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A 60-year-old male patient suffered from frequent episodes of atrial tachycardia (AT), after the index procedure of catheter ablation for paroxysmal atrial fibrillation. During the repeat procedure, the activation map showed that the earliest activation site was located at the roof of left atrium. Multiple ablations at the earliest activation site on the roof failed to terminate the AT; however, ablation within the pulmonary artery at an adjacent anatomical site successfully eliminated the AT, even without recording distinct near-field potential., (© 2024 Wiley Periodicals LLC.)

Competing Interests: Funding Support and Author Disclosures This study was supported by the National Natural Science Foundation of China (No. 81970273, 82000312, 82000375), the Clinical Research Plan of Shenkang Hospital Development Center of Shanghai (No. SHDC2020CR4009, SHDC2020CR6012), the Shanghai Pujiang Program (21PJD057), and the Clinical Research Plan of Shanghai Municipal Health Commission (No. 202040461). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Background: Ablation index (AI), a novel lesion quality marker, includes contact force, time, and power of radiofrequency (RF) application, but not regional variation in wall thickness within the wide antral catheter ablation (WACA) circle. This study explored the relationships among AI target value, atrial wall thickness, and gap formation within the WACA circle in patients with paroxysmal atrial fibrillation (PAF)., Methods: We evaluated 102 consecutive patients (mean age, 65 ± 9 years) with PAF who underwent AI-guided WACA for ipsilateral pulmonary vein isolation (PVI). Each WACA circle was subdivided into eight segments, and overall 7143 RF applications were delivered, including 125 gaps in PVI ablation lines. For each RF tag within the ablation circle, we collected data on ablation lesion depth surrogates (time of application, delivery power, impedance drop, average contact force, force-time integral [FTI], and AI) and left atrial wall thickness measured by multidetector computer tomography scanning., Results: The anterior and roof walls were the thickest segments of the ablation circle, in which 85.8% of gaps concentrated, while the posterior and inferior walls were the thinnest. Gap formation was significantly associated with FTI, AI, wall thickness, FTI/wall thickness, and AI/wall thickness. AI/wall thickness had the highest predictive value for gap formation, with a cutoff of 195.6 au/mm for effective ablation., Conclusions: In AI-guided PVI of PAF, AI/wall thickness by normalizing myocardial thickness variation along the WACA circle was a strong predictor of gap formation, with a target of 195.6 au/mm appearing suitable for effective ablation., (© 2020 Wiley Periodicals LLC.)

Introduction: Left atrial posterior wall (LAPW) isolation may be performed as an additional atrial fibrillation (AF) ablation strategy based on pulmonary vein isolation. A modified posterior-inferior line (MPL) was proposed for reducing esophageal injury. The aim of this study was to evaluate the anatomical characteristics of the MPL, compared with the conventional posterior line (CPL)., Methods and Results: Multidetector computed tomography was performed in 102 consecutive AF patients (male/female = 60/42) preoperative, and the parameters were evaluated as follows: the distance from MPL and CPL to the esophagus, fat pad presence and thickness in the course of MPL and CPL, and the esophageal route below CPL. The average distance from the MPL to the esophagus was longer than from CPL to the esophagus (3.7 ± 1.5 vs. 1.7 ± 0.4 mm, p < .001). Proportion of fat pad was higher in the course of MPL than CPL. The myocardium tissue and fat pad under MPL was thicker than under CPL (2.9 ± 1.1 vs. 1.6 ± 0.3 mm, p < .001; 1.4 ± 0.6 vs. 0.9 ± 0.2 mm, p < .001), respectively. In patients whose esophagus was unconfined in a triangular space at the left inferior pulmonary vein level, the average distance from MPL to esophagus was longer than the confined patients (4.0 ± 1.7 vs. 3.2 ± 1.0 mm, p = .001)., Conclusion: The MPL was far away from the esophagus with thicker myocardium tissue and more fat pad than the CPL; thus, MPL could serve as a favorable alternative in linear ablation for LAPW isolation., (© 2020 Wiley Periodicals LLC.)

Background: Data on the incidence, clinical characteristics, and implications of acute conduction recurrence during mitral isthmus (MI) ablation are scarce., Methods: MI ablation was performed in patients with atrial fibrillation. After confirming bidirectional conduction block, the acute conduction recurrence of MI was systematically evaluated. Clinical and electrophysiological characteristics were analyzed., Results: A total of 66 consecutive patients in whom bidirectional conduction block of MI was achieved were prospectively enrolled in a single center. Acute conduction recurrence of MI developed in 12 (18.2%) patients within 14.2 ± 11.5 minutes after the confirmation of bidirectional conduction block. There were two recurrent conduction breakthrough sites of MI along the course of the great cardiac vein (4.5 ± 3.5 min) in two patients and 11 along the course of the ligament of Marshall (LOM) (16.0 ± 11.6 min, P = .035) in 11 patients. LOM accounted for most (84.6%, 11/13) acute MI conduction recurrence. MI length, total ablation time, and procedure time for MI were greater in patients with acute conduction recurrence than in those without acute conduction recurrence. During follow-up, arrhythmia recurrences were less observed in patients with acute conduction when compared to patients without acute conduction recurrence (0% vs 26.4%, P = .055)., Conclusion: Acute conduction recurrence, predominantly due to recurrent LOM conduction, was a common phenomenon during MI ablation, and its evaluation should therefore be the focus to improve MI ablation efficacy and durability., (© 2020 Wiley Periodicals LLC.)

Aims: The mechanisms of the QRS complex axis deviation changing of idiopathic left fascicular ventricular tachycardia (FVT) during or after radiofrequency catheter ablation were investigated in this study, which were still not well defined., Methods and Results: In the index procedure, FVTs characterized by right bundle branch block configuration and left-axis deviation (LAD-FVT) were ablated at the VT exit site guided by the earliest ventricular activation with fused presystolic Purkinje potential (PP) in 234 consecutive patients. A new type of FVT characterized by right-axis deviation (RAD-FVT) was identified after successful elimination of the LAD-FVT in 12 patients, including 9 patients during the index procedure and 3 patients during follow-up. The QRS duration of RAD-FVT was shorter than that of LAD-FVT (115.3 ± 15.2 vs. 125.3 ± 16.4 ms, P = 0.006). The RAD-FVTs showed an earliest ventricle activation site localized at anterior fascicle area in 11 patients and anterior-median fascicle area in 1. However, the earliest PP during the RAD-FVT was still identified within the posterior fascicular network. Elimination of the RAD-FVTs was successfully achieved by applying radiofrequency current at a more proximal site within the left posterior fascicular network guided by the earliest PP. After a mean of 1.6 ± 0.8 ablation procedures and median follow-up of 132 (range 19-216) months since the last procedure, no recurrence was observed in any patients., Conclusion: The axis deviation changing of QRS complex in FVT may be attributed to the different exit sites of the reentry., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aim: To evaluate the clinical safety and efficacy of radiofrequency catheter ablation for atrial fibrillation (AF) in patients aged ≥80 years., Methods: A total of 333 AF patients aged ≥60 years were enrolled, who underwent contact force-guided radiofrequency catheter ablation with uninterrupted anticoagulation. All patients were followed-up for at least 12 months. Success was defined by the absence of episodes of AF/atrial tachycardia lasting more than 30 seconds after a 3-month blanking period, without antiarrhythmic drugs., Results: Compared to patients aged 60-79 years (Group 2, n = 244), patients aged ≥80 years (Group 1, n = 89) were presented with higher rate of diabetes (36.0% vs 22.1%, P = .011), lower body mass index (23.4 ± 3.1 vs 24.9 ± 3.4 kg/m 2 , P = .001), lower creatinine clearance (56.9 ± 16.5 vs 83.3 ± 24.5 mL/min, P < .001), higher CHA 2 DS 2 -VASc score (4.3 ± 1.3 vs 3.3 ± 1.4, P < .001), and HAS-BLED score (2.2 ± 0.8 vs 1.8 ± 0.8, P < .001). Wide antral pulmonary vein isolation was achieved in all patients, and there was no significant difference in procedure time, ablation time, fluoroscopy time, and complications rate between two age groups (P > .05). After a mean follow-up of 24.4 ± 9.6 months, the overall success rate was 78.2% in Group 1 and 78.9% in Group 2 (P = .622)., Conclusions: Radiofrequency ablation with contact force sensing catheters for AF is safe and effective in selected patients aged ≥80 years., (© 2020 Wiley Periodicals LLC.)

Aims: Mitral isthmus (MI) ablation is challenging. We hoped to close those conduction breakthrough sites (CBS) across the MI by elaborate mapping., Methods and Results: After the initial linear ablation, elaborately mapping large areas above and below the MI line and inside the coronary sinus (CS) was sequentially performed to identify the CBS. The shortest distance from the CBS to the MI line was measured. The distant CBS (D-CBS) was identified as those CBS >5.0 mm away from the MI line. We prospectively enrolled 177 consecutive patients. Bidirectional conduction blockage across MI was obtained in 50 (28.2%) patients after the initial linear ablation and was achieved in additional 115 (65.0%) patients following elaborate mapping and reinforcement ablation. After initial linear ablation, 272 CBS (2.14 ± 0.99 CBS/person) were identified, and 226 (83.1%) of them were characterized as D-CBS, including 98 sites (36.0%) >10.0 mm and 39 sites (14.3%) >15.0 mm away. Endocardial and epicardial (CS) reinforcement ablation eliminated 119/272 (43.8%) and 58/272 (21.3%) CBS, respectively. Among the 177 eliminated CBS, 138 D-CBS (78.0%, 11.2 ± 5.6 mm) were confirmed in 95 (74.8%) patients. Moreover, CBS along the course of ligament of Marshall was closed by endocardial ablation more frequently than that along the course of great cardiac vein (52.6%% vs. 35.1%, P = 0.004). Eventually, CS ablation was required only in 64 (38.8%) patients., Conclusion: Distant CBS, accounted for the majorities of the residual conduction across the MI after initial ablation, could be effectively identified and accurately eliminated by elaborate mapping and ablation around the MI ablation line., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Endovenous laser ablation is an established alternative to surgery with stripping for the treatment of varicose veins. Ecchymoses and pain are frequently reported side effects of endovenous laser ablation. Device-related complications are rare but serious. We describe here an exceptional complication, necessitating an additional surgical procedure to remove a segment of laser fiber that had migrated into the pelvic cavity. Fortunately, severe damage had not occurred. This case highlights the importance of checking the completeness of the guidewire, catheter, and laser fiber after endovenous laser ablation., (© The Author(s) 2014.)

Aims: The mechanisms of the QRS complex axis deviation changing of idiopathic left fascicular ventricular tachycardia (FVT) during or after radiofrequency catheter ablation were investigated in this study, which were still not well defined.Methods and Results: In the index procedure, FVTs characterized by right bundle branch block configuration and left-axis deviation (LAD-FVT) were ablated at the VT exit site guided by the earliest ventricular activation with fused presystolic Purkinje potential (PP) in 234 consecutive patients. A new type of FVT characterized by right-axis deviation (RAD-FVT) was identified after successful elimination of the LAD-FVT in 12 patients, including 9 patients during the index procedure and 3 patients during follow-up. The QRS duration of RAD-FVT was shorter than that of LAD-FVT (115.3 ± 15.2 vs. 125.3 ± 16.4 ms, P = 0.006). The RAD-FVTs showed an earliest ventricle activation site localized at anterior fascicle area in 11 patients and anterior-median fascicle area in 1. However, the earliest PP during the RAD-FVT was still identified within the posterior fascicular network. Elimination of the RAD-FVTs was successfully achieved by applying radiofrequency current at a more proximal site within the left posterior fascicular network guided by the earliest PP. After a mean of 1.6 ± 0.8 ablation procedures and median follow-up of 132 (range 19-216) months since the last procedure, no recurrence was observed in any patients.Conclusion: The axis deviation changing of QRS complex in FVT may be attributed to the different exit sites of the reentry. [ABSTRACT FROM AUTHOR]

Aims: Mitral isthmus (MI) ablation is challenging. We hoped to close those conduction breakthrough sites (CBS) across the MI by elaborate mapping.Methods and Results: After the initial linear ablation, elaborately mapping large areas above and below the MI line and inside the coronary sinus (CS) was sequentially performed to identify the CBS. The shortest distance from the CBS to the MI line was measured. The distant CBS (D-CBS) was identified as those CBS >5.0 mm away from the MI line. We prospectively enrolled 177 consecutive patients. Bidirectional conduction blockage across MI was obtained in 50 (28.2%) patients after the initial linear ablation and was achieved in additional 115 (65.0%) patients following elaborate mapping and reinforcement ablation. After initial linear ablation, 272 CBS (2.14 ± 0.99 CBS/person) were identified, and 226 (83.1%) of them were characterized as D-CBS, including 98 sites (36.0%) >10.0 mm and 39 sites (14.3%) >15.0 mm away. Endocardial and epicardial (CS) reinforcement ablation eliminated 119/272 (43.8%) and 58/272 (21.3%) CBS, respectively. Among the 177 eliminated CBS, 138 D-CBS (78.0%, 11.2 ± 5.6 mm) were confirmed in 95 (74.8%) patients. Moreover, CBS along the course of ligament of Marshall was closed by endocardial ablation more frequently than that along the course of great cardiac vein (52.6%% vs. 35.1%, P = 0.004). Eventually, CS ablation was required only in 64 (38.8%) patients.Conclusion: Distant CBS, accounted for the majorities of the residual conduction across the MI after initial ablation, could be effectively identified and accurately eliminated by elaborate mapping and ablation around the MI ablation line. [ABSTRACT FROM AUTHOR]