Figure - available from: Clinical Research in Cardiology
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Left atrium postero-anterior view. Example of different arrangement of myocardial extensions inside pulmonary veins (PVs). In right superior PV (RSPV) non-parallel arrangement is present (asterisk), in right inferior PV (RIPV), left superior PV (LSPV), left inferior PV (LIPV) a parallel arrangement of the muscle fibers is present
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Introduction:
Atrial fibrillation (AF) is mainly triggered by arrhythmogenic foci originating from atrial myocardial extensions (MEs) into the pulmonary veins (PVs). Aim of the study was to evaluate endocardial voltage maps of PVs as a surrogate parameter for the extent of MEs in subjects with AF through a ultra-high-density mapping system.
Metho...
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Background: Although Ablation Index (AI)-guided ablation facilitates creation of lesions of consistent depth, pulmonary vein (PV) reconnection is still commonly observed after AI-guided pulmonary vein isolation (PVI). The present study aimed to investigate the impact of local left atrial wall thickness on the incidence of acute PV reconnection afte...
Citations
... CS = coronary sinus; 20A 1-2 to 19-20 = multipolar PentaRay catheter; PA = posteroanterior projection. rhythmogenic tissue being preserved by the procedure, and result in the posterior wall of the left atrium becoming a prominent site for initiators and drivers of atrial arrhythmias [13]. It is also possible that viable myocardium from inside the pulmonary veins, which was demonstrated in our case by documenting automaticity in the isolated left pulmonary vein, migrates towards the recipient's left atrium and forms a myocardial bridge predisposing to atrial arrhythmias in the long term. ...
... (69) Certaines données récentes suggèrent que l'allongement de l'intervalle PR sur l'ECG pourrait jouer un rôle dans la réponse à la RC, mais il manque des données cliniques prospectives permettant de les valider. (70) Comme nous l'avons évoqué précédemment, la réponse clinique à la RC chez les patients en FA reste également plus difficile à évaluer, ainsi que la nécessité d'y associer ou pas une ablation de la jonction nodo-hissienne. ...
L’insuffisance cardiaque est un problème de santé publique dans les pays développés, touchant 1 à 2% de la population générale, mais dont la prévalence atteint 10% après 70 ans. Les progrès thérapeutiques ont permis d’améliorer le pronostic des patients, notamment ceux ayant une altération de la fonction systolique ventriculaire gauche. Les troubles du rythme sont fréquents et nécessitent une pris en charge particulière au cours des situations d’insuffisance cardiaque. Cependant, il reste des questions non résolues : comment améliorer l’efficacité du traitement de l’insuffisance cardiaque à fonction systolique préservée, comment mieux sélectionner les patients pouvant bénéficier de la prévention primaire de la mort subite par un défibrillateur implantable, les patients âgés peuvent-ils bénéficier de la même prise en charge que les patients plus jeunes, et pour finir comment améliorer les résultats de l’ablation de fibrillation auriculaire dans les situations d’insuffisance cardiaque. Nous avons mis en place une étude prospective chez des patients présentant une dysfonction diastolique pour évaluer l’intérêt de l’algorithme de surveillance de l’apnée du sommeil disponible dans des stimulateurs cardiaques. En parallèle, nous avons analysé l’impact de l’évaluation par résonance magnétique des patients candidats à un défibrillateur sur la prédiction des évènements rythmiques, mais aussi le devenir des patients de plus de 75 ans appareillés avec un système de resynchronisation cardiaque. Enfin, nous nous sommes intéressés aux résultats d’un nouveau système de cartographie électroanatomique ultra-haute densité pour guider les procédures d’ablation de troubles du rythme supraventriculaires complexes chez des patients insuffisants cardiaques comparés à des patients contrôles.
... [1][2][3] Furthermore, a number of human studies reported data in a wide range of real-world clinical settings including the use of mapping for both atrial and ventricular arrhythmias. [4][5][6][7][8][9][10][11][12][13][14] Although most of these studies have shown that the system is safe, efficacious and clinically useful in specific settings, to date there has been no prospective study to assess the acute safety, acute effectiveness and clinical use of the system on a wide spectrum of different arrhythmias to guide ablation in real-world clinical practice. The TRUE HD study (Prospective Registry on User Experience With The Rhythmia TM Mapping System For Ablation Procedures) was conducted to address this question. ...
Aims:
The objective of this study was to verify acute safety, performance, and usage of a novel ultra-high density mapping system in patients undergoing ablation procedure in a real-world clinical setting.
Methods and results:
The TRUE HD study enrolled patients undergoing catheter ablation with mapping for all arrhythmias (excluding de novo atrial fibrillation) who were followed for 1 month. Safety was determined by collecting all serious adverse events and adverse events associated with the study devices. Performance was determined as the composite of: ability to map the arrhythmia/substrate, complete the ablation applications, arrhythmia termination (where applicable), and ablation validation. Use of mapping system in the ablation validation workflow was also evaluated. Among the 519 patients who underwent a complete (504) or attempted (15) procedure, 21 (4%) serious ablation-related complications were collected, with 3 (0.57%) potentially related to the mapping catheter. Four hundred and twenty treated patients resulted in a successful procedure confirmed by arrhythmia-specific validation techniques (83.3%; 95% confidence interval: 79.8-86.5%). A total of 1419 electroanatomical maps were created with a median acquisition time of 9:23 min per map. Of these, 372 maps in 222 (44%) patients were collected for ablation validation purposes. Following validation mapping, 162/222 (73%) patients required additional ablation.
Conclusion:
In the TRUE HD study mapping was associated with rates of acute success and complications consistent with previously published reports. Importantly, a low percentage of events (0.57%) was attributed to the mapping catheter. When performed, validation mapping was useful for identifying additional targets for ablation in the majority of patients.
... In our opinion, the low electrical resolution of ablation catheters with standard interelectrode spacing might account for the inability to localize Mahaim fibers in some cases. As previously demonstrated for other complex arrhythmias, multipolar mapping catheters might help overcoming this limitation [3,[7][8][9]. As a prove of principle, in both of our ablation procedures, the Mahaim potential could never be recorded with the ablation catheter even at the exact position identified with the Penta-Ray™ catheter. ...
... Catheter ablation has become an important therapeutic option for patients with highly symptomatic and drug-refractory atrial fibrillation [34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52]. Circumferential pulmonary vein ablation is still the cornerstone of nearly all ablation strategies in patients with paroxysmal (or persistent) AF. ...
Background:
Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory paroxysmal atrial fibrillation. Circumferential pulmonary vein ablation is still the standard approach in these patients. The occurrence of an atrioesophageal fistula is a rare but life-threatening complication after such ablation procedures. This is due to the fact that the esophagus does frequently have a very close anatomical relationship to the left or right pulmonary vein ostia. The aim of our study was to evaluate whether the exclusion of areas adjacent to the esophagus does have a significant effect on the success rate after circumferential pulmonary vein ablation.
Methods:
Two hundred consecutive patients [121 men, 69 women; mean age 59.1 years (SD ± 11.3 years)] with symptomatic paroxysmal atrial fibrillation underwent a circumferential pulmonary vein ablation procedure (using the CARTO- or the NAVX-system). In 100 patients, a complete circumferential pulmonary vein ablation was attempted regardless of the anatomical relationship between the ablation sites and the esophagus (group A). In the remaining 100 patients, the esophagus was marked by a special EP catheter and areas adjacent to the esophagus were excluded from the ablation procedure. After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, 6, 9, 12, 24 and 36 months after the ablation procedure.
Results:
The ablation procedure could be performed as planned in all 200 patients. In group A, all pulmonary veins could be isolated successfully in 88 out of 100 patients (88%). A mean number of 3.9 pulmonary veins (SD ± 0.37 PVs) were isolated per patient. The 12 cases of an incomplete pulmonary vein isolation were due to poorly accessible pulmonary vein ostia. In group B, all pulmonary veins could be isolated successfully in only 58 out of 100 patients (58%; P < 0.01). A mean number of 3.5 PVs (SD ± 0.6 PVs) were isolated per patient (P < 0.01). This was mostly due to a close anatomical relationship to the esophagus. The ablation strategy had to be modified in 46/100 patients in group B because of a close anatomical relationship between the right (n = 25) or left (n = 21) pulmonary vein ostia and the esophagus. One year after the ablation procedure, 87% of patients in group A (87/100) and 79% of patients in group B (79/100) were free from an arrhythmia recurrence (P = 0.19). Three years after catheter ablation, the success rate was 80% (no arrhythmia recurrence in 80 out of 100 patients) in group A and 66% in group B (no arrhythmia recurrence in 66 out of 100 patients; P = 0.04). There were no major complications during long-term follow-up.
Conclusions:
The exclusion of areas adjacent to the esophagus results in a markedly higher percentage of incompletely isolated pulmonary veins after circumferential pulmonary vein ablation procedures. This results in a significantly higher arrhythmia recurrence rate during long-term follow-up.
... Mes were more prevalent in superior PVs. both left and right and have a heterogeneous arrangement that is in 60% uniform and in 40% non-uniform ( Figure 3). 33 Complete abolishment of electrical activity inside the Mes represent an important target especially in treatment of paroxysmal aF. ...
Introduction:
Catheter ablation (CA) is an established and widespread treatment option for drug refractory atrial fibrillation (AF). CA has undergone considerable improvements during the last years and several ablation strategies have been proposed for different AF patterns.
Evidence acquisition:
The main cornerstone is the electrical isolation of pulmonary veins (PVs) especially among patients with paroxysmal AF. This can be achieved mainly with the use of radiofrequency or cryo-energy. However ablation strategy remains uncertain in patients with persistent AF.
Evidence synthesis:
Several mapping systems have been developed in order to acquire electrical and anatomical information of the left and right atrium. For patients with persistent atrial fibrillation new systems are able to identity potential AF triggers arising out of the PVs, but the role of ablation of this triggers is still not clear.
Conclusions:
Although several improvements have been performed in CA of AF, the main cornerstone of treatment remains the electrical isolation of PVs. This approach provides good clinical results at long-term follow-up in patients with paroxysmal AF. However, the ablation strategy apart from electrical isolation of PV in patients with persistent AF is still not well defined. Further improvement of mapping systems could provide more information about alternative ablation strategies.
Three-dimensional mapping systems are used for the characterization and treatment of complex arrhythmias, such as atrial reentrant tachycardias, atrial fibrillation, or ventricular tachycardia. The Rhythmia™ mapping system (Boston Scientific, Natick, MA, USA) belongs to a novel generation of mapping systems that are able to rapidly create high-density and high-resolution three-dimensional maps in an automated manner. Mapping is performed with a magnetic- and impedance-based tracked bidirectional deflectable 64-pole basket catheter (IntellaMap Orion™, Boston Scientific). Based on previous studies, the system is effective and safe for the treatment of complex atrial and ventricular arrhythmias.
Background: Successful pulmonary vein isolation (PVI) is the most reliable predictor of success after ablation in patients with atrial fibrillation (AF). Adenosine triphosphate (ATP) unmasks the dormant conduction and can be used to improve the effectiveness of PVI. The impact of ATP guided PVI on clinical outcomes is discordant in various randomized controlled trials (RCTs).
Objectives: To delineate the incremental benefit of ATP during PVI in patients with AF through a meta-analysis.
Methods and Results: Database searches through January 2017 identified 5 RCTs (enrolling 2839 patients) comparing ATP guided PVI versus standard PVI (non-ATP). Four trials exclusively studied paroxysmal AF while one trial included both paroxysmal and non-paroxysmal AF patients. Baseline characteristics, dose of adenosine and ablation strategies were clearly identified among all the trials. The risk ratio (RR) for AF episodes lasting >30 seconds after 3-month blanking period was calculated with random effects meta-analysis and showed no difference at a median follow up of 12 months [RR: 1.02, 95 % Confidence interval (CI): 0.85 to 1.25; p= 0.82]. Similarly, the number of repeat ablation was similar in both groups [RR: 1.02, 95 % CI: 0.63, 1.56; p= 0.98].
Conclusions: ATP guided PVI does not decrease the recurrence of AF or the need for repeat ablation at 12 months.
