Search

Background: Patients with both atrial fibrillation (AF) and heart failure (HF) with reduced left ventricular ejection fraction (LVEF<55%) have a significantly higher risk of stroke and mortality. Improvement of LVEF has been reported in patients with AF and HF after endocardial ablation, but endocardial ablation in patients with persistent (PersAF) and longstanding persistent AF (LSPAF) has had low success in long-term freedom from atrial arrhythmias without repeat procedures. In this population, we sought to determine if a hybrid approach combining endocardial catheter ablation and epicardial surgical ablation would improve LVEF. Objective: To determine the effect of Hybrid Convergent ablation on LVEF in patients with AF. Methods: A multicenter, retrospective analysis of LVEF pre- and post- Hybrid Convergent was performed in consecutive patients with AF. LVEF was measured through 2D echocardiography. Mean baseline and post-procedure LVEF were compared by one sample t-test or Wilcoxon signed rank test. Results: Data from 158 patients, of whom 98% had PersAF/LSPAF, were included. At baseline, patients were a mean 65.7 ± 8.6 years of age, 74% male, BMI of 33 ± 5.7 kg/m2, and had a mean 6.4 ± 6.5 years history of continuous AF and approximately 27% had failed previous endocardial ablation. Patients with reduced baseline LVEF (<55%) experienced a significant improvement in LVEF versus baseline (+6.84% improved; p < 0.0001) at a mean follow up of 7.8 ± 8.7 months. The observed improvement was greatest in patients with severely reduced LVEF (<40% at baseline, +10.9% improved with mean follow-up of 9.3 ± 10.9 months, p = 0.0002). No change in LVEF was observed in patients with a normal baseline LVEF (p = 0.776). Conclusion: A significant improvement in LVEF was observed in patients with non-paroxysmal AF and reduced EF at baseline, particularly in those with severely reduced LVEF, after Hybrid Convergent ablation. [ABSTRACT FROM AUTHOR]

Background: Hybrid / Convergent (HA) ablation using surgical epicardial and catheter endocardial RF ablation improves freedom from AF in patients with persistent AF. Triggers in the left atrial appendage may contribute to recurrence of AF following catheter ablation. Objective: Assess the impact on AF recurrence following HA with LAA closure (LAAC) with the AtriClip device. Methods: Consecutive patients from 2014-2019 with persistent AF without prior ablation were treated with HA. In 2016 LAAC was added to further reduce both arrhythmia substrate and stroke risk. We assessed one-year outcomes. Recurrence was defined as clinical episode of atrial arrhythmia (AA) after a 90-day blanking period. Results: 139 patients with persistent AF without prior ablation underwent HA. 59 (48%) had HA alone, and 64 (52%) had HA with LAAC. Baseline characteristics were similar in both groups with longer AF chronicity in patients with HA plus LAAC (6.4 vs 4.6 years p=0.15). Complete LAAC was noted in 61 (95%) patients treated with LAAC. There was a trend to improved freedom from any AA in the HA with LAAC group (88% vs 76%; p=0.15). Freedom from any AA off antiarrhythmic drug was significantly improved with HA and LAAC compared to HA alone (77% vs 58%; p=0.04). LAAC patients required fewer repeat catheter ablations at 1 year (p<0.05). No strokes, or deaths were noted in either group. Conclusion: Patients with persistent AF treated with HA and LAAC using the AtriClip device had a significant reduction in AF recurrence off antiarrhythmic drug at one year. [ABSTRACT FROM AUTHOR]

Remote Magnetic Navigation (RMN) is an evolving technology, allowing operators to reduce radiation exposure in addition to providing precise catheter positioning. While many studies are available to characterize the utility of RMN in different arrhythmia subtypes, there is a paucity of literature evaluating RMN in SVT ablations. In this review, we summarize available literature, caveats and benefits of RMN in SVT ablation. [ABSTRACT FROM AUTHOR]

Background: The utility of ultra-high definition mapping (UHDM) for ablation of premature ventricular contractions (PVC) remains undetermined. The aim of this study was to investigate UHDM for PVC ablation, and additionally to compare to conventional technique. Methods: Twenty patients investigated using UHDM were prospectively included and analyzed. Electrophysiological caracteristics and results were compared to 40 patients ablated using fluoroscopy only. Results: 2541±2033 EGMs and 331±240 PVC beats were recorded for each patient. Surfaces of isochronal activations were 2.3±1.7 and 6.9±6.1 cm2 (first 10 and 20 ms). Local scar was present in 40% and local block in 65%. Areas of pace-mapping > 95, 90 and 85% concordance were 1.5±3.4, 2.1±3.9 and 3.3±5 cm2. Mean distance between the ablation site and the site of best pace-mapping or of earliest activation was 8±8 mm and 5±7 mm. Pre-potential was noted in 17% vs 26% controls (ns). QS pattern was present in 83% vs 83% controls (ns), and earliest activation was - 31±50 vs - 25±14 ms in controls (ns). Procedure (100±36 vs 190±51 min, p< 0.0001) and fluoroscopy duration (15±9 vs 24±9 min, p=0.005) were shorter in controls. Acute success was achieved in 65% patients with UHDM and in 72% controls (p=ns) with lower residual PVC burden in the control group. Over a follow-up of 19±12 months, long-term success was similar between groups (65 vs 68%). Conclusion: UHDM may reveal poorly recognized activation features and PVC mechanism. In this series, conventional mapping was quicker and did clinically as well as UHDM. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation of long-standing persistent AF (LSAF) remains challenging. Since AF-Nest (AFN) description, we have observed that a stable, protected, fast source firing, namely "Background Tachycardia"(BT), could be hidden beneath the chaotic AF. Following pulmonary vein isolation (PVI)+AFN ablation one or more BT may arise or be induced in 30-40% of patients, which could be the culprit forAF maintenance and ablation recurrences. Methods and Results: We studied 114 patients, from 322 sequential LSAF regular ablations, having spontaneous or induced residual BT after EGM-guided PVI+AFN ablation of LSAF; 55.6±11y/o, 97males (85.1%), EF=65.5±8%, LA=42.8±6.7mm. Macroreentrant tachycardias were excluded. Pre-ablationAF 12-leads ECG Digital processing(DP) and spectral analysis(SA) was performed searching for BT before AF ablation and its correlation with BT during ablation. After PVI, 38.1±9 AFN sites/patient and 135 sustained BTs (1-3, 1.2±0.5/patient) were ablated. BT cycle length(CL) was 246.3±37.3ms. In 79 patients presenting suitable DP for SA, the BT-CL was 241.6±34.3ms with intra procedure BT-CL correlation r=0.83/p<0.01. Following BT ablation, AF could not be induced. During FU of 13→60 months(22.8±12m), AF freedom for BT RF(+) vs. BT RF(-) groups were 77.9% vs. 56.4% (p=0.009), respectively. There was no significant complication. Conclusions: BT ablation following PVI and AFN ablation improved long-term outcomes ofLSAF ablation. BT is likely due to sustained microreentry, protected during AF by entry block. BT can be suspected by spectral analysis of the pre-ablation ECG and is likely one important AF perpetuator by causing electrical resonance of the AFN. This ablation strategy warrants randomized, multicenter investigation. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common arrhythmia in the population. Still there is no unity in understanding of mechanisms and their influence on catheter ablation results. In our study we tried to evaluate accurate initial quantitative indicators of electromechanical remodeling that can border patients from expected good to expected poor results of catheter ablation. We performed electroanatomical mapping and ablation procedures in 94 patient (45 female) in 2012 with 3-year follow-up period. The target points were left atria surface area, complex fragmentation atrial electrograms (CFAE) duration and surface area. We investigated primary procedure efficacy and initial preoperative patterns of patients in sinus rhythm after 3-year follow-up. Patients with paroxysmal AF had about 3-4 such areas with the median duration of fragmentation 84,5 msec and area 10,4 cm2. In persistent AF were 5-6 zones, duration of 149 msec and area 22,95 cm2. In long standing (LS) persistent AF 6-9 zones with duration up to 200 msec and area close to 30 cm2. General efficacy of radiofrequency ablation (RFA) in paroxysmal group was 58,8%, in persistent 33,3% and in LS persistent 12,9% according to Kaplan-Meyer curve with p=0,001. Retrospectively we found that every index in AF recurrence group was 1,5-2 times higher than its equivalent in sinus group. LA surface area was 131,8 cm2 vs 103,7 cm2 respectively. Median CFAE duration in AF patients was 157 msec and 87,5 msec in sinus patients. The principal index of CFAE square area was 2,5 times bigger (24,6 cm2 vs 10,3 cm2 relatively). We concluded that parameters of mechanical (LA volume and surface area) and electrical (CFAE duration and surface area) remodeling have to be defining in tactics and prognosis of catheter ablation in different types of AF. In order to achieve higher efficacy we advise to use stepwise tactic. [ABSTRACT FROM AUTHOR]

Introduction: PVI is an effective, guideline-based treatment for drug refractory symptomatic AF. Balloon cryoablation has been shown to be a safe and effective method for PVI. In the STOP-AF trial, data was produced from practitioners performing PVI with significant experience at high volume centers. This study evaluates the effectiveness and safety of treating symptomatic, drug refractory AF with PVI via cryoablation after implementation in a regional medical center. Method: This represents a retrospective analysis of outcomes after cryoablation treatment for AF in 71 patients over 354.7 +/- 164.4 days. Reported and recorded episodes of AF were categorized into a representative percent of AF "burden" for each 90 day period. Primary effectiveness and safety end points paralleled those of the STOP-AF trial. Results: Patients undergoing cryoablation had a 91% reduction of AF burden at 6 months following the procedure with an event-free survival rate of 45.5 % at a mean follow up of 12 months. The mean burden reduction was 3.21% per quarter. Anti-arrhythmic and anticoagulant medication use was reduced by 14.3% and 26.8% respectively. Significant complications included one report of pulmonary vein stenosis, one report of pseudoaneurysm and 5.5% of patients had transient pericarditis or pericardial effusion following the procedure. Conclusion: The results of this study were comparable to those of the high volume multi-center STOP-AF trial. PVI via cryoablation is a safe and effective alternative treatment of drug refractory symptomatic AF in the setting of a regional medical center. [ABSTRACT FROM AUTHOR]

This case report highlights the variety of wide complex tachycardias, and the need for their prompt management, in the growing population of patients with circulatory support devices. We present a case that demonstrates how a wide complex supraventricular tachycardia in a patient with a biventricular assist device can be safely and effectively targeted for treatment using percutaneous radiofrequency catheter ablation, allowing for clinical improvement, weaning of RVAD treatment, and discharge home with LVAD alone. [ABSTRACT FROM AUTHOR]