RESUMEN
INTRODUCTION: Both atrial fibrillation (AF) and amyloidosis increase stroke risk. We evaluated the best anticoagulation strategy in AF patients with coexistent amyloidosis. METHODS: Consecutive AF patients with concomitant amyloidosis were divided into two groups based on the postablation stroke-prophylaxis approach; group 1: left atrial appendage occlusion (LAAO) in eligible patients and group 2: oral anticoagulation (OAC). Group 1 patients were further divided into Gr. 1A: LAAO + half-does NOAC (HD-NOAC) for 6 months followed by aspirin 81 mg/day and Gr. 1B: LAAO + HD-NOAC. In group 1 patients, with complete occlusion at the 45-day transesophageal echocardiogram, patients were switched to aspirin, 81 mg/day at 6 months. In case of leak, or dense "smoke" in the left atrium (LA) or enlarged LA, they were placed on long-term half-dose (HD) NOAC. Group 2 patients remained on full-dose NOAC during the whole study period. RESULTS: A total of 92 patients were included in the analysis; group 1: 56 and group 2: 36. After the 45-day TEE, 31 patients from group 1 remained on baby-aspirin and 25 on HD NOAC. At 1-year follow-up, four stroke, one TIA and six device-thrombus were reported in group 1A, compared to none in patients in group 1B (5/31 vs. 0/25, p = .03). No bleeding events were reported in group 1, whereas group 2 had five bleeding events (one subdural hematoma, one retinal hemorrhage, and four GI bleedings). Additionally, one stroke was reported in group 2 that happened during brief discontinuation of OAC. CONCLUSION: In patients with coexistent AF and amyloidosis, half-dose NOAC following LAAO was observed to be the safest stroke-prophylaxis strategy.
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Amiloidosis , Anticoagulantes , Apéndice Atrial , Fibrilación Atrial , Ablación por Catéter , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Masculino , Femenino , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/fisiopatología , Apéndice Atrial/cirugía , Anciano , Persona de Mediana Edad , Resultado del Tratamiento , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/diagnóstico , Ablación por Catéter/efectos adversos , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Factores de Riesgo , Factores de Tiempo , Amiloidosis/complicaciones , Amiloidosis/diagnóstico , Amiloidosis/diagnóstico por imagen , Hemorragia/inducido químicamente , Administración Oral , Estudios Retrospectivos , Medición de Riesgo , Aspirina/administración & dosificación , Aspirina/efectos adversos , Esquema de Medicación , Cardiomiopatías/diagnóstico por imagen , Cardiomiopatías/complicaciones , Cardiomiopatías/diagnósticoRESUMEN
INTRODUCTION: Atrial fibrillation (AF) and premature ventricular complexes (PVC) are common arrhythmias. We aimed to investigate AF prevalence in patients with PVC and its impact on PVC ablation outcomes. METHODS: Consecutive patients undergoing PVC ablation at a single institution between 2016 and 2019 were included and prospectively followed for 2 years. Patients with severe valvular heart disease, hyperthyroidism, malignancy, alcohol use disorder and advanced renal/hepatic diseases were excluded. Twelve-lead electrocardiograms were used to diagnose AF and assess PVC morphology. All PVCs were targeted for ablation using 4-mm irrigated-tip catheters at standardized radiofrequency power guided by 3-D mapping and intracardiac echocardiography. Patients were followed with remote monitoring, device interrogations and office visits every 6 months for 2 years. Detection of any PVCs in follow-up was considered as recurrence. RESULTS: A total of 394 patients underwent PVC ablation and 96 (24%) had concurrent AF. Patients with PVC and AF were significantly older (68.2 ± 10.8 vs. 58.3 ± 15.8 years, p < .001), had lower LV ejection fraction (43.3 ± 13.3% vs. 49.6 ± 12.4%, p < .001), higher CHA2 DS2 -VASc (2.8 ± 1.3 vs. 2.0 ± 1.3, p < .001) than those without. PVCs with ≥2 morphologies were detected in 60.4% and 13.7% patients with vs without AF (p < .001). At 2-year follow-up, PVC recurrence rate was significantly higher in patients with vs without AF (17.7% vs. 9.4%, p = .02). CONCLUSION: AF was documented in 1/4 of patients undergoing PVC ablation and was associated with lower procedural success at long-term follow-up. This was likely attributed to older age, worse LV function and higher prevalence of multiple PVC morphologies in patients with concurrent AF.
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Fibrilación Atrial , Ablación por Catéter , Complejos Prematuros Ventriculares , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Resultado del Tratamiento , Prevalencia , Volumen Sistólico , Complejos Prematuros Ventriculares/diagnóstico , Complejos Prematuros Ventriculares/epidemiología , Complejos Prematuros Ventriculares/cirugía , Ablación por Catéter/efectos adversosRESUMEN
BACKGROUND: Intracardiac electrogram data remain one of the primary diagnostic inputs guiding complex ablation procedures. However, the technology to collect, process, and display intracardiac signals has known shortcomings and has not advanced in several decades. OBJECTIVE: The purpose of this study was to evaluate a new signal processing platform, the PURE EP™ system (PURE), in a multi-center, prospective study. METHODS: Intracardiac signal data of clinical interest were collected from 51 patients undergoing ablation procedures with PURE, the signal recording system, and the 3D mapping system at the same time stamps. The samples were randomized and subjected to blinded, controlled evaluation by three independent electrophysiologists to determine the overall quality and clinical utility of PURE signals when compared to conventional sources. Each reviewer assessed the same (92) signal sample sets and responded to (235) questions using a 10-point rating scale. If two or more reviewers rated the PURE signal higher than the control, it was deemed superior. RESULTS: A total of 93% of question responses showed consensus amongst the blinded reviewers. Based on the ratings for each pair of signals, a cumulative total of 164 PURE signals out of 218 (75.2%) were statistically rated as Superior for this data set (p < .001). Only 14 PURE signals out of 218 were rated as Inferior (6.4%). CONCLUSION: The PURE intracardiac signals were statistically rated as superior when compared to conventional systems.
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Electrofisiología Cardíaca , Ablación por Catéter , Técnicas Electrofisiológicas Cardíacas , Corazón , Humanos , Estudios Prospectivos , Procesamiento de Señales Asistido por ComputadorRESUMEN
INTRODUCTION: Watchman FLX has been recently approved for left atrial appendage occlusion (LAAO) in the US. Intracardiac echocardiography (ICE) - which is already commonly used to guide trans-septal access - can serve as an alternative to TEE, simplifying the procedure and reducing associated costs. Herein, we report our experience with ICE-guided LAAO with Watchman FLX. METHODS AND RESULTS: This cohort study included the first 190 consecutive patients who underwent LAAO with Watchman FLX in our center. LAAO was successful in all patients without significant peri-procedural, device-related complications in either group. Compared to TEE, we observed a significant reduction in procedural times when using ICE. In addition, there was a potentially clinically relevant reduction in fluoroscopy dose, mainly secondary to fewer cine acquisition runs. At follow-up, no cases of device embolism were noted, whereas the rate of device-related thrombosis and peri-device leaks were comparable between groups. CONCLUSION: ICE-guided LAAO with Watchman FLX is safe and feasible, with a significant reduction in procedural time and potential reduction in fluoroscopy dose when compared to TEE.
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Apéndice Atrial , Fibrilación Atrial , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/cirugía , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Cateterismo Cardíaco/efectos adversos , Estudios de Cohortes , Ecocardiografía Transesofágica , Humanos , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: The creation of effective and permanent lesions is a crucial factor in determining the success rate of atrial fibrillation (AF) ablation. By increasing the efficacy of radiofrequency (RF) energy-mediated lesion formation, half-normal saline (HNS) as an irrigant for open-irrigated ablation catheters has the potential to reduce procedural times and improve acute and long-term outcomes. METHODS: This is a double-blind randomized clinical trial of 99 patients undergoing first-time RF catheter ablation for AF. Patients enrolled were randomly assigned in a 1:1 fashion to perform ablation using HNS or normal saline (NS) as an irrigant for the ablation catheter. RESULTS: The use of HNS is associated with shorter RF times (26 vs. 33 min; p = .02) with comparable procedure times (104 vs. 104 min). The rate of acute pulmonary vein reconnections (16% vs. 18%) was comparable, with a median of 1 vein reconnection in the HNS arm versus 2 in the NS arm. There was no difference in procedure-related complications, including the incidence of postprocedural hyponatremia when using HNS. Over the 1-year follow-up, there is no significant difference between the HNS and NS with respect to the recurrence of any atrial arrhythmia (off antiarrhythmic drugs [AAD]: 47% vs. 52%; hazard ratio [HR]: 1.17, 95% confidence interval [CI]: 0.66-2.06; off/on AAD: 66% vs. 66%, HR: 1.06, 95% CI: 0.53-2.12), with a potential benefit of using HNS when considering the paroxysmal AF cohort (on/off AAD 73% vs. 62%, HR: 0.72, 95% CI: 0.19-2.70). CONCLUSIONS: In a mixed cohort of patients undergoing first-time AF ablation, irrigation of open-irrigated RF ablation catheters with HNS is associated with shorter RF times, with a comparably low rate of procedure-related complications. In the long term, there is no significant difference with respect to the recurrence of any atrial arrhythmia. Larger studies with a more homogeneous population are necessary to determine whether HNS improves clinical outcomes.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Catéteres , Diseño de Equipo , Humanos , Venas Pulmonares/cirugía , Recurrencia , Solución Salina , Resultado del TratamientoRESUMEN
A recent surveillance analysis indicates that cardiac arrest/death occurs in ≈1:50,000 professional or semi-professional athletes, and the most common cause is attributable to life-threatening ventricular arrhythmias (VAs). It is critically important to diagnose any inherited/acquired cardiac disease, including coronary artery disease, since it frequently represents the arrhythmogenic substrate in a substantial part of the athletes presenting with major VAs. New insights indicate that athletes develop a specific electro-anatomical remodeling, with peculiar anatomic distribution and VAs patterns. However, because of the scarcity of clinical data concerning the natural history of VAs in sports performers, there are no dedicated recommendations for VA ablation. The treatment remains at the mercy of several individual factors, including the type of VA, the athlete's age, and the operator's expertise. With the present review, we aimed to illustrate the prevalence, electrocardiographic (ECG) features, and imaging correlations of the most common VAs in athletes, focusing on etiology, outcomes, and sports eligibility after catheter ablation.
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Ablación por Catéter , Deportes , Arritmias Cardíacas , Atletas , Electrocardiografía , Corazón , HumanosRESUMEN
Rhythm control of persistent atrial fibrillation (AF) patients represents a challenge for the modern interventional cardiac electrophysiologist; as a matter of fact, there is still divergence regarding the best ablative approach to adopt in this population. Different investigational endpoints, variability of techniques and tools, significant technological evolution, and the lack of universally accepted pathophysiological models engendered a considerable heterogeneity in terms of techniques and outcomes, so much that the treatment of persistent subtypes of AF commonly still relies mainly on pulmonary vein (PV) isolation. The purpose of the present review is to report the current experimental and clinical evidence supporting the importance of mapping and ablating non-PV triggers and describe our institutional approach for the ablation of nonparoxysmal AF.
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Fibrilación Atrial , Ablación por Catéter , Venas Pulmonares , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Humanos , Venas Pulmonares/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: It is common to find residual stump after the amputation or clip exclusion of the left atrial appendage (LAA). We evaluated the arrhythmogenic and thrombogenic potential of LAA stumps in atrial fibrillation (AF) patients. METHODS: Consecutive patients undergoing catheter ablation for AF recurrence with LAA stump detected at baseline transesophageal echocardiogram (TEE) were included in the analysis. Nonpulmonary vein (non-PV) triggers were ablated based on operator's discretion. RESULTS: A total of 213 patients with LAA stump were included in the analysis. Firing from the LAA stump was detected in 186 cases, of which 145 received stump isolation (group I) and the stump was not targeted for isolation in 41 (group II) patients. In 27 patients with no firing from the stump (group III) only non-PV triggers from sites other than the LAA stump were targeted for ablation. At 16.7 ± 8.5 months of follow-up, 126 (86.9%) patients from group I, eight (19.5%) from group II, and eight (33.3%) from group III remained arrhythmia-free off antiarrhythmic drugs (AAD) (P < 0.001). Sixty out of 70 patients underwent redo procedure; electrical isolation of the stump and ablation of other non-PV triggers was done in all 60 cases. At 1 year after the repeat procedure, 55 (91.7%) patients remained arrhythmia-free off-AAD. A total of four (1.88%) thromboembolic (TE) events reported, three of which were transient ischemic attacks and all three patients had "smoke" detected in the left atrium. CONCLUSION: LAA stump is arrhythmogenic and electrical isolation improves clinical outcome. TE events are rare and mostly associated with left atrial smoke in this subset of AF population.
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Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Ataque Isquémico Transitorio/etiología , Tromboembolia/etiología , Anciano , Apéndice Atrial/diagnóstico por imagen , Apéndice Atrial/fisiopatología , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Supervivencia sin Progresión , Recurrencia , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Tromboembolia/diagnóstico por imagen , Factores de TiempoRESUMEN
The objective of this study was to evaluate the long-term efficacy of FIRM ablation with PVAI vs PVAI plus posterior wall isolation (PWI) and non-PV trigger ablation in persistent (PeAF) and long-standing persistent AF (LSPAF) patients. The procedure time was recorded to be 180.6⯱â¯35.9 and 124.03⯱â¯45.4â¯minutes in the FIRM+PVI and PVIâ¯+â¯PWIâ¯+â¯non-PV trigger ablation group respectively. At 24-month follow-up, 24% (95% CI 8.7%-37.8%) in the FIRM-ablation group and 48% (95% CI 27.6-63.3%) in the non-PV trigger ablation group remained arrhythmia-free off-antiarrhythmic drugs after a single procedure. Clinical Trial Registration:ClinicalTrials.gov (Identifier: NCT02533843).
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Frecuencia Cardíaca/fisiología , Anciano , Fibrilación Atrial/fisiopatología , Mapeo del Potencial de Superficie Corporal , Electrocardiografía Ambulatoria , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Outcome data after catheter ablation (CA) for longstanding persistent atrial fibrillation (LSPAF) lasting less than 2 years are limited and highly variable with different ablation approaches. We aimed to assess the long-term outcomes in patients with LSPAF lasting less than 2 years undergoing extended pulmonary vein antrum isolation (PVAI) versus those with additional non-pulmonary vein (PV) trigger ablation. METHODS AND RESULTS: In this prospective analysis, 381 consecutive patients with LSPAF lasting less than 2 years (age: 64 ± 9 years, 76% male, atrial fibrillation duration: 19 ± 5 months) undergoing their first CA were classified into two groups: Group 1 (n = 104) received PVAI extended to PW plus isolation of superior vena cava (SVC) and Group 2 ( n = 277) received PVAI + PW + SVC + non-PV-trigger ablation. All patients were followed-up for at least 2 years. In case of recurrence, repeat procedure was offered and non-PV triggers were targeted for ablation in all. After a single procedure, 26 (25%) patients in Group 1 and 172 (62.1%) in Group 2 remained arrhythmia-free (P < 0.001). A second procedure was performed in 58 of 78 (74.4%) patients in Group 1 and 77 of 105 (73.3%) patients in Group 2. Non-PV triggers were identified in 52 (89.6%) and 54 (70.1%) patients in Groups 1 and 2, respectively, and targeted for ablation. Overall, 72 (69.2%) patients in Group 1 and 238 (86%) in Group 2 remained arrhythmia-free ( P < 0.001). CONCLUSION: In patients with LSPAF lasting less than 2 years, extended PVAI plus SVC isolation was less likely to achieve long-term sinus rhythm. In the majority of patients, recurrence was due to non-PV triggers and ablation of those resulted in better outcome.
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Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter/tendencias , Anciano , Fibrilación Atrial/diagnóstico , Ablación por Catéter/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIMS: This study investigated the impact of weight loss in longstanding persistent (LSPAF) patients undergoing catheter ablation (CA). METHODS: Ninety consecutive obese LSPAF patients were approached; 58 volunteered to try weight loss interventions for up to 1 year (group 1), while 32 patients declined weight loss interventions and were included as a control (group 2). Both groups remained on antiarrhythmic drugs. If they continued to experience AF, CA was performed. Body weight was measured at 6-month intervals and arrhythmia status was assessed by event recorder, electrocardiogram (ECG), and Holter monitoring. Symptom severity and quality of life (QoL) were evaluated by AFSS and SF-36 survey, respectively. A scoring algorithm with two summary measures, physical component score (PCS) and mental component score (MCS), was prepared for QoL analysis. RESULTS: Significant reduction in body weight (median -24.9 (IQR -19.1 to -56.7) kg, P < 0.001) was observed in the group 1 patients, while no such change was seen in group 2. The PCS and MCS scores improved significantly in group 1 only, with a change from baseline of 8.4 ± 3 (P = 0.013) and 12.8 ± 8.2 (P < 0.02). However, AF symptom severity remained unchanged from baseline in both groups (P = 0.84). All 90 patients eventually underwent CA and received PVAI+ posterior wall+ non-PV triggers ablation. At 1-year follow-up after single procedure, 37 (63.8%) in group 1 and 19 (59.3%) patients in group 2 remained arrhythmia-free off AAD (P = 0.68). CONCLUSION: In this prospective analysis, in LSPAF patients weight loss improved QoL but had no impact on symptom severity and long-term ablation outcome.
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Fibrilación Atrial/cirugía , Ablación por Catéter , Obesidad/terapia , Pérdida de Peso , Potenciales de Acción , Anciano , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Estudios de Casos y Controles , Ablación por Catéter/efectos adversos , Bases de Datos Factuales , Electrocardiografía Ambulatoria , Femenino , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Obesidad/complicaciones , Obesidad/diagnóstico , Obesidad/fisiopatología , Supervivencia sin Progresión , Estudios Prospectivos , Calidad de Vida , Recurrencia , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
Aims: Superior vena cava (SVC) isolation might be difficult to achieve because of the vicinity of the phrenic nerve (PN) and sinus node. Based on its embryogenesis, we hypothesized the presence of preferential conduction from the right atrial (RA) posterior wall, making it possible to isolate the SVC antrally, sparing its anterior and lateral aspect. Methods and results: This is a descriptive cohort study of 105 consecutive patients in which SVC isolation was obtained with radiofrequency ablation, starting in the septal aspect of the SVC-RA junction and continued posteriorly and inferiorly targeting sites of early activation until electrical isolation was obtained. Acute SVC isolation was achieved in 103 (98%) patients; the mean distance between the site of SVC isolation and the SVC-RA junction was 19.9 ± 5.3 (range 9.7-33.7) mm. During follow-up, 2 (2%) patients developed symptomatic diaphragmatic paralysis due to transient right PN injury; 13 patients underwent a repeat ablation: SVC reconnection was observed in 5 patients, and re-isolation was easily achieved by targeting the corresponding sites of early activation. Conclusion: Superior vena cava isolation can be completed by targeting its septal segment and sites of early activation in the posterior SVC-RA junction and RA posterior wall; this is a feasible alternative ablation strategy in patients in which SVC isolation cannot be completed with the standard approach. The risk of sinus node injury or SVC stenosis are eliminated; PN injury is still possible but can easily be prevented with high-output pacing to exclude a true posterior course of the PN.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Atrios Cardíacos/cirugía , Vena Cava Superior/cirugía , Anciano , Estudios de Cohortes , Femenino , Humanos , Complicaciones Intraoperatorias/epidemiología , Masculino , Persona de Mediana Edad , Traumatismos de los Nervios Periféricos/epidemiología , Nervio Frénico/lesiones , Estudios Prospectivos , Ablación por Radiofrecuencia/métodosRESUMEN
INTRODUCTION: This study reports the procedural findings and ablation outcome in AF patients referred after ≥2 failed PV isolation (PVI). METHODS: Three hundred and five consecutive AF patients referred after ≥2 PVI were included in the analysis. High-dose isoproterenol challenge was used to identify PV reconnection and non-PV triggers; the latter were ablated based on the operator's discretion during the index procedure. At the repeat procedure, non-PV triggers were ablated in all. Empirical isolation of LA appendage (LAA) and coronary sinus (CS) was performed if the PVs were silent and no non-PV triggers were detected. RESULTS: PV reconnection was detected in 226 and non-PV triggers were identified or empirically isolated in 285 patients during the index procedure. At follow-up, 182 (60%) patients were recurrence-free off-AAD; the success rate with and without non-PV ablation was 81% vs. 8% (P < 0.0001). 104 patients underwent repeat procedure with non-PV trigger ablation in all. At 1 year, 90% were arrhythmia free off-AAD in non-PV ablation group, and 72% who did not receive non-PV triggers ablation at the index procedure (P = 0.035). The success rate of empirical LAA and CS isolation was 78.5% and 82% after the index and repeat procedure, respectively. CONCLUSION: In patients experiencing AF recurrence after multiple failed PVI, despite PV reconnection, non-PV triggers were found to be responsible for AF maintenance in the majority and ablating those triggers increased ablation success. Additionally, in the presence of permanent PVI and no non-PV triggers on isoproterenol, empirical isolation of LAA and CS provided high rate of arrhythmia-free survival.
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Fibrilación Atrial/fisiopatología , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Derivación y Consulta , Anciano , Fibrilación Atrial/diagnóstico , Ablación por Catéter/tendencias , Electrocardiografía/tendencias , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Recurrencia , Derivación y Consulta/tendencias , Sistema de Registros , Factores de Riesgo , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
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.
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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 TratamientoRESUMEN
INTRODUCTION: Ablation of longstanding persistent atrial fibrillation (LSPAF) is the most challenging procedure in the treatment of AF, either by surgical or by percutaneous approach. OBJECTIVE: We investigated the difference in success and complication rates between combined surgical epicardial and endocardial catheter ablation procedure and our standard endocardial ablation procedure. METHODS AND RESULTS: Twenty-four consecutive patients (group 1) with LSPAF and enlarged left atrium (>4.5 cm) underwent a combined procedure, consisting of surgical, closed-chest, epicardial, radiofrequency ablation (nContact, NC, USA) via pericardial access, and concomitant endocardial ablation (hybrid procedure). Procedural complications and long-term outcomes were compared to those of 35 consecutive patients who refused the hybrid procedure and underwent standard endocardial only ablation (group 2). Baseline characteristics were comparable. In group 1, 1 patient (4.2%) developed post-procedural cardio-embolic stroke and 3 (12.5%) died (1 atrio-esophageal fistula, 1 fatal stroke, 1 of unknown cause in early follow-up), while no strokes or deaths occurred in group 2. Overall complication rates were higher for group 1 (P = 0.036). At 24-month follow-up, 4 (19%) patients in group 1 and 19 (54.3%) in group 2 were arrhythmia-free after a single procedure, on or off antiarrhythmic drugs (P<0.001). Total procedural time (276.9 ± 63.5 vs. 203.15 ± 67.3 minutes) and length of hospital stay (5 [IQR 3-8] vs. 1 [IQR 1-3] days were significantly shorter for group 2 (P <0.001). CONCLUSIONS: In patients with LSPAF and enlarged left atrium, a concomitant combined surgical/endocardial ablation approach increases complication rate and does not improve outcomes when compared to extensive endocardial ablation only.
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Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Endocardio/cirugía , Atrios Cardíacos/cirugía , Pericardio/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Ablación por Catéter/mortalidad , Supervivencia sin Enfermedad , Endocardio/fisiopatología , Femenino , Atrios Cardíacos/fisiopatología , Frecuencia Cardíaca , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Pericardio/fisiopatología , Complicaciones Posoperatorias/etiología , Recurrencia , Factores de Riesgo , Texas , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Because of the absence of a dedicated reversal agent, the outcome of pericardial effusion (PE) following procedures performed with uninterrupted apixaban or rivaroxaban is unknown. We report the characteristics of PEs presenting with tamponade in patients undergoing AF ablation with uninterrupted factor Xa inhibition (FXaI) to understand their management and prognosis. METHODS AND RESULTS: We performed a multicenter cross-sectional survey in 10 centers across the United States. Patient data were obtained by chart review. In all patients the procedure was performed with uninterrupted FXaI. A total of 16 PEs requiring intervention were reported from 5 centers. Two patients were on apixaban 5 mg BD, the remaining on rivaroxaban 20 mg OD. Eleven PEs occurred in the periprocedural setting, and 5 PEs occurred from 1 to 28 days after the procedure. Pericardiocentesis and drainage were performed in all cases. Protamine and 4-factor prothrombin complex concentrate (4F-PCC) were given in all periprocedural cases. Two patients required surgery: in one case coagulation of the pericardial blood prevented effective drainage, and in the other bleeding was secondary to a steam pop-induced atrial tear. None of the postprocedural cases required FXaI reversal and the dose of rivaroxaban was temporarily reduced. No fatal outcomes or thromboembolic events were reported. CONCLUSION: Pericardiocentesis and drainage with FXaI reversal proved effective in the management of acute PEs with tamponade occurring periprocedurally in patients undergoing AF ablation with uninterrupted FXaI. Early postprocedural effusions can be treated with pericardiocentesis without the need of a reversal agent.
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Fibrilación Atrial/cirugía , Oclusión con Balón/métodos , Ablación por Catéter/efectos adversos , Inhibidores del Factor Xa/administración & dosificación , Derrame Pericárdico/prevención & control , Tromboembolia/prevención & control , Anciano , Anticoagulantes/administración & dosificación , Fibrilación Atrial/complicaciones , Estudios Transversales , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Derrame Pericárdico/etiología , Complicaciones Posoperatorias/prevención & control , Premedicación/métodos , Pronóstico , Tromboembolia/etiología , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Periprocedural thromboembolic and hemorrhagic events are worrisome complications of catheter ablation for atrial fibrillation (AF). The periprocedural anticoagulation management could play a role in the incidence of these complications. Although ablation procedures performed without warfarin discontinuation seem to be associated with lower thromboembolic risk, no randomized study exists. METHODS AND RESULTS: This was a prospective, open-label, randomized, parallel-group, multicenter study assessing the role of continuous warfarin therapy in preventing periprocedural thromboembolic and hemorrhagic events after radiofrequency catheter ablation. Patients with CHADS2 score ≥1 were included. Patients were randomly assigned in a 1:1 ratio to the off-warfarin or on-warfarin arm. The incidence of thromboembolic events in the 48 hours after ablation was the primary end point of the study. The study enrolled 1584 patients: 790 assigned to discontinue warfarin (group 1) and 794 assigned to continuous warfarin (group 2). No statistical difference in baseline characteristics was observed. There were 39 thromboembolic events (3.7% strokes [n=29] and 1.3% transient ischemic attacks [n=10]) in group 1: two events (0.87%) in patients with paroxysmal AF, 4 (2.3%) in patients with persistent AF, and 33 (8.5%) in patients with long-standing persistent AF. Only 2 strokes (0.25%) in patients with long-standing persistent AF were observed in group 2 (P<0.001). Warfarin discontinuation emerged as a strong predictor of periprocedural thromboembolism (odds ratio, 13; 95% confidence interval, 3.1-55.6; P<0.001). CONCLUSION: This is the first randomized study showing that performing catheter ablation of AF without warfarin discontinuation reduces the occurrence of periprocedural stroke and minor bleeding complications compared with bridging with low-molecular-weight heparin. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01006876.
Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/cirugía , Ablación por Catéter/efectos adversos , Hemorragia/epidemiología , Accidente Cerebrovascular/epidemiología , Tromboembolia/prevención & control , Warfarina/uso terapéutico , Anciano , Anticoagulantes/efectos adversos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Periodo Perioperatorio , Estudios Prospectivos , Factores de Riesgo , Tromboembolia/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Warfarina/efectos adversos , Privación de TratamientoRESUMEN
BACKGROUND: This study examined incidence of AF following cavotricuspid isthmus (CTI) ablation alone or CTI plus prophylactic pulmonary vein isolation (PVI) in patients presenting with isolated atrial flutter (AFL) with no history of AF. METHODS AND RESULTS: We enrolled 216 patients with isolated typical atrial flutter and randomized them to CTI alone (group 1, n = 108, 61.2 ± 9.7 year, 75% male) or CTI+PVI ablation (group 2, n = 108, 62.4 ± 9.3 year, 73% male). Insertible loop recorder (ILR) was implanted in 21 and 19 patients from groups 1 and 2, respectively. Remaining patients were monitored with event recorders, ECG, 7-day Holter. Follow-up period was for 18 ± 6 months. Compared to group 1, group 2 had significantly longer procedural duration (75.9 ± 33 min vs. 161 ± 48 min [P < 0.001]) and fluoroscopy time (15.9 ± 12.3 min vs. 56.4+21 min [P < 0.001]). At the end of follow-up, 65 (60.2%) in group 1 and 77 (71.3%) in group 2 were arrhythmia free off-AAD (log-rank P = 0.044). A subgroup analysis was performed with 55 year age cut-off. In the <55 age group the CTI only population had similar success as in CTI+PVI, (21 of 24 [83.3%] vs. 19 of 22 [86.4%], respectively, log-rank P = 0.74). In the ≥55 group, having CTI+PVI showed significantly higher success compared to CTI only; 45 of 84 (53.6%) were AF/AT free in CTI only group versus 58 of 86 (67.4%) with CTI+PVI (log-rank P = 0.029). CONCLUSION: Prophylactic PVI reduced new-onset AF in patients with lone atrial flutter.
Asunto(s)
Fibrilación Atrial/prevención & control , Aleteo Atrial/cirugía , Ablación por Catéter/métodos , Venas Pulmonares/cirugía , Potenciales de Acción , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/fisiopatología , Aleteo Atrial/diagnóstico , Aleteo Atrial/epidemiología , Aleteo Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Supervivencia sin Enfermedad , Electrocardiografía Ambulatoria , Femenino , Frecuencia Cardíaca , Humanos , Incidencia , Italia/epidemiología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Proyectos Piloto , Modelos de Riesgos Proporcionales , Venas Pulmonares/fisiopatología , Factores de Riesgo , Telemetría , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
We present a case of persistent complete atrioventricular block that occurred during the diagnostic portion of a premature ventricular contractions' radiofrequency ablation in a complex heart failure patient. The case was managed by bailout deep left ventricular septal pacing after bipolar radiofrequency elimination of premature ventricular contractions.
RESUMEN
BACKGROUND: Studies have reported development of pulmonary hypertension (PH) secondary to reduced LA compliance following AF ablation. OBJECTIVES: This study aimed to compare the risk of worsening of baseline PH between non-paroxysmal AF patients undergoing pulsed-field ablation (PFA) and standard radiofrequency ablation (RFA). METHODS: This multicenter study included 28 nonparoxysmal AF patients with PH undergoing a PFA-based ablation procedure after >1 failed RFA. A cohort of 28 AF patients with PH, scheduled for repeat RFA, 1:1 propensity-score matched using a multivariable logistic model, were used as the comparator group. Right heart catheterization and echocardiography were performed before and after the procedure to assess the pulmonary artery pressure (PAP). PH was defined as resting mean PAP of >20 mm Hg. RESULTS: The baseline characteristics of the PFA and propensity-matched RFA groups were comparable. The mean PAP assessments at baseline, follow-up, and change from baseline were analyzed. The groups had comparable baseline mean pulmonary artery pressures (mPAP) (P = 0.177). After adjustment for baseline mPAP in an analysis of covariance model, the least-squares means change at 3 months after ablation was -1.71 ± 1.03 mm Hg and 19.67 ± 1.03 mm Hg in PFA and RFA, respectively (P <0.001). CONCLUSIONS: In this propensity-matched population, no worsening of mPAP was detected following pulsed-field ablation in patients with pre-existing PH undergoing a repeat procedure for recurrence.