Left atrial low-voltage zone ablation of persistent atrial fibrillation in a patient with myotonic dystrophy: A case report

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft (DFG) through DO637/22-3 Ministerium für Wissenschaft, Forschung und Kunst Baden-Württemberg through the Research Seed Capital (RiSC) program. Introduction Presence of left atrial (LA) fibrotic low voltage substrate (LVS) is associated with high risk for arrhythmia recurrences in patients undergoing pulmonary vein isolation (PVI) for atrial fibrillation (AF). PVI and additional ablation of LVS - as identified by mapping in sinus rhythm (SR) or AF - has been reported to improve SR maintenance rates, despite differences of the extent and distribution of LA-LVS in SR versus AF. Aims To study the relationship between SR and AF voltage maps, we sought to identify the optimal AF voltage threshold providing the highest concordance in the extent and distribution of LVS when comparing voltage maps in SR vs. AF. Methods Using the statistical shape modelling software Scalismo, the voltage information from the SR and AF maps (acquired prior to PVI) from 28 patients (66 ± 7 years, 46% male, 82% persistent AF) was projected onto a representative LA-geometry. Sensitivity and specificity of LVS identification were calculated for varying thresholds during AF and the correlation between the SR (threshold 0.5mV) and AF maps was assessed and areas of agreeing LVS classification (SR & AF) were identified for each patient. The data of all 28 patients were combined to a spatial histogram of agreement between SR and AF low voltage maps. Results The correlation between SR and AF maps was high across all patients, with agreement at 60-95% of all mapped sites (Figure A: each red triangle represents one patient and the respective agreement of LVS classification and substrate extent). The optimal AF threshold - to identify LA-LVS <0.5 mV in SR - was 0.29 mV (Q1-3: 0.20-0.37 mV) and was independent of the underlying extent of LVS during SR (Figure A: each blue asterisk represents one patient and the corresponding AF threshold and substrate extent). Agreement between LVS in AF vs. SR was high across most (>90) patients on the anterior LA, lateral LA and the left atrial appendage. Lower agreement (60% of patients) was observed in the posterior wall (Figure B). Conclusions SR and AF voltage maps reveal high spatial concordance in low voltage substrate at the anterior LA, lateral LA and LA appendage, however significant discordances in LVS are found in 40% of patients at the posterior LA. Further studies on an extended patient cohort should assess if regional voltage-thresholds would result in an improved substrate concordance between AF and SR substrate maps. Abstract Figure.

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The Duration of the Amplified Sinus-P-Wave Identifies Presence of Left Atrial Low Voltage Substrate and Predicts Outcome After Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation

JACC: Clinical Electrophysiology ◽

10.1016/j.jacep.2017.12.001 ◽

2018 ◽

Vol 4 (4) ◽

pp. 531-543 ◽

Cited By ~ 20

Author(s):

Amir Jadidi ◽

Björn Müller-Edenborn ◽

Juan Chen ◽

Cornelius Keyl ◽

Reinhold Weber ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Left Atrial ◽

Low Voltage ◽

Persistent Atrial Fibrillation ◽

P Wave

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P359Predictors of left atrial low voltage zones and success of substrate modification in persistent atrial fibrillation

EP Europace ◽

10.1093/ehjci/eux141.085 ◽

2017 ◽

Vol 19 (suppl_3) ◽

pp. iii65-iii65

Author(s):

A. Schade ◽

A. Fischer ◽

V. Mattea ◽

C. Boettcher ◽

S. Rohmann ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Low Voltage ◽

Persistent Atrial Fibrillation ◽

Substrate Modification

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Transseptal puncture for ablation of atrial fibrillation in a patient with an implanted atrial flow regulator: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa242 ◽

2020 ◽

Vol 4 (5) ◽

pp. 1-4

Author(s):

Cornelia Biller ◽

Karlo Filipovic ◽

Jakob Lüker ◽

Daniel Steven

Keyword(s):

Atrial Fibrillation ◽

Case Report ◽

Left Atrial ◽

Three Dimensional ◽

Persistent Atrial Fibrillation ◽

Transseptal Puncture ◽

First Case ◽

Three Dimensional Mapping ◽

Atrial Ablation ◽

Flow Regulator

Abstract Background Atrial flow regulator (AFR) (Occlutech, Helsingborg, Sweden) are self-expanding, circular devices. A flexible waist in the centre connects the two discs and has a centrally located shunt. Case summary We report a case of an 80-year-old woman undergoing a repeat left atrial ablation for persistent atrial fibrillation with an implanted AFR. The AFR was implanted 1 year prior to the procedure for heart failure with preserved ejection fraction as part of the AFR-PRELIEVE trial. A single, fluoroscopy-guided, transseptal puncture was performed infero-posterior to the device, allowing the positioning of the mapping (LASSO® 20 mm, Biosense Webster, Irvine, CA, USA) and ablation (Thermocool Smarttouch SF, CARTO®, Biosense Webster, Irvine, CA, USA) catheter in the left atrium. Three-dimensional mapping (CARTO®, Biosense Webster, Irvine, CA, USA) and left atrial ablation were successfully performed. After the procedure, fluoroscopy and transthoracic echocardiography showed an unchanged device position. Discussion To our knowledge, this is the first case report of a transseptal puncture in a patient with an implanted AFR. Transseptal puncture in patients with an implanted AFR seems to be safe and feasible. With device diameters of 21–23 mm and based on previous studies on similar devices, transseptal puncture should be possible in most patients, as opposed to puncture through the device.

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Left and right atrial appendage functional features as predictors for voltage-defined left atrial remodelling in patients with long-standing persistent atrial fibrillation

Heart and Vessels ◽

10.1007/s00380-020-01752-4 ◽

2021 ◽

Author(s):

Radoslaw Marek Kiedrowicz ◽

Maciej Wielusinski ◽

Andrzej Wojtarowicz ◽

Jaroslaw Kazmierczak

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Low Voltage ◽

Regional Distribution ◽

Persistent Atrial Fibrillation ◽

Atrial Appendage ◽

Right Atrial ◽

Functional Features ◽

The Impact ◽

Flow Velocities

AbstractIt was hypothesised that left atrial (LA) fibrosis identified by the presence of low-voltage areas (LVA) may influence the mechanical and electrical function of the left (LAA) and right (RAA) atrial appendage among the long-standing persistent atrial fibrillation (LSPAF) population. 140 consecutive patients underwent voltage mapping of LA with a multielectrode catheter following pulmonary vein isolation and restoration of sinus rhythm with cardioversion. Echocardiography determined LAA peak outflow and inflow velocities and intracardiac catheter-based mean LAA and RAA AF cycle length (AFCL) were obtained during AF before ablation. The impact of flow velocities and AFCL on the prevalence and location of LVA was further evaluated. LVA were detected in 54% of the patients. 14% of the patients presented severe global LVA burden > 20% of the total LA surface area. 29% of the patients presented a disseminated pattern of remodelling as 3 out of 5 LA segments were affected. LAA AFCL, RAA AFCL, LAA flow velocities did not predict the absolute presence of LVA. However LAA AFCL > 155 ms predicted disseminated LVA pattern and LAA AFCL > 165 ms severe LVA incidence. LAA AFCL > 155 ms was predictive for existence of LVA within antero-septal LA segments whilst LAA emptying velocity ≤ 0.2 m/s within lateral wall. Moreover RAA AFCL > 165 ms was strongly related to the presence of LAA AFCL > 15 ms and > 165 ms. LAA and RAA functional assessment was predictive of the presence of advanced stages of voltage-defined LA fibrosis and its regional distribution among LSPAF population

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