Pub Date : 2019-08-26DOI: 10.1161/CIRCEP.119.007158
M. Takigawa, J. Relan, T. Kitamura, Claire A. Martin, Steven J. Kim, Ruairidh Martin, G. Cheniti, K. Vlachos, G. Massoullié, A. Frontera, N. Thompson, Michael Wolf, F. Bourier, A. Lam, J. Duchâteau, T. Pambrun, A. Denis, N. Derval, X. Pillois, J. Magat, J. Naulin, M. Merle, Florent Collot, B. Quesson, H. Cochet, M. Hocini, M. Haïssaguerre, F. Sacher, P. Jaïs
BACKGROUND Multipolar catheters are increasingly used for high-density mapping. However, the threshold to define scar areas has not been well described for each configuration. We sought to elucidate the impact of bipolar spacing and orientation on the optimal threshold to match magnetic resonance imaging-defined scar. METHOD The HD-Grid catheter uniquely allows for different spatially stable bipolar configurations to be tested. We analyzed the electrograms with settings of HD-16 (3 mm spacing in both along and across bipoles) and HD-32 (1 mm spacing in along bipoles and 3 mm spacing in across bipoles) and determined the optimal cutoff for scar detection in 6 infarcted sheep. RESULTS From 456 total acquisition sites (mean 76±12 per case), 14 750 points with the HD-16 and 32286 points with the HD-32 configuration for bipolar electrograms were analyzed. For bipolar voltages, the optimal cutoff value to detect the magnetic resonance imaging-defined scar based on the Youden's Index, and the area under the receiver operating characteristic curve (AUROC) differed depending on the spacing and orientation of bipoles; across 0.84 mV (AUROC, 0.920; 95% CI, 0.911-0.928), along 0.76 mV (AUROC, 0.903; 95% CI, 0.893-0.912), north-east direction 0.95 mV (AUROC, 0.923; 95% CI, 0.913-0.932), and south-east direction, 0.87 mV (AUROC, 0.906; 95% CI, 0.895-0.917) in HD-16; and across 0.83 mV (AUROC, 0.917; 95% CI, 0.911-0.924), along 0.46 mV (AUROC, 0.890; 95% CI, 0.883-0.897), north-east direction 0.89 mV (AUROC, 0.923; 95% CI, 0.917-0.929), and south-east direction 0.83 mV (AUROC, 0.913; 95% CI, 0.906-0.920) in HD-32. Significant differences in AUROC were seen between HD-16 along versus across (P=0.002), HD-16 north-east direction versus south-east direction (P=0.01), HD-32 north-east direction versus south-east direction (P<0.0001), and HD-16 along versus HD-32 along (P=0.006). The AUROC was significantly larger (P<0.01) when only the best points on each given site were selected for analysis, compared with when all points were used. CONCLUSIONS Spacing and orientation of bipoles impacts the accuracy of scar detection. Optimal threshold specific to each bipolar configuration should be determined. Selecting one best voltage point among multiple points projected on the same surface is also critical on the Ensite-system to increase the accuracy of scar-mapping.
{"title":"Impact of Spacing and Orientation on the Scar Threshold With a High-Density Grid Catheter.","authors":"M. Takigawa, J. Relan, T. Kitamura, Claire A. Martin, Steven J. Kim, Ruairidh Martin, G. Cheniti, K. Vlachos, G. Massoullié, A. Frontera, N. Thompson, Michael Wolf, F. Bourier, A. Lam, J. Duchâteau, T. Pambrun, A. Denis, N. Derval, X. Pillois, J. Magat, J. Naulin, M. Merle, Florent Collot, B. Quesson, H. Cochet, M. Hocini, M. Haïssaguerre, F. Sacher, P. Jaïs","doi":"10.1161/CIRCEP.119.007158","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007158","url":null,"abstract":"BACKGROUND\u0000Multipolar catheters are increasingly used for high-density mapping. However, the threshold to define scar areas has not been well described for each configuration. We sought to elucidate the impact of bipolar spacing and orientation on the optimal threshold to match magnetic resonance imaging-defined scar.\u0000\u0000\u0000METHOD\u0000The HD-Grid catheter uniquely allows for different spatially stable bipolar configurations to be tested. We analyzed the electrograms with settings of HD-16 (3 mm spacing in both along and across bipoles) and HD-32 (1 mm spacing in along bipoles and 3 mm spacing in across bipoles) and determined the optimal cutoff for scar detection in 6 infarcted sheep.\u0000\u0000\u0000RESULTS\u0000From 456 total acquisition sites (mean 76±12 per case), 14 750 points with the HD-16 and 32286 points with the HD-32 configuration for bipolar electrograms were analyzed. For bipolar voltages, the optimal cutoff value to detect the magnetic resonance imaging-defined scar based on the Youden's Index, and the area under the receiver operating characteristic curve (AUROC) differed depending on the spacing and orientation of bipoles; across 0.84 mV (AUROC, 0.920; 95% CI, 0.911-0.928), along 0.76 mV (AUROC, 0.903; 95% CI, 0.893-0.912), north-east direction 0.95 mV (AUROC, 0.923; 95% CI, 0.913-0.932), and south-east direction, 0.87 mV (AUROC, 0.906; 95% CI, 0.895-0.917) in HD-16; and across 0.83 mV (AUROC, 0.917; 95% CI, 0.911-0.924), along 0.46 mV (AUROC, 0.890; 95% CI, 0.883-0.897), north-east direction 0.89 mV (AUROC, 0.923; 95% CI, 0.917-0.929), and south-east direction 0.83 mV (AUROC, 0.913; 95% CI, 0.906-0.920) in HD-32. Significant differences in AUROC were seen between HD-16 along versus across (P=0.002), HD-16 north-east direction versus south-east direction (P=0.01), HD-32 north-east direction versus south-east direction (P<0.0001), and HD-16 along versus HD-32 along (P=0.006). The AUROC was significantly larger (P<0.01) when only the best points on each given site were selected for analysis, compared with when all points were used.\u0000\u0000\u0000CONCLUSIONS\u0000Spacing and orientation of bipoles impacts the accuracy of scar detection. Optimal threshold specific to each bipolar configuration should be determined. Selecting one best voltage point among multiple points projected on the same surface is also critical on the Ensite-system to increase the accuracy of scar-mapping.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"165 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74320065","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-21DOI: 10.1161/CIRCEP.119.007414
Z. Asad, A. Yousif, M. Khan, S. Al‐Khatib, S. Stavrakis
BACKGROUND Despite the publication of several randomized clinical trials comparing catheter ablation (CA) with medical therapy (MT) in patients with atrial fibrillation (AF), the superiority of one strategy over another is still questioned by many. In this meta-analysis of randomized controlled trials, we compared the efficacy and safety of CA with MT for AF. METHODS We systematically searched MEDLINE, EMBASE, and other online sources for randomized controlled trials of AF patients that compared CA with MT. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular hospitalizations and recurrence of atrial arrhythmia. Subgroup analyses stratified by the presence of heart failure with reduced ejection fraction, type of AF, age, and sex were performed. Risk ratios (RRs) with 95% CIs were calculated using a random effects model, and Mantel-Haenszel method was used to pool RR. RESULTS Eighteen randomized controlled trials comprising 4464 patients (CA, n=2286; MT, n=2178) were included. CA resulted in a significant reduction in all-cause mortality (RR, 0.69; 95% CI, 0.54-0.88; P=0.003) that was driven by patients with AF and heart failure with reduced ejection fraction (RR, 0.52; 95% CI, 0.35-0.76; P=0.0009). CA resulted in significantly fewer cardiovascular hospitalizations (hazard ratio, 0.56; 95% CI, 0.39-0.81; P=0.002) and fewer recurrences of atrial arrhythmias (RR, 0.42; 95% CI, 0.33-0.53; P<0.00001). Subgroup analyses suggested that younger patients (age, <65 years) and men derived more benefit from CA compared with MT. CONCLUSIONS CA is associated with all-cause mortality benefit, that is driven by patients with AF and heart failure with reduced ejection fraction. CA reduces cardiovascular hospitalizations and recurrences of atrial arrhythmia for patients with AF. Younger patients and men appear to derive more benefit from CA.
{"title":"Catheter Ablation Versus Medical Therapy for Atrial Fibrillation.","authors":"Z. Asad, A. Yousif, M. Khan, S. Al‐Khatib, S. Stavrakis","doi":"10.1161/CIRCEP.119.007414","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007414","url":null,"abstract":"BACKGROUND\u0000Despite the publication of several randomized clinical trials comparing catheter ablation (CA) with medical therapy (MT) in patients with atrial fibrillation (AF), the superiority of one strategy over another is still questioned by many. In this meta-analysis of randomized controlled trials, we compared the efficacy and safety of CA with MT for AF.\u0000\u0000\u0000METHODS\u0000We systematically searched MEDLINE, EMBASE, and other online sources for randomized controlled trials of AF patients that compared CA with MT. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular hospitalizations and recurrence of atrial arrhythmia. Subgroup analyses stratified by the presence of heart failure with reduced ejection fraction, type of AF, age, and sex were performed. Risk ratios (RRs) with 95% CIs were calculated using a random effects model, and Mantel-Haenszel method was used to pool RR.\u0000\u0000\u0000RESULTS\u0000Eighteen randomized controlled trials comprising 4464 patients (CA, n=2286; MT, n=2178) were included. CA resulted in a significant reduction in all-cause mortality (RR, 0.69; 95% CI, 0.54-0.88; P=0.003) that was driven by patients with AF and heart failure with reduced ejection fraction (RR, 0.52; 95% CI, 0.35-0.76; P=0.0009). CA resulted in significantly fewer cardiovascular hospitalizations (hazard ratio, 0.56; 95% CI, 0.39-0.81; P=0.002) and fewer recurrences of atrial arrhythmias (RR, 0.42; 95% CI, 0.33-0.53; P<0.00001). Subgroup analyses suggested that younger patients (age, <65 years) and men derived more benefit from CA compared with MT.\u0000\u0000\u0000CONCLUSIONS\u0000CA is associated with all-cause mortality benefit, that is driven by patients with AF and heart failure with reduced ejection fraction. CA reduces cardiovascular hospitalizations and recurrences of atrial arrhythmia for patients with AF. Younger patients and men appear to derive more benefit from CA.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"181 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75754300","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/CIRCEP.119.007453
B. Gray, M. Ackerman, C. Semsarian, E. Behr
Sudden cardiac death is defined as a death occurring usually within an hour of onset of symptoms, arising from an underlying cardiac disease. Sudden cardiac death is a complication of a number of cardiovascular diseases and is often unexpected. In individuals aged <35 years, unexplained sudden cardiac death is the most common presentation. A significant proportion of sudden cardiac death in the young (≤35 years) events may be precipitated by underlying inherited cardiac conditions, including both heritable cardiomyopathies and inherited arrhythmia syndromes (also known as cardiac channelopathies). Tragically, sudden death may be the first manifestation of the disease in a family and, therefore, clinical and genetic evaluation of surviving family members forms a key role in diagnosing the underlying inherited cardiac condition in the family. This is particularly relevant when considering that most inherited cardiac conditions are inherited in an autosomal dominant manner meaning that surviving family members have a 50% chance of inheriting the same disease substrate. This review will outline the underlying causes of sudden cardiac death in the young and outline our universal approach to familial evaluation following a young person's sudden death.
{"title":"Evaluation After Sudden Death in the Young.","authors":"B. Gray, M. Ackerman, C. Semsarian, E. Behr","doi":"10.1161/CIRCEP.119.007453","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007453","url":null,"abstract":"Sudden cardiac death is defined as a death occurring usually within an hour of onset of symptoms, arising from an underlying cardiac disease. Sudden cardiac death is a complication of a number of cardiovascular diseases and is often unexpected. In individuals aged <35 years, unexplained sudden cardiac death is the most common presentation. A significant proportion of sudden cardiac death in the young (≤35 years) events may be precipitated by underlying inherited cardiac conditions, including both heritable cardiomyopathies and inherited arrhythmia syndromes (also known as cardiac channelopathies). Tragically, sudden death may be the first manifestation of the disease in a family and, therefore, clinical and genetic evaluation of surviving family members forms a key role in diagnosing the underlying inherited cardiac condition in the family. This is particularly relevant when considering that most inherited cardiac conditions are inherited in an autosomal dominant manner meaning that surviving family members have a 50% chance of inheriting the same disease substrate. This review will outline the underlying causes of sudden cardiac death in the young and outline our universal approach to familial evaluation following a young person's sudden death.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"48 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86457896","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
BACKGROUND Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) can be ablated from the great cardiac vein and remote endocardial sites. The ablation sites are determined by mapping in the great cardiac vein and left ventricular outflow tract. This study investigated whether that mapping could accurately predict the sites of LVS-VA origins. METHODS We studied 26 consecutive patients with idiopathic LVS-VA origins that were identified in the basal and apical LVS in 15 and 11 patients, respectively. RESULTS Radiofrequency catheter ablation of the apical LVS-VAs was successful in the great cardiac vein in 9 patients and in the apical LV outflow tract in 2. That of the basal LVS-VAs was successful in the aortomitral continuity in 9 patients, at the junction of the left and right coronary cusps in 4, and in the left coronary cusp in 2. Three apical LVS-VAs exhibited an eccentric endocardial activation pattern that was from the basal to apical LV outflow tract. In 11 basal LVS-VAs, the activation pattern was eccentric because the ventricular activation within the great cardiac vein in the apical LVS was earlier than that in the basal LV outflow tract. In 2 basal LVS-VAs, the activation pattern was eccentric because a relatively early ventricular activation was recorded at multiple sites away from the successful ablation site. CONCLUSIONS Eccentric activation patterns often occurred during idiopathic LVS-VAs, which could mislead the catheter ablation of those VAs. Understanding such eccentric activation patterns was suggested to be able to improve the outcomes of the catheter ablation of those VAs by the anatomic approach.
{"title":"Eccentric Activation Patterns in the Left Ventricular Outflow Tract during Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Summit.","authors":"Takumi Yamada, Vineet Kumar, Naoki Yoshida, Harish Doppalapudi","doi":"10.1161/CIRCEP.119.007419","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007419","url":null,"abstract":"BACKGROUND\u0000Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) can be ablated from the great cardiac vein and remote endocardial sites. The ablation sites are determined by mapping in the great cardiac vein and left ventricular outflow tract. This study investigated whether that mapping could accurately predict the sites of LVS-VA origins.\u0000\u0000\u0000METHODS\u0000We studied 26 consecutive patients with idiopathic LVS-VA origins that were identified in the basal and apical LVS in 15 and 11 patients, respectively.\u0000\u0000\u0000RESULTS\u0000Radiofrequency catheter ablation of the apical LVS-VAs was successful in the great cardiac vein in 9 patients and in the apical LV outflow tract in 2. That of the basal LVS-VAs was successful in the aortomitral continuity in 9 patients, at the junction of the left and right coronary cusps in 4, and in the left coronary cusp in 2. Three apical LVS-VAs exhibited an eccentric endocardial activation pattern that was from the basal to apical LV outflow tract. In 11 basal LVS-VAs, the activation pattern was eccentric because the ventricular activation within the great cardiac vein in the apical LVS was earlier than that in the basal LV outflow tract. In 2 basal LVS-VAs, the activation pattern was eccentric because a relatively early ventricular activation was recorded at multiple sites away from the successful ablation site.\u0000\u0000\u0000CONCLUSIONS\u0000Eccentric activation patterns often occurred during idiopathic LVS-VAs, which could mislead the catheter ablation of those VAs. Understanding such eccentric activation patterns was suggested to be able to improve the outcomes of the catheter ablation of those VAs by the anatomic approach.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86192766","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/hae.0000000000000042
{"title":"Correction to: Feasibility of an Entirely Extracardiac, Minimally Invasive,Temporary Pacing System","authors":"","doi":"10.1161/hae.0000000000000042","DOIUrl":"https://doi.org/10.1161/hae.0000000000000042","url":null,"abstract":"","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"147 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86649399","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/CIRCEP.119.007174
Franziska Fochler, T. Yamaguchi, Mobin Kheirkahan, E. Kholmovski, A. Morris, N. Marrouche
BACKGROUND Macroreentrant atrial tachycardia (AT) accounts for 40% to 60% of recurrent atrial arrhythmias after atrial fibrillation (AF) ablation. To describe late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-detected scar-based dechanneling as new ablation strategy to treat ATs after AF ablation. METHODS Data from 102 patients who underwent initial AF ablation and repeat ablation for recurrent atrial arrhythmia within 1-year follow-up were analyzed. All patients underwent LGE-MRI before initial and repeat ablation. Depending on the recurrent rhythm, patients with AF and AT recurrence were assigned to group 1 or 2, respectively. Group 1 underwent fibrosis homogenization as second procedure. Group 2 underwent LGE-MRI-detected scar-based dechanneling. Both groups underwent reisolation of pulmonary veins if necessary. RESULTS Forty-six patients (45%) presented with AF, and 56 patients (55%) presented with AT recurrence during follow-up after initial ablation. In the first 25 patients from group 2, the AT was electroanatomically mapped, and a critical isthmus was defined. It was found that those isthmi were located in the regions with nontransmural scarring detected by LGE-MRI. In the last 31 patients from group 2, an empirical LGE-MRI-based dechanneling was performed solely based on the LGE-MRI results. During 1-year follow-up after second ablation, 67% patients in group 1 and 64% patients in group 2 were free from recurrence (log-rank, P=1.000). In group 2, 64% in the electroanatomically guided and 65% in the LGE-MRI dechanneling group were free from recurrence (log-rank, P=0.900). CONCLUSIONS Anatomic targeting of LGE-MRI-detected gaps and superficial atrial scar is feasible and effective to treat recurrent arrhythmias post-AF ablation. Homogenization of existing scar is the appropriate treatment for recurrent AF, whereas dechanneling of existing isthmi seems the right approach for patients recurring with AT.
{"title":"Late Gadolinium Enhancement Magnetic Resonance Imaging Guided Treatment of Post-Atrial Fibrillation Ablation Recurrent Arrhythmia.","authors":"Franziska Fochler, T. Yamaguchi, Mobin Kheirkahan, E. Kholmovski, A. Morris, N. Marrouche","doi":"10.1161/CIRCEP.119.007174","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007174","url":null,"abstract":"BACKGROUND\u0000Macroreentrant atrial tachycardia (AT) accounts for 40% to 60% of recurrent atrial arrhythmias after atrial fibrillation (AF) ablation. To describe late gadolinium enhancement magnetic resonance imaging (LGE-MRI)-detected scar-based dechanneling as new ablation strategy to treat ATs after AF ablation.\u0000\u0000\u0000METHODS\u0000Data from 102 patients who underwent initial AF ablation and repeat ablation for recurrent atrial arrhythmia within 1-year follow-up were analyzed. All patients underwent LGE-MRI before initial and repeat ablation. Depending on the recurrent rhythm, patients with AF and AT recurrence were assigned to group 1 or 2, respectively. Group 1 underwent fibrosis homogenization as second procedure. Group 2 underwent LGE-MRI-detected scar-based dechanneling. Both groups underwent reisolation of pulmonary veins if necessary.\u0000\u0000\u0000RESULTS\u0000Forty-six patients (45%) presented with AF, and 56 patients (55%) presented with AT recurrence during follow-up after initial ablation. In the first 25 patients from group 2, the AT was electroanatomically mapped, and a critical isthmus was defined. It was found that those isthmi were located in the regions with nontransmural scarring detected by LGE-MRI. In the last 31 patients from group 2, an empirical LGE-MRI-based dechanneling was performed solely based on the LGE-MRI results. During 1-year follow-up after second ablation, 67% patients in group 1 and 64% patients in group 2 were free from recurrence (log-rank, P=1.000). In group 2, 64% in the electroanatomically guided and 65% in the LGE-MRI dechanneling group were free from recurrence (log-rank, P=0.900).\u0000\u0000\u0000CONCLUSIONS\u0000Anatomic targeting of LGE-MRI-detected gaps and superficial atrial scar is feasible and effective to treat recurrent arrhythmias post-AF ablation. Homogenization of existing scar is the appropriate treatment for recurrent AF, whereas dechanneling of existing isthmi seems the right approach for patients recurring with AT.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"154 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74351032","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/CIRCEP.118.007394
V. Luther, S. Agarwal, A. Chow, M. Koa‐Wing, N. Cortez-Dias, L. Carpinteiro, J. de Sousa, R. Balasubramaniam, D. Farwell, S. Jamil-Copley, N. Srinivasan, H. Abbas, James Mason, N. Jones, G. Katritsis, P. Lim, N. Peters, N. Qureshi, Z. Whinnett, N. Linton, P. Kanagaratnam
BACKGROUND Ripple mapping (RM) is an alternative approach to activation mapping of atrial tachycardia (AT) that avoids electrogram annotation. We tested whether RM is superior to conventional annotation based local activation time (LAT) mapping for AT diagnosis in a randomized and multicenter study. METHODS Patients with AT were randomized to either RM or LAT mapping using the CARTO3v4 CONFIDENSE system. Operators determined the diagnosis using the assigned 3D mapping arm alone, before being permitted a single confirmatory entrainment manuever if needed. A planned ablation lesion set was defined. The primary end point was AT termination with delivery of the planned ablation lesion set. The inability to terminate AT with this first lesion set, the use of more than one entrainment manuever, or the need to crossover to the other mapping arm was defined as failure to achieve the primary end point. RESULTS One hundred five patients from 7 centers were recruited with 22 patients excluded due to premature AT termination, noninducibility or left atrial appendage thrombus. Eighty-three patients (pts; RM=42, LAT=41) completed mapping and ablation within the 2 groups of similar characteristics (RM versus LAT: prior ablation or cardiac surgery n=35 [83%] versus n=35 [85%], P=0.80). The primary end point occurred in 38/42 pts (90%) in the RM group and 29/41pts (71%) in the LAT group (P=0.045). This was achieved without any entrainment in 31/42 pts (74%) with RM and 18/41 pts (44%) with LAT (P=0.01). Of those patients who failed to achieve the primary end point, AT termination was achieved in 9/12 pts (75%) in the LAT group following crossover to RM with entrainment, but 0/4 pts (0%) in the RM group crossing over to LAT mapping with entrainment (P=0.04). CONCLUSIONS RM is superior to LAT mapping on the CARTO3v4 CONFIDENSE system in guiding ablation to terminate AT with the first lesion set and with reduced entrainment to assist diagnosis. CLINICAL TRIALS REGISTRATION https://www.clinicaltrials.gov. Unique identifier: NCT02451995.
背景:滴波映射(RM)是一种替代心房心动过速(AT)激活映射的方法，避免了电图注释。我们在一项随机多中心研究中测试了RM是否优于传统的基于注释的局部激活时间(LAT)映射用于AT诊断。方法采用CARTO3v4 confidence系统对AT患者随机进行RM或LAT制图。操作人员仅使用指定的3D绘图臂确定诊断，然后在需要时允许进行单个确认夹带操作。确定计划消融病灶组。主要终点是AT终止和计划消融病灶组的交付。无法在第一个病变组终止AT，使用多个夹带手法，或需要切换到另一个测绘臂被定义为未能达到主要终点。结果共纳入7个中心的105例患者，其中22例因AT过早终止、不可诱导或左心耳血栓而被排除。83例患者;RM=42, LAT=41)在两组具有相似特征的患者中完成了定位和消融(RM vs LAT:既往消融或心脏手术n=35 [83%] vs n=35 [85%]， P=0.80)。主要终点发生在RM组的38/42(90%)和LAT组的29/41 (71%)(P=0.045)。RM组的31/42分(74%)和LAT组的18/41分(44%)在没有任何干扰的情况下实现了这一目标(P=0.01)。在未能达到主要终点的患者中，LAT组中有9/12(75%)的患者在转入RM伴夹带后终止了AT，而RM组中有0/4(0%)的患者转入LAT伴夹带后终止了AT (P=0.04)。结论srm在引导消融以第一个病灶集终止AT、减少夹带辅助诊断方面优于在CARTO3v4 confense系统上的LAT定位。临床试验注册https://www.clinicaltrials.gov。唯一标识符:NCT02451995。
{"title":"Ripple-AT Study.","authors":"V. Luther, S. Agarwal, A. Chow, M. Koa‐Wing, N. Cortez-Dias, L. Carpinteiro, J. de Sousa, R. Balasubramaniam, D. Farwell, S. Jamil-Copley, N. Srinivasan, H. Abbas, James Mason, N. Jones, G. Katritsis, P. Lim, N. Peters, N. Qureshi, Z. Whinnett, N. Linton, P. Kanagaratnam","doi":"10.1161/CIRCEP.118.007394","DOIUrl":"https://doi.org/10.1161/CIRCEP.118.007394","url":null,"abstract":"BACKGROUND\u0000Ripple mapping (RM) is an alternative approach to activation mapping of atrial tachycardia (AT) that avoids electrogram annotation. We tested whether RM is superior to conventional annotation based local activation time (LAT) mapping for AT diagnosis in a randomized and multicenter study.\u0000\u0000\u0000METHODS\u0000Patients with AT were randomized to either RM or LAT mapping using the CARTO3v4 CONFIDENSE system. Operators determined the diagnosis using the assigned 3D mapping arm alone, before being permitted a single confirmatory entrainment manuever if needed. A planned ablation lesion set was defined. The primary end point was AT termination with delivery of the planned ablation lesion set. The inability to terminate AT with this first lesion set, the use of more than one entrainment manuever, or the need to crossover to the other mapping arm was defined as failure to achieve the primary end point.\u0000\u0000\u0000RESULTS\u0000One hundred five patients from 7 centers were recruited with 22 patients excluded due to premature AT termination, noninducibility or left atrial appendage thrombus. Eighty-three patients (pts; RM=42, LAT=41) completed mapping and ablation within the 2 groups of similar characteristics (RM versus LAT: prior ablation or cardiac surgery n=35 [83%] versus n=35 [85%], P=0.80). The primary end point occurred in 38/42 pts (90%) in the RM group and 29/41pts (71%) in the LAT group (P=0.045). This was achieved without any entrainment in 31/42 pts (74%) with RM and 18/41 pts (44%) with LAT (P=0.01). Of those patients who failed to achieve the primary end point, AT termination was achieved in 9/12 pts (75%) in the LAT group following crossover to RM with entrainment, but 0/4 pts (0%) in the RM group crossing over to LAT mapping with entrainment (P=0.04).\u0000\u0000\u0000CONCLUSIONS\u0000RM is superior to LAT mapping on the CARTO3v4 CONFIDENSE system in guiding ablation to terminate AT with the first lesion set and with reduced entrainment to assist diagnosis.\u0000\u0000\u0000CLINICAL TRIALS REGISTRATION\u0000https://www.clinicaltrials.gov. Unique identifier: NCT02451995.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"57 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89939347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/CIRCEP.119.007266
R. Azarrafiy, D. Tsang, B. Wilkoff, R. Carrillo
BACKGROUND Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon. METHODS We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration-maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality. RESULTS From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used (P=0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04-0.40; P<0.001). CONCLUSIONS From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.
{"title":"Endovascular Occlusion Balloon for Treatment of Superior Vena Cava Tears During Transvenous Lead Extraction.","authors":"R. Azarrafiy, D. Tsang, B. Wilkoff, R. Carrillo","doi":"10.1161/CIRCEP.119.007266","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007266","url":null,"abstract":"BACKGROUND\u0000Superior vena cava (SVC) tears are one of the most lethal complications in transvenous lead extraction. An endovascular balloon can occlude the SVC in the event of a laceration, preventing blood loss and offering a more controlled surgical field for repair. An early study demonstrated that proper use of this device is associated with reduced mortality. Thereafter, high-volume extractors at the Eleventh Annual Lead Management Symposium developed a best practice protocol for the endovascular balloon.\u0000\u0000\u0000METHODS\u0000We collected data on adverse events in lead extraction from July 1, 2016, to July 31, 2018. Data were prospectively collected from both a US Food and Drug Administration-maintained database and physician reports of adverse events as they occurred. We gathered case details directly from extracting physicians. Confirmed SVC tears were analyzed for patient demographics, case details, and index hospitalization mortality.\u0000\u0000\u0000RESULTS\u0000From July 1, 2016, to July 31, 2018, 116 confirmed SVC events were identified, of which 44.0% involved proper balloon use and 56.0% involved no use or improper use. When an endovascular balloon was properly used, 45 of 51 patients (88.2%) survived in comparison to 37 of 65 patients (56.9%) when a balloon was not used or improperly used (P=0.0002). Furthermore, multivariate regression modeling found that proper balloon deployment was an independent, negative predictor of in-hospital mortality for patients who experienced an SVC laceration (odds ratio, 0.13; 95% CI, 0.04-0.40; P<0.001).\u0000\u0000\u0000CONCLUSIONS\u0000From July 1, 2016, through July 31, 2018, patients undergoing lead extraction were more likely to survive SVC tears when treatment included an endovascular balloon.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"53 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78475169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/CIRCEP.119.007667
Mark Zamani, M. Wininger
{"title":"Letter by Zamani and Wininger Regarding Article, \"Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis\".","authors":"Mark Zamani, M. Wininger","doi":"10.1161/CIRCEP.119.007667","DOIUrl":"https://doi.org/10.1161/CIRCEP.119.007667","url":null,"abstract":"","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"85 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88649854","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-01DOI: 10.1161/CIRCEP.118.007005
A. Thiyagarajah, K. Kadhim, D. Lau, M. Emami, D. Linz, K. Khokhar, D. Munawar, R. Mishima, V. Malik, C. O’Shea, R. Mahajan, P. Sanders
BACKGROUND The posterior left atrium is an arrhythmogenic substrate that contributes to the initiation and maintenance of atrial fibrillation (AF); however, the feasibility, safety, and efficacy of posterior wall isolation (PWI) as an AF ablation strategy has not been widely reported. METHODS We undertook a systematic review and meta-analysis of studies performing PWI to assess (1) acute procedural success including the ability to achieve PWI and the number of procedure-related complications, (2) Long-term, clinical success including rates of arrhythmia recurrence and posterior wall reconnection, and (3) The efficacy of PWI compared with pulmonary vein isolation on preventing arrhythmia recurrence. MEDLINE, EMBASE, and Web of Science databases were searched in May 2018 to retrieve relevant studies. Results were pooled using a random effects model. RESULTS Seventeen studies (13 box isolation, 3 single ring isolation, and 1 debulking ablation) comprising 1643 patients (31.3% paroxysmal AF, left atrial diameter 41±3.1 mm) were included in the final analysis. In studies focusing specifically on PWI, the acute procedural success rate for achieving PWI was 94.1% (95% CI, 87.2%-99.3%). Single-procedure 12-month freedom from atrial arrhythmia was 65.3% (95% CI, 57.7%-73.9%) overall and 61.9% (54.2%-70.8%) for persistent AF. Randomized control trials comparing PWI to pulmonary vein isolation (3 studies, 444 patients) yielded conflicting results and could not confirm an incremental benefit to PWI. Fifteen major complications (0.1%), including 2 atrio-esophageal fistulas, were reported. CONCLUSIONS PWI as an end point of AF ablation can be achieved in a large proportion of cases with good rates of 12-month freedom from atrial arrhythmia. Although the procedure-related complication rate is low, it did not eliminate the risk of atrio-esophageal fistula. Registration: URL: http://www.crd.york.ac.uk/prospero. PROSPERO registration number: CRD42018107212.
背景左后心房是诱发心律失常的底物，有助于心房颤动(AF)的发生和维持;然而，后壁隔离(PWI)作为房颤消融策略的可行性、安全性和有效性尚未得到广泛报道。方法我们对实施PWI的研究进行了系统回顾和荟萃分析，以评估(1)急性手术成功(包括实现PWI的能力和手术相关并发症的数量)，(2)长期临床成功(包括心律失常复发率和后壁重连率)，以及(3)PWI与肺静脉隔离在预防心律失常复发方面的效果。2018年5月检索MEDLINE、EMBASE和Web of Science数据库检索相关研究。结果采用随机效应模型汇总。结果17项研究共纳入1643例患者(阵发性房颤31.3%，左房内径41±3.1 mm)，其中箱体隔离13例，单环隔离3例，消融术1例。在专门针对PWI的研究中，实现PWI的急性手术成功率为94.1% (95% CI, 87.2%-99.3%)。单次手术12个月房性心律失常的总体自由率为65.3% (95% CI, 57.7%-73.9%)，持续性房颤的自由率为61.9%(54.2%-70.8%)。比较PWI与肺静脉隔离的随机对照试验(3项研究，444例患者)得出了相互矛盾的结果，不能证实PWI有增加的益处。报告了15例主要并发症(0.1%)，包括2例心房-食管瘘。结论spwi作为房颤消融术的终点，在房颤12个月无心律失常的患者中可达到较高比例。虽然手术相关并发症发生率较低，但并不能消除房-食管瘘的风险。注册地址:http://www.crd.york.ac.uk/prospero。普洛斯彼罗注册号:CRD42018107212。
{"title":"Feasibility, Safety, and Efficacy of Posterior Wall Isolation During Atrial Fibrillation Ablation.","authors":"A. Thiyagarajah, K. Kadhim, D. Lau, M. Emami, D. Linz, K. Khokhar, D. Munawar, R. Mishima, V. Malik, C. O’Shea, R. Mahajan, P. Sanders","doi":"10.1161/CIRCEP.118.007005","DOIUrl":"https://doi.org/10.1161/CIRCEP.118.007005","url":null,"abstract":"BACKGROUND\u0000The posterior left atrium is an arrhythmogenic substrate that contributes to the initiation and maintenance of atrial fibrillation (AF); however, the feasibility, safety, and efficacy of posterior wall isolation (PWI) as an AF ablation strategy has not been widely reported.\u0000\u0000\u0000METHODS\u0000We undertook a systematic review and meta-analysis of studies performing PWI to assess (1) acute procedural success including the ability to achieve PWI and the number of procedure-related complications, (2) Long-term, clinical success including rates of arrhythmia recurrence and posterior wall reconnection, and (3) The efficacy of PWI compared with pulmonary vein isolation on preventing arrhythmia recurrence. MEDLINE, EMBASE, and Web of Science databases were searched in May 2018 to retrieve relevant studies. Results were pooled using a random effects model.\u0000\u0000\u0000RESULTS\u0000Seventeen studies (13 box isolation, 3 single ring isolation, and 1 debulking ablation) comprising 1643 patients (31.3% paroxysmal AF, left atrial diameter 41±3.1 mm) were included in the final analysis. In studies focusing specifically on PWI, the acute procedural success rate for achieving PWI was 94.1% (95% CI, 87.2%-99.3%). Single-procedure 12-month freedom from atrial arrhythmia was 65.3% (95% CI, 57.7%-73.9%) overall and 61.9% (54.2%-70.8%) for persistent AF. Randomized control trials comparing PWI to pulmonary vein isolation (3 studies, 444 patients) yielded conflicting results and could not confirm an incremental benefit to PWI. Fifteen major complications (0.1%), including 2 atrio-esophageal fistulas, were reported.\u0000\u0000\u0000CONCLUSIONS\u0000PWI as an end point of AF ablation can be achieved in a large proportion of cases with good rates of 12-month freedom from atrial arrhythmia. Although the procedure-related complication rate is low, it did not eliminate the risk of atrio-esophageal fistula. Registration: URL: http://www.crd.york.ac.uk/prospero. PROSPERO registration number: CRD42018107212.","PeriodicalId":10167,"journal":{"name":"Circulation: Arrhythmia and Electrophysiology","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80043666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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