Anticoagulation Intensity during Appendage Occlusion: Lessons from Silent Cerebral Embolism.

INTRODUCTION: Endovascular left atrial appendage occlusion (LAAO) is associated with a high incidence of peri-procedure silent cerebral embolism (SCE), while the recommended activated clotting time (ACT) level by the expert consensus is lower than that in atrial fibrillation (AF) ablation. The aim of our study was to investigate whether raising the targeted ACT level during LAAO to the same level as AF ablation could decrease the incidence of SCE. METHODS: It was a prospective observational cohort study. Consecutive AF patients receiving LAAO between January 2021 and December 2022 were included and categorized into two groups based on the time of enrollment. Patients enrolled in 2021 (group 250) maintained a target ACT level of ≥250 s during LAAO procedure, while patients enrolled in 2022 (group 300) maintained the peri-procedure ACT ≥300 s. All patients underwent cerebral magnetic resonance imaging before and after the procedure. RESULTS: A total of 81 patients were included (38 in the group 250 and 43 in the group 300). After inverse probability of treatment weighting (IPTW), patients in the group 250 showed a significantly lower incidence of SCE than group 300 (IPTW p = 0.038). Only a stable high ACT pattern could decrease the risk of SCE. No significant differences were found between other ACT change patterns on the SCE incidence. CONCLUSION: Raising the peri-procedure ACT level to a stable 300 s could decrease the risk of the SCE without increasing the major bleeding events.

Value of q waves in lateral and left precordial leads in patients with left bundle branch block to predict the response to cardiac resynchronization therapy.

BACKGROUND: The cardiac resynchronization therapy (CRT) non-response rate can reach 30% in heart failure (HF) patients with left bundle branch block (LBBB). This study aimed to evaluate the value of baseline q waves in leads I, V5, or V6 in predicting response to CRT in patients with HF and LBBB. METHODS: Patients with HF (left ventricular ejection fraction ≤35%) and LBBB receiving CRT implantation were retrospectively enrolled. Baseline characteristics and electrocardiogram parameters, including lateral and left precordial q waves were evaluated. Non-response to CRT was defined as the improvement of left ventricular ejection fraction (LVEF) < 5% at a 6-month follow-up. RESULTS: A total of 132 patients (mean age 63.0 ± 10.4 years, 94 [71.2%] male) were included. Among them, 32 patients with q waves in leads I, V5, or V6 were classified into the qLBBB (+) group, and the rest without q waves in these leads were defined as the qLBBB (-) group. The CRT non-response rate in the qLBBB (+) group was markedly higher than that in the qLBBB (-) group (68.8% vs. 33.3%, p < .001). Multivariable logistic regression analysis revealed that the presence of baseline q waves in leads I, V5, or V6 remained significantly associated with a higher rate of CRT non-response in patients with HF and LBBB (odds ratio: 4.8, 95% confidence interval: 1.5-15.0, p = .007). CONCLUSION: Any q wave in leads I, V5, or V6 was an independent predictive factor for CRT non-response in patients with HF and LBBB.

The feasibility of atrial Fibrillatory wave amplitude in predicting ablation outcomes in persistent atrial fibrillation.

BACKGROUND: Atrial fibrosis has a significant impact on the success rate of catheter ablation (CA) treatment of atrial fibrillation (AF). The fibrotic tissues could be reflected by the amplitude of the fibrillatory wave (F-wave). METHODS AND RESULTS: 704 patients with persistent AF and at least 1-year follow-up after CA were included as the internal group. 101 patients from another hospital were used as the external validation cohort. A 12­lead ECG was performed before CA and the maximum FWA in three ECG leads (aVL, aVF, V1) were measured. The FWA score (0 to 6 points according to the amplitude range of the three leads) of each patients was calculated. Five models including clinical features, FWA score, CHA2DS2-VASc score, APPLE score and the fusion of clinical features and FWA score were built. The FWA score was superior to the model constructed by clinical variables, CHA2DS2-VASc score and APPLE score. It not only had good predictive performance for AF recurrence, with an AUC value of 0.812 (95% CI 0.724-0.900), but also showed a significant predictive value for the recurrence rate according to F-wave amplitude. In the external validation cohort, the FWA score showed similar results (AUC 0.768, 95% CI 0.672-0.865). CONCLUSIONS: The present study reveals the significant predictive value of the FWA score for persistent AF ablation recurrence.

Early onset atrial lesions in a patient with a novel LMNA frameshift mutation.

Genetic mutations in the lamin A/C gene (LMNA) have been linked to cardiomyopathy. Different mutational sites exhibit different clinical manifestations and prognoses. Herein, we identified a novel LMNA frameshift mutation, p.P485Tfs*67, from a patient with early-onset atrial disease. To verify the pathogenicity of this variation, a transgenic zebrafish model was constructed, which demonstrated that adult zebrafish with the LMNA mutation showed an abnormal ECG and impaired myocardial structure. Our study suggests the atrial pathogenicity of the LMNA-P485Tfs mutation, which is helpful to understand the function of the Ig-like domain of lamin A/C.

Arrhythmogenesis of surgical atrial incisions and lesions in Maze procedure: insights from high-resolution mapping of atrial tachycardias.

BACKGROUND: Atrial tachycardias (ATs) frequently develop after a surgical Maze procedure. We aimed to elucidate the electrophysiologic mechanisms and their arrhythmogenic substrates of these ATs. METHODS AND RESULTS: We retrospectively reviewed 20 patients (14 females, mean age of 55.5 ± 8.6 years) with post-Maze ATs who underwent high-resolution mapping at three institutions. The slow conduction areas, reentry circuits, voltage signals, complex electrograms, and their correlation with the surgical incisions and lesions placed in the surgical Maze procedures were analyzed. Thirty-six ATs with a mean cycle length of 260.0 ± 67.6 ms were mapped in these patients. Among them, 22 (61.1%) were anatomical macro-reentrant ATs (AMAT), 12 (33.3%) non-AMATs (localized ATs), and 2 (5.6%) focal ATs, respectively. Epicardial conduction bridges were observed in 6/20 (30.0%) patients and 7/36 (19.4%) ATs. Different arrhythmogenic substrates were identified in these ATs, including slow conduction regions within the previous lesion areas or between the incisions and anatomical structures, the prolonged activation pathways caused by the short lesions connecting the tricuspid annulus, and the circuits around the long incisions and/or lesions. CONCLUSIONS: Reentry is the main mechanism of the post-Maze ATs. The pro-arrhythmic substrates are most likely caused by surgical incisions and lesions. The slow conduction regions and the protected channels yielded from these areas are the major arrhythmogenic factors.

Plasma 8-Hydroxy-2'-Deoxyguanosine, a Potential Valuable Biomarker for Atrial Fibrosis Is Influenced by Polymorphism of DNA Methylation Gene.

BACKGROUND: Previous studies revealed a relationship between 8-hydroxy-2'-deoxyguanosine (8-OHdG) and the occurrence/recurrence of atrial fibrillation (AF). This 2-part study aimed to validate whether DNA damage related to 8-OHdG is associated with left atrial (LA) fibrosis in AF patients quantified by voltage mapping (Part I), and to identify the underlying genetic components regulating the 8-OHdG level (Part II).Methods and Results: Plasma 8-OHdG determination, DNA extraction, and genotyping were conducted before catheter ablation. LA voltage mapping was performed under sinus rhythm. According to the percentage of low voltage area (LVA), patients were categorized as stage I (<5%), stage II (5-10%), stage III (10-20%), and stage IV (>20%). Part I included 209 AF patients. The 8-OHdG level showed an upward trend together with advanced LVA stage (stage I 8.1 [6.1, 10.5] ng/mL, stage II 8.5 [5.7, 14.1] ng/mL, stage III 14.3 [12.1, 16.5] ng/mL, stage IV 13.9 [10.5, 16.0] ng/mL, P<0.000). Part II included 175 of the 209 patients from Part I. Gene-set analysis based on genome-wide association study summary data identified that the gene set named 'DNA methylation on cytosine' was the only genetic component significantly associated with 8-OHdG concentration. CONCLUSIONS: Higher 8-OHdG levels may predict more advanced LVA of the LA in AF patients. DNA methylation is the putative genetic component underlying oxidative DNA damage in AF patients.

Persistent left superior vena cava isolation in patients with atrial fibrillation: Selective or empirical?

BACKGROUND: Persistent left superior vena cava (PLSVC) is the most prevalent form of thoracic venous abnormality and can serve as a significant arrhythmogenic source in atrial fibrillation (AF). METHODS AND RESULTS: Among the 3950 patients who underwent radiofrequency ablation for AF between September 2014 to April 2020, 17 patients (mean age 59.4 ± 8.0 years, 64.7% male) with PLSVC were identified. Among them, nine patients (52.9%) had a prior history of pulmonary vein isolation (PVI) alone. Eight out of nine patients who experienced AF recurrence underwent PLSVC isolation with or without pulmonary vein (PV) reconnection. For the remaining eight patients (47.1%), PVI plus PLSVC isolation were performed during the index procedure. Ectopy originating from PLSVC was documented in 11 patients (64.7%) and successful PLSVC isolation was achieved in 16 patients (94.1%). After a median follow-up of 28.3 months, freedom from AF/ atrial tachycardia (AT) was observed in 13 patients (76.5%). CONCLUSION: Empirical PLSVC isolation beyond PVI appears to be a feasible and safe strategy to prevent AF recurrence in patients with concomitant PLSVC.

Predictors of pacemaker implantation within three months after catheter ablation of atrial fibrillation.

BACKGROUND: It is inevitable for patients to have a temporary or permanent pacemaker implanted during or after radiofrequency catheter ablation (RFCA) for treatment of atrial fibrillation (AF) in some cases. The aim of our study was to evaluate the incidence of pacemaker implantation (PMI) during or within 3 months of RFCA for AF and to identify the risk factors that were associated with PMI. METHODS: We performed a retrospective analysis of consecutive AF patients who underwent RFCA between August 2018 and October 2020 at our center. The incidence of PMI within 3 months during or after RFCA were assessed. A multivariate logistic regression model was performed to identify predictors of PMI. RESULTS: One thousand and five patients (mean age, 60.2 ± 10.3 years; 37.6% women) were included in this analysis. PVI was performed in all patients. A total of 23 (2.3%) patients had a pacemaker implanted within 3 months during or after ablation. Multivariable logistic regression analysis revealed that older age (OR: 1.08 [95% CI 1.03-1.13], p = .003), female sex (OR: 3.08 [95% CI 1.28-7.45], p = .012), paroxysmal AF (OR: 4.71 [95% CI 1.09-20.45], p = .038) and repeated ablation (OR: 2.78 [95% CI 1.04-7.40], p = .041) were the independent predictors for PMI. CONCLUSIONS: Older age, female sex, paroxysmal AF and repeated ablation were identified as predictive risk factors for PMI after RFCA in patients with AF. A "watch and wait" strategy could be taken for patients with temporary PMI after ablation, especially for those with prolonged sinus pause after AF termination.

Scar-related atrial macroreentries: Different arrhymogenic basis generates different reentry type.

BACKGROUND: Catheter ablation is an established therapeutic strategy to treat scar-related macroreentry atrial tachycardia (MAT). However, the scar properties and arrhythmogenicity and the reentry type have not been clearly defined. METHODS AND RESULTS: A total of 122 patients with scar-related MAT were enrolled in this study. The atrial scars were classified into two categories: spontaneous scars (Group A: n = 28) and iatrogenic scars (Group B: n = 94). According to the relationship between scar location and the reentry circuit, MAT was described as scar pro-flutter MAT, scar-dependent MAT, and scar-mediated MAT. The reentry type of MAT was significantly different between Groups A and B: pro-flutter (40.5% vs. 62.0%, p = 0.02), scar-dependent AT (40.5% vs. 13.0%, p < 0.001), and scar-mediated AT (19.0% vs. 25.0%, p = 0.42). After a median follow-up of 25 months, 21 patients with AT recurrence were observed. Compared with the spontaneous group, there was a lower recurrence rate of MAT in the iatrogenic group (28.6% vs. 10.6%, p = 0.03). CONCLUSION: Scar-related MAT has three reentry types, and the proportion of each type varies with the scar properties and its arrhythmogenic basis. Optimization of the ablation strategy based on the scar properties to improve the long-term outcome of catheter ablation of MAT is necessary.

Endovascular thrombectomy for acute ischemic stroke in elderly patients with atrial fibrillation.

BACKGROUND: To assess the clinical outcomes after endovascular thrombectomy (EVT) in elderly large vessel occlusion (LVO)-related acute ischemic stroke (AIS) patients with atrial fibrillation (AF). METHODS: Between January 2019 and December 2020, consecutive AF patients who received EVT due to anterior-circulation stroke were enrolled. The primary outcome was modified Rankin scale (mRS) score at 90 days. Secondary outcomes included all-cause mortality, the recanalization status after EVT (assessed using modified thrombolysis in cerebral infarction scale, mTICI) and any intracranial hemorrhage (ICH). A multivariate logistic regression model was performed to identify predictors of the functional outcome. RESULTS: A total of 148 eligible patients were finally enrolled. Among them, 42 were ≥ 80 years old. Compared to their younger counterparts, patients aged ≥80 years had lower likelihood of good functional outcome (mRS score 0-2) at 90 days (26.2% vs. 48.1%, P = 0.015), less satisfied recanalization (mTICI, 2b-3) (78.6% vs. 94.3%, P = 0.004) and higher all-cause mortality rate (35.7% vs. 14.2%, P = 0.003). A multivariable logistic regression analysis showed that age ≥ 80 years at baseline were the significant predictors for a poor functional outcome (OR: 3.72, 95% CI: 1.17-11.89, p = 0.027). Intravenous thrombolysis (IVT) prior to EVT and longer time intervals from onset of symptoms to EVT tended to be associated with poor functional outcome in patients ≥80 years old. CONCLUSIONS: Age ≥ 80 years was a significant predictor of unfavorable outcomes after EVT for AIS patients with AF. An increased risk of adverse events must be balanced against the benefit from EVT in elderly patients with AF.

Strategy for Failed Transvenous Left-Ventricular Lead Placement in Cardiac Resynchronization Therapy: Surrender or Struggle?

INTRODUCTION: For those cardiac resynchronization therapy (CRT) candidates who experience left-ventricular (LV) lead placement failure or underwent concomitant cardiac surgeries, surgical placement of epicardial LV lead guided by electroanatomic mapping may be a promising alternative. METHODS: Electroanatomic mapping was used to guide positioning of the LV lead through a surgical approach. The LV lead was placed at the region with the latest local LV activation and normal voltage, away from the scar. RESULTS: From April 2010 to September 2018, 10 consecutive patients (3 female) underwent surgical epicardial LV lead implantation. Among them, 3 had other surgical indications simultaneously (including 1 CRT non-responder), and 7 had failed transvenous LV lead placement. After CRT, the QRS duration was shortened from 149.3 ± 20.4 ms to 125.1 ± 15.2 ms (p = 0.01). At 6 months, the LV ejection fraction was significantly improved and remained stable in the follow-up (FU) period thereafter (baseline vs. 6 months, 31.0 ± 8.3% vs. 42.2 ± 13.4%, p = 0.006). Other parameters, including the threshold and impedance of the LV lead, were also stable at a mean FU of 755 ± 406 days, and the NYHA functional classification decreased from 2.9 ± 0.7 to 1.8 ± 0.8 (p = 0.002). CONCLUSIONS: Placement of an epicardial LV lead guided by electroanatomic mapping could be used as an adjunctive strategy in patients who were unable or refractory to conventional CRT therapy. This approach could also be applied in patients who had other surgical indications at the same time.

The characteristics of pre-excitation syndrome concomitant with atrial tachyarrhythmia and the effect of radiofrequency ablation.

BACKGROUND: Wolff-Parkinson-White (WPW) concomitant with atrial tachyarrhythmia (ATA) has not been systemically characterized. METHODS: Detailed electroanatomical mapping of the right atrium (RA) and/or left atrium (LA) was performed using three-dimensional mapping and the accessory pathway (AP) was mapped. RESULTS: WPW syndrome with ATA was diagnosed in 11 patients (median age 60 years). The characteristic of unidirectional anterograde conduction over the AP was displayed in nine patients, six of whom were intermittent. Sustained atrial tachycardia, that is, counterclockwise atrial flutter (AFL) with a median tachycardia cycle length (TCL) of 225 (220-275) ms, was mapped in eight patients; furthermore, "figure 8" right atrial reentry was mapped with TCL 250 ms in one patient with a surgical history of ventricular septal defect repair. The remaining two patients underwent mitral annulus-dependent AT after paroxysmal atrial fibrillation (PAF) ablation and LA micro-reentry AT, respectively. In four patients, the location of the APs was left posterior. Left-lateral APs were identified in four patients. The locations of the APs in the remaining three patients were the right posterior and middle septum. All ATAs and APs were successfully ablated. After a median follow-up of 37 (15-72) months, no anterograde conduction over the AP was recorded, new onset of PAF was recorded in three patients, and all of them underwent circumferential pulmonary vein isolation. CONCLUSIONS: WPW with concomitant ATA frequently had continuous anterograde conduction over the AP with a rapid ventricular rate. Most WPWs displayed the characteristic of unidirectional anterograde conduction.

Nonatrial Fibrillation Patients With Complete P Wave Disappearance: An Overlooked Population With High Stroke Risk.

BACKGROUND AND PURPOSE: Complete P wave disappearance (CPWD) in patients without atrial fibrillation is an uncommon clinical phenomenon. We aimed to study the relationship between CPWD and thromboembolism. METHODS: Between July 2007 and December 2018, consecutive patients with CPWD on surface ECG and 24-hour Holter recording were recruited into the study from 4 centers in China. All recruited patients underwent transesophageal echocardiography or cardiac computed tomography to screen for atrial thrombus. Atrial electrical activity and scar were assessed by electrophysiological study (EPS) and 3-dimensional electroanatomic mapping. Cardiac structure and function were assessed by multimodality cardiac imaging. RESULTS: Twenty-three consecutive patients (8 male; mean age 48.5±14.7 years) with CPWD were included. Only 3 patients demonstrated complete atrial electrical silence with atrial noncapture. Thirteen patients who had invasive atrial endocardial mapping demonstrated extensive scar. Pulse-wave mitral inflow Doppler demonstrated absent and dampened A waves in 18 and 5 patients, respectively. Pulse-wave tricuspid inflow Doppler showed absent and dampened A waves in 19 and 4 patients, respectively. Upon recruitment, 8 patients had previous stroke and 3 patients had atrial thrombus. Warfarin was prescribed to all patients. During median follow-up of 42.0 months, 2 patients developed massive ischemic stroke due to warfarin discontinuation. CONCLUSIONS: Our study suggested that CPWD reflects extensive atrial electrical silence and significantly impaired atrial mechanical function. It was strongly associated with thromboembolism and the clinical triad of CPWD-atrial paralysis-stroke was proposed. Anticoagulation should be recommended in such patients.

Clinical characteristics and therapeutic strategy of frequent accelerated idioventricular rhythm.

BACKGROUND: Accelerated idioventricular rhythm (AIVR) is often transient, considered benign and requires no treatment. This observational study aims to investigate the clinical manifestations, treatment, and prognosis of frequent AIVR. METHODS: Twenty-seven patients (20 male; mean age 32.2 ± 17.0 years) diagnosed with frequent AIVR were enrolled in our study. Inclusion criteria were as follows: (1) at least three recordings of AIVR on 24-h Holter monitoring with an interval of over one month between each recording; and (2) resting ectopic ventricular rate between 50 to 110 bpm on ECG. Electrophysiological study (EPS) and catheter ablation were performed in patients with distinct indications. RESULTS: All 27 patients experienced palpitation or chest discomfort, and two had syncope or presyncope on exertion. Impaired left ventricular ejection fraction (LVEF) was identified in 5 patients, and LVEF was negatively correlated with AIVR burden (P < 0.001). AIVR burden of over 73.8%/day could predict impaired LVEF with a sensitivity of 100% and specificity of 94.1%. Seventeen patients received EPS and ablation, five of whom had decreased LVEF. During a median follow-up of 60 (32, 84) months, LVEF of patients with impaired LV function returned to normal levels 6 months post-discharge, except one with dilated cardiomyopathy (DCM). Two patients died during follow-up. The DCM patient died due to late stage of heart failure, and another patient who refused ablation died of AIVR over-acceleration under fever. CONCLUSIONS: Frequent AIVR has unique clinical manifestations. AIVR patients with burden of over 70%, impaired LVEF, and/or symptoms of syncope or presyncope due to over-response to sympathetic tone should be considered for catheter ablation.

Role of sST2 in predicting recurrence of atrial fibrillation after radiofrequency catheter ablation.

INTRODUCTION: Atrial fibrosis is associated with atrial fibrillation (AF) recurrence after ablation. This study aims to determine the relationship between soluble ST2 (sST2), a profibrotic biomarker, and AF recurrence after radiofrequency catheter ablation (RFCA). METHODS: AF patients referred for RFCA were consecutively included from October 2017 to May 2019. Baseline characteristics were collected, and sST2 levels were determined before ablation. Left atrial substrate mapping was performed after circumferential pulmonary vein isolation under sinus rhythm, and substrate was modified in low-voltage zones. A second procedure was recommended under recurrence. RESULTS: Two hundred fifty-eight patients (146 males, average age 61.0 ± 8.8) were included. After a medium follow-up of 13.5 months, 52 patients (20.2%) had recurrence and received a second procedure. Preoperative sST2 level in patients with recurrence was significantly higher than that in patients without (31.3 ng/mL vs 20.3 ng/mL, P < .001). In those undergoing second ablation, sST2 level in patients with new abnormalities during endocardial mapping was significantly higher than that in patients without (43.0 ng/mL vs 22.1 ng/mL, P < .001). An sST2 level over 26.9 ng/mL could predict AF recurrence with new abnormalities during endocardial mapping with a sensitivity of 100% and a specificity of 75.9%. Multiple logistic analysis showed that sST2 level was an independent predictor of AF recurrence with new abnormalities during endocardial mapping (P < .001). CONCLUSIONS: sST2 level was associated with new abnormalities during endocardial mapping and recurrence of AF after ablation. It might have significance in choosing treatment strategies for AF.

Atrial electromechanical delay assessment in early phase after catheter ablation for patients with atrial fibrillation.

BACKGROUND: Variation of atrial electromechanical delay (AED) in early phase after catheter ablation in patients with atrial fibrillation (AF) is lacking. METHODS: Fifty-five consecutive patients restored sinus rhythm after ablation was included. Echocardiography was performed at 4 h, 1 day, and 3 days after radiofrequency catheter ablation, and AED was measured simultaneously by echocardiography with pulse Doppler imaging and pulse wave tissue Doppler imaging. RESULTS: AED parameters were significantly longer in the nonparoxysmal atrial fibrillation (NPAF) group than in the paroxysmal atrial fibrillation (PAF) group at each checking point after ablation (P < 0.05). Compared with other checking points, AED parameters were significantly longer 4 h postablation in the NPAF group, while no significant difference was found between different checking points in the PAF group. AED-leap, representing the variation of AED in NPAF patients, was significantly positively correlated with the duration of NPAF (r = 0.5291, P = 0.0113). CONCLUSIONS: Compared with PAF, NPAF patients have a longer AED postablation, and an abrupt decrease in the initial-h postablation. Such phenomenon gives rise to the different clinical features of PAF and NPAF, and could guide different assessment and treatment strategies for different types of AF.

Efficacy of sole pulmonary vein isolation in patients with nonparoxysmal atrial fibrillation without significant left atrium scar.

BACKGROUND: Catheter ablation strategies for nonparoxysmal atrial fibrillation (NPAF) are in varied forms. The mechanisms that circumferential pulmonary vein isolation (CPVI) alone could achieve success in some of the patients with NPAF are not well studied. This study sought to assess the clinical outcome of only CPVI approach in NPAF patients without significant left atrium scar. METHODS AND RESULTS: A total of 241 consecutive patients with NPAF undergoing an initial ablation procedure were studied. After CPVI, cavotricuspid isthmus ablation and direct current cardioversion, high-density atrial voltage mapping was performed during sinus rhythm. Transitional-voltage zone (TZ) was defined as 0.4-1.3 mV, and low-voltage zone (LVZ) as <0.4 mV. No LVZs were identified in 101 patients (41.9%), and only CPVI was performed. Among the patients without LVZs, single-procedure freedom from atrial fibrillation (AF)/atrial tachycardia was achieved in 73 patients (72%), while 28 patients (28%) had AF recurrence with mean follow-up of 29 ± 14 months. TZ index (TZi) was deduced by calculating the ratio of all TZ points over the total number of points and was found to be a univariate predictor of recurrence after a single procedure (P  =  0.047). CONCLUSIONS: The CPVI alone strategy for patients with NPAF can be performed in highly selective patients without LVZs. TZi may reflect healthy extent of left atrium, which has trend toward the association with AF recurrence.

Longstanding persistent accelerated idioatrial rhythm: Benign sinus node-like rhythm or insidious rhythm?

INTRODUCTION: Detailed description of longstanding persistent accelerated idioatrial rhythm (AIAR) is lacking. This observational study investigated the clinical manifestations, electrophysiological characteristics, diagnosis, treatment, and prognosis of this unusual arrhythmia. METHODS AND RESULTS: Fifteen patients (11 males; average age 25.9 ± 15.7 years) suspected with longstanding persistent AIAR were enrolled in our study. All patients had electrocardiogram (ECG), 24-hour Holter monitoring, isoproterenol provocation test, echocardiogram, and exercise treadmill test. Electrophysiological study (EPS) and catheter ablation were performed if necessary. The above noninvasive tests would be repeated during follow-up. Among the patients, 10 were asymptomatic; 5 had concomitant paroxysmal atrial tachycardia. Two asymptomatic patients had impaired left ventricular function. AIAR was observed throughout 24-hour Holter monitoring, showing chronotropic profile similar to sinus rhythm (SR). Such AIAR exhibited competitive property with SR when provoked by isoproterenol or during treadmill test. Twelve patients had EPS and 8 of them had successful ablation to eliminate AIAR. During a medium follow-up of 3.7 years, all patients were in well clinical course and preserved left ventricular dysfunction, and 3 patients spontaneously reverted to SR at 10-year follow-up. CONCLUSIONS: Longstanding persistent AIAR is an unusual entity of atrial arrhythmias and in most situations a benign rhythm requiring no treatment. The clinical course will be worsened when AIAR develops rapid focal firing, is associated with focal atrial tachycardias or results in tachycardia-mediated cardiomyopathy, but can be resolved via catheter ablation.