High incidence of left atrial dysfunction and low voltage zone in patients requiring multiple atrial fibrillation ablation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T Oka ◽  
I Yoshimoto ◽  
Y Koyama ◽  
K Tanaka ◽  
Y Hirao ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Recurrence Rate ◽  
Left Atrial ◽  
Low Voltage ◽  
Peak Voltage ◽  
Af Ablation ◽  
Recurrent Atrial Fibrillation ◽  
Linear Ablation ◽  
Left Atrial Dysfunction

Abstract Background While multiple catheter ablation for recurrent atrial fibrillation (AF) is effective for the maintenance of sinus rhythm, some of patients have ablation-refractory AF. Left atrial (LA) dysfunction and the presence of low voltage zone (LVZ) are associated with recurrence after AF ablation. The association between recurrence and LA dysfunction/ LVZ among patients undergoing multiple AF ablation remains unclear. Purpose We aimed to compare (i)LA function, (ii)the prevalence of LVZ among patients undergoing first, second and third or more AF ablation procedures. Further, we investigated whether LA dysfunction and LVZ are associated with recurrence after multiple procedures. Methods We retrospectively analyzed 460 patients undergoing AF ablation procedures including first, second and third or more sessions from January 2017 to October 2019 in our institute. Before each session, 256-slice MDCT was performed under sinus rhythm to measure pre-ablation LA emptying fraction (LAEF) as the representative of LA function. At the end of each session, we checked the presence of LVZ, which was defined as regions where bipolar peak-to-peak voltage was <0.5mV. All patients underwent pulmonary vein isolation (PVI). If necessary, additional ablation (e.g. linear ablation, non-PV foci ablation and LVZ ablation) was performed. Results Out of 460 sessions, 295 were first (follow-up years: 1.5 [0.8, 2.0]), 134 were second (1.0 [0.5, 1.8]), and 31 were third or more sessions (1.2 [0.7, 2.0]). As the number of sessions increased, the recurrence rate was increased (19% vs. 31% vs. 61%, first vs. second vs. ≥third, P<0.0001), LAEF decreased (39.7±10.5% vs. 32.6±10.1% vs. 25.3±11.8%, P<0.0001) and the incidence of LVZ increased (18% vs. 34% vs. 68%, P<0.0001) (Figure 1). In patients with recurrence (N=104) after multiple ablation (second or more sessions), LAEF was lower and the prevalence of LVZ was higher than those without recurrence (N=61) (LAEF: 27.3±10.3% vs. 33.5±10.5%, with vs. without, P=0.0003; LVZ: 57% vs. 31%, P=0.0014). Conclusions As the number of sessions increased, the recurrence rate was increased. The prevalence of LA dysfunction and LVZ was high in patients requiring multiple ablation procedure. LA dysfunction and LVZ possibly reflect arrhytmogenic substrate causing recurrence of ablation-refractory AF. We should carefully consider repeated AF ablation in patients with severe LA dysfunction and extensive LVZ. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0260834
Author(s):  
Hao-Tien Liu ◽  
Chia-Hung Yang ◽  
Hui-Ling Lee ◽  
Po-Cheng Chang ◽  
Hung-Ta Wo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Paroxysmal Atrial Fibrillation ◽  
Left Atrial ◽  
Low Voltage ◽  
Reverse Remodeling ◽  
Voltage Mapping ◽  
Linear Ablation

Background The therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients. Methods We retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn’t convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA. Results After a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation. Conclusions LVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.

P383Epicardial voltage fingerprinting of sinus rhythm in patients with mitral valve disease

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
M S Van Schie ◽  
R Starreveld ◽  
M C Roos-Serote ◽  
A J J C Bogers ◽  
N M S De Groot
Keyword(s):  
Atrial Fibrillation ◽  
Mitral Valve ◽  
Sinus Rhythm ◽  
Mitral Valve Disease ◽  
Low Voltage ◽  
Electrical Signal ◽  
Valve Disease ◽  
Related Factors ◽  
Peak Voltage ◽  
Conduction Disorders

Abstract Funding Acknowledgements CVON-AFFIP [grant number 914728], NWO-Vidi [grant number 91717339], Biosense Webster USA [ICD 783454] and Medical Delta Background Voltage mapping is increasingly used for identifying the substrate of cardiac arrhythmias like atrial fibrillation (AF). Low bipolar voltage areas are regarded as indicators of structurally remodeled tissue. However, non-substrate related factors such as wavefront activation direction also influence voltages of bipolar EGMs. Unipolar electrograms (U-EGMs), on the other hand, are independent of the electrode orientation and atrial wavefront direction. It is for these reasons that U-EGMs are increasingly used in electrophysiological studies and newly developed mapping systems guiding ablation procedures. Objective The goal of this study is to examine U-EGM voltages at a high resolution scales during sinus rhythm (SR) in patients with mitral valve disease (MVD). Methods Intra-operative epicardial mapping (interelectrode distance 2mm) of the right and left atrium (RA, LA), Bachmann’s Bundle (BB) and pulmonary vein area (PVA) was performed during SR in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal atrial fibrillation (PAF). U-EGMs were analyzed according to their potential type and peak-to-peak voltage. Low voltage was defined as the proportion of potentials with an amplitude below 1.0 mV. Results In all patients, there was a considerable variation in voltage distribution between all atrial regions and clear inter-individual differences were found. In patients without AF, there were no statistical differences in median potential voltages between the various atrial regions (P = 0.869). In the PAF group, however, unipolar voltages of BB potentials were lower compared to RA potentials (3.30 [2.25–4.57] mV vs. 4.64 [3.85–6.08] mV, P = 0.006) and LA potentials (3.30 [2.25–4.57] mV vs. 4.86 [3.72–5.86] mV, P = 0.009). In addition, unipolar voltages at BB were lower in the patients with PAF compared to those without AF (no AF: 4.94 [3.56–5.98] mV, PAF:  3.30 [2.25–4.57] mV, P = 0.006). A larger number of low voltage potentials were recorded at BB in the PAF group (no AF: 2.13 [0.52–7.68] %, PAF: 12.86 [3.18–23.59] %, P = 0.001). In addition, a higher number of fractionated potentials was found in patients with PAF at the PVA (12.81 [9.19–18.03] % vs. 20.94 [13.54–27.37] %, P < 0.001) and LA (11.47 [7.30–18.30] % vs. 17.80 [12.93–21.34] %, P = 0.045). Lower voltages were found in potentials with a progressively higher degree of fractionation (R=-0.76, P < 0.001). Conclusions Even in SR, patients with MVD and AF episodes are characterized by decreased potential voltages at BB and a higher degree of low voltage potentials. Both considerable intra- and inter-individual variation in potential voltages were found in our study population, which underlines the interest of an individualized electrical signal profile which can be used to characterize complex conduction disorders. Abstract Figure. Epicardial voltage maps

scholarly journals Atrial Tachycardias Arising from Ablation of Atrial Fibrillation: A Proarrhythmic Bump or an Antiarrhythmic Turn?

2010 ◽  
Vol 2010 ◽  
pp. 1-9 ◽  
Author(s):  
Ashok J. Shah ◽  
Amir Jadidi ◽  
Xingpeng Liu ◽  
Shinsuke Miyazaki ◽  
Andrei Forclaz ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Sinus Rhythm ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Direct Function ◽  
Mapping Strategy ◽  
Linear Ablation ◽  
Mitral Isthmus ◽  
Focal Ablation

The occurrence of atrial tachycardias (AT) is a direct function of the volume of atrial tissue ablated in the patients with atrial fibrillation (AF). Thus, the incidence of AT is highest in persistent AF patients undergoing stepwise ablation using the strategic combination of pulmonary vein isolation, electrogram based ablation and left atrial linear ablation. Using deductive mapping strategy, AT can be divided into three clinical categories viz. the macroreentry, the focal and the newly described localized reentry all of which are amenable to catheter ablation with success rate of 95%. Perimitral, roof dependent and cavotricuspid isthmus dependent AT involve large reentrant circuits which can be successfully ablated at the left mitral isthmus, left atrial roof and tricuspid isthmus respectively. Complete bidirectional block across the sites of linear ablation is a necessary endpoint. Focal and localized reentrant AT commonly originate from but are not limited to the septum, posteroinferior left atrium, venous ostia, base of the left atrial appendage and left mitral isthmus and they respond quickly to focal ablation. AT not only represents ablation-induced proarrhythmia but also forms a bridge between AF and sinus rhythm in longstanding AF patients treated successfully with catheter ablation.

Influence of the left atrial contact areas on fixed low-voltage zones during atrial fibrillation and sinus rhythm in persistent atrial fibrillation

2017 ◽  
Vol 28 (11) ◽  
pp. 1259-1268
Author(s):  
Shiro Nakahara ◽  
Yuichi Hori ◽  
Naoki Nishiyama ◽  
Yasuo Okumura ◽  
Reiko Fukuda ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Left Atrial ◽  
Low Voltage ◽  
Persistent Atrial Fibrillation ◽  
Contact Areas

scholarly journals 525Correlation of left atrial low voltage and fractionation substrate between sinus rhythm and atrial fibrillation: high density mapping study in persistent AF

EP Europace ◽  
2018 ◽  
Vol 20 (suppl_1) ◽  
pp. i100-i101
Author(s):  
J Chen ◽  
A Jadidi ◽  
Z Moreno-Weidmann ◽  
B Mueller-Edenborn ◽  
H Lehrmann ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Left Atrial ◽  
Low Voltage ◽  
High Density ◽  
Mapping Study ◽  
Density Mapping

scholarly journals Spatial and quantitative assessment of the correlation between sinus rhythm and atrial fibrillation voltage mapping to identify low voltage substrate in persistent atrial fibrillation

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
D Nairn ◽  
C Nagel ◽  
B Mueller-Edenborn ◽  
H Lehrmann ◽  
A Jadidi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Sinus Rhythm ◽  
Left Atrial ◽  
Low Voltage ◽  
Persistent Atrial Fibrillation ◽  
Posterior Wall ◽  
Shape Modelling ◽  
National Budget ◽  
Spatial Concordance ◽  
Public Grant

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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