Focal AF-ablation after Pulmonary Vein Isolation in a Patient with Hypertrophic Cardiomyopathy Using Cryothermal Energy

2008 ◽  
Vol 31 (10) ◽  
pp. 1358-1361 ◽  
Author(s):  
YVES VAN BELLE ◽  
MICHELLE MICHELS ◽  
LUC JORDAENS
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Af Ablation ◽  
Cryothermal Energy

scholarly journals Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: Treatment Strategy, Characteristics of Consecutive Atrial Tachycardia and Long‐Term Outcome

2021 ◽  
Vol 10 (3) ◽  
Author(s):  
Leon Dinshaw ◽  
Paula Münkler ◽  
Benjamin Schäffer ◽  
Niklas Klatt ◽  
Christiane Jungen ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Drug Therapy ◽  
Hypertrophic Cardiomyopathy ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Antiarrhythmic Drug Therapy ◽  
Af Ablation

Background Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and is associated with a deterioration of clinical status. Ablation of symptomatic AF is an established therapy, but in HCM, the characteristics of recurrent atrial arrhythmias and the long‐term outcome are uncertain. Methods and Results Sixty‐five patients with HCM (aged 64.5±9.9 years, 42 [64.6%] men) underwent AF ablation. The ablation strategy included pulmonary vein isolation in all patients and ablation of complex fractionated atrial electrograms or subsequent atrial tachycardias (AT) if appropriate. Paroxysmal, persistent AF, and a primary AT was present in 13 (20.0%), 51 (78.5%), and 1 (1.5%) patients, respectively. Twenty‐five (38.4%) patients developed AT with a total number of 54 ATs. Stable AT was observed in 15 (23.1%) and unstable AT in 10 (15.3%) patients. The mechanism was characterized as a macroreentry in 37 (68.5%), as a localized reentry in 12 (22.2%), a focal mechanism in 1 (1.9%), and not classified in 4 (7.4%) ATs. After 1.9±1.2 ablation procedures and a follow‐up of 48.1±32.5 months, freedom of AF/AT recurrences was demonstrated in 60.0% of patients. No recurrences occurred in 84.6% and 52.9% of patients with paroxysmal and persistent AF, respectively ( P <0.01). Antiarrhythmic drug therapy was maintained in 24 (36.9%) patients. Conclusions AF ablation in patients with HCM is effective for long‐term rhythm control, and especially patients with paroxysmal AF undergoing pulmonary vein isolation have a good clinical outcome. ATs after AF ablation are frequently observed in HCM. Freedom of atrial arrhythmia is achieved by persistent AF ablation in a reasonable number of patients even though the use of antiarrhythmic drug therapy remains high.

Real-time local impedance monitoring to assess tissue lesion during pulmonary vein isolation: a new tool for AF ablation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Di Cori ◽  
L Segreti ◽  
G Zucchelli ◽  
S Viani ◽  
F Tarasco ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Contact Force ◽  
Vascular Complications ◽  
Lesion Formation ◽  
Tissue Impedance ◽  
Af Ablation ◽  
Group 2 ◽  
Group 1

Abstract Background Contact force catheter ablation is the gold standard for treatment of atrial fibrillation (AF). Local tissue impedance (LI) evaluation has been recently studied to evaluate lesion formation during radiofrequency ablation. Purpose Aim of the study was to assess the outcomes of an irrigated catether with LI alghorithm compared to contact force (CF)-sensing catheters in the treatment of symptomatic AF. Methods A prospective, single-center, nonrandomized study was conducted, to compare outcomes between CF-AF ablation (Group 1) and LI-AF ablation (Group 2). For Group 1 ablation was performed using the Carto 3© System with the SmartTouch SF catheter and, as ablation target, an ablation index value of 500 anterior and 400 posterior. For Group 2, ablation was performed using the Rhythmia™ System with novel ablation catheter with a dedicated algorithm (DirectSense) used to measure LI at the distal electrode of this catheter. An absolute impedance drop greater than 20Ω was used at each targeted. According to the Close Protocol, ablation included a point by point pulmonary vein isolation (PVI) with an Inter-lesion space ≤5 mm in both Groups. Procedural endpoint was PVI, with confirmed bidirectional block. Results A total of 116 patients were enrolled, 59 patients in Group 1 (CF) and 57 in Group 2 (LI), 65 (63%) with a paroxismal AF and 36 (37%) with a persistent AF. Baseline patients features were not different between groups (P=ns). LI-Group showed a comparable procedural time (180±89 vs 180±56, P=0.59) but with a longer fluoroscopy time (20±12 vs 13±9 min, P=0.002). Wide antral isolation was more often observed in CF-Group (95% vs 80%, P=0.022), while LI-Group 2 required frequently additional right or left carina ablation (28% vs 14%, P=0.013). The mean LI was 106±14Ω prior to ablation and 92.5±11Ω after ablation (mean LI drop of 13.5±8Ω) during a median RF time of 26 [19–34] sec for each ablation spot. No steam pops or complications during the procedures were reported. The acute procedural success was 100%, with all PVs successfully isolated in all study patients. Regarding safety, only minor vascular complications were observed (5%), without differences between groups (p=0.97). During follow up, 9-month freedom from atrial fibrillation/atrial flutter/atrial tachycardia recurrence was 86% in Group 1 and 75% in Group 2 (P=0.2). Conclusions An LI-guided PV ablation strategy seems to be safe and effective, with acute and mid-term outcomes comparable to the current contact force strategy. LI monitoring could be a promising complementary parameter to evaluate not only wall contact but also lesion formation during power delivery. Procedural Outcomes Funding Acknowledgement Type of funding source: None

Abstract 15934: Comparison of Atrial Fibrillation Burden Reduction in Patients With Paroxysmal and Persistent Atrial Fibrillation Undergoing Cryoballoon Pulmonary Vein Isolation

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Dan L Musat ◽  
Nicolle S Milstein ◽  
Jacqueline Pimienta ◽  
Advay Bhatt ◽  
Tina C Sichrovsky ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Persistent Atrial Fibrillation ◽  
Loop Recorder ◽  
Similar Reduction ◽  
Af Ablation ◽  
Ablation Success ◽  
One Year ◽  
Af Recurrence

Background: Pulmonary vein isolation (PVI) is a cornerstone of atrial fibrillation (AF) ablation procedures to treat symptomatic AF. Ablation success is defined by absence of AF recurrence >30 seconds. However, reduction in AF burden (AFB) is also an important endpoint. Whether patients with paroxysmal (PAF) and persistent AF (PeAF) have similar reduction in AFB post-ablation is unknown. Objective: To compare the decrease in AFB following cryoballoon (CB) PVI in patients with PAF and PeAF. Methods: We enrolled consecutive pts with an implantable loop recorder (ILR) who subsequently underwent CB PVI. All patients were followed prospectively for at least one year, or until repeat ablation; we compared AFB pre and post-ablation. Results: The cohort included had 47 patients (66 ± 10 years; 32 [68%] male; PAF [n=23, 49%]; CHA 2 DS 2 -VASc 2.7 ± 1.7, 34 [72%] on AAD at the time of ablation). A median of 136 days [IQR 280, 73; minimum of 30 days] of ILR data pre-ablation were available. The median AFB for PAF was 4.7% [IQR 0.9, 14.8] and PeAF was 6.8% [IQR 1.1, 40.4]. After excluding a 3-month post-ablation blanking period, recurrent AF occurred in 12 (52%) PAF and 11 (46%) PeAF patients. The median AFB post-ablation for PAF and PeAF cohorts was 0.03%, [IQR 0, 0.3] and 0.04%, [IQR 0, 1.1], respectively. This represents a >99% reduction in AFB. Conclusion: Although 50% of patients undergoing CB PVI for PAF or PeAF had a recurrence of AF, there was >99% reduction in AFB in both groups. These data highlight the importance of using AFB burden as a marker of therapeutic efficacy post-AF ablation.

P2846Focal impulse and rotor modulation ablation versus pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (FIRMAP AF study)

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
R Tilz ◽  
C L Lenz ◽  
P S Sommer ◽  
N Sawan ◽  
R Meyer-Saraei ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Paroxysmal Atrial Fibrillation ◽  
Gold Standard ◽  
Artery Aneurysm ◽  
Rf Ablation ◽  
Af Ablation ◽  
Number Of Patients

Abstract Background Based on the assumption of trigger elimination, pulmonary vein isolation (PVI) currently presents the gold standard of atrial fibrillation (AF) ablation. Recently, rapidly spinning rotors or focal impulse formation has been raised as a crucial sustaining mechanism of AF. Ablation of these rotors may potentially obviate the need for trigger elimination with PVI. Purpose This study sought to compare the safety and effectiveness of Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation only with the gold standard of pulmonary vein isolation (PVI) in patients with paroxysmal AF. Methods This was a post-market, prospective, single-blinded, randomized, multi-center trial. Patients were enrolled at three centers and equally (1:1) randomized between those undergoing conventional RF ablation with PVI (PVI group) vs. those treated with FIRM-guided RF ablation without PVI (FIRM group). Data was collected at enrollment, procedure, and at 7-day, 3-month, 6-month, and 12-month follow-up visits. The study was closed early by the sponsor. At the time of study closure, any pending follow-up visits were waived. Results From February 2016 until February 2018, a total of 51 (out of a planned 170) patients (mean age 63±10.6 years, 57% male) were enrolled and randomized. Four patients withdrew from the study prior to treatment, resulting in 23 patients allocated to the FIRM group and 24 in the PVI group. Only 13 patients in the FIRM group and 11 patients in the PVI group completed the 12-month follow-up. Statistical analysis was not completed given the small number of patients. Single-procedure effectiveness (freedom from AF/atrial tachycardia recurrence after blanking period) was 52.9% (9/17) in the FIRM group and 85.7% (12/14) in the PVI group at 6 months; and 31.3% (5/16) in the FIRM group and 80% (8/10) in the PVI group at 12 months. Repeat procedures were performed in 45.8% (11/24) patients in the FIRM group and 7.4% (2/27) in the PVI group. The acute safety endpoint [freedom from procedure-related serious adverse events (SAE)] was achieved in 87% (20/23) of FIRM group patients and 100% (24/24) of PVI group patients. Procedure related SAEs occurred in three patients in the FIRM group: 1 femoral artery aneurysm and 2 injection site hematomas. No additional procedure-related SAEs were reported >7 days post-procedure. Conclusions These partial study effectiveness results reinforce the importance of PVI in paroxysmal atrial fibrillation patients and suggest that FIRM-guided ablation alone (without PVI) is not an effective strategy for treatment of paroxysmal AF in most patients. Further study is needed to understand the effectiveness of adding FIRM-guided ablation as an adjunct to PVI in this patient group. Acknowledgement/Funding Abbot

Intraprocedural endpoints to predict durable pulmonary vein isolation: a randomized trial of four post-ablation techniques

EP Europace ◽  
2019 ◽  
Vol 22 (4) ◽  
pp. 567-575 ◽  
Author(s):  
Ruhong Jiang ◽  
Minglong Chen ◽  
Bing Yang ◽  
Qiang Liu ◽  
Zuwen Zhang ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Af Ablation ◽  
Group 4 ◽  
Initial Procedure ◽  
Group 2 ◽  
Waiting Periods ◽  
The Impact ◽  
Af Recurrence

Abstract Aims The optimal procedural endpoint to achieve permanent pulmonary vein isolation (PVI) during ablation of atrial fibrillation (AF) remains unknown. We aimed to compare the impact of prolonged waiting periods and adenosine triphosphate (ATP) testing after PVI on long-term freedom from AF. Methods and results In total, 538 patients (median age 61 years, 62% male) undergoing first-time radiofrequency ablation for paroxysmal AF were randomized into four groups: Group 1 [PVI (no testing), n = 121], Group 2 (PVI + 30min waiting phase, n = 151), Group 3 (PVI+ATP, n = 131), and Group 4 (PVI + 30min+ATP, n = 135). The primary endpoint was freedom from AF. Repeat mapping to assess for late pulmonary vein (PV) reconnection was performed in patients who remained AF-free for &gt;3 years (n = 46) and in those who had repeat ablation for AF recurrence (n = 82). During initial procedure, acute PV reconnection was observed in 33%, 26%, and 42% of patients in Groups 2, 3, and 4, respectively. At 36 months, no significant differences in freedom from AF recurrence were observed among all four groups (55%, 61%, 50%, and 62% for Groups 1, 2, 3, and 4, respectively; P = 0.258). Late PV reconnection was commonly observed, with a similar incidence between patients with and without AF recurrence (74% vs. 83%; P = 0.224). Conclusion Although PVI remains the cornerstone for AF ablation, intraprocedural techniques to assess for PV reconnection did not improve long-term success. Patients without AF recurrence after 3 years exhibited similarly high rates of PV reconnection as those that underwent repeat ablation for AF recurrence. The therapeutic mechanisms of AF ablation may not be solely predicated upon durable PVI.

P2849Prevalence and significance of sustained pulmonary vein isolation in repeat AF ablation procedures

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D J Nascimento Matos ◽  
D Cavaco ◽  
G Rodrigues ◽  
J Carmo ◽  
M S Carvalho ◽  
...  
Keyword(s):  
Catheter Ablation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Cox Regression ◽  
Vena Cava ◽  
Cox Regression Analysis ◽  
Af Ablation ◽  
Rf Applications ◽  
The Right ◽  
Af Recurrence

Abstract Introduction Pulmonary vein (PV) reconnection is a common cause of relapse after catheter ablation of atrial fibrillation (AF). However, some patients have AF recurrence despite durable PV isolation. The aim of this study was to assess the PV isolation status at the time of a second catheter ablation (redo) procedure, and its relationship with subsequent AF relapse. Methods Consecutive patients with symptomatic drug-resistant AF who underwent redo procedures from January 2006 to December 2017 were identified in a single-center observational registry. Pulmonary vein isolation status was assessed during the electrophysiologic study with a circular mapping catheter. Additional radiofrequency (RF) energy applications were also recorded. AF relapse was defined as symptomatic or documented AF/atrial tachycardia/atrial flutter after a 3-month blanking period. Results We identified 240 patients (77 [32%] females, median age 61 [IQR 53–67] years, 85 [35%] with non-paroxysmal AF) undergoing redo procedures during the study period. At the time of redo, 17 (7%) of the patients presented bidirectional conduction block of all PVs. PV reconnection occurred in 157 (65%) of cases in the left superior vein, 142 (59%) in the left inferior vein, 177 (73%) in the right superior vein, and 163 (68%) in the right inferior vein (table). All of the PVs were reconducted in 91 (38%) patients. Additional RF applications were performed in the left atrium (LA) roof, LA posterior wall, cavotricuspid isthmus, mitral isthmus, superior vena cava, coronary sinus, and left atrial appendage ostium, at the operator's discretion (table 1). Over a median follow-up of 2-years (IQR 1–5), 126 patients (53%) suffered AF recurrence, yielding a mean relapse rate of 17%/year. In multivariate Cox regression analysis, the lack of PV reconnection at the time of redo emerged as an independent predictor of subsequent relapse (HR 1.97, 95% CI 1.12–3.49, p=0.019) even after adjustment for univariate predictors including non-paroxysmal AF, body mass index, female sex, and active smoking. Conclusion In patients undergoing redo AF ablation procedures, less than 10% present with complete PV isolation. Despite being relatively infrequent, this finding is independently associated with greater likelihood of subsequent recurrence, suggesting that other mechanisms, not fully addressed by additional RF applications, are at play.

scholarly journals Procedural Patterns and Safety of Atrial Fibrillation Ablation

2020 ◽  
Vol 13 (9) ◽  
Author(s):  
Zak Loring ◽  
DaJuanicia N. Holmes ◽  
Roland A. Matsouaka ◽  
Anne B. Curtis ◽  
John D. Day ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Radiofrequency Ablation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Contact Force ◽  
De Novo ◽  
Class I ◽  
Cryoballoon Ablation ◽  
Af Ablation ◽  
Life Threatening

Background: Catheter ablation is an increasingly used treatment for symptomatic atrial fibrillation (AF). However, there are limited prospective, nationwide data on patient selection and procedural characteristics. This study describes patient characteristics, techniques, treatment patterns, and safety outcomes of patients undergoing AF ablation. Methods: A total of 3139 patients undergoing AF ablation between 2016 and 2018 in the Get With The Guidelines-Atrial Fibrillation registry from 24 US centers were included. Patient demographics, medical history, procedural details, and complications were abstracted. Differences between paroxysmal and patients with persistent AF were compared using Pearson χ 2 and Wilcoxon rank-sum tests. Results: Patients undergoing AF ablation were predominantly male (63.9%) and White (93.2%) with a median age of 65. Hypertension was the most common comorbidity (67.6%), and patients with persistent AF had more comorbidities than patients with paroxysmal AF. Drug refractory, paroxysmal AF was the most common ablation indication (class I, 53.6%) followed by drug refractory, persistent AF (class I, 41.8%). Radiofrequency ablation with contact force sensing was the most common ablation modality (70.5%); 23.7% of patients underwent cryoballoon ablation. Pulmonary vein isolation was performed in 94.6% of de novo ablations; the most common adjunctive lesions included left atrial roof or posterior/inferior lines, and cavotricuspid isthmus ablation. Complications were uncommon (5.1%) and were life-threatening in 0.7% of cases. Conclusions: More than 98% of AF ablations among participating sites are performed for class I or class IIA indications. Contact force-guided radiofrequency ablation is the dominant technique and pulmonary vein isolation the principal lesion set. In-hospital complications are uncommon and rarely life-threatening.

Ablation therapy for persistent atrial fibrillation

2021 ◽  
Vol 17 ◽  
Author(s):  
Ikechukwu Ifedili ◽  
Kristina Mouksian ◽  
David Jones ◽  
Ibrahim El Masri ◽  
Mark Heckle ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Persistent Atrial Fibrillation ◽  
Morbidity And Mortality ◽  
Ablation Therapy ◽  
Af Ablation ◽  
Patient Morbidity ◽  
Important Challenge ◽  
Clinically Significant

: Atrial fibrillation (AF) is the most common form of electrical disturbance of the heart and contributes to significant patient morbidity and mortality. With better understanding of the mechanisms of atrial fibrillation and improvements in mapping and ablation technologies, ablation has become a preferred therapy for patients with symptomatic AF. Pulmonary vein isolation (PVI) is the cornerstone for AF ablation therapy, but particularly in patients with AF occurring for longer than 7 days (persistent AF), identifying clinically significant non pulmonary vein targets and achieving durability of ablation lesions remain an important challenge.

P1059Recurrence of AF after pulmonary vein isolation: how many times?

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
P Silverio Antonio ◽  
N Cortez-Dias ◽  
A Nunes-Ferreira ◽  
G Lima ◽  
I Aguiar-Ricardo ◽  
...  
Keyword(s):  
Prospective Study ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Pulmonary Veins ◽  
High Rate ◽  
Isolation Rate ◽  
Af Ablation ◽  
Mitral Isthmus ◽  
The Right ◽  
Af Recurrence

Abstract Introduction Ablation of atrial fibrillation (AF) by catheter is an effective therapy, particularly in cases of refractoriness to medical therapy. Pulmonary vein isolation (PVI) has a significative long-term recurrence rate of AF, but the recurrence factors after this procedure are poorly defined. Purpose To characterize the causes of AF recurrence after PVI and to evaluate complementary strategies that can optimize the therapeutic efficacy. Methods A single centre prospective study of patients (pts) with AF submitted consecutively to PVI since September 2004. The variables responsible for the recurrence of AF, the complementary strategies of optimization of AF ablation and the occurrence of other dysrhythmias were evaluated. Results A population of 521 pts were submitted to PVI as a primary strategy for AF treatment - 36.1% for paroxysmal AF, 32.5% for persistent AF &lt;1 year, 14.5% persistent AF&gt; 1 year. Eighty-three pts needed to perform 2 ablations and 10 pts performed 3 ablations. The higher the number of AF ablations, the higher the incidence of atypical atrial flutter (2% in the 1st AF ablation, 17% in the 2nd and 44% after 3 ablations). In the pts with recurrence of AF undergoing the 2nd ablation, it was verified that most of the pulmonary veins (PV) were not isolated, with an isolation rate of only 34.1% for the right inferior PV; 29.4% for superior PV right, 29.4% lower left VP, 28.2% upper left PV. In this group, in addition to a new PVI in the pts with re-conduction of PV, 45% performed complementary ablation strategies such as: ablation of the cavo-tricuspid isthmus (52.6%); ablation of the left atrium roof line (29%); mitral isthmus ablation line (26%); applications in the scar zone (26%); posterior atrial left line (8%), atrioventricular nodal reentrant atrioventricular ablation (5%), atrial tachycardia ablation (2.6%). In the pts submitted to the 3rd ablation, again a low PV isolation rate was confirmed: only 44.4% for the both left PV and upper right PV, and 55.6% for the right lower VP. 33.3% also performed cavo-tricuspid isthmus ablation, 22.2% lower mitral isthmus isolation and 22.2% re-isolation of gaps in the roof or intracicritricial line. Conclusion This prospective study demonstrates a high rate of PV re-conduction after PVI and its role in AF recurrence. Therefore, the need for a more effective and definitive IVP technique is evident.

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