scholarly journals Stepwise Endo-/Epicardial Catheter Ablation for Atrial Fibrillation: the Mediterranea Approach

2021 ◽  
Author(s):  
Giuseppe De Martino ◽  
Paolo Compagnucci ◽  
Carmine Mancusi ◽  
Enrico Vassallo ◽  
Claudia Calvanese ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Atrial Tachycardia ◽  
Antiarrhythmic Drugs ◽  
Kidney Injury ◽  
Single Stage ◽  
Secondary Outcome ◽  
Symptom Status ◽  
Procedural Success

Background: Outcomes of catheter ablation (CA) among patients with non-paroxysmal atrial fibrillation (AF) are largely disappointing. Objective: We sought to evaluate the feasibility, effectiveness, and safety of a single-stage stepwise endo-/epicardial approach in patients with persistent/longstanding-persistent AF. Methods: We enrolled 25 consecutive patients with symptomatic persistent (n=4) or longstanding-persistent (n=21) AF and at least one prior endocardial procedure, who underwent CA using an endo-/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann’s bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3-month blanking period. The secondary outcome was patients’ symptom status during follow-up. Results: The stepwise endo-/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly (n=6, 24%) or after AF organization into atrial tachycardia (n=12, 48%). BB’s ablation was commonly implicated in arrhythmia termination. After a median follow-up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9-month follow-up (0% vs- 56%, p=0.02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion: a single-stage endo-/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding-persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.

scholarly journals Stepwise endo-/epicardial catheter ablation for atrial fibrillation: the Mediterranea approach

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
P Compagnucci ◽  
G De Martino ◽  
C Mancusi ◽  
E Vassallo ◽  
C Calvanese ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Atrial Tachycardia ◽  
Kidney Injury ◽  
Single Stage ◽  
Secondary Outcome ◽  
Funding Sources ◽  
Symptom Status ◽  
Procedural Success

Abstract Background Outcomes of catheter ablation (CA) among patients with non-paroxysmal atrial fibrillation (AF) are largely disappointing. Purpose We sought to evaluate the feasibility, effectiveness, and safety of a single-stage stepwise endo-/epicardial approach in patients with persistent/longstanding-persistent AF. Methods We enrolled 25 consecutive patients with symptomatic persistent (n=4) or longstanding-persistent (n=21) AF and at least one prior endocardial procedure, who underwent CA using an endo-/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann's bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3-month blanking period. The secondary outcome was patients' symptom status during follow-up. Results The stepwise endo-/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly (n=6, 24%) or after AF organization into atrial tachycardia (n=12, 48%). BB's ablation was commonly implicated in arrhythmia termination. After a median follow-up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9-month follow-up (0% vs- 56%, p=0.02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion A single-stage endo-/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding-persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Early arrhythmia recurrence after catheter ablation for persistent atrial fibrillation: is it predictive for late recurrence?

2021 ◽  
Author(s):  
Miruna A. Popa ◽  
Marc Kottmaier ◽  
Elena Risse ◽  
Marta Telishevska ◽  
Sarah Lengauer ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Antiarrhythmic Drugs ◽  
De Novo ◽  
Persistent Atrial Fibrillation ◽  
Late Recurrence ◽  
Early Recurrence ◽  
Transient Phenomenon ◽  
Future Studies

Abstract Background Early recurrence of atrial tachyarrhythmia (ERAT) is common after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF), but its clinical significance in patients with persistent AF remains unclear. We sought to determine the predictive value of ERAT for rhythm outcome after RFCA for persistent AF. Methods The study included 207 consecutive patients (mean age 66.4 ± 10.7 years, male 66.2%) with persistent and long-standing persistent AF undergoing de novo pulmonary vein isolation (± atrial substrate ablation). All patients remained off antiarrhythmic drugs. ERAT was defined as any atrial arrhythmia ≥ 30 s occurring within the first 30 days. Late recurrence (LR) was determined during follow-up visits scheduled 1, 3, 6 and 12 months post-ablation using 7-day Holter ECGs. Results ERAT occurred in 143/207 (69.1%) patients as AF (60%) or atrial tachycardia (40%) and was persistent in 82% of cases. During a median follow-up of 22.2 months, LR occurred significantly more often in patients with ERAT than in patients without ERAT (92.3 vs. 43.8%, P < 0.001). The only independent predictors for LR were ERAT (OR 16.8, 95% CI 6.184–45.797, P < 0.001) and intraprocedural termination to sinus rhythm (OR 0.052, 95% CI 0.003–0.851, P = 0.038). Extending the blanking period from 30 to 90 days did not impact LR rates. Conclusion ERAT following ablation of persistent AF is strongly associated with late arrhythmia recurrence, which challenges the assumption that ERAT represents merely a transient phenomenon. While limiting the blanking period to 30 days seems justified, the benefit of early re-ablations remains to be addressed in future studies. Graphic abstract

P2834Diagnostic yield of holter recording after atrial fibrillation ablation - detection of asymptomatic recurrences during a one-year follow-up period

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
S P G Van Vugt ◽  
R H J A Volleberg ◽  
S W Westra ◽  
J Thannhauser ◽  
R Evertz ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Diagnostic Yield ◽  
Holter Monitoring ◽  
Implantable Devices ◽  
Cryoballoon Ablation ◽  
Procedural Success ◽  
One Year ◽  
The One

Abstract Background Strategies to detect recurrences after atrial fibrillation (AF) catheter ablation vary widely. Whereas a symptom-based approach may overestimate procedural success due to asymptomatic recurrences, continuous invasive monitoring with implantable devices may be refused by patients and is not routinely recommended. In trial settings, Holter monitoring is recommended at one year after ablation, though more frequent and intensive follow-up is encouraged for more accurate detection of arrhythmia recurrences. Purpose To study the diagnostic yield of Holter monitoring in the detection of asymptomatic recurrent arrhythmias after cryoballoon catheter ablation for AF. Methods Prospective registry on AF patients who underwent cryoballoon ablation with subsequent follow-up in our centre. Follow-up comprised routine (i.e. at 3, 6, and 12 months) and symptom-driven electrocardiographic (ECG) registrations after a three-month blanking period. In addition, patients were scheduled for six-day Holter monitoring shortly after the blanking period, at six months and at the end of the one-year follow-up period. For the current analysis, we studied the Holter recordings of the patients without previously detected arrhythmia recurrence and determined the proportion of asymptomatic recurrences at each respective monitoring period. Results We studied 364 patients with a median age of 60 years (IQR 54–66) and a median CHA2DS2-VASc score of 1 (IQR 1–2). One-year recurrences were documented in 119 (32.7%) patients, of which 90 were initially detected on Holter recording and 39 on ECG registrations (Table). A total of 34 patients did not report symptoms during the documentation of recurrent arrhythmia and comprised 28.6% (34/119) of all recurrences and 37.8% (34/90) of the Holter-detected recurrences. At the three-month Holter registration, 33.3% of the patients with recurrences did not report symptoms, which was 29.4% and 62.5% at the six- and twelve-month registrations, respectively (Figure). Timing and detection of recurrences Time after ablation 3 months 3–6 months 6 months 6–12 months 12 months Patients with Holter-detected recurrences 57/119 (47.9%) 17/119 (14.3%) 16/119 (13.4%) Patients with ECG-documented recurrences 18/119 (15.1%) 11/119 (9.2%) Proportions of asymptomatic recurrences Conclusions In this cohort of AF patients with serial six-day Holter monitoring after cryoballoon ablation, up to one-third of the patients had asymptomatic recurrences. Whereas Holter monitoring shortly after the blanking period detected nearly half of all one-year recurrences, the proportion of asymptomatic detected recurrences was higher in recordings at one year and seems therefore important in the detection of asymptomatic recurrences after catheter ablation.

Abstract 5665: Assessment of Noninducibility after Catheter Ablation for Atrial Fibrillation: High Dose Isoproterenol vs Rapid Atrial Pacing

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Thomas Crawford ◽  
Jean F Sarrazin ◽  
Michael Kuhne ◽  
Nagib Chalfoun ◽  
Darryl Wells ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Sinus Rhythm ◽  
Antiarrhythmic Drugs ◽  
High Dose ◽  
Atrial Pacing ◽  
Target Sites ◽  
Isoproterenol Infusion ◽  
Complex Fractionated Atrial Electrograms

Background: Noninducibility of atrial fibrillation (AF) after catheter ablation of paroxysmal AF (PAF) identifies patients who are more likely to remain in sinus rhythm (SR). However, it is not clear whether assessment of noninducibility by rapid atrial pacing (RAP) is incremental to high dose isoproterenol (ISO) infusion. Methods and Results: There were 65 patients (age=56±13 years) with PAF who presented in sinus rhythm for catheter ablation. ISO was administered in escalating doses of 5/10/15/20 μg/min every 2 minutes prior to ablation. AF (or frequent PACs in 4) was inducible in 61/65 patients (94%) at a mean dose of 15±6 μg/min. Antral pulmonary vein (PV) isolation (APVI) was performed in all patients with complete isolation of all PVs. If AF did not terminate during APVI, complex fractionated atrial electrograms (CFAEs) were targeted in the left atrium (16) or coronary sinus (2) until AF terminated or all target sites were ablated. AF terminated during ablation in 41/65 (63%). Following conversion to sinus rhythm, 54 of the 61 patients (89%) who were initially inducible with ISO became noninducible during ISO re-challenge. Among these 54 patients who were noninducible by ISO, rapid atrial pacing (RAP) down to a cycle length of 180 ms (≥5 times) induced sustained AF (>60 seconds) in 17 patients (31%). At a mean follow-up of 9±4 months after a single ablation procedure, 35/54 patients (65%) who were noninducible by ISO and 2/7 patients (29%) who were inducible were in sinus rhythm without antiarrhythmic drugs. However, 11/17 patients (65%) who were inducible by RAP and 26/37 (70%) who were noninducible by RAP were in sinus rhythm without antiarrhyhtmic drug therapy (P=0.8). Conclusions: Noninducibility of AF in response to high dose isoproterenol infusion identifies patients who are more likely to remain in sinus rhythm after catheter ablation. Rapid atrial pacing may still result in induction of AF in 30% of patients who are noninducible by isoproterenol. However, inducibility of AF by rapid atrial pacing in patients who are noninducible by isoproterenol appears to be a nonspecific observation.

scholarly journals Predictors of early and late left atrial tachycardia and left atrial flutter after catheter ablation of atrial fibrillation: Long-term follow-up

2015 ◽  
Vol 22 (5) ◽  
pp. 557-566 ◽  
Author(s):  
Maciej Wójcik ◽  
Alexander Berkowitsch ◽  
Sergey Zaltsberg ◽  
Christian W. Hamm ◽  
Heinz F. Pitschner ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Atrial Flutter ◽  
Left Atrial ◽  
Atrial Tachycardia ◽  
Long Term Follow Up

scholarly journals Thoracoscopic surgical ablation versus catheter ablation as first-line treatment for long-standing persistent atrial fibrillation: the CASA-AF RCT

2021 ◽  
Vol 8 (18) ◽  
pp. 1-122
Author(s):  
Shouvik Haldar ◽  
Habib R Khan ◽  
Vennela Boyalla ◽  
Ines Kralj-Hans ◽  
Simon Jones ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Antiarrhythmic Drugs ◽  
Persistent Atrial Fibrillation ◽  
Loop Recorder ◽  
Surgical Ablation ◽  
Single Procedure

Background Standalone thoracoscopic surgical ablation may be more effective than catheter ablation in patients with long-standing persistent atrial fibrillation. Objectives To determine whether or not surgical ablation is clinically superior to catheter ablation as the first-line treatment strategy in long-standing persistent atrial fibrillation. Design This was a prospective, multicentre, randomised control trial. Setting Four NHS tertiary centres in England. Participants Adults with long-standing persistent atrial fibrillation, who had European Heart Rhythm Association symptom scores > 2 and who were naive to previous catheter ablation or thoracic/cardiac surgery. Interventions Minimally invasive thoracoscopic surgical ablation and conventional catheter ablation (control intervention). Main outcome measures The primary outcome was freedom from atrial fibrillation/tachycardia ≥ 30 seconds after a single procedure without antiarrhythmic drugs (class 1C/3) at 1 year, excluding a 3-month blanking period. The secondary outcomes include the intervention-related major complication rate; clinical success (≥ 75% reduction in arrhythmia burden); and changes in symptoms, quality of life and cost-effectiveness. Methods Patients (n = 120) were randomised to surgical ablation (n = 60) or catheter ablation (n = 60). An implanted loop recorder provided continuous cardiac monitoring following ablation. Follow-up visits were at 3, 6, 9 and 12 months. Loop recorder data were reviewed monthly by a physiologist who was blinded to the randomisation outcome. Results The study treatment was received by 55 patients in the surgical ablation arm and 60 patients in the catheter ablation arm; five patients withdrew from surgical ablation before treatment. Data from randomised and treated patients were analysed as per intention to treat. Patients had a mean age of 62.3 (standard deviation 9.6) years, were predominantly male (74%), had a mean left atrial diameter of 44.6 mm (standard deviation 6 mm) and were in continuous atrial fibrillation for 22 months (range 16–31 months). At 12 months, 26% of patients in the surgical ablation arm (14/54) and 28% of patients in the catheter ablation arm (17/60) were free from atrial arrhythmias after a single procedure without antiarrhythmic drugs (odds ratio 1.13, 95% confidence interval 0.46 to 2.83; p = 0.84). An arrhythmia burden reduction of ≥ 75% was seen in 36 out of 54 (67%) patients in the surgical ablation arm, compared with 46 out of 60 (77%) patients in the catheter ablation arm (odds ratio 1.64, 95% confidence interval 0.67 to 4.08; p = 0.3). Procedure-related serious complications within 30 days of the intervention occurred in 15% (8/55) of patients in the surgical ablation arm (including one death) compared with 10% (6/60) of patients in the catheter ablation arm (p = 0.46). Surgical ablation was associated with significantly higher costs (£23,221 vs. £18,186; p = 0.02) and fewer quality-adjusted life-years than catheter ablation (0.76 vs. 0.83; p = 0.02). Limitations This study was conducted in four highly specialised cardiology centres that have substantial experience in both treatment modalities; therefore, the results may not be widely generalisable. The study was not powered to detect small differences in efficacy. Conclusions We found no evidence to suggest that standalone thoracoscopic surgical ablation outcomes were superior to catheter ablation outcomes in achieving freedom from atrial arrhythmia after a single procedure without antiarrhythmic drugs. Moreover, surgical ablation is associated with a longer hospital stay, smaller improvements in quality of life and higher health-care costs than catheter ablation (standard care therapy). Future work Evaluation of the impact of ablation treatments on sinus rhythm maintenance and quality of life with extended follow-up to 3 years. Model-based economic analysis to estimate long-term benefits, harms and costs of surgical and catheter ablation compared with antiarrhythmic drug therapy in long-standing persistent atrial fibrillation patients. Trial registration Current Controlled Trials ISRCTN18250790 and ClinicalTrials.gov NCT02755688. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This study was supported by the UK Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is part funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London and the NIHR Evaluation, Trials and Studies Coordinating Centre. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 18. See the NIHR Journals Library website for further project information.

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