25Invasive transseptal assessment of posterior wall isolation >4yrs post surgical AF ablation in stable sinus rhythm and recurrent af patients. is isolation required for success?

Background: Atrial fibrillation (AF) is associated with left atrial (LA) remodeling caused by LA pressure or volume (LAV) overload represented by the elevated left ventricular filling pressure or LA enlargement. Pulmonary capillary wedge pressure (PCWP) as well as LAV may be useful predictor for successful outcome of AF ablation. The aim of the study was to elucidate the most useful predictor for successful outcome in AF ablation including PCWP measured by a speckle tracking echocardiography (STE). Methods: We measured LAV, LA emptying function (EF), strain and strain rate (SR) by the STE during sinus rhythm before ablation in 137 patients with paroxysmal AF (61±10 years, 80 men) who underwent pulmonary vein isolation. The parameters were compared between non-recurrence (successful) group (n=107, age 61±11, sinus rhythm was continued for more than 1 year) and recurrence group (n=30, age 60±10). The estimated PCWP (ePCWP) was determined as 10.7 - 12.4 x log (active LAEF / minimum LAV), as we previously reported. LA stiffness was calculated as ePCWP/LA strain. We also measured PCWP and LA pressure by cardiac catheterization just before AF ablation in 59 patients. Results: The ePCWP was correlated with PCWP measured by cardiac catheterization (r=0.71, p<0.01). The ePCWP and maximum LAV before ablation in recurrence group increased compared with non-recurrence group (15±3 vs. 11±4 mmHg, and 58±15 vs. 49±15 ml/m2, respectively). LA total and active EF decreased, and LA stiffness increased in recurrence group (39±10 vs. 44±11%, 20±7 vs. 25±10% and 0.83±0.59 vs. 0.47±0.33). In multivariate analysis, ePCWP was independently associated with successful ablation best among LAEF, active EF, maximum LAV and ePCWP. Using 13 mmHg of ePCWP as a cutoff, the sensitivity and specificity for successful ablation were 77 and 73% and the positive and negative predictive value were 44 and 92% (AUC= 0.81). Conclusion: Elevation of ePCWP before AF ablation was the best predictor of AF recurrence after AF ablation. This suggested a strong relation between LV filling pressure and the progression of LA remodeling responsible for AF. The ePCWP estimated by STE is useful to predict the successful outcome of AF ablation.

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Abstract 15692: Voltage Mapping in Atrial Fibrillation vs Sinus Rhythm: Results From the Mavs Study

Circulation ◽

10.1161/circ.142.suppl_3.15692 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Carola Gianni ◽

Jerri A Cunningham ◽

Sanghamitra Mohanty ◽

CHINTAN TRIVEDI ◽

Domenico G Della Rocca ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Low Voltage ◽

Lateral Wall ◽

Posterior Wall ◽

Anterior Wall ◽

Inferior Wall ◽

Voltage Mapping ◽

First Time ◽

Mapping Catheter

Background: Left atrial (LA) scar can be identified with bipolar voltage mapping during sinus rhythm (SR). It is not clear whether the same voltage criteria can be applied during atrial fibrillation (AF). Objective: Aim of this study was to compare voltage maps performed in the same patient both in AF and SR. Methods: Voltage mapping was performed using a 10-pole circular mapping catheter in patients with non-paroxysmal AF undergoing first time RF ablation. For descriptive purposes, the LA was divided in 6 regions: septum, posterior wall (PW), inferior wall (IW), lateral wall, anterior wall, and roof. The threshold for low voltage was <0.5 mV (with a color range setting 0.2-0.5 mV). Mild “scar” was defined as an area low voltage 5-20%, moderate 20-35% and severe as >35%. Results: 16 patients (62% persistent AF, 38% longstanding persistent AF) were included in the study. The map density was comparable during AF and SR (mean points per map 551 vs 547, paired t test P = NS). 2 patients displayed normal voltage during both AF and SR. 14 patients showed areas of low voltage during AF, which were still present during SR in 8. All patients with mild “scarring” during AF (n = 4), showed normal voltage during SR. Of the 7 patients with moderate “scarring”, 2 patients showed normal voltage during SR, while in the remaining 5 “scarring” was only mild during SR. 3 patients showed extensive “scarring” during AF, which was only moderate during SR. During AF, areas of low voltage were more commonly observed in the PW (12/14) followed by the IW (6/14) and antero-septum (4/14); while in SR, in the antero-septum (4/8), PW (3/8) and IW (3/8). Interestingly, in all patients both the PW/IW and (less dramatically) the antero-septum showed more “scarring” during AF as compared to SR. Conclusion: Areas of low voltage are more severe and diffuse during AF when compared to SR. When areas of low voltage are detected during AF, they are more commonly seen in the PW, IW and antero-septal areas.

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Surgical Ablation for Atrial Fibrillation in Cardiac Surgery a Meta-Analysis and Systematic Review

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e3181d9199b ◽

2010 ◽

Vol 5 (2) ◽

pp. 84-96 ◽

Cited By ~ 49

Author(s):

Davy C. H. Cheng ◽

Niv Ad ◽

Janet Martin ◽

Eva E. Berglin ◽

Byung-Chul Chang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Sinus Rhythm ◽

Resource Utilization ◽

Meta Analysis ◽

Surgical Ablation ◽

Af Ablation ◽

All Cause Mortality ◽

Meta Regression

Objectives This meta-analysis sought to determine whether surgical ablation improves clinical outcomes and resource utilization compared with no ablation in adult patients with persistent and permanent atrial fibrillation (AF) undergoing cardiac surgery. Methods A comprehensive search was undertaken to identify all randomized (RCT) and nonrandomized (non-RCT) controlled trials of surgical ablation versus no ablation in patients with AF undergoing cardiac surgery up to April 2009. The primary outcome was sinus rhythm. Secondary outcomes included survival and any other reported clinically relevant outcome or indicator of resource utilization. Odds ratios (OR) and weighted mean differences (WMD) and their 95% confidence intervals (95% CI) were analyzed as appropriate using the random effects model. Heterogeneity was measured using the I2 statistic. Meta-regression was performed to explore the relationship between the benefit from surgical AF and duration of follow-up. Results Thirty-three studies met the inclusion criteria (10 RCTs and 23 non-RCTs) for a total of 4647 patients. The number of patients in sinus rhythm was significantly improved at discharge in the surgical AF ablation group versus (68.6%) the surgery alone group (23.0%) in RCTs (OR 10.1, 95% CI 4.5–22.5) and non-RCTs (OR 7.15, 95% CI 3.42–14.95). This effect on sinus rhythm (74.6% vs. 18.4%) remained at follow-up of 1 to 5 years (OR 6.7, 95% CI 2.8–15.7 for RCT, and OR 15.5, 95% CI 6.6–36.7 for non-RCT). The risk of all-cause mortality at 30 days was not different between the groups in RCT (OR 1.20, 95% CI 0.52–3.16) or non-RCT studies (OR 0.99, 95% CI 0.52–1.87). In studies reporting all-cause mortality at 1 year or more (up to 5 years), mortality did not differ in RCT studies (OR 1.21, 95% CI 0.59–2.51) but was significantly reduced in non-RCT studies (OR 0.54, 95% CI 0.31–0.96). Stroke incidence was not reduced significantly; however, in meta-regression, the risk of stroke decreased significantly with longer follow-up. Other clinical outcomes were similar between groups. Operation time was significantly increased with surgical AF ablation; however, overall impact on length of stay was variable. Conclusions In patients with persistent or permanent AF who present for cardiac surgery, the addition of surgical AF ablation led to a significantly higher rate of sinus rhythm in RCT and non-RCT studies compared with cardiac surgery alone, and this effect remains robust over the longer term (1–5 years). Although non-RCT studies suggest the possibility of reduced risk of stroke and death, this remains to be proven in prospective RCTs with adequate power and follow-up.

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Rate versus rhythm control therapy for atrial fibrillation

10.1093/med/9780198784906.003.0511 ◽

2018 ◽

Author(s):

Albert L. Waldo

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Control Strategy ◽

Rate Control ◽

Anticoagulation Therapy ◽

Rhythm Control ◽

Rate Versus ◽

Ventricular Response ◽

Tachycardia Induced Cardiomyopathy ◽

Stable Sinus Rhythm

Based on data from several clinical trials, either rate control or rhythm control is an acceptable primary therapeutic strategy for patients with atrial fibrillation. However, since atrial fibrillation tends to recur no matter the therapy, rate control should almost always be a part of the treatment. If a rhythm control strategy is selected, it is important to recognize that recurrence of atrial fibrillation is common, but not clinical failure per se. Rather, the frequency and duration of episodes, as well as severity of symptoms during atrial fibrillation episodes should guide treatment decisions. Thus, occasional recurrence of atrial fibrillation despite therapy may well be clinically acceptable. However, for some patients, rhythm control may be the only strategy that is acceptable. In short, for most patients, either a rate or rhythm control strategy should be considered. However, for all patients, there are two main goals of therapy. One is to avoid stroke and/or systemic embolism, and the other is to avoid a tachycardia-induced cardiomyopathy. Also, because of the frequency of atrial fibrillation recurrence despite the treatment strategy selected, patients with stroke risks should receive anticoagulation therapy despite seemingly having achieved stable sinus rhythm. For patients in whom a rate control strategy is selected, a lenient approach to the acceptable ventricular response rate is a resting heart rate of 110 bpm, and probably 90 bpm. The importance of achieving and maintaining sinus rhythm in patients with atrial fibrillation and heart failure remains to be clearly established.

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Incessant Automatic Atrial Tachycardia in a Neonate Successfully Treated with Nadolol and Closely Spaced Doses of Flecainide: A Case Report

Pediatric Reports ◽

10.3390/pediatric12030024 ◽

2020 ◽

Vol 12 (3) ◽

pp. 108-113

Author(s):

Gilda Belli ◽

Mattia Giovannini ◽

Giulio Porcedda ◽

Marco Moroni ◽

Giancarlo la Marca ◽

...

Keyword(s):

Case Report ◽

Sinus Rhythm ◽

Atrial Tachycardia ◽

Electrophysiological Study ◽

Common Type ◽

Supraventricular Tachyarrhythmia ◽

Risk Of Mortality ◽

Wide Complex Tachycardia ◽

Stable Sinus Rhythm ◽

Narrow Complex Tachycardia

Supraventricular tachyarrhythmia (SVT) is the most common type of arrhythmia in childhood. Management can be challenging with an associated risk of mortality. A female neonate was diagnosed with episodes of SVT, controlled antenatally with digoxin. Flecainide was commenced prophylactically at birth. Despite treatment, the infant developed a narrow complex tachycardia at 5 days of age. The electrocardiogram features were suggestive of either re-entry tachycardia or of automatic atrial tachycardia (AAT). Following several unsuccessful treatments, a wide complex tachycardia developed. A transesophageal electrophysiological study led to a diagnosis of AAT. Stable sinus rhythm was finally achieved through increasing daily administrations of flecainide up to six times a day, in association with nadolol. The shortening of intervals to this extent has never been reported before and supports the evidence of a personal, age-specific variability in pharmacokinetics of flecainide. Larger studies are needed to better define the appropriate dose and timing of administration.

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Ablation for Ventricular Tachycardia During Stable Sinus Rhythm

Circulation ◽

10.1161/circulationaha.112.107458 ◽

2012 ◽

Vol 125 (18) ◽

pp. 2175-2177 ◽

Cited By ~ 2

Author(s):

William G. Stevenson ◽

Usha B. Tedrow

Keyword(s):

Ventricular Tachycardia ◽

Sinus Rhythm ◽

Stable Sinus Rhythm

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Dancing Bundles With Stable Sinus Rhythm

Circulation ◽

10.1161/circulationaha.121.058218 ◽

2022 ◽

Vol 145 (1) ◽

pp. 84-86

Author(s):

Jaya Batra ◽

Angelo Biviano ◽

Hirad Yarmohammadi

Keyword(s):

Sinus Rhythm ◽

Stable Sinus Rhythm

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Impact of Sinus Rhythm Maintenance on Major Adverse Cardiac and Cerebrovascular Events after Catheter Ablation of Atrial Fibrillation: Insights from AF Frontier Ablation Registry

10.22541/au.161058060.07089740/v1 ◽

2021 ◽

Author(s):

Keisuke Usuda ◽

Takeshi Kato ◽

Toyonobu Tsuda ◽

Hayato Tada ◽

Satoru Niwa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Sinus Rhythm ◽

Primary Endpoint ◽

Cardiovascular Events ◽

Af Ablation ◽

Multicenter Cohort ◽

Cerebrovascular Events ◽

The Impact ◽

Sinus Rhythm Maintenance

Introduction: The impact of catheter ablation for atrial fibrillation (AF) on cardiovascular events and mortality is controversial. We investigated the impact of sinus rhythm maintenance on major adverse cardiac and cerebrovascular events after AF ablation from a Japanese multicenter cohort of AF ablation. Methods and Results: We investigated 2737 consecutive patients (25.6% female, mean age 63.4 ± 10.3 years) who underwent a first catheter ablation for AF from the Atrial Fibrillation registry to Follow the long-teRm Outcomes and use of aNTIcoagulants aftER Ablation (AF Frontier Ablation Registry). The primary endpoint was a composite of stroke, transient ischemic attack, cardiovascular events, and all-cause death. During a mean follow-up of 25.2 months, 2070 (75.6%) patients were free from AF after catheter ablation, and the primary composite endpoint occurred in 122 (4.5%) patients. The AF nonrecurrence group had a significantly lower incidence of the primary endpoint (1.7 per 100 person-years) compared with the AF recurrence group (3.2 per 100 person-years; P = 0.001). The multivariate analysis revealed that freedom from AF (hazard ratio 0.57; 95% confidence interval 0.39–0.83; P = 0.003) was independently associated with the incidence of the composite event.¬¬ Conclusion: In the multicenter cohort of AF ablation, sinus rhythm maintenance after catheter ablation was independently associated with lower rates of major adverse cardiac and cerebrovascular events.

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AF Ablation by 4PV and LA Posterior Wall Isolation

Journal of Arrhythmia ◽

10.4020/jhrs.27.op09_1 ◽

2011 ◽

Vol 27 (Supplement) ◽

pp. OP09_1

Author(s):

Hideki Origuchi ◽

Hitoshi Yoshimura ◽

Kan Kikuchi ◽

Masahiro Mohri ◽

Hideo Yamamoto

Keyword(s):

Posterior Wall ◽

Af Ablation

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Thoracoscopic infrared ablation to create a box lesion as a treatment for atrial fibrillation

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01750-1 ◽

2022 ◽

Vol 17 (1) ◽

Author(s):

Hiroshi Kubota ◽

Toshiya Ohtsuka ◽

Mikio Ninomiya ◽

Takahiro Nonaka ◽

Motoyuki Hisagi ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Left Atrial Appendage ◽

Thoracoscopic Surgery ◽

Posterior Wall ◽

Beating Heart ◽

Bottom Line ◽

Case Presentation ◽

Permanent Atrial Fibrillation ◽

Direct Current Cardioversion

Abstract Background Creating a box lesion in the posterior wall of the left atrium from the epicardial side of the beating heart remains a challenge. Although a transmural lesion can be created by applying radiofrequency (RF) energy at clampable sites, it is still difficult to create a transmural lesion at unclampable sites because the inner blood flow in the unclampable free wall weakens the thermal effect on the outside. Our aim was to apply the newly developed infrared coagulator to create linear transmural lesions on the beating heart thoracoscopically to treat atrial fibrillation (AF). Case presentation A 71-year-old male was referred to our hospital with a diagnosis of hypertrophic cardiomyopathy and permanent atrial fibrillation. The patient was first diagnosed with atrial fibrillation 20 years before. Direct current cardioversion had been performed every few years a total of four times, but sinus rhythm restoration had always been temporary. On February 27, 2020, thoracoscopic PV isolation together with infrared roof- and bottom-line ablation to create a box lesion and left atrial appendage amputation (LAAA) were performed. The coagulator could be applied to clinical thoracoscopic surgery to successfully create a box lesion without any complication. The patient restored a regular sinus rhythm, it has been maintained for eleven months, and there have been no adverse events. Conclusions The infrared coagulator might have enough potential to create transmural lesions on the beating heart in thoracoscopic AF surgery.

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