Posterior Wall of the Left Atrium

We present a novel technique for resolving the problem of radical size mismatch at the time of orthotopic transplantation. A 48-year-old man presented with chronic rheumatic heart disease and a giant left atrium. Twenty-three years before, he had undergone mitral valve replacement with a mechanical prosthesis. At the time of the repeated intervention, the volume of his left atrium was 350 mL. Surgical features of the transplantation included approximation of the pulmonary vein ostia by gathering sutures intentionally, in order to decrease the area of the left atrial posterior wall and thereby enable appropriate coaptation with the donor left atrium. After the operation, left atrial volume had been reduced to 60 mL.

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P1415Wide antral circumferential pulmonary vein isolation ablation using a novel balloon cryoablation catheter

EP Europace ◽

10.1093/europace/euaa162.203 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A P Martin ◽

M Fowler ◽

N Lever

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Vein Isolation ◽

Paroxysmal Atrial Fibrillation ◽

Left Atrial ◽

Pulmonary Veins ◽

Posterior Wall ◽

The Novel ◽

Median Treatment

Abstract Background Pulmonary vein isolation using cryotherapy is an established treatment for the management of patients with paroxysmal atrial fibrillation. Ablation using the commercially available balloon cryocatheter has been shown to create wide antral pulmonary vein isolation. A novel balloon cryocatheter (BCC) has been designed to maintain uniform pressure and size during ablation, potentially improving contact with the antral anatomy. The extent of ablation created using the novel BCC has not previously been established. Purpose To determine the anatomical extent of pulmonary vein isolation using electroanatomical mapping when performing catheter ablation for paroxysmal atrial fibrillation using the novel BCC. Methods Nine consecutive patients underwent pre-procedure computed tomography angiography of the left atrium to quantify the chamber dimensions. An electroanatomical map was created using the cryoablation system mapping catheter and a high definition mapping system. A bipolar voltage map was obtained following ablation to determine the extent of pulmonary vein isolation ablation. A volumetric technique was used to quantify the extent of vein and posterior wall electrical isolation in addition to traditional techniques for proving entrance and exit block. Results All patients had paroxysmal atrial fibrillation, mean age 56 years, 7 (78%) male. Electrical isolation was achieved for 100% of the pulmonary veins; mean total procedure time was 109 min (+/- 26 SD), and fluoroscopy time 14.9 min (+/- 2.4 SD). The median treatment applications per vein was one (range one - four), and median treatment duration 180 sec (range 180 -240). Left atrial volume 32 mL/m2 (+/- 7 SD), and mean left atrial posterior wall area 22 cm2 (+/- 4 SD). Data was available for quantitative assessment of the extent of ablation for eight patients. No lesions (0 of 32) were ostial in nature. The antral surface area of ablation was not statistically different between the left and right sided pulmonary veins (p 0.63), which were 5.9 (1.6 SD) and 5.4 (2.1 SD) cm2 respectively. In total 50% of the posterior left atrial wall was ablated. Conclusion Pulmonary vein isolation using a novel BCC provides a wide and antral lesion set. There is significant debulking of the posterior wall of the left atrium. Abstract Figure.

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Tangential Triangular Resection An Option to Treat the Giant Left Atrium

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e3181d8c55c ◽

2010 ◽

Vol 5 (2) ◽

pp. 125-127

Author(s):

Pablo M. A. Pomerantzeff ◽

Carlos M. A. Brandão ◽

Marco A. V. Guedes ◽

Noedir A. G. Stolf

Keyword(s):

Heart Failure ◽

Magnetic Resonance ◽

Left Atrium ◽

Pulmonary Veins ◽

Posterior Wall ◽

Magnetic Resonance Study ◽

Tricuspid Insufficiency ◽

Size Evolution ◽

Giant Left Atrium ◽

Left Atrium Size

A 21-year-old woman presented with congestive heart failure caused by congenital mitral and tricuspid insufficiency, associated with great left atrium enlargement. Transthoracic echo-cardiogram revealed heart dextroversion associated with mitral and tricuspid severe insufficiency and left atrium enlargement (14 cm), confirmed by magnetic resonance study. The left atrium was reduced by a tangential triangular resection of the posterior wall, between the pulmonary veins, suturing the edges of the left atrium with bovine pericardium strip reinforcement. Mitral and tricuspid valves were repaired. The postoperative course was uneventful, and the patient was discharged in the 15th postoperative day. A control magnetic resonance study revealed a 50% reduction in left atrium size. Evolution of left atrium resection is excellent, with low recurrence of arrhythmias, embolism, or heart failure.

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A rare case of stiff left atrial syndrome caused by both coconut left atrium and vertebral compression: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz154 ◽

2019 ◽

Vol 3 (3) ◽

Author(s):

Junichi Ooka ◽

Kensuke Matsumoto ◽

Morihiko Kondo ◽

Toshiyuki Otomo

Keyword(s):

Left Atrium ◽

Vertebral Body ◽

Rare Condition ◽

Posterior Wall ◽

Decompensated Heart Failure ◽

Unusual Complication ◽

Multidetector Row Computed Tomography ◽

Pulmonary Capillary ◽

History Of ◽

V Wave

Abstract Background Calcification of the left atrium (LA) is a rare condition and can be the result of long-standing rheumatic mitral stenosis or an unusual complication after mitral valve replacement. Cases of massive LA calcification have sometimes been referred to as those with ‘coconut LA’ or ‘porcelain LA’. Case summary A 75-year-old woman was referred to our hospital because of chest discomfort and exertional dyspnoea. Doppler echocardiography revealed the presence of elevated filling pressure with significant LA dysfunction. A cardiac catheter examination revealed a quite impressive pulmonary capillary wedge pressure waveform with a steep up-slope and prominent v wave of 43 mmHg (mean: 15 mmHg). Multidetector row computed tomography revealed that LA was sandwiched by dense calcifications along the roof and bottom of the LA, and the posterior wall was compressed by a vertebral body. Integration of these functional and anatomical findings ultimately led to the diagnosis of ‘stiff LA syndrome’. Discussion She had a history of tuberculosis but no history of rheumatic fever or cardiac surgery. Thus, it appeared that the tuberculous pericarditis might have led to the calcified LA by long lasting inflammation. In this case, the LA was encased by a dense calcification and compressed by vertebral body from the posterior direction. Therefore, we speculated that the LA pressure could easily elevate even with a slight haemodynamic load in this special case, and thus eventually resulting in decompensated heart failure.

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Comparing rates of atrioesophageal fistula with contact force-sensing and non-contact force-sensing catheters: analysis of post-market safety surveillance data

Journal of Interventional Cardiac Electrophysiology ◽

10.1007/s10840-019-00653-5 ◽

2019 ◽

Vol 59 (1) ◽

pp. 49-55 ◽

Cited By ~ 2

Author(s):

Hugh Calkins ◽

Andrea Natale ◽

Tara Gomez ◽

Alex Etlin ◽

Moe Bishara

Keyword(s):

Left Atrium ◽

Contact Force ◽

Posterior Wall ◽

Incidence Rates ◽

Force Sensing ◽

Limited Data ◽

Serious Adverse Events ◽

Atrioesophageal Fistula ◽

Post Market ◽

Low Incidence

Abstract Purpose There is limited data on the specific incidence of serious adverse events, such as atrioesophageal fistula (AEF), associated with either contact force (CF) or non-CF ablation catheters. Since the actual number of procedures performed with each type of catheter is unknown, making direct comparisons is difficult. The purpose of this study was to assess the incidence of AEF associated with the use of CF and non-CF catheters. Additionally, we aimed to understand the workflow present in confirmed AEF cases voluntarily provided by physicians. Methods The number of AEFs for 2014–2017 associated with each type of catheter was extracted from an ablation device manufacturer’s complaint database. Proprietary device sales data, a proxy for the total number of procedures, were used as the denominator to calculate the incidence rates. Additional survey and workflow data were systematically reviewed. Results Both CF and non-CF ablation catheters have comparably low incidence of AEF (0.006 ± 0.003% and 0.005 ± 0.003%, respectively, p = 0.69). CF catheters are the catheter of choice for left atrium (LA) procedures which pose the greatest risk for AEF injury. Retrospective analysis of seven AEF cases demonstrated that high power and force and long RF duration were delivered on the posterior wall of the left atrium in all cases. Conclusions CF and non-CF ablation catheters were found to have similar AEF incidence, despite CF catheters being the catheter of choice for LA procedures. More investigation is needed to understand the range of parameters which may create risk for AEF.

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Power, Lesion Size Index and Oesophageal Temperature Alerts During Atrial Fibrillation Ablation

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.120.008316 ◽

2020 ◽

Vol 13 (10) ◽

Author(s):

Milena Leo ◽

Michala Pedersen ◽

Kim Rajappan ◽

Matthew R. Ginks ◽

Ross J. Hunter ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Pulmonary Vein ◽

Recurrence Rate ◽

Posterior Wall ◽

Lesion Size ◽

Atrial Fibrillation Recurrence ◽

Esophageal Temperature ◽

Size Index

Background: Low radiofrequency powers are commonly used on the posterior wall of the left atrium for atrial fibrillation ablation to prevent esophageal damage. Compared with higher powers, they require longer ablation durations to achieve a target lesion size index (LSI). Esophageal heating during ablation is the result of a time-dependent process of conductive heating produced by nearby radiofrequency delivery. This randomized study was conducted to compare risk of esophageal heating and acute procedure success of different LSI-guided ablation protocols combining higher or lower radiofrequency power and different target LSI values. Methods: Eighty consecutive patients were prospectively enrolled and randomized to one of 4 combinations of radiofrequency power and target LSI for ablation on the left atrium posterior wall (20 W/LSI 4, 20 W/LSI 5, 40 W/LSI 4, and 40 W/LSI 5). The primary end point of the study was the occurrence and number of esophageal temperature alerts per patient during ablation. Acute indicators of procedure success were considered as secondary end points. Long-term follow-up data were also collected for all patients. Results: Esophageal temperature alerts occurred in a similar proportion of patients in all groups. Significantly, shorter radiofrequency durations were required to achieve the target LSI in the 40 W groups. Less than 50% of the radiofrequency lesions reached the target LSI of 5 when using 20 W despite a longer radiofrequency duration. A lower rate of first-pass pulmonary vein isolation and a higher rate of acute pulmonary vein reconnection were recorded in the group 20 W/LSI 5. A lower atrial fibrillation recurrence rate was observed in the 40 W groups compared with the 20 W groups at 29 months follow-up. Conclusions: When guided by LSI, posterior wall ablation with 40 W is associated with a similar rate of esophageal temperature alerts and a lower atrial fibrillation recurrence rate at follow-up if compared with 20 W. These data will provide a basis to plan future randomized trials. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02619396.

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412 Prevalence of pulmonary hypertension in patients referred for sleep apnea diagnostics

SLEEP ◽

10.1093/sleep/zsab072.411 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A163-A164

Author(s):

Eugeniya Elfimova ◽

Oxana Mikhailova ◽

Nikolai Danilov ◽

Alexander Litvin ◽

Alexander Pevzner ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Sleep Apnea ◽

Left Atrium ◽

Interventricular Septum ◽

Posterior Wall ◽

Severe Form ◽

Left Ventricular ◽

Chronic Obstructive ◽

Systolic Pulmonary Artery Pressure ◽

Sleep Laboratory

Abstract Introduction The aim to evaluate the prevalence of pulmonary hypertension according to echocardiography in patients referred for sleep apnea diagnostics. Methods We included 145 patients referred to Sleep laboratory for sleep apnea diagnostics. Mean age 63,8 ± 10,4 years, BMI 34,0 ± 5,7 kg/m2, AHI 31,3 ± 20,3/h, ODI 3% 28,2 ± 19,5/h, min SpO2 77,4 ± 9,8%, systolic pulmonary artery pressure (systolic PAP) 25,9 ± 16,4 mmHg. All patients underwent cardiorespiratory and respiratory diagnostics for sleep apnea and echocardiography. Results From the random sample of patients referred to Sleep laboratory 14,5% (21) had systolic PAP > 40 mmHg (by echocardiography). Patients with higher levels of systolic PAP (Systolic PAP, mmHg 49,9 [43,6; 56,2] vs 20,7 [19,9; 23,5],p=0.000) had more severe OSA (AHI 35,7 [27,1; 44,3] vs 26,6 [22,6; 30,6], p = 0.029, ODI 3%, /h 35,8 [25,1; 46,4] vs 23,8 [19,8; 27,8], p= 0.017) and were more obese (BMI 37,1 [33,8; 40,4] vs 33,4 [32,4; 34,5], p=0.024). Prevalence of AHI > 30 /h was 62% in group with systolic PAP > 40 mmHg vs 23% in the group with systolic PAP < 40 mmHg. We observed differences in echocardiography, in group with systolic PAP > 40 mmHg: left atrium (4.6 ± 0,5 vs 4,2 ± 0,4 cm, p=0.012), left atrium volume (94.0 ± 23.6 vs 71.7 ± 16.5 ml, p=0.001) and right atrium area (24.5 ± 4.9 vs 18.4 ± 3.8cm2, p=0.000) were higher. Though ejection fraction (58.2 ± 3.8 vs 59.0 ± 3.8%, p=0.268), interventricular septum thickness (1,13 ± 0,2 vs 1,06 ± 0,3 cm, p=0,654) and left ventricular posterior wall thickness (1,05 ± 0,08 vs 1,00 ± 0,13 cm, p=0,117) didn’t differ. In terms of excessive daytime sleepiness, snoring and nocturia groups didn’t differ, as well as for the prevalence of arterial hypertension, coronary artery disease, chronic heart failure, diabetes mellitus and chronic obstructive pulmonary disease. Conclusion Pulmonary hypertension is frequently observed in patients with OSA and appears to be related to the severity of sleep apnea and obesity. PH should be considered in the regular clinical assessment of all patients with sleep apnea, especially with severe form. Support (if any):

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Radiofrequency Is Necessary for Left Atrium Posterior Wall Isolation

JACC: Clinical Electrophysiology ◽

10.1016/j.jacep.2021.03.018 ◽

2021 ◽

Vol 7 (5) ◽

pp. 677-678

Author(s):

Pablo Elpidio García-Granja ◽

Gonzalo Fernández-Palacios ◽

María Sandín-Fuentes ◽

Emilio García-Morán

Keyword(s):

Left Atrium ◽

Posterior Wall

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P4763High power radiofrequency ablation with fixed short duration is rapid, efficient and safe for circumferential pulmonary vein isolation

European Heart Journal ◽

10.1093/eurheartj/ehz745.1139 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J Schreieck ◽

M Duckheim ◽

U Yurtbil ◽

J Flassak ◽

C Scheckenbach ◽

...

Keyword(s):

Left Atrium ◽

Short Duration ◽

Temperature Rise ◽

Posterior Wall ◽

Rf Ablation ◽

Esophageal Temperature ◽

Single Spot ◽

Rf Applications ◽

Circumferential Pulmonary Vein Isolation

Abstract Background Short duration 50 Watt radiofrequency (RF) ablation has been shown to be feasible for atrial fibrillation (AF) ablation with short procedure times. Purpose We evaluated 50 Watt RF power with a different fixed short application duration at the anterior and posterior left atrial wall using contact force (CF) sensing catheters for circumferential pulmonary vein isolation (PVI). Methods Consecutive patients (pts) with indication for de novo AF ablation (n=40, age 64±12 years) with paroxysmal (n=23) or persistent (n=17) AF underwent high density 3D mapping of the left atrium. Low voltage areas of more than 5% of the left atrium were only found in 20% of pts. Thereafter, circumferential PVI using CF sensing catheters was performed. For each RF application (50 Watt, RF duration 11–13s at the anterior wall, 9–11s at the posterior wall) a stable catheter tip position with minimal mean CF of 3g was required and application was stopped in case of CF more than 30g. Esophageal temperature measurement was performed with temperature cut off 39.0°C. In case of temperature rise, ablation protocol was switched to conventional 20 Watt RF applications for ablation adjacent to the esophagus. Results Complete PVI was achieved in all pts with 81±29 short RF applications resulting in cumulative RF applications duration of 13.1±4.2min and an ablation duration of 59±17min for complete PVI. Even RF application with low CF (3–5g) were effective. Due to esophageal temperature rise, switch to conventional RF application with 20 Watt was performed in 43% of pts at least at one posterior PV entrance. After a waiting period of 20 min only in 33% of pts any PV conduction recurs, in 28% of pts only at a single spot and reconnected fibers were not associated with low CF application at that spot, but clearly associated with low energy application at the posterior wall. All PV were successfully re-isolated in most of pts with a single spot high energy RF application. No serious complications occurred in association with PVI. Follow up will be available at presentation time. Conclusion RF ablation with 50 Watt fixed short duration is efficient and safe for circumferential PVI. Ablation procedure durations are shorter and early recurrence rates are lower compared to reported conventional ablation procedures. The importance of CF titration seems to be diminished by 50 Watt RF applications in the left atrium. Further follow up have to be waited.

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