity (CV) in the area showing low electrogram amplitude (EA) is characteristic of reentry circuit of atypical atrial flutter (AFL). The quantitative relationship between CV and EA remains unclear. We characterized AFL reentry circuit in the right atrium (RA), focusing on the relationship between local CV and bipolar EA on the circuit. METHODS AND RESULTS: We investigated 26 RA AFL (10 with typical AFL; 10 atypical incisional AFL; 6 atypical nonincisional AFL) using CARTO system. By referring to isochronal and propagation maps delineated during AFL, points activated faster on the circuit were selected (median, 7 per circuit). At the 196 selected points obtained from all patients, local CV measured between the adjacent points and bipolar EA were analyzed. There was a highly significant correlation between local CV and natural logarithm of EA (lnEA) (R(2) = 0.809, P < 0.001). Among 26 AFL, linear regression analysis of mean CV, calculated by dividing circuit length (152.3 ± 41.7 mm) by tachycardia cycle length (TCL) (median 246 msec), and mean lnEA, calculated by dividing area under curve of lnEA during one tachycardia cycle by TCL, showed y = 0.695 + 0.191x (where: y = mean CV, x = lnEA; R(2) = 0.993, P < 0.001). Local CV estimated from EA with the use of this formula showed a highly significant linear correlation with that measured by the map (R(2) = 0.809, P < 0.001). CONCLUSION: The lnEA and estimated local CV show a highly positive linear correlation. CV is possibly estimated by EA measured by CARTO mapping.

Three-dimensional cardiac image integration of electroanatomical mapping of only left atrial posterior wall with CT image to guide circumferential pulmonary vein ablation.

BACKGROUND: CARTO merge™ is used in integrating left atrial (LA) CARTO and computed tomography (CT) images, but the integration method is not established. The relative anatomic position and configuration of the LA posterior wall (LAPW) between the right and left pulmonary veins (PVs) are not greatly affected by respiration, LA contraction or hydration state. LAPW and adjacent roof area has an anatomically curved structure which is geometrically amenable to integration using a surface registration software. METHODS: We examined the accuracy of surface registration using only the LAPW CARTO image constructed by mapping of a mean of 101 ± 34 points in 108 consecutive AF patients before PV isolation. After visual alignment of CARTO LAPW and LA CT images using one anatomically defined position in each image, the two images were integrated with an installed surface registration program. Points with differences ≥ 4.0 mm between the two images were deleted (mean, 17 points/patient) and a second surface registration was performed. RESULTS: The mean distance between CARTO and CT images was 1.37 ± 0.23 mm, with mean minimum and maximum values of 0.03 and 3.99 mm, respectively. The accuracy of integration was verified in 34 patients by measuring the gaps between the catheter tip on the LA wall and the design line delineated for PV isolation on the integrated image. The gaps (mm) at the superior, inferior, anterior and posterior sites on the right PV side were 0.8 ± 0.5, 0.9 ± 0.7, 1.3 ± 1.0, and 0.8 ± 0.7, respectively, and those on the left side were 0.8 ± 0.5, 0.9 ± 0.7, 1.0 ± 0.5, and 1.0 ± 0.6, respectively. Thus, the gaps were all <1.0 mm, except for the right anterior aspect. CONCLUSIONS: These results show that surface registration using only the LAPW image can accurately integrate CARTO and CT images.

Effect of pilsicainide on dominant frequency in the right and left atria and pulmonary veins during atrial fibrillation: association with its atrial fibrillation terminating effect.

Dominant frequency reflects the peak cycle length of atrial fibrillation. In 34 patients with atrial fibrillation, bipolar electrograms were recorded from multiple atrial sites and pulmonary veins and the effect of pilsicainide, class Ic antiarrhythmic drug, on dominant frequency was examined. At baseline, mean dominant frequencies (Hz) in the right and left atria, coronary sinus and right and left superior pulmonary veins were 5.87 +/- 0.76, 6.08 +/- 0.60, 5.65 +/- 0.95, 6.12 +/- 0.88 and 6.59 +/- 0.89, respectively (P < 0.05, left superior pulmonary vein vs right atrium and coronary sinus). After pilsicainide (1.0 mg/kg/5 min), dominant frequency decreased at all sites in all patients. Atrial fibrillation was terminated at 5.9 +/- 2.2 min in 16 patients (Group A) with a decrease in the average of mean dominant frequencies at all sites from 5.80 +/- 0.72 to 3.57 +/- 0.63 Hz, was converted to atrial flutter at 7.3 +/- 1.4 min in 5 (Group B) with a decrease in the average dominant frequency from 5.83 +/- 0.48 to 3.08 +/- 0.19 Hz, and was not terminated in the other 13 (Group C) despite the average dominant frequency decrease from 6.59 +/- 0.76 to 4.42 +/- 0.52 Hz. In 14 of the 21 Groups A and B patients (67%), mean dominant frequencies at all recording sites were < 4.0 after pilsicainide, while they were < 4.0 in 1 of the 13 Group C patients (8%, P < 0.01). In conclusion, the degree of dominant frequency decrease by pilsicainide is closely related to its atrial fibrillation terminating effect: When dominant frequency in the atria decreases to < 4.0 Hz, atrial fibrillation is terminated with 93% positive and 63% negative predictive values.