scholarly journals Anatomic variants of pulmonary venous drainage and their relation to recurrences of atrial fibrillation after pulmonary vein isolation

2021 ◽  
Vol 27 (3) ◽  
pp. 55-68
Author(s):  
Svetla Dineva ◽  
Milko Stoyanov ◽  
Aneliya Partenova ◽  
Boyan Kunev ◽  
Victoria Stoyanova ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Local Population ◽  
Venous Drainage ◽  
Anatomical Variant ◽  
Cox Regression Analysis ◽  
Anatomical Variants ◽  
The Impact ◽  
Variant Anatomy ◽  
Af Recurrence

Anatomical variants of pulmonary venous drainage in the left atrium are often found. Divergent results have been reported on the impact of variant anatomy on atrial fi brillation (AF) recurrence after catheter ablation. We aimed to study the frequency of different anatomical variants of pulmonary venous drainage and their relationship with documented recurrences of AF after ablation. Material and methods: A retrospective study of patients with AF in whom radiofrequency pulmonary vein isolation was done after previously performed cardiac contrast-enhanced multidetector computed tomography. Clinical and procedural characteristics, type and frequency of anatomical variants of the veno-atrial junction and their association with AF recurrences were studied. Results: One hundred seventy-seven patients (112 men, 63.3%) with AF were studied, of which 148 (83.6%) with paroxysmal AF. Variant anatomy was found in 91 patients (51.4%). In 20.9% there was a common left trunk, in 23.2% – more or less than two right-sided veins, and in 7.3% – variations for both right and left veins. No differences in clinical and procedural characteristics were found between the groups with normal and variant anatomy. Recurrences of AF and their association with pulmonary venous anatomy were studied in 104 patients with follow-up ≥ 3 months. No signifi cant relation was found between the presence of variant anatomy and AF recurrences within the blinding period after ablation, OR = 0.864, 95% CI = 0.397 – 1.88, p = 0.843, nor afterwards, OR = 1.12, 95% CI = 0.5 – 2.5, p = 0.839. Cox regression analysis showed no differences in AF recurrence-free survival regardless of the anatomical variant of pulmonary venous drainage, HR = 1.09, 95% CI = 0.58 – 2.05, p = 0.779. Conclusion: In this local population of patients with AF, the incidence of variant pulmonary venous drainage is just over 50%. No association was found between variant anatomy and the rate of AF recurrences after fi rst pulmonary vein isolation.

scholarly journals The Role of Adenosine in Pulmonary Vein Isolation: A Critical Review

2016 ◽  
Vol 2016 ◽  
pp. 1-13 ◽  
Author(s):  
Paolo D. Dallaglio ◽  
Timothy R. Betts ◽  
Matthew Ginks ◽  
Yaver Bashir ◽  
Ignasi Anguera ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
At Risk ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Waiting Time ◽  
Critical Review ◽  
Recurrence Rates ◽  
The Impact ◽  
Af Recurrence

The cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI), which can be achieved in more than 95% of patients at the end of the procedure. However, AF recurrence rates remain high and are related to recovery of PV conduction. Adenosine testing is used to unmask dormant pulmonary vein conduction (DC). The aim of this study is to review the available literature addressing the role of adenosine testing and determine the impact of ablation at sites of PV reconnection on freedom from AF. Adenosine infusion, by restoring the excitability threshold, unmasks reversible injury that could lead to recovery of PV conduction. The studies included in this review suggest that adenosine is useful to unmask nontransmural lesions at risk of reconnection and that further ablation at sites of DC is associated with improvement in freedom from AF. Nevertheless it has been demonstrated that adenosine is not able to predict all veins at risk of later reconnection, which means that veins without DC are not necessarily at low risk. The role of the waiting period in the setting of adenosine testing has also been analyzed, suggesting that in the acute phase adenosine use should be accompanied by enough waiting time.

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 >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 Does use of an antiarrhythmic drug prior to cryoballoon pulmonary vein isolation impact the duration of the post-ablation blanking period?

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Saberito ◽  
N Milstein ◽  
A Bhatt ◽  
M Habibi ◽  
T Sichrovsky ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Antiarrhythmic Drug ◽  
Loop Recorder ◽  
Funding Sources ◽  
Long Term Follow Up ◽  
The Impact ◽  
First 90 Days ◽  
Af Recurrence

Abstract Background At time of cryoballoon (CB) pulmonary vein isolation (PVI), some patients with atrial fibrillation (AF) are on an antiarrhythmic drug (AAD) while others are not. The impact of AAD use at time of CB PVI on the duration of post-ablation blanking period (BP) is unknown. Objective To determine whether the optimal BP duration differs between pts who were and were not taking an AAD at time of CB PVI. Methods We enrolled consecutive pts with AF who had initial CB PVI; all pts had an implantable loop recorder (ILR). We prospectively followed all pts and determined the time to last AF episode during the 90-day post-PVI BP. This was then correlated with likelihood of having an AF recurrence between 3–12 months post-PVI. Results The cohort included 165 pts (66±9 years; 99 [60%] male; 91 [55%] PAF; CHA2DS2-VASc 2.7±1.6). An AAD was being used at some point prior to ablation in 120 (73%) pts. An AAD was being used at time of CB PVI in 92 (77%) of these 120 pts; this was stopped at a median of 80 [36, 105] days post-PVI. We defined 4 distinct groups: (1) no AF in 90-day BP (n=75 [45%]); (2) last AF within 30 days of PVI (n=32 [19%]); (3) last AF within 60 days of PVI (n=17 [10%]); and (4) last AF within 90 days of PVI (n=41 [25%]). Patients not exposed to an AAD prior to CB PVI had significantly lower likelihood of having no AF in the first 90-days post ablation (p=0.004, Figure). In contrast, if AF was observed post-ablation, as time from ablation to recurrence increased, so did likelihood of long-term failure from ablation (Figure); this relationship was not impacted by use of an AAD. Conclusion The best long-term outcomes post CB PVI are seen in pts who had no prior exposure to an AAD and had no AF within the first 90 days of ablation. Subsequently, as the time from ablation to AF recurrence increased within the 90-day BP, so did likelihood of recurrent AF during long-term follow-up, irrespective of whether an AAD was or was not used. FUNDunding Acknowledgement Type of funding sources: None.

Orientation of the right superior pulmonary vein affects outcome after pulmonary vein isolation

2021 ◽  
Author(s):  
Nándor Szegedi ◽  
Milán Vecsey-Nagy ◽  
Judit Simon ◽  
Bálint Szilveszter ◽  
Szilvia Herczeg ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Anatomical Variations ◽  
Effective Diameter ◽  
Free Survival ◽  
Female Sex ◽  
The Right ◽  
The Impact ◽  
Af Recurrence

Abstract Aims Controversial results have been published regarding the influence of pulmonary vein (PV) anatomical variations on outcomes after pulmonary vein isolation (PVI). However, no data are available on the impact of PV orientation on the long-term success rates of point-by-point PVI. We sought to determine the impact of PV anatomy and orientation on atrial fibrillation (AF)-free survival in patients undergoing PVI using the radiofrequency point-by-point technique. Methods and results We retrospectively included 448 patients who underwent initial point-by-point radiofrequency ablation for AF at our department. Left atrial computed tomography angiography was performed before each procedure. PV anatomical variations, ostial parameters (area, effective diameter, and eccentricity), orientation, and their associations with 24-month AF-free survival were analysed. PV anatomical variations and ostial parameters were not predictive for AF-free survival (all P > 0.05). Univariate analysis showed that female sex (P = 0.025) was associated with higher rates of AF recurrence, ventral-caudal (P = 0.002), dorsal-cranial (P = 0.034), and dorsal-caudal (P = 0.042) orientation of the right superior PV (RSPV), on the other hand, showed an association with lower rates of AF recurrence, when compared with the reference ventral-cranial orientation. On multivariate analysis, both female sex [odds ratio (OR) 1.83, 95% CI 1.15–2.93, P = 0.011] and ventral-caudal RSPV orientation, compared with ventral-cranial orientation, proved to be independent predictors of 24-month AF recurrence (OR 0.37, 95% CI 0.19–0.71, P = 0.003). Conclusion Female sex and ventral-caudal RSPV orientation have an impact on long-term arrhythmia-free survival. Assessment of PV orientation may be a useful tool in predicting AF-free survival and may contribute to a more personalized management of AF.

scholarly journals High-sensitivity cardiac Troponin T delta concentration after repeat pulmonary vein isolation

2019 ◽  
Vol 29 (2) ◽  
pp. 407-412
Author(s):  
Ivan Zeljkovic ◽  
Sven Knecht ◽  
Christian Sticherling ◽  
Michael Kühne ◽  
Stefan Osswald ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Cardiac Troponin ◽  
Troponin T ◽  
High Sensitivity ◽  
Cardiac Troponin T ◽  
Cox Regression Analysis ◽  
Prognostic Power ◽  
Af Recurrence

Introduction: Difference between high-sensitivity cardiac troponin T concentrations (hs-cTnT) before and after ablation procedure (delta concentration) reflects the amount of myocardial injury. The aim of the study was to investigate hs-cTnT prognostic power for predicting atrial fibrillation (AF) recurrence after repeat pulmonary vein isolation (PVI) procedure. Materials and methods: Consecutive patients with paroxysmal AF undergoing repeat PVI using a focal radiofrequency catheter were included in the study. Hs-cTnT was measured before and 18-24 hours after the procedure. Standardized 3, 6 and 12-month follow-up was performed. Cox-regression analysis was used to identify predictors of AF recurrence. Results: A total of 105 patients undergoing repeat PVI were analysed (24% female, median age 61 years). Median (interquartile range) hs-cTnT delta after repeat PVI was 283 (127 - 489) ng/L. After a median follow-up of 12 months, AF recurred in 24 (23%) patients. A weak linear relationship between the total radiofrequency energy delivery time and delta hs-cTnT was observed (Pearson R2 = 0.31, P = 0.030). Delta Hs-cTnT was not identified as a significant long-term predictor of AF recurrence after repeated PVI (P = 0.920). Conclusion: This was the first study evaluating the prognostic power of delta hs-cTnT in predicting AF recurrence after repeat PVI. Delta hs-cTnT does not predict AF recurrence after repeat PVI procedures. Systematic measurement of hs-cTnT after repeat PVI does not add information relevant to outcome.

scholarly journals Orientation of the right superior pulmonary vein affects outcome after pulmonary vein isolation

2021 ◽  
Vol 22 (Supplement_3) ◽  
Author(s):  
M Vecsey-Nagy ◽  
N Szegedi ◽  
J Simon ◽  
B Szilveszter ◽  
M Kolossvary ◽  
...  
Keyword(s):  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Anatomical Variations ◽  
Effective Diameter ◽  
Free Survival ◽  
Female Sex ◽  
The Right ◽  
The Impact ◽  
Af Recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Aims Controversial results have been published regarding the influence of pulmonary vein (PV) anatomical variations on outcomes after pulmonary vein isolation (PVI). However, no data is available on the impact of PV orientation on the long-term success rates of point-by-point PVI. We sought to determine the impact of PV anatomy and orientation on atrial fibrillation (AF)-free survival in patients undergoing PVI using the radiofrequency point-by-point technique. Methods and results We retrospectively included 448 patients who underwent initial point-by-point radiofrequency ablation for AF at our department. Left atrial CT-angiography (CTA) was performed before each procedure. PV anatomical variations, ostial parameters (area, effective diameter and eccentricity), orientation and their associations with 24-month AF-free survival were analyzed. PV anatomical variations and ostial parameters were not predictive for AF-free survival (all p > 0.05). Univariate analysis showed that female sex (p = 0.025) was associated with higher rates of AF recurrence, ventral-caudal (p = 0.002), dorsal-cranial (p = 0.034) and dorsal-caudal (p = 0.042) orientation of the right superior PV (RSPV), on the other hand, showed an association with lower rates of AF recurrence, as compared to the reference ventral-cranial orientation. On multivariate analysis, both female sex [odds ratio(OR) 1.83, 95% CI 1.15-2.93, p = 0.011] and ventral-caudal RSPV orientation, compared with ventral-cranial orientation, proved to be independent predictors of 24-month AF recurrence (OR 0.37, 95% CI 0.19-0.71, p = 0.003). Conclusion   Female sex and ventral-caudal RSPV orientation have an impact on long-term arrhythmia-free survival. Assessment of PV orientation may be a useful tool in predicting AF-free survival and may contribute to a more personalized management of AF.

Changes of QT interval in the acute phase after pulmonary vein isolation for paroxysmal atrial fibrillation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Chikata ◽  
T Kato ◽  
K Ududa ◽  
S Fujita ◽  
K Otowa ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Female Patient ◽  
Pulmonary Vein Isolation ◽  
Acute Phase ◽  
Paroxysmal Atrial Fibrillation ◽  
Qt Interval ◽  
Qt Prolongation ◽  
Qtc Interval ◽  
The Impact

Abstract Introduction Pulmonary vein isolation (PVI) affects ganglionated plexi (GP) around the atrium, leading to a modification of the intrinsic cardiac autonomic system (ANS). In animal models, GP ablation has a potential risk of QT prolongation and ventricular arrhythmias. However, the impact of PVI on QT intervals in humans remains unclear. Purpose This study aims to evaluate the Impact of PVI on QT interval in patients with paroxysmal atrial fibrillation. Methods We analyzed consecutive 117 PAF patients for their first PVI procedures. 12-lead ECG was evaluated at baseline, 4 hr, day 1, 1 month, and 3 months after ablation. Only patients with sinus rhythm on 12-lead ECG at each evaluation point without antiarrhythmic drugs were included. Results Heart rate significantly increased at 4 hr, day 1, and 1 month. Raw QT interval prolonged at 4 hr (417.1±41.6 ms, P<0.001) but shortened at day 1 (376.4±34.1 ms, P<0.001), 1 month (382.2±31.5 ms, P<0.001), and 3 months (385.1±32.8 ms, P<0.001) compared to baseline (391.6±31.4 ms). Bazett- and Fridericia- corrected QTc intervals significantly prolonged at 4hr (Bazett: 430.8±27.9 ms, P<0.001; Fridericia: 425.8±27.4 ms, P<0.001), day1 (Bazett: 434.8±22.3 ms, P<0.001; Fridericia: 414.1±23.7 ms, P<0.001), 1M (Bazett: 434.8±22.3 ms, P<0.001; Fridericia: 408.2±21.0 ms, P<0.05), and 3M (Bazett: 420.1±21.8 ms, P<0.001; Fridericia: 407.8±21.1 ms, P<0.05) compared to baseline (Bazett: 404.9±25.2 ms; Fridericia: 400.0±22.6 ms). On the other hand, Framingham- and Hodges- corrected QTc interval significantly prolonged only at 4hr (Framingham: 424.1±26.6 ms, P<0.001; Hodges: 426.8±28.4 ms, P<0.001) and at day1 (Framingham: 412.3±29.3 ms, P<0.01; Hodges: 410.6±40.2 ms, P<0.05) compared to baseline (Framingham: 399.2±22.7 ms; Hodges: 400.7±22.8 ms). At 4 hr after ablation, raw QT and QTc of all formulas significantly prolonged than baseline. Raw QT and QTc prolongation at 4hr after ablation were more frequently observed in female patients. Multiple regression analysis revealed that female patient is a significant predictor of raw QT and QTc interval prolongation of all formulas 4hr after PVI. Conclusions Raw QT and QTc prolonged after PVI, especially in the acute phase. Female patient is a risk factor for QT prolongation in the acute phase after PVI. Funding Acknowledgement Type of funding source: None

Predictors of recurrence after durable pulmonary vein isolation for paroxysmal atrial fibrillation

EP Europace ◽  
2020 ◽  
Author(s):  
Michelle Lycke ◽  
Maria Kyriakopoulou ◽  
Milad El Haddad ◽  
Jean-Yves Wielandts ◽  
Gabriela Hilfiker ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Paroxysmal Atrial Fibrillation ◽  
Prospective Trial ◽  
High Rate ◽  
Binary Logistic Regression Analysis ◽  
Ablation Time ◽  
Increased Risk ◽  
Af Recurrence

Abstract Aims Catheter ablation of paroxysmal atrial fibrillation (AF) reduces AF recurrence, AF burden, and improves quality of life. Data on clinical and procedural predictors of arrhythmia recurrence are scarce and are flawed by the high rate of pulmonary vein reconnection evidenced during repeat procedures after pulmonary vein isolation (PVI). In this study, we identified clinical and procedural predictors for AF recurrence 1 year after CLOSE-guided PVI, as this strategy has been associated with an increased PVI durability. Methods and results Patients with paroxysmal AF, who received CLOSE-guided PVI and who participated in a prospective trial in our centre, were included in this study. Uni- and multivariate models were plotted to find clinical and procedural predictors for AF recurrence within 1 year. Three hundred twenty-five patients with a mean age of 63 years (CHA2DS2VASc 1 [1–3], left atrium diameter 41 ± 6 mm) were included. About 60.9% were male individuals. After 1 year, AF recurrence occurred in 10.5% of patients. In a binary logistic regression analysis, the diagnosis-to-ablation time (DAT) was found to be the strongest predictor of AF recurrence (P = 0.011). Diagnosis-to-ablation time ≥1 year was associated with a nearly two-fold increased risk for developing AF recurrence. Conclusion The DAT is the most important predictor of arrhythmia recurrence in low-risk patients treated with durable pulmonary vein isolation for paroxysmal AF. Whether reducing the DAT could improve long-term outcomes should be investigated in another trial.

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