Incidental left atrial appendage isolation after catheter ablation of persistent atrial fibrillation: Mechanisms and long-term risk of thromboembolism.

INTRODUCTION: Incidental left atrial appendage (LAA) isolation may occur during radiofrequency ablation of persistent atrial fibrillation (AF). The study aims to describe the mechanisms and long-term thromboembolic risk related to incidental LAA isolation. METHODS: Patients who experienced incidental LAA isolation after AF ablation were included. Culprit sites where ablation resulted in LAA isolation were identified. Thromboembolic risk despite oral anticoagulation (OAC) was compared to that in a propensity-matched control group without LAA isolation. RESULTS: Forty-one patients with LAA isolation, and 82 matched patients without LAA isolation were included. The patient age, ejection fraction, LA diameter, and CHA2 DS2 -VASc score were 64 ± 11 years, 55 ± 12%, 45.0 ± 7 mm and 2.62 ± 1.5, respectively. Culprit sites included the LAA base, mitral isthmus, inferior LA, Bachmann's bundle, coronary sinus, and Marshall vein. After 4.2 ± 3.6 years follow-up, thromboembolism occurred in 7 of 41 patients (17%) with LAA isolation versus 3 of 82 patients (4%) without isolation (log rank p < .009, HR 5.14, 95% CI [1.32-19.94], p = .02). Patients with and without thromboembolism had similar CHA2 DS2 -VASc scores (2.65 ± 1.3 vs. 2.71 ± 0.76, p = .89). Thromboembolism occurred during noncompliance with or temporary discontinuation of OAC in four of the seven patients. CONCLUSIONS: Incidental LAA isolation may occur during ablation of atrial arrhythmias in the vicinity of, or even at sites remote from the appendage. Patients with incidental LAA isolation had higher rates of thromboembolism compared to patients without isolation. Since thromboembolism may occur despite prescription for OAC, the risks of LAA isolation must be weighed against clinical benefit and appendage occlusion devices should be considered in vulnerable patients.

Ventricular tachycardia targeted in the aortic sinuses of Valsalva in patients with prior myocardial infarction.

INTRODUCTION: Ventricular tachycardia (VT) in structurally normal hearts or nonischemic cardiomyopathy can originate from the aortic sinuses of Valsalva (SoV). It is unknown whether VT can originate from the SoVs in patients with prior myocardial infarction (MI). OBJECTIVE: To evaluate the prevalence, arrhythmogenic substrate, and ablation outcomes of postinfarction VT originating from the SoVs. METHODS: Among 217 consecutive patients with postinfarction VT undergoing ablation, we identified 13 (6%) patients who had ≥1 VT mapped in a SoV. Control groups of 13 patients with idiopathic SoV VT and 13 postinfarction patients without SoV VT were included. RESULTS: In the study group, 17 VTs were mapped in a SoV (right n = 5, left-right commissure n = 6, left n = 6). SoV VT target sites had low bipolar voltage during sinus rhythm [median 0.42 (IQR: 0.16-0.53) mV] which was significantly lower than target sites in patients with idiopathic SoV VTs [median 1.02 (IQR: 0.89-1.52) mV; p < .001]. An area of endocardial low voltage was found below the aortic valve in all patients with postinfarction SoV VTs compared to 9 (69%) of the patients in the postinfarction control group without SoV VT (p = .02). Morphology characteristics of postinfarction SoV VTs differed from idiopathic SoV VTs. None of the postinfarction SoV VTs were inducible after ablation and none recurred after a median follow-up of 14 months. CONCLUSION: In patients with prior MI, VT can be targeted in an aortic SoV. The SoVs should be routinely investigated in postinfarction patients with inferior axis VT and an area of low voltage below the aortic valve.

A comparison of clinical outcomes and cost of radiofrequency catheter ablation for atrial fibrillation with monitored anesthesia care versus general anesthesia.

INTRODUCTION: Monitored anesthesia care (MAC) or general anesthesia (GA) can be used during catheter ablation (CA) of atrial fibrillation (AF). However, each approach may have advantages and disadvantages with variability in operator preferences. The optimal approach has not been well established. The purpose of this study was to compare procedural efficacy, safety, clinical outcomes, and cost of CA for AF performed with MAC versus GA. METHODS: The study population consisted of 810 consecutive patients (mean age: 63 ± 10 years, paroxysmal AF: 48%) who underwent a first CA for AF. All patients completed a preprocedural evaluation by the anesthesiologists. Among the 810 patients, MAC was used in 534 (66%) and GA in 276 (34%). Ten patients (1.5%) had to convert to GA during the CA. RESULTS: Although the total anesthesia care was longer with GA particularly in patients with persistent AF, CA was shorter by 5 min with GA than MAC (p < 0.01). Prevalence of perioperative complications was similar between the two groups (4% vs. 4%, p = 0.89). There was no atrioesophageal fistula with either approach. GA was associated with a small, ~7% increase in total charges due to longer anesthesia care. During 43 ± 17 months of follow-up after a single ablation procedure, 271/534 patients (51%) in the MAC and 129/276 (47%) patients in the GA groups were in sinus rhythm without concomitant antiarrhythmic drug therapy (p = 0.28). CONCLUSION: With the participation of an anesthesiologist, and proper preoperative assessment, CA of AF using GA or MAC has similar efficacy and safety.

Arrhythmia exacerbation after post-infarction ventricular tachycardia ablation: prevalence and prognostic significance.

AIMS: Catheter ablation is an effective treatment for post-infarction ventricular tachycardia (VT). However, some patients may experience a worsened arrhythmia phenotype after ablation. We aimed to determine the prevalence and prognostic impact of arrhythmia exacerbation (AE) after post-infarction VT ablation. METHODS AND RESULTS: A total of 1187 consecutive patients (93% men, median age 68 years, median ejection fraction 30%) who underwent post-infarction VT ablation at six centres were included. Arrhythmia exacerbation was defined as post-ablation VT storm or incessant VT in patients without prior similar events. During follow-up (median 717 days), 426 (36%) patients experienced VT recurrence. Events qualifying as AE occurred in 67 patients (6%). Median times to VT recurrence with and without AE were 238 [interquartile range (IQR) 35-640] days and 135 (IQR 22-521) days, respectively (P = 0.25). Almost half of the patients (46%) who experienced AE experienced it within 6 months of the index procedure. Patients with AE had had longer ablation times during the ablation procedures compared to the rest of the patients (median 42 vs. 34 min, P = 0.02). Among patients with VT recurrence, the risk of death or heart transplantation was significantly higher in patients with than without AE (hazard ratio 1.99, 95% CI 1.28-3.10; P = 0.002) after adjusting for age, gender, ejection fraction, cardiac resynchronization therapy, post-ablation non-inducibility, and post-ablation amiodarone use. CONCLUSION: Arrhythmia exacerbation after ablation of infarct-related VT is infrequent but is independently associated with an adverse long-term outcome among patients who experience a VT recurrence. The mechanisms and mitigation strategies of AE after catheter ablation require further investigation.

Ablation of paroxysmal atrial fibrillation using a second-generation cryoballoon catheter or contact-force sensing radiofrequency ablation catheter: A comparison of costs and long-term clinical outcomes.

INTRODUCTION: Although noninferiority of cryoballoon ablation (CBA) and radiofrequency catheter ablation for antral pulmonary vein isolation (APVI) has been reported in patients with paroxysmal atrial fibrillation (PAF), it is not clear whether contact force sensing (CF-RFA) and CBA with the second-generation catheter have similar procedural costs and long-term outcomes. The objective of this study is to compare the long-term efficacy and cost implications of CBA and CF-RFA in patients with PAF. METHODS AND RESULTS: A first APVI was performed in 146 consecutive patients (age: 63 ± 10 years, men: 95 [65%], left atrial diameter: 42 ± 6 mm) with PAF using CBA (71) or CF-RFA (75). Clinical outcomes and procedural costs were compared. The mean procedure time was significantly shorter with CBA than with CF-RFA (98 ± 39 vs. 158 ± 47 minutes, P < 0.0001). Despite a higher equipment cost in the CBA than the CF-RFA group, the total procedure cost was similar between the two groups (P = 0.26), primarily driven by a shorter procedure duration that resulted in a lower anesthesia cost. At 25 ± 5 months after a single ablation procedure, 51 patients (72%) in the CBA, and 55 patients (73%) in the CF-RFA groups remained free from atrial arrhythmias without antiarrhythmic drug therapy (P = 0.84). CONCLUSIONS: The procedure duration was approximately 60 minutes shorter with CBA than CF-RFA. The procedural costs were similar with both approaches. At 2 years after a single procedure, CBA and CF-RFA have similar single-procedure efficacies of 72-73%.

Value of Cardiac Magnetic Resonance Imaging in Patients With Failed Ablation Procedures for Ventricular Tachycardia.

BACKGROUND: Ventricular tachycardia (VT) in patients with cardiomyopathy originates in scar tissue. Intramural or epicardial scar may result in ineffective ablation if mapping and ablation are limited to the endocardium. The purpose of this study was to investigate whether preprocedural magnetic resonance imaging (MRI) is beneficial in patients with failed endocardial VT ablations in determining an appropriate ablation strategy. METHODS AND RESULTS: A cardiac MRI was performed in 20 patients with a failed ablation procedure and cardiomyopathy (nonischemic n = 12, ischemic n = 8). A subsequent ablation strategy was determined by a delayed enhanced MRI (DE-MRI) and an epicardial subxyphoid access was planned only in patients with epicardial or intramural free-wall scar. MRIs were performed in all patients with or without an implanted cardioverter defibrillator (ICD). The location of scar tissue in the MRI predicted the origin of VT in all patients. In 9/20 patients an epicardial procedure was performed based on the result of the MRI. An endocardial procedure was performed in the remaining 11 patients who had either endocardial or septal scarring and one patient in whom the MRI only showed artifact. Five patients remained inducible postablation and four patients had VT recurrence within a follow-up period of 17 ± 22 months. All of the latter patients had an intramural scar pattern. CONCLUSIONS: Imaging with DE-MRI prior to VT ablation in patients with previously failed endocardial ablation procedures is beneficial in identifying an ablation strategy, helps to focus on an area of interest intraprocedurally, and provides valuable outcomes information.

Infrequent intraprocedural premature ventricular complexes: implications for ablation outcome.

BACKGROUND: Frequent premature ventricular complexes (PVCs) can be eliminated with an ablation procedure. Ablation success rates have been reported to be in the 80% range. Reasons for failure of ablation have not been described in detail. The purpose of this study was to determine whether the paucity of PVCs at the beginning of the ablation procedure affects the outcome. METHODS: Catheter ablation was attempted in a consecutive series of 194 patients (age: 50 ± 14 years, 91 male, ejection fraction: 56.4 ± 8.4%) with frequent idiopathic PVCs. Based on receiver operator characteristics (ROC) analysis, patients were divided into 2 groups: Patients with frequent PVCs (≥32 PVCs within the first 30 minutes of the procedure: n = 135 [70%]); and patients with infrequent PVCs (<32 PVCs within the first 30 minutes of the procedure: n = 59 [30%]). Procedural outcomes were compared at 3 months postablation. A successful ablation was defined as a ≥80% reduction in the PVC burden compared to baseline. RESULTS: A successful procedure was performed in 148 patients (76%) resulting in a decrease in the PVC burden from 19.1 ± 13.6% to 0.38 ± 0.98%(P < 0.0001). Patients with frequent intraprocedural PVCs had a higher success rate than patients with infrequent intraprocedural PVCs (85% vs. 56%, P = 0.0001). Administration of sedation was no different in the 2 groups. The paucity of PVCs was independent of the site of origin in predicting procedural failure (OR: 6.9, 95% CI: 3.0-16.2 P = 0.0001). CONCLUSION: Paucity of PVCs at the beginning of an ablation procedure is associated with a lower ablation success rate independent of the site of origin.

Anatomic relationships between the coronary venous system, surrounding structures, and the site of origin of epicardial ventricular arrhythmias.

BACKGROUND: Epicardial left ventricular (LV) idiopathic ventricular arrhythmias (VAs) can be approached via the pericardial space, the coronary venous system (CVS), or other surrounding structures. The anatomic relationships between epicardial sites of origin (SOO) of VAs and surrounding anatomic structures have not been systematically described. METHODS AND RESULTS: In 17 patients with idiopathic epicardial VAs, the relationships between the SOO and the CVS and other neighboring anatomic structures were assessed by computed tomographic angiography. Ablation was successful in 12/17 patients (71%). In 10/17 patients, the SOO was at a distance of ≤4 mm from a coronary artery. The SOO was closer to the CVS (2.1 ± 1.5 mm) than to the pericardial space (9.7 ± 3.7 mm) or the LV endocardium (7.7 ± 2.7 mm). Successful ablations were carried out from the CVS (n = 3), the CVS and LV endocardium (n = 5), the CVS and the aortic cusp (n = 1), the CVS, the LV endocardium, and the aortic cusp (n = 1), the LV endocardium (n = 1), and the CVS and the pericardial space (n = 1). In the remaining 5 patients, a subxyphoid pericardial ablation procedure was attempted and failed in all 5 patients. CONCLUSION: The CVS is closer to the SOO of epicardial idiopathic VAs than the pericardial space, the ventricular endocardium, and the aortic cusps. Given the proximity to coronary arteries at the SOO, radiofrequency energy often cannot be safely delivered to eliminate a VA and ablation may also need to be performed from adjacent structures. A subxyphoid pericardial ablation procedure has a low probability of success in patients with idiopathic epicardial VAs.

Predictors of outcome after catheter ablation of premature ventricular complexes.

BACKGROUND: The purpose of this study was to assess how well acute procedural outcomes predict the clinical outcome of catheter ablation of premature ventricular complexes (PVCs). METHODS: A consecutive series of 50 patients (28 women, age: 51 ± 13 years) with frequent PVCs was referred for PVC ablation. Acute failure was defined as inability to eliminate the predominant PVC or recurrence of the predominant PVC within 12 hours. The PVC burden was reassessed 3 months after the ablation procedure. A successful procedure was defined as reduction of the PVC burden at 3 months by ≥80% of the initial burden. RESULTS: The procedure was acutely effective in 37 patients (74%) and at 3 months in 40 patients (80%). The presence or absence of the predominant PVC in the 12 hours postablation had the highest accuracy for outcome at 3 months (accuracy: 90%). From among the 13/50 patients (26%) with evidence of acute failure, 4 had a PVC reduction of ≥80% at 3 months and 10 had a PVC reduction of >50% resulting in symptomatic improvement at 3 months. CONCLUSION: The presence or absence of the predominant PVC within 12 hours postablation best correlated with the 3-month-efficacy data. Recurrence of the predominant PVC shortly after ablation did not indicate a procedural failure and the necessity for a repeat procedure. The majority of these patients had a significant, clinically meaningful reduction in their PVC burden. Acute predictors for procedural outcome at 3 months have a high positive but rather low negative predictive value.

Posterior left atrial isolation is associated with a lower incidence of atrial tachycardia in patients with persistent atrial fibrillation.

BACKGROUND: Patients may develop atrial tachycardia (AT) after left atrial (LA) ablation of persistent atrial fibrillation (AF). METHODS: The population consisted of 101 consecutive patients (age = 64.3 ± 8.7 years, 70 males (69%), LA = 4.6 ± 0.8 cm, ejection fraction = 48.5 ± 16%) undergoing their initial procedure for persistent AF. After pulmonary vein isolation, patients either underwent posterior LA isolation (n = 50; study group) or linear ablation at the LA roof with verification of conduction block (n = 51; control group). RESULTS: A repeat procedure was performed in 17 (34%) and 28 (55%) patients in the study and control groups, respectively (p = 0.02). Patients in the study group were less likely to develop AT (9/50 [18%] vs. 18/51 [35%]; p = 0.02), roof-dependent (1/50 [2%] vs. 8/51 [16%]; p = 0.008), and multi-loop AT (6/50 [12%] vs. 14/51 [27%]; p = 0.03) as compared to controls. Among various factors, only posterior LA isolation was associated with a lower likelihood of AT recurrence and roof tachycardia at redo procedure (OR, 0.37; 95% CI, 0.1 to 1.00, p = 0.05, and OR, 0.1, 95% CI, 0.01 to 0.96; p < 0.05, respectively). CONCLUSIONS: In patients with persistent AF, posterior LA isolation is associated with a lower risk of a redo procedure, roof-dependent macro-reentry, and post-ablation AT in general as compared to controls who only received roof ablation. Posterior LA isolation also obviates the need for pacing maneuvers, and may be a more definitive endpoint than linear ablation at the LA roof.

Pleomorphism of premature ventricular complexes originating from papillary muscles and their myocardial connections.

BACKGROUND: Patients with arrhythmias originating from papillary muscles (PAPs) often have pleomorphic ventricular arrhythmias (PVAs) that can result in failed ablations. The mechanism of PVAs is unknown. OBJECTIVE: The purpose of this study was to assess the prevalence and mechanisms of PVAs and the impact on outcomes in patients with focal left ventricular PAP ventricular arrhythmias (VAs). METHODS: The sites of origin (SOOs) of VAs in 43 consecutive patients referred for ablation of focal left ventricular PAP VAs were determined by activation and pacemapping. SOOs were classified as (1) unifocal generating a single VA morphology; (2) unifocal from a deeper-seated origin generating multiple VA morphologies; (3) unifocal located on a PAP branching site; (4) multifocal from a single or multiple PAPs generating multiple VA morphologies; and (5) multifocal from a PAP and a different anatomic source. RESULTS: Most patients had multiple morphologies (n = 34 [79%]) and multiple mechanisms (79%) generating the different VA morphologies. Most of the patients with PVAs had multiple SOOs from a single or different PAPs (n = 23 [68%]), followed by patients with SOOs from PAP and non-PAP sites (n = 19 [56%]). In 13 patients (38%), single SOOs accounted for the observed PVAs. The frequent observation (n = 20) of changing QRS morphologies after radiofrequency energy delivery targeting a single VA suggests the presence of a deeper focus with changing sites of preferential conduction. CONCLUSION: VA pleomorphism in patients with PAP arrhythmias is most often due to premature ventricular complexes originating from different SOOs. The second most common cause is preferential conduction from a single SOO via PAP branching sites.

Implications of the anatomy of papillary muscle connections for mapping and ablation of focal ventricular arrhythmias.

BACKGROUND: Ventricular arrhythmias (VAs) originating from papillary muscles (PAPs) can be challenging when targeted with catheter ablation. Reasons may include premature ventricular complex pleomorphism, structurally abnormal PAPs, or unusual origins of VAs from PAP-myocardial connections (PAP-MYCs). OBJECTIVE: The purpose of this study was to correlate PAP anatomy with mapping and ablation of PAP VAs. METHODS: In a series of 43 consecutive patients with frequent PAP arrhythmias referred for ablation, the anatomy and structure of PAPs and VA origins were analyzed using multimodality imaging. Successful ablation sites were analyzed for location on the PAP body or a PAP-MYC. RESULTS: In a total of 17 of 43 patients (40%), VAs originated from a PAP-MYC (in 5 of 17 patients, the PAP inserted into the mitral valve anulus); and in 41 patients, VAs originated from a PAP body. VAs from a PAP-MYC more often had delayed R-wave transition than did other PAP VAs (69% vs 28%; P < .001). Patients with failed procedures had more PAP-MYCs (24.8 ± 8 PAP-MYCs per patient vs 16 ± 7 PAP-MYCs per patient; P < .001). CONCLUSION: Multimodality imaging identifies anatomic details of PAPs that facilitate mapping and ablation of VAs. In more than a third of patients with PAP VAs, VAs originate from connections between PAPs and the surrounding myocardium or between other PAPs. VA electrocardiographic morphologies are different when VAs originate from PAP-connection sites as compared with VAs originating from the PAP body.

Intra-atrial conduction block mimicking atrioventricular nodal block after multiple catheter ablation procedures for atrial tachycardia in a patient with cardiomyopathy.

A 42-year-old woman with a history of cardiomyopathy and multiple ablation procedures for atrial tachycardia developed intra-atrial conduction block that mimicked atrioventricular (AV) nodal block during radiofrequency ablation at the cavotricuspid isthmus. She was treated with atrial pacing (from the coronary sinus), which overcame intra-atrial conduction block and resulted in AV nodal conduction.

Role of imaging in ablation therapy of ventricular arrhythmias. Focus on cardiac magnetic resonance imaging.

Cardiac magnetic resonance imaging (MRI) has a central role in the management of patients with ventricular arrhythmias. Cardiac MRIs help to identify patients with risk for life-threatening arrhythmias. Delayed enhancement identifies scar tissue within the heart. Because scar harbors the arrhythmic substrate in patients with structural heart disease, areas of delayed enhancement can be targeted in order to eliminate ventricular arrhythmias with catheter ablation procedures. In this article, we will discuss the role of MRI in diagnosing different forms of non-ischemic cardiomyopathy and its role in risk stratification. Furthermore, we will discuss the role of MRI in imaging of the arrhythmogenic substrate in patients with structural heart disease.

Presence of structural heart disease and left ventricular dysfunction predict hospitalizations for new-onset heart failure after right ventricular apical pacing.

AIMS: Long-standing right ventricular apical pacing (RVAP) may result in impaired left ventricular (LV) function and systolic heart failure (HF) in selected patients. However, which patients are susceptible to those harmful effects is unknown. METHODS AND RESULTS: In 367 consecutive patients undergoing pacemaker implantations (PMIs) and RVAP, the clinical, laboratory, and echocardiographic data before the PMIs, electrocardiographic parameters [baseline and paced QRS duration (QRSd)], and echocardiography were analysed. The cumulative per cent of those ventricularly paced (Cum%VP) was >90% in all subjects. During a mean follow-up period of 113±69 months, the occurrence of HF requiring hospitalization for the intravenous administration of HF medications was found in 60 patients (16%; HF group), but not in the remaining 307 (84%; no-HF group). The prevalence of structural heart disease (SHD; P<0.0001), cardiothoracic ratio (P<0.0001), baseline left atrial size (P=0.0001), LV end-diastolic volume (P<0.005) and end-systolic volume (P<0.0005), LV mass index (P<0.001), and baseline and paced QRSd (both for P<0.001) were greater in the HF group than in the no-HF group. Inversely, the LV ejection fraction (LVEF) in the HF group was smaller than that in the no-HF group (P<0.001). The multivariate Cox regression analysis revealed that the presence of SHD [hazard ratio (HR)=3.12; 95% confidence interval (CI), 1.7-5.7; P<0.001] and the LVEF (<40%; HR=2.57; 95% CI, 1.09-6.07; P<0.05) were associated with hospitalizations due to HF after RVAP. CONCLUSION: The presence of SHD and an impaired LV systolic function before the PMI may predict hospitalizations due to HF after RVAP.

Comparison of the point-by-point versus catheter dragging technique for curative radiofrequency ablation of atrial fibrillation.

BACKGROUND: The relationship between the applied techniques and clinical outcomes after radiofrequency (RF) ablation of atrial fibrillation (AF) remains unclear. We compared the results of ablation by RF delivered via a point-by-point versus catheter dragging technique for the treatment of AF. METHODS: This study included 66 patients with drug-refractory AF who underwent circumferential pulmonary vein (PV) ablation. A point-by-point technique was used in 35 (53%) patients (Group I), and catheter dragging technique in the remaining 31 (47%) patients (Group II). If AF persisted or remained inducible after the PV isolation, additional ablation of complex fractionated atrial electrograms and linear ablation were performed. RESULTS: Significantly, fewer RF applications were delivered in Group II than in Group I. The total RF energy duration delivered was comparable between the two groups (P = 0.55). However, the total energy of RF deliveries was significantly greater in Group II than in Group I (P = 0.02). Despite a longer fluoroscopic exposure time (P = 0.01), the total procedural duration was significantly shorter in Group II than in Group I (P = 0.005). Within 3 months after a single ablation procedure, 24 patients (69%) in Group I versus 13 patients (42%) in Group II had ≥1 recurrence(s) of atrial tachyarrhythmias (P = 0.03). A multivariate analysis showed that a point-by-point ablation was the only independent predictor of early atrial tachyarrhythmia recurrences. CONCLUSIONS: The catheter dragging technique for ablation of AF was associated with a lower early recurrence rate of atrial tachyarrhythmias than the point-by-point technique.

Clinical significance of myocardial scar in patients with frequent premature ventricular complexes undergoing catheter ablation.

BACKGROUND: Frequent premature ventricular complexes (PVCs) can result in PVC-induced cardiomyopathy (PICM). Scarring has been described in patients with frequent PVCs in the absence of apparent heart disease and in patients with known cardiomyopathy. OBJECTIVE: The purpose of this study was to determine the impact of focal myocardial scarring as detected by cardiac magnetic resonance imaging (CMR) on PICM, procedural outcomes, and recovery of left ventricular function in patients with frequent PVCs. METHODS: A total of 351 consecutive patients (181 men; age 53 ± 15 years; ejection fraction [EF] 51% ± 12%) with frequent PVCs referred for ablation were included. CMR was performed in all patients before the ablation procedure. A ≥10% increase in EF or normalization of a previously abnormal EF was defined as evidence of PICM. RESULTS: Myocardial scarring was present in 134 of 351 patients (38%); 66 of 134 patients (49%) with scarring and 54 of 217 patients (25%) without scarring had improvement or normalization of EF after ablation. The presence of myocardial scarring, PVC burden >22%, male sex, asymptomatic status, and PVC QRS width >150 ms were associated with PICM by univariate analysis (P <.01 for all). The presence of scar was independently associated with PICM (odds ratio 2.2; 95% confidence interval 1.3-3.7; P <.005). The success rate of PVC ablation was lower in patients with scarring than in patients without focal scarring (mean 70% vs 82%; P <.01). CONCLUSION: Focal scar defined by CMR is independently associated with PICM. Although ablation outcomes are worse in the presence of scarring, EF recovery can occur in most of these patients after ablation.

Catheter ablation of the left and right atrial appendages without isolation in persistent atrial fibrillation.

BACKGROUND: Electrical isolation of the left atrial appendage (LAA) improves outcomes of patients with persistent atrial fibrillation (AF) but may increase the risk of thromboembolism. OBJECTIVE: The purpose of this study was to describe a method to map and ablate appendage drivers without complete electrical isolation. METHODS: One hundred thirteen patients underwent an ablation procedure for persistent AF. The procedure was performed during AF and consisted of pulmonary vein and posterior LA isolation as well as ablation of the LAA. The right atrium (RA) was targeted in patients with a right-to-left gradient in cycle length (CL). The end point of appendage ablation was CL slowing or AF termination but not complete isolation. RESULTS: Among the 113 patients (mean age 64.6 ± 8.6 years; ejection fraction 54% ± 13%; LA diameter 46 ± 6.5 mm), radiofrequency ablation terminated AF in 51 patients (45%). RA ablation was performed in 41 patients (36%) at the index or repeat procedure. The mean AF CL in the RA appendage (RAA) was shorter than that in the LAA (160 ± 32 ms vs 186 ± 29 ms; P < .01) in these patients. The most frequent target in the RA was the RAA (CLs approaching 50-60 ms). Discontinuing radiofrequency ablation upon AF termination or conduction slowing prevented LAA isolation. After a mean follow-up of 24 ± 15 months, 89 patients (78%) remained arrhythmia-free without antiarrhythmic medications. CONCLUSION: An ablation strategy guided by the AF CL addresses LAA drivers without complete electrical isolation and also helps identify the RAA as a source of persistent AF.

Neurally mediated syncope as a cause of syncope in patients with Brugada electrocardiogram.

INTRODUCTION: Patients with type 1 Brugada electrocardiogram (ECG) and an episode of syncope are diagnosed as symptomatic Brugada syndrome; however, all episodes of syncope may not be due to ventricular tachyarrhythmia. METHODS AND RESULTS: Forty-six patients with type 1 Brugada ECG (all males, 51 +/- 13 years, 29 spontaneous, 17 Ic-drug induced), 20 healthy control subjects (all males, 35 +/- 11 years), and 15 patients with suspected neurally mediated syncope (NMS; 9 males, 54 +/- 22 years) underwent the head-up tilt (HUT) test. During the HUT test, 12-lead ECGs were recorded in all patients, and the heart rate variability was investigated in some patients. Sixteen (35%) of 46 patients with Brugada ECG, 2 (10%) of 20 control subjects, and 10 (67%) of 15 patients with suspected NMS showed positive responses to the HUT test. Although no significant differences were observed in HUT-positive rate among Brugada patients with documented VT (7/14; 50%), syncope (5/19; 26%) and asymptomatic patients (4/13; 31%), the HUT-positive rate was significantly higher in patients with documented VT (50%) and those with VT or no symptoms (11/27, 41%) compared to that in control subjects (10%) (P < 0.05). Augmentation of ST-segment amplitude (> or =0.05 mV) in leads V1-V3 was observed in 11 (69%) of 16 HUT-positive patients with Brugada ECG during vasovagal responses, and was associated with augmentation of parasympathetic tone following sympathetic withdrawal. CONCLUSION: Thirty-five percent of patients with Brugada ECG showed vasovagal responses during the HUT test, suggesting that some Brugada patients have impaired balance of autonomic nervous system, which may relate to their syncopal episodes.

Thickening of the left atrial wall shortly after radiofrequency ablation predicts early recurrence of atrial fibrillation.

BACKGROUND: Inflammatory responses following atrial fibrillation (AF) ablation may aggravate arrhythmogenic activity and cause an early recurrence of AF (ERAF). METHODS AND RESULTS: In 56 patients who underwent circumferential pulmonary vein ablation (CPVA) for paroxysmal AF, cardiovascular magnetic resonance imaging (CMRI) was evaluated in 5 subdivided left atrial (LA) regions before the CPVA and at 1 day and 1 month after. At a mean of 7+/-10 days after the CPVA, 23 patients (41%) developed 1 or more episodes of AF (ERAF group), while 33 patients (59%) remained free from AF during the first month of follow up (no-ERAF group). LA wall thickness increased 1 day after the CPVA in both groups, as demonstrated by high T2-weighted signal. The LA roof thickness and its increase, however, were greater in the ERAF group than in the no-ERAF group (P<0.05). Regions of delayed enhancement (DE) were also frequently detected in both groups, but the total number of DE regions did not differ between the 2 groups. The thickening of the LA wall associated with a high T2-weighted signal resolved within 1 month. No significant difference between the 2 groups was found in any of the CMRI parameters before or 1 month after CPVA. CONCLUSIONS: Thickening of the LA roof shortly after CPVA may predict an ERAF.