Figure 1 - available from: Journal of Interventional Cardiac Electrophysiology
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Classification of PV anatomy. a Separate ostia of left-sided and right-sided PVs. b Common trunk of left-sided PVs (defined as joint part of superior and inferior PVs of >5 mm, before entering left atrium). c Additional right-sided PV (defined as supranumerary vein directly entering left atrium)
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PurposeLeft atrial volume (LA) and pulmonary vein (PV) anatomy may potentially relate to technical challenges in achieving stable and effective catheter position in case of atrial fibrillation (AF) ablation by means of “one-shot” catheters. The aim of this study was to investigate whether LA volume and PV anatomy, evaluated by computed tomography (...
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Background
The single procedure success rates of durable pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) varies between 80 and 90%. Ablation index, incorporating contact force, stability, time and power is a more profound parameter of significant lesion size and has been established. Equally important is a stringent contigui...
Catheter ablation is the most effective treatment for atrial fibrillation (AF). Electrical pulmonary veins isolation (PVI) forms the cornerstone ablation strategy. Radiofrequency (RF) in combination with 3D mapping system is the traditional ablation approach to treat AF. As a single-shot ablation system, cryoballoon (CB) has been an established abl...
Catheter ablation is the most effective treatment option for patients suffering from symptomatic atrial fibrillation. Electrical isolation of the pulmonary veins is the procedural cornerstone. Point-by-point radiofrequency current energy ablation in combination with a 3D electro-anatomical mapping system is the established approach to ablation. In...
IntroductionPulmonary vein isolation is the cornerstone of rhythm-control therapy for atrial fibrillation (AF). The very high-power, short-duration (vHPSD) radiofrequency (RF) ablation is a novel technology that favors resistive heating while decreasing the role of conductive heating. Our study aimed to evaluate the correlations between contact for...
Aims
To investigate the radius of transmural (TM) ablation effect at the left atrial posterior wall (LAPW) during contact force (CF)-guided pulmonary vein isolation (PVI), using pure R unipolar electrogram (UE) morphology change – a histologically validated marker of radiofrequency (RF)-induced TM atrial ablation.
Methods
Following PVI in 24 conse...
Citations
... Several imaging studies have found substantial variation in PV anatomy among patients with AF (Wittkampf et al., 2003;Schwartzman et al., 2004;Mlčochová et al., 2005;Cronin et al., 2007;Kaseno et al., 2008;Bittner et al., 2011). The left common PV has been found to be a prevalent anomaly among patients with AF (Porres et al., 2013;McLellan et al., 2014;Chen et al., 2017;Stabile et al., 2017). Here we describe how the method detailed in Subsection 2.2 can be extended to anatomies with left common pulmonary trunk. ...
Atrial fibrillation (AF) is the most common arrhythmia encountered clinically, and as the population ages, its prevalence is increasing. Although the CHA 2 DS 2 ⁻ VASc score is the most used risk-stratification system for stroke risk in AF, it lacks personalization. Patient-specific computer models of the atria can facilitate personalized risk assessment and treatment planning. However, a challenge faced in creating such models is the complexity of the atrial muscle arrangement and its influence on the atrial fiber architecture. This work proposes a semi-automated rule-based algorithm to generate the local fiber orientation in the left atrium (LA). We use the solutions of several harmonic equations to decompose the LA anatomy into subregions. Solution gradients define a two-layer fiber field in each subregion. The robustness of our approach is demonstrated by recreating the fiber orientation on nine models of the LA obtained from AF patients who underwent WATCHMAN device implantation. This cohort of patients encompasses a variety of morphology variants of the left atrium, both in terms of the left atrial appendages (LAAs) and the number of pulmonary veins (PVs). We test the fiber construction algorithm by performing electrophysiology (EP) simulations. Furthermore, this study is the first to compare its results with other rule-based algorithms for the LA fiber architecture definition available in the literature. This analysis suggests that a multi-layer fiber architecture is important to capture complex electrical activation patterns. A notable advantage of our approach is the ability to reconstruct the main LA fiber bundles in a variety of morphologies while solving for a small number of harmonic fields, leading to a comparatively straightforward and reproducible approach.
... T A B L E 1 Characteristics of each study included in the variations part of this meta-analysis Stabile et al., 2017;Subotich et al., 2009;Vasamreddy et al., 2004;Wei et al., 2014Wei et al., , 2019Wittkampf et al., 2003;Yamane et al., 2008;Yen Ho et al., 1999;Yu et al., 2007 The included studies differed in imaging the number and arrangement of the pulmonary veins. Computed tomography, echocardiography, magnetic resonance imaging, magnetic resonance angiography, intraoperative imaging, and cadaver dissection methods were used in the analyzed studies to establish PV arrangements. ...
This study aimed to establish the most accurate and up‐to‐date anatomical knowledge of pulmonary veins (PV), ostia variations, diameters and ostial area, to provide physicians, especially heart and thoracic surgeons with exact knowledge concerning this area. The main online medical databases, such as PubMed, Embase, Scopus, Web of Science, and Google Scholar, were searched to gather all studies in which the variations, maximal diameter, and ostial area of the PVs were investigated. During the study, the preferred reporting items for systematic reviews and meta‐analyses (PRISMA) guidelines were followed. Additionally, the critical appraisal tool for anatomical meta‐analysis (CATAM) was used to provide the highest quality findings. The most common ostia variation is the classical one, which contains the left superior pulmonary vein (LSPV), left inferior pulmonary vein (LIPV), right superior pulmonary vein (RSPV) and right inferior pulmonary vein (RIPV). The mean diameter and ostial area of each pulmonary vein were established in the general population and in multiple variations considering the method of collecting the data and geographical location. Significant variability in PV ostia is observed. Left‐sided PVs have smaller ostia than the corresponding right‐sided PVs, and the inferior PVs ostia are smaller than the superior. The LCPV ostium size is the largest among all veins analyzed, while the RMPV ostium is the smallest. The results of this meta‐analysis are hoped to help clinicians in planning and performing procedures that involve the pulmonary and cardiac areas, especially catheter ablation for atrial fibrillation.
... In a study published in 2017 by Stabile et al., [33] and was done on 75 patients (mean age 58±11 years, 67% male) for symptomatic PAF ablation. ...
INTRODUCTION: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation techniques for the treatment of paroxysmal atrial fibrillation (PAF), with significantly improved efficacy compared to antiarrhythmic drugs as shown in CABANA trial. However, the question arises in which PAF patients whether the procedure can be limited to PVs only showing potentials (segmental), or it is really necessary to isolate all PV (circumferential). Even though success rates for circumferential PV ablation (CPVA) have been reported to be higher (up to 90%), than segmental PV ablation, most CPVA procedures previously reported included left atrial linear ablation, additional ablation lesions or lines connecting the mitral valve to the posterior PVs or along the roof of the left atrium which made bias to these studies. AIM: Thus, we initiated this randomized controlled study to evaluate the efficacy of CPVA versus SPVI in subjects undergoing ablation of PAF. METHODS: Our study included 31 consecutive patients who underwent their first radiofrequency ablation for PAF between March 2015 and March 2017. Patients were randomized for circumferential or segmental ablation on the day of the procedure. We had two groups, circumferential (17 patients) and segmental group (14 patients). RESULTS: There was no difference between two groups on our primary endpoint, the recurrence, which was 2 out of 14 patients (14.3%) in the segmental ablation group, compared to 3 out of 17 patients (17.6%) who were circumferential ablated. This difference is statistically insignificant (p = 1). For other endpoints, there was also no statistically significant difference between circumferential and segmental regarding fluoroscopy time, 53.47 ± 8.7 min versus 54.93 ± 15.02 min, p = 0.738, procedure time, 184.18 ±19.28 min versus 191.43 ± 20 min p = 0.315, and even for radio frequency time which was lower in segmental group but did not differ statistically, 35.71 ± 5.73 min versus 34.79 ± 5.29, min p = 0.649. CONCLUSION: The previous studies showed the superiority of circumferential PVI on segmental strategy regarding effectiveness, but in those studies, linear ablations were added to circumferential strategy and done in cases of persistent and PAF. In our randomized study, we compared between two methods in cases of PAF, which showed that segmental ablation is not inferior to circumferential ablation of PVI.
... There were also trends toward significance in multivariate analysis for increased left and right inferior PV dimensions as predictors of need for repeat ablation. Clinical variables including male gender and LVEF were no longer significant predictors of need for repeat ablation after Two studies which used pre-ablation CT to characterize PV and LA anatomy found that anomalous PV anatomy (e.g., presence of left common PV trunk or presence of middle accessory PVs) was not correlated with procedure outcome [12,13] . To our knowledge, only one other study investigated the effect of PV size. ...
AIM
To identify predictors of need for repeat procedures after initial atrial fibrillation (AF) ablation.
METHODS
We identified a cohort undergoing first time AF ablation at our institution from January 2004 to February 2014 who had cardiac magnetic resonance (CMR) imaging performed prior to ablation. Clinical variables and anatomic characteristics (determined from CMR) were assessed as predictors of need for repeat ablation. The decision regarding need for and timing of repeat ablation was at the discretion of the treating physician.
RESULTS
From a cohort of 331 patients, 142 patients (43%) underwent repeat ablation at a mean of 13.6 ± 18.4 mo after the index procedure. Both male gender (81% vs 71%, P = 0.05) and lower ejection fraction (57.4% ± 10.3% vs 59.8% ± 9.4%, P = 0.04) were associated with need for repeat ablation. On pre-ablation CMR, mean pulmonary vein (PV) diameters were significantly larger in all four PVs among patients requiring repeat procedures. In multivariate analysis, increased right superior PV diameter significantly predicted need for repeat ablation (odds ratio 1.08 per millimeter increase in diameter, 95%CI: 1.00-1.16, P = 0.05). There were also trends toward significance for increased left and right inferior PV sizes among those requiring repeat procedures.
CONCLUSION
Increased PV size predicts the need for repeat AF ablation, with each millimeter increase in PV diameter associated with an approximately 5%-10% increased risk of requiring repeat procedures.
Objective
To analyze the anatomic characteristics of the left atrium and pulmonary veins in individuals undergoing ablation for atrial fibrillation and to identify possible anatomic factors related with recurrence.
Material and methods
We retrospectively reviewed the CT angiography studies done to plan radiofrequency ablation for atrial fibrillation in 95 patients (57 men; mean age, 65 ± 10 y). We reviewed the anatomy of the pulmonary veins and recorded the diameters of their ostia as well as the diameter and volume of the left atrium. We analyzed these parameters according to the type of arrhythmia and the response to treatment.
Results
In 71 (74.7%) patients, the anatomy of the pulmonary veins was normal (i.e., two right pulmonary veins and two left pulmonary veins). Compared to patients with paroxysmal atrial fibrillation, patients with persistent atrial fibrillation had slightly larger diameter of the left pulmonary veins (left superior pulmonary vein 17.9 ± 2.6 mm vs. 16.7 ± 2.2 mm, p = 0.04; left inferior pulmonary vein 15.3 ± 2 mm vs. 13.8 ± 2.2 mm, p = 0.009) and larger left atrial volume (91.9 ± 24.9 cm³ vs. 70.7 ± 20.3 mm³, p = 0.001). After 22.1 ± 12.1 months’ mean follow-up, 41 patients had sinus rhythm. Compared to patients in whom the sinus rhythm was restored, patients with recurrence had greater left atrial volume (81.4 ± 23.0 mm³ vs. 71.1 ± 23.2 mm³, p = 0.03). No significant differences in pulmonary vein diameters or clinical parameters were observed between patients with recurrence and those without.
Conclusion
The volume of the left atrium is greater in patients with persistent atrial fibrillation and in those who do not respond to ablation.
Resumen
Objetivo
Definir las características anatómicas de la aurícula izquierda y las venas pulmonares (VP) en sujetos sometidos a ablación de fibrilación auricular (FA) e identificar posibles factores anatómicos relacionados con la recurrencia.
Material y métodos
Se estudiaron de manera retrospectiva los estudios de angio-TC de 95 pacientes (57 hombres, edad media 65 ± 10 años), realizados para planificación de ablación por radiofrecuencia de FA. Se revisó la anatomía de las VP y se recogieron los diámetros de sus ostia y los diámetros y volumen de la aurícula izquierda. Estos parámetros fueron comparados con el tipo de arritmia y la respuesta al tratamiento.
Resultados
La anatomía de las venas pulmonares fue normal (dos venas pulmonares derechas y dos izquierdas) en la mayoría de los pacientes (74,7%). Los pacientes con FA persistente presentaron diámetros ligeramente superiores de las venas pulmonares izquierdas (VPSI de 17,9 ± 2,6 mm vs. 16,7 ± 2,2 mm, p = 0,04; VPII de 15,3 ± 2 mm vs. 13,8 ± 2,2 mm, p = 0,009) y mayor volumen de la aurícula izquierda (91,9 ± 24,9 cm³ vs. 70,7 ± 20,3 mm³, p = 0,001) que los sujetos con FA paroxística. Tras un seguimiento medio de 22,1 ± 12,1 meses, el 43% de los pacientes presentaba ritmo sinusal. Los pacientes con recurrencia mostraron mayor volumen de la aurícula izquierda (81,4 ± 23 mm³ vs. 71,1 ± 23,2 mm³, p = 0,03). No se objetivaron diferencias significativas en los diámetros de las VP ni en los parámetros clínicos estudiados en ambos grupos.
Conclusión
El volumen de la aurícula izquierda es mayor en pacientes con FA persistente y en pacientes que no responden al procedimiento de ablación.
Background:
Catheter ablation (CA) has become a conventional treatment for atrial fibrillation (AF), but remains with high recurrence rate. The aim of this meta-analysis was to determine left atrial (LA) structure and function indices that predict recurrence of AF.
Methods:
We systematically searched PubMed-Medline, EMBASE, Scopus, Google Scholar and the Cochrane Central Registry, up to September 2017 in order to select clinical trials and observational studies which reported echocardiographic predictors of AF recurrence after CA. Eighty-five articles with a total of 16,126 patients were finally included.
Results:
The pooled analysis showed that after a follow-up period of 21±12 months, patients with AF recurrence had larger LA diameter with Weighted Mean Difference (WMD : 2.99 ([95% CI 2.50-3.47], P<0.001), larger LA volume index (LAVI) maximal and LAVI minimal (P<0.0001 for both), larger LA area (P<0.0001), lower LA strain (P<0.0001) and lower LA total emptying fraction (LA EF) (P<0.0001) compared to those without AF recurrence. The most powerful LA predictors (in accuracy order) of AF recurrence were: LA strain <19% (OR: 3.1[95% CI, 0.93-10.4], p<0.0001), followed by LA diameter ≥50mm (OR: 2.75, [95% CI 1.66-4.56,] p<0.0001), and LAVmax >150ml (OR: 2.25, [95% CI, 0.91-5.6], p=0.0002).
Conclusions:
Based on this meta-analysis results, a dilated left atrium with diameter more than 50 mm and volume above 150 ml or myocardial strain below 19% reflect an unstable LA that is unlikely to hold sinus rhythm after catheter ablation for atrial fibrillation.
Introduction
A left common pulmonary vein (LCPV) is a common anatomical variant in atrial fibrillation (AF) patients. Whether a LCPV influences outcomes of repeated radiofrequency catheter ablation (RFCA) for AF has not been elucidated.
Methods
From a prospectively collected database, we enrolled 154 patients who received repeated RFCA for recurrent AF after the initial RFCA (56 ± 9 years, 72% paroxysmal AF, 32 patients with a LCPV and 122 patients with typical left‐sided PVs). Median post‐procedural follow‐up was 26 months. The primary outcome was any episode of AF, atrial tachyarrhythmia or atrial flutter lasting for more than 30 s, after the 3 months blanking period following the repeated procedure.
Results
After the follow‐up period, 75 patients suffered recurrence after repeated ablation. In the Kaplan‐Meier analysis, a LCPV was significantly associated with less recurrence (HR: 0.39, 95% CI: 0.28 – 0.79, P = 0.005). In subgroup analysis, the significant association persisted in paroxysmal AF patients. Regarding persistent AF patients, a LCPV tended to be associated with less recurrence with no statistical significance (HR: 0.40, 95% CI: 0.20 – 1.03, P = 0.067). In multivariate analyses, a LCPV still independently predicted freedom from recurrence (HR: 0.44, 95% CI: 0.22 – 0.88, P = 0.02).
Conclusion
Compared with typical left‐sided PVs, a LCPV was independently associated with better outcomes after repeated RFCA of AF, particularly in patients with paroxysmal AF.
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Background:
Radiofrequency and cryoballoon pulmonary vein isolation are common approaches for paroxysmal atrial fibrillation treatment, showing similar results in recent multicenter studies, including heterogeneous tools and protocols. The aim of this study is to compare prospectively in a single, high-volume center the outcome of paroxysmal atrial fibrillation ablation performed specifically by second-generation cryoballoon or contact force radiofrequency ablation.
Methods:
Consecutive patients scheduled for paroxysmal atrial fibrillation transcatheter ablation have been included and prospectively followed up. Aiming to reduce potential bias deriving from baseline characteristics, a propensity score matching analysis has been performed to analyze safety and efficacy outcomes.
Results:
Out of consecutive patients undergoing atrial fibrillation transcatheter ablation between January 2015 and December 2016, 46 patients approached by cryoablation were matched 1 : 1 by propensity score to a similar population treated by last-generation radiofrequency ablation. Freedom from atrial fibrillation after 12 months (76 vs. 78%, P = 0.804) and incidence of complications (4 vs. 6%, P = 0.168) did not differ between the two groups. Radiological exposure was higher for the cryoballoon group (11 vs. 4 min, P < 0.001), whereas procedural duration did not differ (P = 0.174). Aiming to assess the potential impact of a learning curve in patients undergoing cryoablation, the first-third of patients (n = 15) were compared with the remaining, reporting longer radiological exposure (P < 0.001), but similar safety and efficacy.
Conclusion:
In this propensity score analysis, last-generation cryoballoon and radiofrequency catheters for atrial fibrillation ablation present similar efficacy and safety. Cryoablation requires longer fluoroscopy exposure compared with radiofrequency, although this is reduced by increased experience.
