Precise Signals with a High-Density Grid Mapping Catheter Are Useful for an Entrainment Study.

Complex atrial tachycardias (ATs) after catheter ablation or a MAZE procedure is sometimes difficult to determine the circuits of the tachycardia. A high-density, grid-shapes mapping catheter has been launched, which can be useful for detecting the detail circuits of tachycardias on three-dimensional mapping systems. The signal quality is also important for performing electrophysiological studies (EPSs), such as entrainment mapping, to identify the circuit. This unique mapping catheter has 1 mm electrodes on 2.5 Fr shafts, which improve the signal quality. The high-quality intracardiac electrograms facilitate differentiating small critical potentials, which allows us to perform detailed entrainment mapping in targeted narrow areas. Here, we describe a patient with a perimetral AT with epi-endocardium breakthrough after a MAZE surgery and catheter ablation, which was treated successfully along with detailed entrainment mapping using the HD Grid. This catheter with high-quality signals could be a significant diagnostic tool for a classic EPS as well as for the construction of 3D mapping.

Repeat pulmonary vein isolation with or without FIRM-guided ablation for recurrent atrial fibrillation with pulmonary vein reconnection.

INTRODUCTION: Focal impulse and rotor modulation (FIRM) ablation can be used to target nonpulmonary vein (PV) sources of atrial fibrillation (AF). No published studies have compared freedom from atrial fibrillation (FFAF) after pulmonary vein reisolation (PVRI) plus FIRM to PVRI alone in patients with reconnected PVs undergoing repeat ablation. METHODS: A 3:1 matched retrospective cohort study was performed on 21 patients with recurrent AF and PV reconnection who underwent PVRI plus FIRM-guided ablation and 63 patients with recurrent AF treated with PVRI alone at a single institution. All patients in the PVRI-alone cohort had cryoballoon PVRI at the time of repeat ablation without additional lesion sets for AF. Cases were matched based on the type of AF (paroxysmal vs nonparoxysmal), left atrial diameter (±4 mm), left ventricular ejection fraction (±10%), duration of AF (±18 months), and age (±5 years). The primary endpoint was FFAF after a 3-month blanking period. RESULTS: Out of 53 total FIRM cases performed at Northwestern Memorial Hospital between 2015 and 2017, 21 patients had PVRI plus FIRM for recurrent AF with PV reconnection. These patients had an average of 3.3 ± 2.1 rotors (60% left atrial) ablated. Over a median follow-up time of 24.7 months (interquartile range, 13-36 months), patients in the PVRI-alone cohort demonstrated a higher rate of FFAF (n = 35; 55.6%) than patients in the PVRI plus FIRM-guided ablation cohort (n = 7; 33.3%) (logrank P = .049). CONCLUSION: In patients undergoing repeat ablation for AF with PV reconnection, PVRI plus FIRM did not increase FFAF compared to PVRI alone.

How does the Cox maze procedure compare? Cost-effectiveness analysis of alternative treatments of atrial fibrillation.

OBJECTIVES: Data related to the cost effectiveness of surgical interventions and catheter ablation is sparse. This model-based analysis assessed the clinical and economic trade-offs involved in using catheter ablation or the Cox maze procedure in treating patients with atrial fibrillation. METHODS: A deterministic model was developed to project 1 year and lifetime health-related outcomes, costs, quality-adjusted life years (QALYs) and cost effectiveness of each treatment in patients with atrial fibrillation. Using previously unpublished Inova Heart and Vascular Institute (IHVI) data for patients undergoing either procedure, 1 year cost and clinical efficacy inputs were estimated. This data was supplemented with published literature and used to estimate costs, utilities, mortality and likelihood of patient improvement. Results were reported as cost-effectiveness ratios in $/QALY. Sensitivity analyses were conducted to assess the robustness of results. RESULTS: Patients initially treated with a Cox maze procedure were estimated to have higher costs than those treated with catheter ablation, both after 1 year and over the lifetime. However, patients undergoing the Cox maze procedure also had lower rates of 1 year mortality than catheter ablation patients (3.5% vs. 8.5%) and the highest rate of improvement following treatment, resulting in higher QALYs (12.4 vs. 10.2). Compared to catheter ablation, the lifetime incremental cost-effectiveness ratio for the Cox maze surgical procedure was $12,794 per QALY gained. Without quality adjustment, the ratio was $11,315. Results were most sensitive to the likelihood of improvement following each intervention and the cost of the initial procedure. CONCLUSIONS: At a societal willingness to pay of $100,000/QALY, Cox maze procedure was found to both increase overall and quality-adjusted survival and constitute an effective use of resources in patients with atrial fibrillation.