A comparison of the electrophysiologic and electroanatomic characteristics between the right and left atrium in persistent atrial fibrillation: Is the right atrium a window into the left?

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Abbott Background The exact pathophysiology of how pulmonary vein (PV) triggers initiate or maintain episodes of atrial fibrillation (AF) has been elusive. Catheter ablation at relatively circumscribed areas of rapidly spinning rotors or very rapid focal impulse formation can significantly affect AF. Targeted ablation of these sources using Focal Impulse and Rotor Modulation (FIRM™) shows promise. Purpose To assess the safety and effectiveness of FIRM-guided procedures for the treatment of any type of symptomatic atrial fibrillation (AF). Methods Two hundred and ninety-nine subjects were enrolled in the E-FIRM Registry at 9 clinical sites in Germany and the Netherlands. Subjects were eligible if they had reported incidence of at least 2 documented episodes of symptomatic AF during the preceding 3 months and had failed at least Class I or III anti-arrhythmia drug. Data was collected at enrollment/baseline, procedure, and at 3-, 6-, and 12-month follow-up visits. Results A majority (59.5%, 178/299) had a history of previous ablation, 81.1% (133/164) in the left side, with an average of 1.5 ± 0.8 [range 0, 5] prior ablations. The primary safety endpoint was defined as freedom from procedure related Serious Adverse Events (SAEs) through 7-days and at 12-months. At 7-days, freedom from procedure related SAEs was 94.8% (257/271). At 12-months, freedom from procedure related SAEs was 84.4% (184/218). There were no deaths. Acute effectiveness success, defined as the elimination of all identified rotors, occurred in 64.0% (165/258) of treated patients. All patients for which data was reported had at least 1 rotor identified. The most common regions to find rotors were the lateral wall of the right atrium, the anterior/septal wall of the left atrium, and the posterior inferior region of the left atrium. 75.2% (194/258) of patients had at least one rotor identified in the right atrium, and 84.1% (217/258) of patients had at least one rotor identified in the left atrium. Success was defined as two sequential endpoints: single procedure freedom from AF recurrence at 3-months and single procedure freedom from AF recurrence. At 12-months, success was achieved in 46.4% (13/28) Paroxysmal, 42.9% (87/203) Persistent, and 0% (0/9) Long Standing AF subjects. Conclusions: Since acute success was reported as being achieved in only ∼2/3 of the treated subjects, it is possible that the full potential benefit of the FIRM-guided ablation was hidden in this evaluation of the full cohort. Considering the previous ablation and disease history of subjects, a single-procedure success rate at 12-months over 40% was considered a positive result. Based on these results, FIRM-guided RF ablation in conjunction with conventional RF ablation practices is both a safe and effective treatment strategy for patients with symptomatic AF.

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P979Persistent atrial fibrillation terminated within the left atrium without recurrence at follow-up demonstrates a gradual intracardiac organization during stepwise ablation

European Heart Journal ◽

10.1093/eurheartj/ehz747.0572 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A Pithon ◽

A Luca ◽

A Buttu ◽

J M Vesin ◽

L Roten ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Persistent Atrial Fibrillation ◽

Right Atrial ◽

Linear Ablation ◽

The Right ◽

Dominant Frequencies ◽

Complex Fractionated Atrial Electrograms

Abstract Introduction We previously reported that patients (pts) with recurrence (Rec) after stepwise catheter ablation (step-CA) of persistent atrial fibrillation (pAF) exhibit high bi-atrial intracardiac dominant frequencies (DF) values before ablation, indicative of a severe bi-atrial electro-anatomical remodeling. Purpose Herein, we hypothesized that a gradual decrease in DF values during step-CA is associated with pAF termination and maintenance of sinus rhythm (SR) on the long term. Method In 40 consecutive pts (61±8 yo, sustained AF duration 19±11 months), pulmonary vein isolation (PVI) and left atrium (LA) ablation were performed until pAF termination or cardioversion. 10-sec intracardiac electrograms (EGMs) epochs were recorded before ablation (BL), during PVI and during complex fractionated atrial electrograms (CFAEs) and linear ablation (post_PVI) in the right atrial (RAA) and left atrial (LAA) appendages and in the coronary sinus (CS). DF was defined as the highest peak within the [3–15] Hz EGM spectrum. Rec was defined as any atrial arrhythmia lasting >30 sec during follow-up (FU). Results pAF was terminated within the LA in 70% (28/40, LT) of the pts, while 30% (12/40, NLT) were not. After a mean FU of 34±14 months, all NLT pts had a Rec, while LT pts presented a Rec in 71% (20/28, LT_rec) and remained in SR in 29% (8/28, LT_norec). Figure 1 shows: 1) a gradient in DF values measured in the LAA (panel A), RAA (panel B) and CS (panel C) with the highest values in NLT pts (red), intermediate values in LT_rec pts (yellow) and lowest DF values in LT_norec pts (green); 2) all three groups displayed a gradual intracardiac organization during LA ablation as shown by decreasing DF values (p<0.05, BL vs post_PVI), but the LT_norec pts (green) exhibited the highest relative changes in DF from BL (p<0.05, LT_norec vs NLT, Δ range: −5.31 to −9.69%). Figure 1. Effect of ablation on DF Conclusion Low DF values before ablation and gradual intracardiac organization until pAF termination are associated with maintenance of SR on the long term.

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Nonreentrant focal activations in pulmonary veins in canine model of sustained atrial fibrillation

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.01109.2001 ◽

2002 ◽

Vol 283 (3) ◽

pp. H1244-H1252 ◽

Cited By ~ 65

Author(s):

Shengmei Zhou ◽

Che-Ming Chang ◽

Tsu-Juey Wu ◽

Yasushi Miyauchi ◽

Yuji Okuyama ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Right Atrium ◽

Cycle Length ◽

Pulmonary Veins ◽

Posterior Wall ◽

Canine Model ◽

Anterior Wall ◽

High Density ◽

The Right

Repetitive rapid activities are present in the pulmonary veins (PVs) in dogs with pacing-induced sustained atrial fibrillation (AF). The mechanisms are unclear. We induced sustained (>48 h) AF by rapidly pacing the left atrium (LA) in six dogs. High-density computerized mapping was done in the PVs and atria. Results show repetitive focal activations in all dogs and in 12 of 18 mapped PVs. Activation originated from the middle of the PV and then propagated to the LA and distal PV with conduction blocks. The right atrium (RA) was usually activated by a single large wavefront. Mean AF cycle length in the PVs (left superior, 82 ± 6 ms; left inferior, 83 ± 6 ms; right inferior, 83 ± 4 ms) and LA posterior wall (87 ± 5 ms) were significantly ( P < 0.05) shorter than those in the LA anterior wall (92 ± 4 ms) and RA (107 ± 5 ms). PVs in normal dogs did not have focal activations during induced AF. No reentrant wavefronts were demonstrated in the PVs. We conclude that nonreentrant focal activations are present in the PVs in a canine model of pacing-induced sustained AF.

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The Spatial Distribution of Atrial Fibrillation Termination Sites in the Right Atrium During Complex Fractionated Atrial Electrograms-Guided Ablation in Patients with Persistent Atrial Fibrillation

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.12187 ◽

2013 ◽

Vol 24 (9) ◽

pp. 949-957 ◽

Cited By ~ 13

Author(s):

YUNG-LUNG CHEN ◽

JI-EUN BAN ◽

YAE-MIN PARK ◽

JONG-IL CHOI ◽

SANG-WEON PARK ◽

...

Keyword(s):

Atrial Fibrillation ◽

Spatial Distribution ◽

Right Atrium ◽

Persistent Atrial Fibrillation ◽

Atrial Electrograms ◽

The Right ◽

Complex Fractionated Atrial Electrograms

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A prospective randomized trial comparing biatrial and isolated left atrial ablation in patients with long-standing persistent atrial fibrillation undergoing CABG

European Heart Journal ◽

10.1093/ehjci/ehaa946.0445 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Kalybekova ◽

A Chernyavskyi ◽

V Lukinov

Keyword(s):

Atrial Fibrillation ◽

Right Atrium ◽

Left Atrial ◽

Heart Surgery ◽

Open Heart Surgery ◽

Persistent Atrial Fibrillation ◽

Coronary Syndrome ◽

Atrial Ablation ◽

The Right

Abstract Purpose To compare the efficacy and safety of left atrial ablation (LAA) with those of biatrial ablation (BA) in patients with long-standing persistent atrial fibrillation (AF) in common with CABG. Background AF is the most common heart rhythm disorder, while CAD is the most common cardiovascular disease. Chronic coronary syndrome and atrial fibrillation coexist in many patients. Long-standing persistent atrial fibrillation (AF) is frequent pathology in patients undergoing CABG. Surgical ablation in such patients is currently an effective treatment of AF. Pulmonary vein isolation (PVI) may reduce AF recurrences in 70% of patients with paroxysmal form of AF. However, the efficacy of ablation in patients with long-standing persistent AF is rather low. Clinical studies have shown that the right atrium can also be involved in the AF initiation and maintenance. Areas localized in both atrias are characterized by rapid electrical activity, which is critical in the AF persistence. Therefore, we have hypothesized that in long-standing persistent AF BA could be more effective than isolated LAA. Methods Between 2016 and 2019, 116 patients with long-standing persistent AF and CAD who underwent open-heart surgery were included in this single blind prospective randomized study and divided into two groups: 58 patients in group 1 underwent isolated LAA + CABG, and group II (58 patients) - BA + CABG. All the patients had Reveal LINQ ICM System (Medtronic, USA) implanted during the index procedure. The mean age was 65 [61; 67.75] years versus 62 [58; 66] years (p=0.050) and 83% versus 84% (p>0.999) were men in BA and LAA groups, respectively. The follow-up time was 22±3 months for two groups. The primary endpoint was freedom from AF during 24-month follow-up based on 24-hour Holter monitoring ECG registration and Reveal device data. Results This study has demonstrated that in CAD patients with long-standing persistent AF, PVI in combination with multiple linear lesions in the right atrium while GABG produce a significantly higher success rate than PVI alone. After 24 months, AF recurred in 38% of patients in the BA group and in 64% – in the LAA group (p=0.010). Univariate logistic regression analysis showed indicators as long axis of left atria in mm (OR 3.45, 95%; CI 1.77 to 7.64, p=0.001) in LAA group and (OR 2.02, 95%; CI 1.03 to 4.26, p=0.049) in-group BA increases the risk of AF. Chronic kidney disease (OR 2.95, 95% CI 1.05 to 9.22, p=0,048), and mitral regurgitation (OR 1.18, 95% CI 1.01 to 1.41, p=0.047) have been found the independent predictors of AF recurrence in the LAA group. Arrhythmia on the third day after procedure increases the risk of AF (OR 3.79, 95% CI 1.45 to 10. 58, p=0.008) in the LAA group in a long-term follow-up. Conclusion The study has demonstrated that BA is more effective for treatment of long-standing persistent AF in CAD patients undergoing CABG. Funding Acknowledgement Type of funding source: None

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The effect of hemodialysis on echocardiographic parameters and on supraventricular cardiac arrhythmias

Cardiosomatics ◽

10.26442/22217185.2020.3.200403 ◽

2020 ◽

Vol 11 (3) ◽

pp. 29-34

Author(s):

Oleg V. Likhachev-Mishchenko ◽

Alexey A. Kornienko ◽

Larisa A. Khaisheva ◽

Anastasia V. Duzhikova ◽

Natalia A. Kornienko ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Right Atrium ◽

Inferior Vena ◽

Vena Cava ◽

Dialysis Session ◽

Supraventricular Arrhythmias ◽

Before And After ◽

Echocardiographic Parameters ◽

The Right

Relevance. Supraventricular arrhythmias are frequent comorbid conditions in patients with end-stage renal failure undergoing dialysis. The prevalence of atrial fibrillation (AF) in this group of patients is higher than in the general population and is associated with increased mortality. Aim. To analyze the effect of a dialysis session on echocardiographic parameters and to assess their relationship with the occurrence of supraventricular arrhythmias and AF during hemodialysis. Material and methods. The study included 78 patients on hemodialysis. All patients underwent Holter electrocardiography monitoring, taking into account the heart rate before and after dialysis, the number and duration of AF episodes associated with the dialysis session. Using echocardiography, which was performed before and after the dialysis procedure, all patients were also evaluated for the presence of left ventricular (LV) hypertrophy, impaired systolic and diastolic function, as well as LV myocardial mass, sizes of the left atrium, its volume, volume of the right atrium and LV ejection fraction. Results. An analysis of the differences in echocardiographic parameters before and after dialysis showed a significantly larger volume of the left atrium, the volume of the right atrium, the width of the inferior vena cava, and the parameter P(early transmitral velocity) before dialysis compared with the state after dialysis. Also, AF paroxysms were recorded much more frequently after dialysis. The volume of the left atrium 32 mm and the right atrium 30 mm (limit values) were observed much more often in patients before dialysis. A relationship was found between an increased number of paroxysms of atrial fibrillation and a decrease in the volume of the right atrium 5 mm and the left atrium 7 mm after dialysis. No correlation was found between the mass of the LV and the volume of the left atrium. Conclusions. 1. The age and duration of dialysis therapy in hemodialysis patients are associated with an increased risk of atrial fibrillation. 2. A decrease in the volumes of the right and left atriums after the hemodialysis procedure has a positive correlation with paroxysmal AF. 3. The hemodialysis procedure leads to a decrease in the volumes of the right and left atriums, as well as the width of the inferior vena cava and a decrease in the speed of movement of the mitral valve in early diastole. 4. No relationship was found between the volume of the left atrium and the mass of the LV myocardium in patients on hemodialysis.

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Anatomical correlation between left atrium pulmonary vein ablation targets of atrial fibrillation and adjacent bronchi and pulmonary arteries by MSCT

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-01881-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yan-Jing Wang ◽

Huan Sun ◽

Xiao-Fei Fan ◽

Meng-Chao Zhang ◽

Ping Yang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrium ◽

Pulmonary Vein ◽

Pulmonary Arteries ◽

Contact Points ◽

Pulmonary Vein Ablation ◽

Adjacent Structures ◽

Anatomical Correlation ◽

The Right

Abstract Background The ablation targets of atrial fibrillation (AF) are adjacent to bronchi and pulmonary arteries (PAs). We used computed tomography (CT) to evaluate the anatomical correlation between left atrium (LA)-pulmonary vein (PV) and adjacent structures. Methods Data were collected from 126 consecutive patients using coronary artery CT angiography. The LA roof was divided into three layers and nine points. The minimal spatial distances from the nine points and four PV orifices to the adjacent bronchi and PAs were measured. The distances from the PV orifices to the nearest contact points of the PVs, bronchi, and PAs were measured. Results The anterior points of the LA roof were farther to the bronchi than the middle or posterior points. The distances from the nine points to the PAs were shorter than those to the bronchi (5.19 ± 3.33 mm vs 8.62 ± 3.07 mm; P < .001). The bilateral superior PV orifices, especially the right superior PV orifices were closer to the PAs than the inferior PV orifices (left superior PV: 7.59 ± 4.14 mm; right superior PV: 4.43 ± 2.51 mm; left inferior PV: 24.74 ± 5.26 mm; right inferior PV: 22.33 ± 4.75 mm) (P < .001). Conclusions The right superior PV orifices were closer to the bronchi and PAs than other PV orifices. The ablation at the mid-posterior LA roof had a higher possibility to damage bronchi. CT is a feasible method to assess the anatomical adjacency in vivo, which might provide guidance for AF ablation.

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P649 Before and after: sinus venosus atrial septal defect

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.331 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

I Marco Clement ◽

R Eiros ◽

R Dalmau ◽

T Lopez ◽

G Guzman ◽

...

Keyword(s):

Atrial Septal Defect ◽

Left Atrium ◽

Atrial Flutter ◽

Superior Vena Cava ◽

Right Atrium ◽

Septal Defect ◽

Superior Vena ◽

Pulmonary Veins ◽

Vena Cava ◽

The Right

Abstract Introduction The diagnosis of sinus venosus atrial septal defect (SVASD) is complex and requires special imaging. Surgery is the conventional treatment; however, transcatheter repair may become an attractive option. Case report A 60 year-old woman was admitted to the cardiology department with several episodes of paroxysmal atrial flutter, atrial fibrillation and atrioventricular nodal reentrant tachycardia. She reported a 10-year history of occasional palpitations which had not been studied. A transthoracic echocardiography revealed severe right ventricle dilatation and moderate dysfunction. Right volume overload appeared to be secondary to a superior SVASD with partial anomalous pulmonary venous drainage. A transesophageal echocardiography confirmed the diagnosis revealing a large SVASD of 16x12 mm (Figure A) with left-right shunt (Qp/Qs 2,2) and two right pulmonary veins draining into the right superior vena cava. Additionally, it demonstrated coronary sinus dilatation secondary to persistent left superior vena cava. CMR and cardiac CT showed right superior and middle pulmonary veins draining into the right superior vena cava 18 mm above the septal defect (Figures B and C). After discussion in clinical session, a percutaneous approach was planned to correct the septal defect and anomalous pulmonary drainage. For this purpose, anatomical data obtained from CMR and CT was needed to plan the procedure. During the intervention two stents graft were deployed in the right superior vena cava. The distal stent was flared at the septal defect level so as to occlude it while redirecting the anomalous pulmonary venous flow to the left atrium (Figure D). Control CT confirmed the complete occlusion of the SVASD without residual communication from pulmonary veins to the right superior vena cava or the right atrium (Figure E). Anomalous right superior and middle pulmonary veins drained into the left atrium below the stents. Transthoracic echocardiographies showed progressive reduction of right atrium and ventricle dilatation. The patient also underwent successful ablation of atrial flutter and intranodal tachycardia. She is currently asymptomatic, without dyspnea or arrhythmic recurrences. Conclusions In this case, multimodality imaging played a key role in every stage of the clinical process. First, it provided the diagnosis and enabled an accurate understanding of the patient’s anatomy, particularly of the anomalous pulmonary venous connections. Secondly, it allowed a transcatheter approach by supplying essential information to guide the procedure. Finally, it assessed the effectiveness of the intervention and the improvement in cardiac hemodynamics during follow-up. Abstract P649 Figure.

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