Functional mapping to reveal slow conduction and substrate progression in atrial fibrillation.

AIMS: The aim of our study was to analyse the response to short-coupled atrial extrastimuli to identify areas of hidden slow conduction (HSC) and their relationship with the atrial fibrillation (AF) phenotype. METHODS AND RESULTS: Twenty consecutive patients with paroxysmal AF and persistent AF (10:10) underwent the first pulmonary vein isolation procedure. Triple short-coupled extrastimuli were delivered in sinus rhythm (SR), and the evoked response was analysed: sites exhibiting double or highly fragmented electrograms (EGM) were defined as positive for HSC (HSC+). The delta of the duration of the bipolar EGM was analysed, and bipolar EGM duration maps were built. High-density maps were acquired using a multipolar catheter during AF, SR, and paced rhythm. Spatial co-localization of HSC+ and complex fractionated atrial EGMs (CFAE) during AF was evaluated. Persistent AF showed a higher number and percentage of HSC+ than paroxysmal AF (13.9% vs. 3.3%, P < 0.001). The delta of EGM duration was 53 ± 22 ms for HSC+ compared with 13 ± 11 (10) ms in sites with negative HSC (HSC-) (P < 0.001). The number and density of HSC+ were lower than CFAE during AF (19 vs. 56 per map, P < 0.001). The reproducibility and distribution of HSC+ in repeated maps were superior to CFAE (P = 0.19 vs. P < 0.001). Sites with negative and positive responses showed a similar bipolar voltage in the preceding sinus beat (1.65 ± 1.34 and 1.48 ± 1.47 mV, P = 0.12). CONCLUSION: Functional mapping identifies more discrete and reproducible abnormal substrates than mapping during AF. The HSC+ sites in response to triple extrastimuli are more frequent in persistent AF than in paroxysmal AF.

Direct Implantation of a Left Atrial Appendage Occluder During Cardiothoracic Surgery.

Surgical suture or exclusion of the left atrial appendage (LAA) is a commonly performed technique in patients undergoing cardiothoracic revascularization or valve repair, or both. However, incomplete surgical sealing of the LAA is not a rare phenomenon and strongly increases the risk for future cerebrovascular embolic events. We report the implantation of a Watchman LAA occluder (Boston Scientific, Natick, MA) during redo minimally invasive open heart surgery. This approach offers a new alternative for LAA occlusion in patients for whom a surgical procedure is scheduled.

Premature ventricular contractions cause a position shift in 3D mapping systems: analysis, quantification, and correction by hybrid activation mapping.

AIMS: Using a modified CARTO 3D mapping system, we studied if premature ventricular contractions (PVCs) cause position shifts within the 3D co-ordinate system. We quantified magnitude of the phenomenon and corrected for it, by creating both an activation map that represents the conventional local activation time (LAT) and one corrected for this position shift (hybrid LAT map). METHODS AND RESULTS: We prospectively enrolled patients planned for PVC ablation. Distances between the earliest LAT, the earliest hybrid-LAT, and the best pacemap positions were calculated in a 3D model. Ablation was performed at the best hybrid-LAT location. Efficacy was evaluated by acute response to ablation as well as clinical outcome on 24-h Holter at 1 year. One hundred and twenty-seven LAT-hybrid pairs were studied in 18 patients (age 48.3 ± 18.0 years, 12 female). Baseline PVC burden was 16 ± 12%. The mean position shift between LAT-hybrid and its associated LAT position was 8.9 ± 5.5 mm. The mean position shift between best LAT-hybrid and best pacemap was 6.2 ± 5.0 mm and the mean shift between best conventional LAT and best pacemap was 13.5 ± 7.0 mm (P < 0.0001 for all pairwise comparisons). Exclusive targeting of best LAT-hybrid position resulted in acute abolition of PVC activity in all patients. After 1-year follow-up, mean PVC burden reduction was 16% (baseline) to <1%. CONCLUSION: Premature ventricular contractions cause a position shift in 3D mapping systems compared with the same endocardial position in sinus rhythm. An approach to account for this phenomenon, correct it and target exclusively the adjusted 3D position is feasible and highly efficient in terms of acute and 1-year clinical outcome after radiofrequency ablation.

Left atrial volume computed by 3D rotational angiography best predicts atrial fibrillation recurrence after circumferential pulmonary vein isolation.

Left atrium (LA) size is a well-studied predictor of atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). Yet, there is still little agreement on the best imaging technique to size the LA, and on the most appropriate sizing parameter. Volumetric assessment of LA with three-dimensional rotational angiography (3DRA LA volume index) might be a valid alternative to the commonly used transthoracic echocardiography (TTE LA volume index). The aim of our study was to investigate whether LA volume by 3DRA at the time of PVI is able to predict the risk of atrial fibrillation recurrence. We analysed 352 consecutive patients with symptomatic paroxysmal or persistent atrial fibrillation referred for PVI to our Institution. In all patients, LA volume index (LAVI) was assessed by TTE and by 3DRA. Sinus rhythm was restored after PVI in 348 patients (99%). Average TTE-LAVI and 3DRA-LAVI were 37 ± 12 and 83 ± 18 ml/m2, respectively. At a median follow-up of 19 (12, 24) months, 27% of patients had AF recurrence after the first PVI. At the univariate analysis, persistent AF (p < 0.01), use of anti-arrhythmic drugs (AAD) (p < 0.05) and 3DRA-LAVI (p < 0.01) were significantly associated with AF recurrence. In contrast, none of the echocardiographic parameters considered, including TTE-LAVI, was associated with AF recurrence (p = 0.29). At the multivariate analysis, 3DRA-LAVI was the only independent predictor for AF recurrence (HR 1.01 [1.00-1.03], p = 0.017). Left atrial volume measured with 3DRA is superior to TTE assessment and to AF history in predicting atrial fibrillation recurrence after PVI.