Publications by authors named "Eric Buch"

78 Publications

Neuroscientific therapies for atrial fibrillation.

Cardiovasc Res 2021 Jun;117(7):1732-1745

University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095, USA.

The cardiac autonomic nervous system (ANS) plays an integral role in normal cardiac physiology as well as in disease states that cause cardiac arrhythmias. The cardiac ANS, comprised of a complex neural hierarchy in a nested series of interacting feedback loops, regulates atrial electrophysiology and is itself susceptible to remodelling by atrial rhythm. In light of the challenges of treating atrial fibrillation (AF) with conventional pharmacologic and myoablative techniques, increasingly interest has begun to focus on targeting the cardiac neuraxis for AF. Strong evidence from animal models and clinical patients demonstrates that parasympathetic and sympathetic activity within this neuraxis may trigger AF, and the ANS may either induce atrial remodelling or undergo remodelling itself to serve as a substrate for AF. Multiple nexus points within the cardiac neuraxis are therapeutic targets, and neuroablative and neuromodulatory therapies for AF include ganglionated plexus ablation, epicardial botulinum toxin injection, vagal nerve (tragus) stimulation, renal denervation, stellate ganglion block/resection, baroreceptor activation therapy, and spinal cord stimulation. Pre-clinical and clinical studies on these modalities have had promising results and are reviewed here.
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http://dx.doi.org/10.1093/cvr/cvab172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8208752PMC
June 2021

Pulmonary vein and left atrial posterior wall isolation for the treatment of atrial fibrillation: Comparable outcomes for adults with congenital heart disease.

J Cardiovasc Electrophysiol 2021 07 14;32(7):1868-1876. Epub 2021 Apr 14.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, California, USA.

Introduction: Optimal treatment strategies for ACHD with AF are unknown. This study sought to assess outcomes of pulmonary vein isolation (PVI) ± left atrial (LA), posterior wall isolation (PWI) for adults with congenital heart disease (ACHD), and atrial fibrillation (AF).

Methods: A retrospective review of all cryoballoon (CB) PVI ± PWI procedures at a single center over a 3-year period were performed. Clinical characteristics and outcomes for patients with and without ACHD were compared. The primary outcome was the occurrence of atrial tachyarrhythmia at 12-months postablation after a 90-day blanking period.

Results: Three-hundred and sixteen patients (mean: 63 ± 12 years, [63% male]) underwent CB PVI ± PWI during the study, including 31 (10%) ACHD (simple 35%, moderate 39% complex 26%; nonparoxysmal AF in 52%). ACHD was younger (51 vs. 64 years; p < .001) with a lower CHADS DS -VASc score (1.2 vs. 2.1; p = .001) but had a greater LA diameter (4.9 vs. 4.0 cm; p < .001) and a number of prior cardioversions (0.9 vs. 0.4; p < .001) versus controls. 12-month freedom from recurrent AF was similar for ACHD and controls (76% vs. 80%; p = .6) and remained nonsignificant in multivariate analysis (hazard ratio: 1.8, 95% confidence interval: 0.7-5.1; p = .22). At 12-months postablation, 75% of ACHD versus 93% of control patients were off antiarrhythmic drug therapy (p = .07).

Conclusion: This study demonstrates younger age and lower conventional stroke risk, yet clinically advanced AF for ACHD relative to controls. CB PVI ± PWI was an effective strategy for the treatment of AF among all forms of ACHD with similar 12-month outcomes as compared to controls.
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http://dx.doi.org/10.1111/jce.15027DOI Listing
July 2021

Atrial tachycardia arising from the distal left atrial appendage requiring high-power endocardial and epicardial ablation.

HeartRhythm Case Rep 2021 Mar 9;7(3):157-161. Epub 2020 Dec 9.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrcr.2020.11.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987893PMC
March 2021

Arrhythmic Risk Profile and Outcomes of Patients Undergoing Cardiac Sympathetic Denervation for Recurrent Monomorphic Ventricular Tachycardia After Ablation.

J Am Heart Assoc 2021 01 14;10(2):e018371. Epub 2021 Jan 14.

UCLA Cardiac Arrhythmia Center Los Angeles CA.

Background Cardiac sympathetic denervation (CSD) has been used as a bailout strategy for refractory ventricular tachycardia (VT). Risk of VT recurrence in patients with scar-related monomorphic VT referred for CSD and the extent to which CSD can modify this risk is unknown. We aimed to quantify arrhythmia recurrence risk and impact of CSD in this population. Methods and Results Adjusted competing risk time to event models were developed to adjust for risk of VT recurrence and sustained VT/implantable cardioverter-defibrillator shocks after VT ablation based on patient comorbidities at the time of VT ablation. Adjusted VT and implantable cardioverter-defibrillator shock recurrence rates were estimated for the subgroup who subsequently required CSD after ablation. The expected adjusted recurrence rates were then compared with the observed rates after CSD. Data from 381 patients with scar-mediated monomorphic VT who underwent VT ablation were analyzed, excluding patients with polymorphic VT. Sixty eight patients underwent CSD for recurrent VT. CSD reduced the expected adjusted VT recurrence rate by 36% (expected rate of 5.61 versus observed rate of 3.58 per 100 person-months, =0.01) and the sustained VT/implantable cardioverter-defibrillator shock rates by 34% (expected rate of 4.34 versus observed 2.85 per 100 person-months, =0.03). The median number of sustained VT/implantable cardioverter-defibrillator shocks in the year before versus the year after CSD was reduced by 90% (10 versus 1, <0.0001). Conclusions Patients referred for CSD for refractory scar-mediated monomorphic VT are at a higher risk of VT recurrence after ablation as compared with those not requiring CSD, mostly because of their cardiac comorbidities. CSD significantly reduced both the expected risk of recurrences and VT burden.
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http://dx.doi.org/10.1161/JAHA.120.018371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955320PMC
January 2021

Left atrial posterior wall isolation in conjunction with pulmonary vein isolation using cryoballoon for treatment of persistent atrial fibrillation (PIVoTAL): study rationale and design.

J Interv Card Electrophysiol 2020 Oct 3. Epub 2020 Oct 3.

Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.

Background: There is growing evidence in support of pulmonary vein isolation (PVI) with concomitant posterior wall isolation (PWI) for the treatment of patients with symptomatic persistent atrial fibrillation (persAF). However, there is limited data on the safety and efficacy of this approach using the cryoballoon.

Objective: The aim of this multicenter, investigational device exemption trial (G190171) is to prospectively evaluate the acute and long-term outcomes of PVI versus PVI+PWI using the cryoballoon in patients with symptomatic persAF.

Methods: The PIVoTAL is a prospective, randomized controlled study ( ClinicalTrials.gov : NCT04505163) in which patients with symptomatic persAF refractory/intolerant to ≥ 1 class I-IV antiarrhythmic drug, undergoing first-time catheter ablation, will be randomized to PVI (n = 183) versus PVI+PWI (n = 183) using the cryoballoon in a 1:1 fashion. The design will be double-blind until randomization immediately after PVI, beyond which the design will transform into a single-blind. PVI using cryoballoon will be standardized using a pre-specified dosing algorithm. Other empiric ablations aside from documented arrhythmias/arrhythmias spontaneously induced during the procedure will not be permitted. The primary efficacy endpoint is defined as AF recurrence at 12 months, after a single procedure and a 90-day blanking period. Arrhythmia outcomes will be assessed by routine electrocardiograms and 7-14 day ambulatory electrocardiographic monitoring at 3, 6, and 12 months post-ablation.

Conclusion: The PIVoTAL is a prospective, randomized controlled trial designed to evaluate the outcomes of PVI alone versus PVI+PWI using the cryoballoon, in patients with symptomatic persAF. We hypothesize that PVI+PWI will prove to be superior to PVI alone for prevention of AF recurrence.
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http://dx.doi.org/10.1007/s10840-020-00885-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210744PMC
October 2020

Diving Deeper for More Insights From the CIRCA-DOSE Study.

Authors:
Eric Buch

JACC Clin Electrophysiol 2020 08;6(8):955-957

University of California-Los Angeles Cardiac Arrhythmia Center, Los Angeles, California, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jacep.2020.06.014DOI Listing
August 2020

Non-invasive stereotactic body radiation therapy for refractory ventricular arrhythmias: an institutional experience.

J Interv Card Electrophysiol 2021 Sep 15;61(3):535-543. Epub 2020 Aug 15.

UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, 100 Medical Plaza, Suite 660, Los Angeles, CA, 90095, USA.

Background: Initial studies have reported excellent safety and efficacy for stereotactic body radiation therapy (SBRT) in patients with refractory ventricular tachycardia (VT).

Methods: This is a single-center retrospective analysis of eight consecutive patients who underwent SBRT for refractory, scar-related VT. The anatomic target for radioablation was defined based on surface 12-lead ECG VT morphology, cardiac magnetic resonance imaging, and electroanatomic mapping data when available. The target volume treated and the prescribed radiation dose (15-25 Gy) was based on the combined clinical assessment of the cardiac electrophysiologist and radiation oncologist. Ventricular arrhythmias, radiation-related outcomes, and adverse events were monitored at follow-up.

Results: Eight patients underwent nine SBRT sessions. All patients were male with an average age of 75 ± 7.3 years and mean ejection fraction of 21 ± 7%. SBRT was performed with delivery of an average of 22.2 ± 3.6 Gy in a single session with a procedure time of 18.2 ± 6.0 min. All but one session was performed on an inpatient basis. No acute complications occurred. During a median follow-up of 7.8 months (IQR 4.8, 9.9), ICD therapies decreased from median 69.5 (43.5, 115.8) pre-SBRT to 13.3 (IQR 7.7, 35.8) post-SBRT (p = 0.036). There were three patient deaths in the follow-up period, unrelated to SBRT. Apparent clinical benefit occurred 33% of the time after SBRT.

Conclusions: The patients experienced overall reduction in VT burden following SBRT, though not with the immediate effect seen in other patient series. Further studies (basic, translational, and clinical) are essential to determine the benefit of SBRT and if so, the optimal protocols and patient selection.
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http://dx.doi.org/10.1007/s10840-020-00849-0DOI Listing
September 2021

Recurrent ventricular tachycardia after cardiac sympathetic denervation: Prolonged cycle length with improved hemodynamic tolerance and ablation outcomes.

J Cardiovasc Electrophysiol 2020 09 30;31(9):2382-2392. Epub 2020 Jun 30.

UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA.

Introduction: Cardiac sympathetic denervation (CSD) is utilized for the management of ventricular tachycardia (VT) in structural heart disease when refractory to radiofrequency ablation (RFA) or when patient/VT characteristics are not conducive to RFA.

Methods: We studied consecutive patients who underwent CSD at our institution from 2009 to 2018 with VT requiring repeat RFA post-CSD. Patient demographics, VT/procedural characteristics, and outcomes were assessed.

Results: Ninety-six patients had CSD, 16 patients underwent RFA for VT post-CSD. There were 15 male and 1 female patients with mean age of 54.2 ± 13.2 years. Fourteen patients had nonischemic cardiomyopathy. A mean of 2.0 ± 0.8 RFAs for VT was unsuccessful before the patient undergoing CSD. The median time between CSD and RFA was 104 days (interquartile range [IQR] = 15-241). The clinical VT cycle length was significantly increased after CSD both spontaneously on ECG and/or ICD interrogation (355 ± 73 ms pre-CSD vs. 422 ± 94 ms post-CSD, p = .001) and intraprocedurally (406 ± 86 ms pre-CSD vs. 457 ± 88 ms post-CSD, p = .03). Two patients had polymorphic and 14 had monomorphic VT (MMVT) pre-CSD, and all patients had MMVT post-CSD. The proportion of mappable, hemodynamically stable VTs increased from 35% during pre-CSD RFA to 58% during post-CSD RFA (p = .038). At median follow-up of 413 days (IQR = 43-1840) after RFA, eight patients had no further VT.

Conclusion: RFA for recurrent MMVT post-CSD is a reasonable treatment option with intermediate-term clinical success in 50% of patients. Clinical VT cycle length was significantly increased after CSD with associated improvement in mappable, hemodynamically tolerated VT during RFA.
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http://dx.doi.org/10.1111/jce.14624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719072PMC
September 2020

Cryoballoon pulmonary vein isolation: Effects on neural control of the heart.

Int J Cardiol 2020 09 19;314:77-78. Epub 2020 Apr 19.

University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2020.04.037DOI Listing
September 2020

Ultrahigh-density mapping supplemented with global chamber activation identifies noncavotricuspid-dependent intra-atrial re-entry conduction isthmuses in adult congenital heart disease.

J Cardiovasc Electrophysiol 2019 12 10;30(12):2797-2805. Epub 2019 Nov 10.

UCLA Medical Center, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California.

Objective: To evaluate the role of ultrahigh-density mapping for conduction isthmus (CI) characterization in adult congenital heart disease (ACHD).

Background: Catheter ablation remains suboptimal for ACHD with atypical intra-atrial reentrant tachycardias (IART) that can be challenging to define using existing mapping technology.

Methods: An ultrahigh-density mapping system was selectively employed over a 1-year period for procedures involving noncavotricuspid isthmus-dependent-IART. A global activation histogram (GAH) was assessed for the ability to predict ablation targets. Procedural characteristics were compared to a group of matched controls.

Results: Twenty patients (mean age 43 ± 15, 70% male) underwent 20 procedures targeting 34 tachycardias during the study period. Diagnoses included single ventricle (8), tetralogy of Fallot (2), left heart obstruction (3), Ebstein's anomaly (2) atrial septal defect (2), Mustard operation (2), and Rasteilli operation (1). Prior catheter ablation/Maze operation had been performed in 12 (60%). The median time per map was 21 minutes (interquartile range [IQR], 16-32), representing 14 834 points per map (IQR 9499-43 191; P < .001 vs controls). Review of GAH maps showed lower trough values were associated with more favorable IART CI characteristics (P ≤ =.001 for all). Acute success was achieved in 19/20 (95%) procedures, with tachycardia termination during the first lesion in eight cases (P = .02 vs controls). There was one recurrence during 0.6 years follow-up.

Conclusions: Ultrahigh-density mapping supplemented with the GAH tool was effective for CI identification in a cohort of complex ACHD patients. Catheter ablation was more efficient compared to controls, suggesting precise CI characterization using this technology.
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http://dx.doi.org/10.1111/jce.14251DOI Listing
December 2019

Renal denervation as adjunctive therapy to cardiac sympathetic denervation for ablation refractory ventricular tachycardia.

Heart Rhythm 2020 02 17;17(2):220-227. Epub 2019 Sep 17.

UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California.

Background: Autonomic modulation is finding an increasing role in the treatment of ventricular arrhythmias. Renal denervation (RDN) has been described as a treatment modality for refractory ventricular tachycardia (VT) in case series.

Objective: The purpose of this study was to evaluate RDN as an adjunctive therapy to cardiac sympathetic denervation (CSD) for ablation refractory VT.

Methods: Patients who underwent RDN after radiofrequency ablation and CSD procedures at our center from 2012 to 2019 were evaluated.

Results: Ten patients underwent RDN after CSD (9 bilateral and 1 left-sided only) with a median follow-up of 23 months. The mean age was 59.9 ± 10.4 years, and 9/10 (90%) were men. All had cardiomyopathy with a mean ejection fraction of 33% ± 11% (20% ischemic). Four (40%) underwent CSD during the same hospitalization as that for RDN. Patients who underwent RDN as adjunctive therapy to CSD had a decrease in all implantable cardioverter-defibrillator therapies (shocks + antitachycardia pacing [ATP]) from 29.5 ± 25.2 to 7.1 ± 10.1 comparing 6 months pre-RDN to 6 months post-RDN (P = .028). Implantable cardioverter-defibrillator shocks were significantly decreased from 7.0 ± 6.1 to 1.7 ± 2.5 comparing 6 months pre-RDN to 6 months post-RDN (P = .026). This benefit was driven by a decrease in therapies for 6 patients who had a staged procedure, not performed during the same hospitalization (28.5 ± 24.3 to 1.0 ± 1.2; P = .043).

Conclusion: RDN demonstrates the potential benefit when VT recurs after radiofrequency ablation and CSD. The benefit is seen in patients who undergo a staged procedure. The need for acute RDN after CSD portends a poor prognosis.
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http://dx.doi.org/10.1016/j.hrthm.2019.09.016DOI Listing
February 2020

Increased baseline ECG R-R dispersion predicts improvement in systolic function after atrial fibrillation ablation.

Open Heart 2019;6(1):e000958. Epub 2019 Jun 25.

Division of Cardiology, University of Minnesota, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.

Background: Atrial fibrillation (AF) is associated with left ventricular (LV) systolic dysfunction which may improve after AF ablation. We hypothesised that increased ventricular irregularity, as measured by R-R dispersion on the baseline ECG, would predict improvement in the left ventricular ejection fraction (LVEF) after AF ablation.

Methods: Patients with LVEF <50% at two US centres (2007-2016), having both a preablation and postablation echocardiogram or cardiac MRI, were included. LVEF improvement was defined as absolute increase in LVEF by >7.5%. Multivariable logistic regression (restricted to echocardiographic/ECG variables) was performed to evaluate predictors of LVEF improvement.

Results: Fifty-two patients were included in this study. LVEF improved in 30 patients (58%) and was unchanged/worsened in 22 patients (42%). Those with versus without LVEF improvement had an increased baseline R-R dispersion (645±155 ms vs 537±154 ms, p=0.02, respectively). The average baseline heart rate in all patients was 93 beats per minute. After multivariable logistic regression, increased R-R dispersion (OR 1.59, 95% CI 1.00 to 2.55, p=0.03) predicted LVEF improvement.

Conclusions: Increased R-R dispersion on ECG was independently associated with improved systolic function after AF ablation. This broadens the existing knowledge of arrhythmia-induced cardiomyopathy, demonstrating that irregular electrical activation (as measured by increased R-R dispersion on ECG) is associated with a cardiomyopathy capable of improving after AF ablation.
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http://dx.doi.org/10.1136/openhrt-2018-000958DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609144PMC
February 2021

Limitations of 12-lead electrocardiogram wide complex tachycardia algorithms in a patient with left atrial flutter and large myocardial infarction.

HeartRhythm Case Rep 2019 Feb 12;5(2):70-73. Epub 2018 Apr 12.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrcr.2018.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379568PMC
February 2019

Feasibility of percutaneous epicardial mapping and ablation for refractory atrial fibrillation: Insights into substrate and lesion transmurality.

Heart Rhythm 2019 08 16;16(8):1151-1159. Epub 2019 Feb 16.

Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois; Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China; UCLA Health System, UCLA Cardiac Arrhythmia Center, UCLA David Geffen School of Medicine, Los Angeles, California. Electronic address:

Background: Recurrences of atrial fibrillation (AF) after ablation have been attributed to conduction gaps and nontransmural ablation lesions.

Objective: The purpose of this study was to assess the feasibility of adjunctive percutaneous mapping of the epicardial regions of the left atrium to characterize the transmural extent of substrate and ablation lesions.

Methods: Between 2014 and 2018, combined epicardial and endocardial mapping of AF was performed in 18 patients via an inferior subxiphoid percutaneous approach (16 with previously failed ablation procedures and 2 patients with long-standing persistent AF) at 2 centers. Epicardial substrate mapping was compared with endocardial mapping to assess transmural uniformity.

Results: Of 18 patients, 4 (22%) demonstrated nontransmural atrial low-voltage regions with relative epicardial sparing in the left atrial posterior wall. Transmural isolation of the posterior wall was achieved after an endocardial "box" lesion set in 6/9 (67%), guided by epicardial voltage data, while epicardial and endocardial dissociation during AF was observed in 1 patient. In 3 patients, epicardial capture along the endocardial pulmonary vein lesion set despite endocardial capture loss and bidirectional block was observed. Two cases of mitral flutter were terminated from the epicardium. A balloon was positioned in the pericardial space in 6 patients for esophageal protection during ablation.

Conclusion: A percutaneous epicardial approach for mapping and ablation of the left atrium is feasible in the electrophysiology laboratory during endocardial catheter ablation for AF and may be useful as an adjunctive approach in refractory cases. High-density epicardial mapping can provide direct evidence of nonuniform lesion and substrate transmurality of the human left atrium before and after ablation.
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http://dx.doi.org/10.1016/j.hrthm.2019.02.018DOI Listing
August 2019

Cryoballoon pulmonary vein isolation after extracardiac Fontan operation.

HeartRhythm Case Rep 2018 Aug 27;4(8):336-338. Epub 2018 Apr 27.

Ahmanson/UCLA Congenital Heart Disease Center, University of California at Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrcr.2018.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6092570PMC
August 2018

Cryoballoon or contact force-guided radiofrequency catheter ablation for persistent atrial fibrillation: Different strategies with similar results.

Heart Rhythm 2018 12 17;15(12):1842-1843. Epub 2018 Jul 17.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California. Electronic address:

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http://dx.doi.org/10.1016/j.hrthm.2018.07.021DOI Listing
December 2018

Soluble Urokinase Plasminogen Activator Receptor (suPAR) as a Predictor of Incident Atrial Fibrillation.

J Atr Fibrillation 2018 Apr 30;10(6):1801. Epub 2018 Apr 30.

Department of Cardiology, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark.

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker of chronic low-grade inflammation and a potent predictor of cardiovascular events. We hypothesized that plasma suPAR levels would predict new-onset atrial fibrillation (AF) in a large cohort of con-secutively admitted acute medical patients during long-term follow-up. In 14,764 acutely ad-mitted patients without prior or current AF, median suPAR measured upon admission was 2.7 ng/ml (interquartile range (IQR) 1.9-4.0). During a median follow-up of 392 days (IQR 218-577), 349 patients (2.4%) were diagnosed with incident AF. suPAR levels at admission significantly predicted subsequent incident AF (HR per doubling of suPAR: 1.21, 95% CI 1.05-1.41, adjusted for age and sex). After further adjustment for Charlson score, plasma C-reactive protein (CRP), plasma creatinine and blood hemoglobin-levels, the result remained essentially unaltered (HR per doubling of suPAR: 1.20, 95% CI: 1.01-1.42). In multivariate ROC curve analysis, combining age, sex, Charlson score, CRP, creatinine, and hemoglobin (AUC 0.77, 95% CI 0.75-0.79), the addition of suPAR did not improve the prediction of incident AF (AUC 0.77, 95% CI 0.75-0.79, P=0.89). Plasma suPAR is independently associated with subsequent new-onset AF in a population of recently hospitalized patients, but the addition of suPAR to baseline risk markers appears not to improve the prediction of AF.
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http://dx.doi.org/10.4022/jafib.1801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6009789PMC
April 2018

Atrioesophageal Fistula After Atrial Fibrillation Ablation: A single center series.

J Atr Fibrillation 2017 Oct-Nov;10(3):1654. Epub 2017 Oct 31.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: The incidence of atrioesophageal fistula (AEF) after atrial fibrillation catheter ablation is reported to be 0.015%-0.04%, though it is likely underreported due to a number of factors including misdiagnosis. We report our institutional experience with AEF.

Methods: Patients with confirmed diagnosis of AEF between 2004 and 2016 at our institution were identified (n=5) and their clinical characteristics and outcome were analyzed.

Results: AEF occurred in 5 patients who underwent AF catheter ablation (3 ablated at our institution; 2 transferred from outside hospitals after diagnosis of AEF). Symptoms were chest pain (n=3), fever (n=3), TIA/stroke (n=3), dysphagia (n=1), and headache (n=1). Chest pain was the earliest symptom and occurred 21-24 days post-RFA. One patient had sudden death without preceding symptoms. Findings included leukocytosis (WBC count range of 17200-19,000) and sepsis. Chest CT was obtained in 3 patients and showed air in the left atrium or mediastinum. Three patients had evidence of multifocal stroke on MRI. Three patients died before surgery could be performed. Two patients (40%) underwent emergent surgery which included partial excision of atrial wall, closure with bovine pericardial patch and closure of esophageal lesion. Surgical outcomes were favorable (100% survival).

Conclusion: Chest pain and fever were the early symptoms of AEF and occurred before the neurologic complications. Chest CT was an excellent tool for detection of AEF. All patients who were diagnosed correctly and underwent surgery survived. Early detection is imperative as prompt surgery may improve survival. Health-care community education is the key to ensure early detection and transfer to a qualified surgical center.
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http://dx.doi.org/10.4022/jafib.1654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725752PMC
October 2017

Hybrid surgical vs percutaneous access epicardial ventricular tachycardia ablation.

Heart Rhythm 2018 04 11;15(4):512-519. Epub 2017 Nov 11.

UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California. Electronic address:

Background: There is limited experience of surgical epicardial access in the contemporary era of ventricular tachycardia ablation after cardiac surgery.

Objectives: The purpose of this study was to describe our institutional experience with surgical epicardial access and the influence of surgical approach and compare outcomes with those of a propensity-matched percutaneous epicardial access control group.

Methods: We performed a retrospective study of consecutive surgical epicardial ventricular tachycardia (VT) ablation cases from a single center. Surgical cases were propensity-matched to percutaneous epicardial ablation controls and short-term and long-term outcomes were compared.

Results: Between 2004 and 2016, 38 patients underwent 40 surgical epicardial access procedures (subxiphoid, n = 22; thoracotomy, n = 18). The commonest indication was prior coronary artery bypass grafting (45%), valve surgery (22%), or ventricular assist device (VAD) (10%). The mean procedure time was 444 minutes (standard deviation, 107 minutes). Mapped epicardial geometry area was 149 cm (interquartile range 182 cm), which comprised 36% of the mapped epicardial geometric area of a percutaneous control group. Subxiphoid access gave preferential access to the inferior and inferolateral left ventricular segments and was less frequently able to access the anterior, anterolateral, and apical segments compared with a thoracotomy approach. When compared with results from a propensity-matched percutaneous-access group, short-term outcomes, complication rates, and 1-year survival free from a combined end point of VT recurrence, death, or transplantation were not statistically different.

Conclusions: Surgical epicardial access after cardiac surgery for ablation of VT in patients with careful preprocedure evaluation can be performed with acceptable safety with no statistical difference in long-term outcomes compared with a propensity-matched percutaneous epicardial cohort. The region of left ventricular epicardium that can be mapped is limited compared with that of percutaneous cases and is determined by the surgical approach.
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http://dx.doi.org/10.1016/j.hrthm.2017.11.009DOI Listing
April 2018

Incidence and significance of adhesions encountered during epicardial mapping and ablation of ventricular tachycardia in patients with no history of prior cardiac surgery or pericarditis.

Heart Rhythm 2018 01 14;15(1):65-74. Epub 2017 Sep 14.

University of California, Los Angeles, Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California. Electronic address:

Background: Pericardial adhesions can prevent epicardial access and restrict catheter movement during mapping and ablation of ventricular tachycardia (VT). The incidence of adhesions in patients without prior cardiac surgery or clinically evident pericarditis is not known.

Objective: To describe the incidence of pericardial adhesions and explore their impact in patients without prior cardiac surgery or pericarditis.

Methods: A retrospective search of our ablation database containing patients who underwent epicardial ablation for VT was undertaken. Adhesions were diagnosed with routine contrast pericardiography after pericardial entry. Demographics and long-term outcomes were compared between patients with and without adhesions.

Results: Between 2004 and 2016, successful epicardial entry was achieved in 188 of 192 attempts (98%). In 155 first-time epicardial access attempts, pericardial adhesions were diagnosed in 13 (8%). When comparing baseline demographics, there was no significant difference. However, adhesions tended to occur more frequently with severe renal impairment (2% of patients without adhesions vs 15% of patients with adhesions, P = .07). No patient with a structurally normal heart had adhesions present. Adhesions were associated with limited epicardial mapping (3% of patients without adhesions vs 85% of patients with adhesions, P < .001) and lower short-term procedural success (68% of patients without adhesions vs 46% of patients with adhesions, P = .02), but complication rates were similar. The presence of adhesions did not translate into lower VT-free survival (P = .64) or freedom from a combined end point of VT recurrence, death, or transplant at 1 year (P = .93).

Conclusion: Adhesions may be unexpectedly encountered in patients without prior cardiac surgery or pericarditis. When present, they can limit mapping and may be associated with lower short-term success. Larger studies are required to determine their impact on long-term outcomes.
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http://dx.doi.org/10.1016/j.hrthm.2017.09.007DOI Listing
January 2018

'Runaway' vagal nerve stimulator: a case of cyclic asystole.

HeartRhythm Case Rep 2016 Sep 28;2(5):388-390. Epub 2016 Jun 28.

UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrcr.2016.05.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5419945PMC
September 2016

Could less be more in catheter ablation for persistent atrial fibrillation? Pulmonary vein isolation reconsidered.

Heart Rhythm 2017 05;14(5):668-669

UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1016/j.hrthm.2017.01.024DOI Listing
May 2017

The continuing search for patient-specific atrial fibrillation ablation targets: Need for rigorously verified and independently replicated data.

Heart Rhythm 2016 12 24;13(12):2331-2332. Epub 2016 Aug 24.

Loma Linda University Medical Center, Loma Linda, California.

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http://dx.doi.org/10.1016/j.hrthm.2016.08.033DOI Listing
December 2016

Long-term clinical outcomes of focal impulse and rotor modulation for treatment of atrial fibrillation: A multicenter experience.

Heart Rhythm 2016 Mar 21;13(3):636-41. Epub 2015 Oct 21.

UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California.

Background: New approaches to ablation of atrial fibrillation (AF) include focal impulse and rotor modulation (FIRM). Studies of this technology with short-term follow-up have shown favorable outcomes.

Objective: The purpose of this study was to characterize the long-term results of FIRM ablation in a cohort of patients treated at 2 academic medical centers.

Methods: All FIRM-guided ablation procedures (n = 43) at UCLA Medical Center and Virginia Commonwealth University Medical Center performed between January 2012 and October 2013 were included for analysis. During AF, FIRM software constructed phase maps from unipolar atrial electrograms to identify putative AF sources. These sites were targeted for ablation, along with pulmonary vein isolation in 77% of patients.

Results: AF was paroxysmal in 56%, and 67% had prior AF ablation. All patients had rotors identified (mean 2.6 ± 1.2 per patient, 77% in LA). Prespecified acute procedural end-point was achieved in 47% of patients (n = 20): AF termination in 4, organization in 7, >10% slowing of AF cycle length in 9. Acute complications occurred in 4 patients (9.3%). At 18 ± 7 months of follow-up, 37% were free from documented recurrent AF after a 3-month blanking period; 21% were free from documented atrial tachyarrhythmias and off antiarrhythmic drugs. Multivariate analysis did not reveal any significant predictors of AF recurrence, including pattern of AF, acute procedural success, or prior failed ablation.

Conclusion: Long-term clinical results after FIRM ablation in this cohort of patients showed poor efficacy, different from previously published studies. Randomized studies are needed to evaluate the efficacy and clinical utility of this ablation approach for treating AF.
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http://dx.doi.org/10.1016/j.hrthm.2015.10.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4762742PMC
March 2016

Catheter Ablation of Atrial Fibrillation: Advent of Second-Generation Technologies.

J Am Coll Cardiol 2015 Sep;66(12):1361-3

UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California. Electronic address:

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http://dx.doi.org/10.1016/j.jacc.2015.07.056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4659817PMC
September 2015

Predicting postoperative atrial fibrillation using CHA2DS2-VASc scores.

J Surg Res 2015 Oct 18;198(2):267-72. Epub 2015 Apr 18.

Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California. Electronic address:

Background: Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery and is associated with increased morbidity and mortality. Pharmacologic prophylaxis is the main method of preventing POAF but needs to be targeted to patients at high risk of developing POAF. The CHA2DS2-VASc scoring system is a clinical guideline for assessing ischemic stroke risk in patients with atrial fibrillation. The present study evaluated the utility of this scoring system in predicting the risk of developing de novo POAF in cardiac surgery patients.

Materials And Methods: A total of 2385 patients undergoing cardiac surgery at our institution from 2008-2014 were identified for analysis. Each patient was assigned a CHA2DS2-VASc score and placed into a low- (score of 0), intermediate- (1), or high-risk (≥2) group. A multivariate regression model was created to control for known risk factors of atrial fibrillation.

Results: POAF occurred in 380 of 2385 patients (15.9%). Mean CHA2DS2-VASc scores among patients with POAF and without POAF were 3.6 ± 1.7 and 2.8 ± 1.7, respectively (P < 0.0001). Using multivariate analysis, as a patient's CHA2DS2-VASc score rose from 0-9, the risk of developing POAF increased from 8.2%-42.3%. Each point increase was associated with higher odds of developing POAF (adjusted odds ratio, 1.27; 95% confidence interval, 1.18-1.36, P < 0.0001). Compared with low-risk patients, patients in the high-risk group were 5.21 times more likely to develop POAF (P < 0.0001).

Conclusions: The CHA2DS2-VASc algorithm is a simple risk-stratification tool that could be used to direct pharmacologic prophylaxis toward patients most likely to experience POAF.
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http://dx.doi.org/10.1016/j.jss.2015.04.047DOI Listing
October 2015

Quantitative analysis of localized sources identified by focal impulse and rotor modulation mapping in atrial fibrillation.

Circ Arrhythm Electrophysiol 2015 Jun 14;8(3):554-61. Epub 2015 Apr 14.

From the UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at University of California, Los Angeles (P.B., E.B., P.F., M.S., R.T., K.S., R.M.); and International Heart Institute, Loma Linda University Medical Center, CA (R.M.).

Background: New approaches to ablation of atrial fibrillation (AF) include focal impulse and rotor modulation (FIRM) mapping, and initial results reported with this technique have been favorable. We sought to independently evaluate the approach by analyzing quantitative characteristics of atrial electrograms used to identify rotors and describe acute procedural outcomes of FIRM-guided ablation.

Methods And Results: All FIRM-guided ablation procedures (n=24; 50% paroxysmal) at University of California, Los Angeles Medical Center were included for analysis. During AF, unipolar atrial electrograms collected from a 64-pole basket catheter were used to construct phase maps and identify putative AF sources. These sites were targeted for ablation, in conjunction with pulmonary vein isolation in most patients (n=19; 79%). All patients had rotors identified (mean, 2.3±0.9 per patient; 72% in left atrium). Prespecified acute procedural end point was achieved in 12 of 24 (50%) patients: AF termination (n=1), organization (n=3), or >10% slowing of AF cycle length (n=8). Basket electrodes were within 1 cm of 54% of left atrial surface area, and a mean of 31 electrodes per patient showed interpretable atrial electrograms. Offline analysis revealed no differences between rotor and distant sites in dominant frequency or Shannon entropy. Electroanatomic mapping showed no rotational activation at FIRM-identified rotor sites in 23 of 24 patients (96%).

Conclusions: FIRM-identified rotor sites did not exhibit quantitative atrial electrogram characteristics expected from rotors and did not differ quantitatively from surrounding tissue. Catheter ablation at these sites, in conjunction with pulmonary vein isolation, resulted in AF termination or organization in a minority of patients (4/24; 17%). Further validation of this approach is necessary.
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http://dx.doi.org/10.1161/CIRCEP.115.002721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4655205PMC
June 2015

Relationship between sinus rhythm late activation zones and critical sites for scar-related ventricular tachycardia: systematic analysis of isochronal late activation mapping.

Circ Arrhythm Electrophysiol 2015 Apr 4;8(2):390-9. Epub 2015 Mar 4.

From the University of California at Los Angeles Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA.

Background: It is not known whether the most delayed late potentials are functionally most specific for scar-related ventricular tachycardia (VT) circuits.

Methods And Results: Isochronal late activation maps were constructed to display ventricular activation during sinus rhythm over 8 isochrones. Analysis was performed at successful VT termination sites and prospectively tested. Thirty-three patients with 47 scar-related VTs where a critical site was demonstrated by termination of VT during ablation were retrospectively analyzed. In those who underwent mapping of multiple surfaces, 90% of critical sites were on the surface that contained the latest late potential. However, only 11% of critical sites were localized to the latest isochrone (87.5%-100%) of ventricular activation. The median percentage of latest activation at critical sites was 78% at a distance from the latest isochrone of 18 mm. Sites critical to reentry were harbored in regions with slow conduction velocity, where 3 isochrones were present within a 1-cm radius. Ten consecutive patients underwent ablation prospectively guided by isochronal late activation maps, targeting concentric isochrones outside of the latest isochrone. Elimination of the targeted VT was achieved in 90%. Termination of VT was achieved in 6 patients at a mean ventricular activation percentage of 78%, with only 1 requiring ablation in the latest isochrone.

Conclusions: Late potentials identified in the latest isochrone of activation during sinus rhythm are infrequently correlated with successful ablation sites for VT. The targeting of slow conduction regions propagating into the latest zone of activation may be a novel and promising strategy for substrate modification.
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http://dx.doi.org/10.1161/CIRCEP.114.002637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695215PMC
April 2015
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