Publications by authors named "Ling Kuo"

35 Publications

2021 TSOC Expert Consensus on the Clinical Features, Diagnosis, and Clinical Management of Cardiac Manifestations of Fabry Disease.

Acta Cardiol Sin 2021 Jul;37(4):337-354

Division of Cardiology, Departments of Internal Medicine, MacKay Memorial Hospital, Taipei.

Fabry disease (FD) is an X-linked, rare inherited lysosomal storage disease caused by α-galactosidase A gene variants resulting in deficient or undetectable α-galactosidase A enzyme activity. Progressive accumulation of pathogenic globotriaosylceramide and its deacylated form globotriaosylsphingosine in multiple cell types and organs is proposed as main pathophysiology of FD, with elicited pro-inflammatory cascade as alternative key pathological process. The clinical manifestations may present with either early onset and multisystemic involvement (cutaneous, neurological, nephrological and the cardiovascular system) with a progressive disease nature in classic phenotype, or present with a later-onset course with predominant cardiac involvement (non-classical or cardiac variant; e.g. IVS4+919G>A in Taiwan) from missense variants. In either form, cardiac involvement is featured by progressive cardiac hypertrophy, myocardial fibrosis, various arrhythmias, and heart failure known as Fabry cardiomyopathy with potential risk of sudden cardiac death. Several plasma biomarkers and advances in imaging modalities along with novel parameters, cardiac magnetic resonance (CMR: native T1/T2 mapping) for myocardial tissue characterization or echocardiographic deformations, have shown promising performance in differentiating from other etiologies of cardiomyopathy and are presumed to be helpful in assessing the extent of cardiac involvement of FD and in guiding or monitoring subsequent treatment. Early recognition from extra-cardiac red flag signs either in classic form or red flags from cardiac manifestations in cardiac variants, and awareness from multispecialty team work remains the cornerstone for timely managements and beneficial responses from therapeutic interventions (e.g. oral chaperone therapy or enzyme replacement therapy) prior to irreversible organ damage. We aim to summarize contemporary knowledge based on literature review and the gap or future perspectives in clinical practice of FD-related cardiomyopathy in an attempt to form a current expert consensus in Taiwan.
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http://dx.doi.org/10.6515/ACS.202107_37(4).20210601ADOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261701PMC
July 2021

Deep Sedation with Intravenous Anesthesia Is Associated with Outcome in Patients Undergoing Cryoablation for Paroxysmal Atrial Fibrillation.

Int Heart J 2021 Jul 6. Epub 2021 Jul 6.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.

Whether deep sedation with intravenous anesthesia will affect the recurrence after cryoballoon ablation (CBA) of paroxysmal atrial fibrillation (AF) is yet to be examined. Thus, in this study, we hypothesize that there is difference in terms of the recurrence between local anesthesia and deep sedation with intravenous anesthesia after an index ablation procedure.In total, 109 patients were enrolled and received CBA, of which 68 (58.2 years) patients underwent pulmonary vein (PV) isolation with a local anesthesia (group 1) and 41 patients (63.2 years) underwent PV isolation with deep sedation using intravenous anesthesia (group 2).During the index procedure, isolation of all major PVs was achieved in 66 patients in group 1 and in 41 patients in group 2. There was no difference in non-PV triggers between the two groups. The periprocedural complication was found to be similar between the two groups (2.9% in group 1 and 4.9% in group 2). Further, 17 patients in group 1 and 4 patients in group 2 experienced recurrences after a follow-up of 19.3 months (P = 0.019). Repeat procedures revealed similar PV reconnection rates between the two groups. It has also been noted that the number of reconnected PV and incidence of atypical flutter seem to increase in group 1.Deep sedation with intravenous anesthesia during CBA for paroxysmal AF is safe and had a better long-term outcome than those with local anesthesia.
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http://dx.doi.org/10.1536/ihj.20-819DOI Listing
July 2021

Stroke and Bleeding Risk Assessment in Atrial Fibrillation: Where Are We Now?

Korean Circ J 2021 Jun 1. Epub 2021 Jun 1.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Most important international guidelines recommend the use of CHA₂DS₂-VASc and HAS-BLED scores for stroke and bleeding risk assessments in atrial fibrillation (AF) patients, respectively. The 2020 AF guidelines of European Society of Cardiology have revised the definition of "C: congestive heart failure (HF)" component, and now patients with either HF with reduced ejection fraction or preserved ejection fraction should be assigned 1 point. Hypertrophic cardiomyopathy was also included. Besides, the revised "V: vascular diseases" component included both prior myocardial infarction and "angiographically significant coronary artery disease". It is important to understand that the stroke and bleeding risks of AF patients were not static and should be re-assessed regularly. A high HAS-BLED score itself should not be the only reason to withhold or discontinue oral anticoagulants, but remind physicians for the corrections of modifiable bleeding risk factors and more regular follow up. In the future, the AF duration and left atrial function may play an important role for personalized evaluation of individual stroke risk while more studies are necessary.
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http://dx.doi.org/10.4070/kcj.2021.0170DOI Listing
June 2021

Optimal Management of Anticoagulation Therapy in Asian Patients With Atrial Fibrillation.

Circ J 2021 Jun 5. Epub 2021 Jun 5.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.

Stroke prevention is the cornerstone of management of atrial fibrillation (AF), and non-vitamin K antagonist oral anticoagulants (NOACs) are commonly prescribed. Because routine monitoring of anticoagulant effects of NOACs is not necessary, appropriate dosing following the criteria of each NOACs defined in pivotal randomized trials is important. Real-world data demonstrate that underdosing NOACs is associated with a higher risk of ischemic stroke without a lower risk of major bleeding. Furthermore, renal function of AF patients should be assessed using the Cockcroft-Gault formula to prevent overestimation that could result in overdosing of NOACs. The assessment of bleeding risk is important, and the HAS-BLED score should be used to help identify patients at high risk of bleeding (HAS-BLED score ≥3). Moreover, the HAS-BLED score should be reassessed at periodic intervals to address potentially modifiable bleeding risk factors because bleeding risks of AF patients are not static. When managing NOAC-related bleeding episodes, the possibility of occult malignancies (e.g., grastrointestinal [GI] tract cancers for patients experiencing GI bleeding and bladder cancer for patients with hematuria) should be kept in mind. Addressing all of these issues is crucial to achieving better clinical outcomes for anticoagulated AF patients. More efforts are necessary to incorporate clear and easy-to-follow recommendations about optimal management of anticoagulation into the guidelines to improve AF patient care.
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http://dx.doi.org/10.1253/circj.CJ-21-0399DOI Listing
June 2021

Efficacy of Patient-Specific Strategy: Catheter Ablation Strategy of Persistent Atrial Fibrillation Based on Morphological Repetitiveness by Periodicity and Similarity.

Circ Arrhythm Electrophysiol 2021 May 17;14(5):e009719. Epub 2021 May 17.

National Yang Ming Chiao Tung University, Hsinchu, Taiwan (C.-Y.L., Y.-J.L., L.K., S.-L.C., L.-W.L., Y.-F.H., T.-F.C., F.-P.C., J.-N.L., T.-Y.C., T.-C.T., C.-I.W., C.-M.L., S.-H.L., W.-H.C., S.-A.C.).

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http://dx.doi.org/10.1161/CIRCEP.121.009719DOI Listing
May 2021

Novel model-based point scoring system for predicting stroke risk in atrial fibrillation patients: Results from a nationwide cohort study with validation.

Int J Cardiol Heart Vasc 2021 Jun 28;34:100787. Epub 2021 Apr 28.

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: The stroke risk scoring system for atrial fibrillation (AF) patients can vary considerably based on patients' status while receiving ablation. This study aimed to demonstrate a novel scoring system for stroke risk stratification based on the status of catheter ablation.

Methods: First, 787 patients with AF undergoing ablation were matched according to age, sex, and underlying diseases with the same number of patients not undergoing ablation using the propensity-score (PS)-matched cohort. Multivariate Cox model-derived coefficients were used to construct a simple point-based clinical model using the PS-matched cohort. Thereafter, the novel model (AF-CA-Stroke score) was validated in a nationwide AF cohort.

Results: The AF-CA-Stroke score was calculated based on age (point = 5), ablation status (point = 4), prior history of stroke (point = 4), chronic kidney disease (point = 2), diabetes mellitus (point = 1), and congestive heart failure (point = 1). Risk function to predict the 1-, 5-, 10-year absolute stroke risks was reported. The estimated area under the receive operating characteristic curve of the AF-CA-Stroke score in the PS-matched cohort was 0.845 (95% confidence interval: 0.824-0.865) to predict long-term stroke. A validation study showed that discrimination abilities in the AF-CA-Stroke scores were significantly higher than those in the CHADS/CHADSVASc scores. The best cut-off value of the AF-CA-Stroke score to predict future strokes was ≥ 5.

Conclusions: This novel model-based point scoring system effectively identifies stroke risk using clinical factors and AF ablation status of patients with AF. Various age stratifications and AF ablation should be considered in AF management.
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http://dx.doi.org/10.1016/j.ijcha.2021.100787DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102915PMC
June 2021

Esophageal luminal temperature rise during atrial fibrillation ablation is associated with lower radiofrequency electrode distance and baseline impedance.

J Cardiovasc Electrophysiol 2021 Jul 28;32(7):1857-1864. Epub 2021 May 28.

Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.

Introduction: Esophageal injury during atrial fibrillation (AF) ablation is a life-threatening complication. We sought to measure the association of esophageal temperature attenuation with radiofrequency (RF) electrode impedance, contact force, and distance from the esophagus.

Methods: The retrospective study cohort included 35 patients with mean age 64 ± 10 years, of whom 74.3% were male, and 40% had persistent AF. All patients had undergone preprocedural cardiac magnetic resonance (CMR) followed by AF ablation with luminal esophageal temperature monitoring. Lesion locations were co-registered with CMR image segmentations of left atrial and esophageal anatomy. Luminal esophageal temperature, time matched RF lesion data, and ablation distance from the nearest esophageal location were collected as panel data.

Results: Luminal esophageal temperature changes corresponding to 3667 distinct lesions, delivered with mean power 27.9 ± 5.5 W over a mean duration of 22.2 ± 10.5 s were analyzed. In multivariable analyses, clustered per patient, examining posterior wall lesions only, and adjusted for lesion power and duration as set by the operator, lesion distance from the esophagus (-0.003°C/mm, p < .001), and baseline impedance (-0.015°C/Ω, p < .001) were associated with changes in luminal esophageal temperature.

Conclusion: Esophageal luminal temperature rises are associated with shorter lesion distance from esophagus and lower baseline impedance during RF lesion delivery. When procedural strategy requires RF delivery near the esophagus, selection of sites with higher baseline impedance may improve safety.
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http://dx.doi.org/10.1111/jce.15097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8256679PMC
July 2021

Case series on stereotactic body radiation therapy in non-ischemic cardiomyopathy patients with recurrent ventricular tachycardia.

Pacing Clin Electrophysiol 2021 Jun 15;44(6):1085-1093. Epub 2021 May 15.

Heart Rhythm Center, Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Introduction: The efficacy of stereotactic body radiation therapy (SBRT) as an alternative treatment for recurrent ventricular tachycardia (VT) is still unclear. This study aimed to report the outcome of SBRT in VT patients with nonischemic cardiomyopathy (NICM).

Methods: The determination of the target substrate for radiation was based on the combination of CMR results and electroanatomical mapping merged with the real-time CT scan image. Radiation therapy was performed by Flattening-filter-free (Truebeam) system, and afterward, patients were followed up for 13.5 ± 2.8 months. We analyzed the outcome of death, incidence of recurrent VT, ICD shocks, anti-tachycardia pacing (ATP) sequences, and possible irradiation side-effects.

Results: A total of three cases of NICM patients with anteroseptal scar detected by CMR. SBRT was successfully performed in all patients. During the follow-up, we found that VT recurrences occurred in all patients. In one patient, it happened during a 6-week blanking period, while the others happened afterward. Re-hospitalization due to VT only appeared in one patient. Through ICD interrogation, we found that all patients have reduced VT burden and ATP therapies. All of the patients died during the follow-up period. Radiotherapy-related adverse events did not occur in all patients.

Conclusions: SBRT therapy reduces the number of VT burden and ATP sequence therapy in NICM patients with VT, which had a failed previous catheter ablation. However, the efficacy and safety aspects, especially in NICM cases, remained unclear.
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http://dx.doi.org/10.1111/pace.14254DOI Listing
June 2021

Clinical significance of J waves with respect to substrate characteristics and ablation outcomes in patients with arrhythmogenic right ventricular cardiomyopathy.

Europace 2021 Mar 18. Epub 2021 Mar 18.

Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei, Taiwan.

Aims: J-wave syndrome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has been linked to an increased risk of ventricular arrhythmia. We investigated the significance of J waves with respect to substrate manifestations and ablation outcomes in patients with ARVC.

Methods And Results: Forty-five patients with ARVC undergoing endocardial/epicardial mapping/ablation were studied. Patients were classified into two groups: 13 (28.9%) and 32 (71.1%) patients with and without J waves, respectively. The baseline characteristics, electrophysiological features, ventricular substrate, and recurrent ventricular tachycardia/fibrillation (VT/VF) were compared. Among the 13 patients with J waves, only the inferior J wave was observed. More ARVC patients with J waves fulfilled the major criteria of ventricular arrhythmias (76.9% vs. 21.9%, P = 0.003). Similar endocardial and epicardial substrate characteristics were observed between the two groups. However, patients with J waves had longer epicardial total activation time than those without (224.7 ± 29.9 vs. 200.8 ± 21.9 ms, P = 0.005). Concordance of latest endo/epicardial activation sites was observed in 29 (90.6%) patients without J waves and in none among those with J waves (P < 0.001). Complete elimination of endocardial/epicardial abnormal potentials resulted in the disappearance of the J wave in 8 of 13 (61.5%) patients. The VT/VF recurrences were not different between ARVC patients with and without J waves.

Conclusion: The presence of J waves was associated with the discordance of endocardial/epicardial activation pattern in terms of transmural depolarization discrepancy in patients with ARVC.
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http://dx.doi.org/10.1093/europace/euab060DOI Listing
March 2021

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT.

JACC Clin Electrophysiol 2021 02 28;7(2):174-186. Epub 2020 Oct 28.

Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes.

Background: The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated.

Methods: This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of ≥0.3 mg/dl over 48 h or an increase of >1.5× the baseline values within 1 week post-procedure.

Results: Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p = 0.004), atrial fibrillation (OR: 2.42; 95% CI: 1.01 to 5.78; p = 0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95% CI: 1.17 to 13.52; p = 0.003). After a median follow-up of 39 months (interquartile range: 6 to 65 months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30 days; hazard ratio [HR]: 9.91; 95% CI: 2.87 to 34.22; p < 0.001) and late mortality (within 1 year) (HR: 4.57; 95% CI: 2.08 to 10.05; p < 0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95% CI: 1.1 to 18.36; p = 0.04, and HR: 3.28; 95% CI: 1.43 to 7.49; p = 0.005, respectively).

Conclusions: Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.
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http://dx.doi.org/10.1016/j.jacep.2020.08.018DOI Listing
February 2021

PRECAF Randomized Controlled Trial.

Circ Arrhythm Electrophysiol 2021 01 10;14(1):e008993. Epub 2020 Dec 10.

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (L.K., D.S.F., A.L., J.A., M.H., P.S., F.E.M., S.N.).

Background: We have previously shown that the presence of dual muscular coronary sinus (CS) to left atrial (LA) connections, coupled with rate-dependent unidirectional block in one limb, is associated with atrial fibrillation (AF) induction. This study sought to examine whether ablation of distal CS to LA connections at a first AF ablation reduces arrhythmia recurrence during follow-up.

Methods: In this single-center, randomized, controlled trial, 35 consecutive patients with drug-refractory AF undergoing first-time ablation between August 2018 and August 2019, were randomly assigned to (1) standard ablation (pulmonary vein isolation and nonpulmonary vein trigger ablation) versus (2) standard ablation plus elimination of distal CS to LA connections targeting the earliest LA activation during distal CS pacing with a deca-polar catheter placed with its proximal electrode at the ostium. Change of the local CS atrial electrogram and LA activation sequence to early activation of the LA septum or roof during distal CS pacing were the end point for CS-LA connection elimination.

Results: Thirty patients completed 6 months study follow-up (15 patients in each group). Demographic characteristics including age and AF persistence were similar in both groups. After a mean follow-up of 170±22 days, there were 7 atrial arrhythmia recurrences in the standard group and 1 recurrence in the CS-LA connection elimination group (46.7% versus 6.7%, hazard ratio, 0.12, =0.047).

Conclusions: Elimination of distal CS to LA connections reduced atrial arrhythmia recurrences compared with standard pulmonary vein isolation and nonpulmonary vein trigger ablation in patients undergoing a first AF ablation procedure in a small randomized study. This strategy warrants further evaluation in a multicenter randomized trial. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03646643.
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http://dx.doi.org/10.1161/CIRCEP.120.008993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054782PMC
January 2021

Association of septal late gadolinium enhancement on cardiac magnetic resonance with ventricular tachycardia ablation targets in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 12 27;31(12):3262-3276. Epub 2020 Oct 27.

Department of Medicine, Cardiovascular Division, Cardiology and Electrophysiology Section, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Ablation of septal substrate-associated ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) is challenging. We sought to standardize the characterization of septal substrates on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and to examine the association of that substrate with VT exit and isthmus sites on invasive mapping.

Methods: LGE-CMR was performed before electroanatomic mapping and ablation for VT in 20 NICM patients. LGE extent and distribution were quantified using myocardial signal-intensity Z scores (SI-Z). The SI-Z thresholds correlating to previously validated voltage thresholds, for abnormal tissue and dense scar were defined.

Results: Bipolar and unipolar (electrogram) voltage amplitude measurements from the LV and RV were negatively associated with SI-Z from LGE-CMR imaging (p < .05). SI-Z thresholds for appropriate CMR identification of septal substrates were determined to be greater than -.15 for border zone and greater than .03 for a dense scar. Among all patients, 34 critical VT sites were identified with SI-Z distribution in the range of -.97 to .06. Thirty (88.2%) critical sites were located in the dense LGE, 1 (2.9%) in the border zone, and 3 (8.9%) in healthy tissue but within 7 mm of LGE. Of note, critical VT sites were all located at the basal septum close to valves (distance to aortic valve: 17.5 ± 31.2 mm, mitral valve: 21.2 ± 8.7 mm) in nonsarcoidosis cases.

Conclusions: Critical sites of septal VT in NICM patients are predominantly in the CMR defined dense scar when using standardized signal-intensity thresholds.
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http://dx.doi.org/10.1111/jce.14777DOI Listing
December 2020

The Clinical Application of the Deep Learning Technique for Predicting Trigger Origins in Patients With Paroxysmal Atrial Fibrillation With Catheter Ablation.

Circ Arrhythm Electrophysiol 2020 11 6;13(11):e008518. Epub 2020 Oct 6.

Heart Rhythm Center, Division of Cardiology, Department of Medicine (C.-M.L., S.-L.C., Y.-J.L., L.-W.L., Y.-F.H., F.-P.C., T.-F.C., T.-C.T., J.-N.L., C.-Y.L., T.-Y.C., C.-I.W., L.K., Y.-C.S., S.-A.C.), Taipei Veterans General Hospital, Taiwan.

Background: Non-pulmonary vein (NPV) trigger has been reported as an important predictor of recurrence post-atrial fibrillation ablation. Elimination of NPV triggers can reduce the recurrence of postablation atrial fibrillation. Deep learning was applied to preablation pulmonary vein computed tomography geometric slices to create a prediction model for NPV triggers in patients with paroxysmal atrial fibrillation.

Methods: We retrospectively analyzed 521 patients with paroxysmal atrial fibrillation who underwent catheter ablation of paroxysmal atrial fibrillation. Among them, pulmonary vein computed tomography geometric slices from 358 patients with nonrecurrent atrial fibrillation (1-3 mm interspace per slice, 20-200 slices for each patient, ranging from the upper border of the left atrium to the bottom of the heart, for a total of 23 683 images of slices) were used in the deep learning process, the ResNet34 of the neural network, to create the prediction model of the NPV trigger. There were 298 (83.2%) patients with only pulmonary vein triggers and 60 (16.8%) patients with NPV triggers±pulmonary vein triggers. The patients were randomly assigned to either training, validation, or test groups, and their data were allocated according to those sets. The image datasets were split into training (n=17 340), validation (n=3491), and testing (n=2852) groups, which had completely independent sets of patients.

Results: The accuracy of prediction in each pulmonary vein computed tomography image for NPV trigger was up to 82.4±2.0%. The sensitivity and specificity were 64.3±5.4% and 88.4±1.9%, respectively. For each patient, the accuracy of prediction for a NPV trigger was 88.6±2.3%. The sensitivity and specificity were 75.0±5.8% and 95.7±1.8%, respectively. The area under the curve for each image and patient were 0.82±0.01 and 0.88±0.07, respectively.

Conclusions: The deep learning model using preablation pulmonary vein computed tomography can be applied to predict the trigger origins in patients with paroxysmal atrial fibrillation receiving catheter ablation. The application of this model may identify patients with a high risk of NPV trigger before ablation.
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http://dx.doi.org/10.1161/CIRCEP.120.008518DOI Listing
November 2020

Precordial T-Wave Inversions in Patients with Arrhythmogenic Right Ventricular Cardiomyopathy Who Present with the Initial Features of Right Ventricular Outflow Tract Arrhythmia.

Acta Cardiol Sin 2020 Sep;36(5):464-474

Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital.

Background: Precordial T-wave inversion (TWI) is an important diagnostic criterion for arrhythmogenic right ventricular cardiomyopathy (ARVC).

Objective: This study aimed to characterize the initial repolarization features of definite ARVC in patients who first presented with right ventricular outflow tract ventricular arrhythmia (RVOT-VA) and TWI.

Methods: Patients who presented with RVOT-VA and TWI ≥ V were retrospectively assessed. The initial characteristics of repolarization between patients with and without a final diagnosis of definite ARVC during follow-up were compared.

Results: TWI ≥ V was observed in 61 of 553 patients (mean age: 44.1 ± 14.7 years; 14 men) with RVOT-VAs. After an average follow-up time of 54.9 ± 33.7 months, 31 (50.8%) patients were classified into the definite ARVC group and 30 (49.2%) into the non-definite ARVC group. The disappearance of precordial TWI ≥ V was observed in eight (13.1%) patients after the elimination of RVOT-VAs. In a multivariate analysis of the initial electrocardiogram features, only fragmented QRS [odds ratio (OR): 15.45, 95% confidence interval (CI): 1.61-148.26, p = 0.02] and precordial V TpTe interval (OR: 1.03, 95% CI: 1.01-1.06, p = 0.02) could independently predict definite ARVC during longitudinal follow-up. An initial V TpTe cutoff value > 88.5 ms could predict the final diagnosis of definite ARVC, with a sensitivity and specificity of 74.2% and 78.6%, respectively.

Conclusions: Despite the high risk of ARVC in RVOT-VAs and TWI ≥ V, "normalization" of TWI was observed after ventricular arrhythmia elimination in 13.1% of the patients. Fragmented QRS and longer V TpTe interval were associated with definite ARVC during longitudinal follow-up.
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http://dx.doi.org/10.6515/ACS.202009_36(5).20200621ADOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490609PMC
September 2020

Multimodality Imaging to Guide Ventricular Tachycardia Ablation in Patients with Non-ischaemic Cardiomyopathy.

Arrhythm Electrophysiol Rev 2020 Feb;8(4):255-264

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US.

Catheter ablation is an effective treatment option for ventricular tachycardia (VT) in patients with non-ischaemic cardiomyopathy (NICM). The heterogeneous nature of NICM aetiologies and VT substrate in patients with NICM play a role in long-term ablation outcomes in this population. Over the past decades, more precise identification of NICM aetiologies and better characterisation of various substrates have been made. Application of multimodal imaging has greatly contributed to the accurate diagnosis of NICM subtypes and improved VT ablation strategies. This article summarises the current knowledge of multimodal imaging used in the characterisation of non-ischaemic NICM substrates, procedural planning and image integration for the optimisation of VT ablation.
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http://dx.doi.org/10.15420/aer.2019.37.3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358957PMC
February 2020

Automated extraction of left atrial volumes from two-dimensional computer tomography images using a deep learning technique.

Int J Cardiol 2020 10 11;316:272-278. Epub 2020 Apr 11.

Institute of Statistics, National Chiao Tung University, Taiwan. Electronic address:

Background: Precise segmentation of the left atrium (LA) in computed tomography (CT) images constitutes a crucial preparatory step for catheter ablation in atrial fibrillation (AF). We aim to apply deep convolutional neural networks (DCNNs) to automate the LA detection/segmentation procedure and create three-dimensional (3D) geometries.

Methods: Five hundred eighteen patients who underwent procedures for circumferential isolation of four pulmonary veins were enrolled. Cardiac CT images (from 97 patients) were used to construct the LA detection and segmentation models. These images were reviewed by the cardiologists such that images containing the LA were identified/segmented as the ground truth for model training. Two DCNNs which incorporated transfer learning with the architectures of ResNet50/U-Net were trained for image-based LA classification/segmentation. The LA geometry created by the deep learning model was correlated to the outcomes of AF ablation.

Results: The LA detection model achieved an overall 99.0% prediction accuracy, as well as a sensitivity of 99.3% and a specificity of 98.7%. Moreover, the LA segmentation model achieved an intersection over union of 91.42%. The estimated mean LA volume of all the 518 patients studied herein with the deep learning model was 123.3 ± 40.4 ml. The greatest area under the curve with a LA volume of 139 ml yielded a positive predictive value of 85.5% without detectable AF episodes over a period of one year following ablation.

Conclusions: The deep learning provides an efficient and accurate way for automatic contouring and LA volume calculation based on the construction of the 3D LA geometry.
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http://dx.doi.org/10.1016/j.ijcard.2020.03.075DOI Listing
October 2020

Trends in Successful Ablation Sites and Outcomes of Ablation for Idiopathic Outflow Tract Ventricular Arrhythmias.

JACC Clin Electrophysiol 2020 02 27;6(2):221-230. Epub 2019 Nov 27.

Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine clinical characteristics of procedural and long-term outcomes in patients undergoing catheter ablation (CA) of outflow tract ventricular arrhythmias (OT-VAs) over 16 years.

Background: CA is an effective treatment strategy for OT-VAs.

Methods: Patients undergoing CA for OT-VAs from 1999 to 2015 were divided into 3 periods: 1999 to 2004 (early), 2005 to 2010 (middle), and 2011 to 2015 (recent). Successful ablation site (right ventricular OT, aortic cusps/left ventricular OT, or coronary venous system/epicardium), VA morphology (right bundle branch block or left bundle branch block), and acute and clinical success rates were assessed.

Results: Six hundred eighty-two patients (336 female) were included (early: n = 97; middle: n = 204; recent: n = 381). Over time there was increase in use of irrigated ablation catheters and electroanatomic mapping, and more VAs were ablated from the aortic cusp/left ventricular OT or coronary venous system/epicardium (14% vs. 45% vs. 56%; p < 0.0001). Acute procedural success was achieved in 585 patients (86%) and was similar between groups (82% vs. 84% vs. 88%; p = 0.27). Clinical success was also similar between groups (86% vs. 87% vs. 88%; p = 0.94), but more patients in earlier periods required repeat ablation (18% vs. 17% vs. 9%; p = 0.02). Overall complication rate was 2% (similar between groups).

Conclusions: Over a 16-year period there was an increase in patients undergoing CA for OT-VTs, with more ablations performed at non-right ventricular outflow tract locations using electroanatomic mapping and irrigated-tip catheters. Over time, single procedure success has improved and complications have remained limited.
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http://dx.doi.org/10.1016/j.jacep.2019.10.004DOI Listing
February 2020

Incidence of Left Atrial Appendage Triggers in Patients With Atrial Fibrillation Undergoing Catheter Ablation.

JACC Clin Electrophysiol 2020 01 30;6(1):21-30. Epub 2019 Oct 30.

Electrophysiology Section, Department of Medicine, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objective: This study sought to investigate incidence of left atrial appendage (LAA) triggers of atrial fibrillation (AF) and/or organized atrial tachycardias (OAT) in patients undergoing AF ablation and to evaluate outcomes after ablation.

Background: Although LAA isolation is being increasingly performed during AF ablation, the true incidence of LAA triggers for AF remains unclear.

Methods: All patients with LAA triggers of AF and/or OAT during AF ablation from 2001 to 2017 were included. LAA triggers were defined as atrial premature depolarizations from the LAA, which initiated sustained AF and/or OAT.

Results: Out of 7,129 patients undergoing AF ablation over 16 years, LAA triggers were observed in 21 (0.3%) subjects (age 60 ± 9 years; 57% males; 52% persistent AF). Twenty (95%) patients were undergoing repeat ablation. The LAA was the only nonpulmonary vein trigger in 3 patients; the remaining 18 patients had both LAA and other nonpulmonary vein triggers. LAA triggers were eliminated in all patients (focal ablation in 19 patients; LAA isolation in 2 patients). Twelve months after ablation, 47.6% remained free from recurrent arrhythmia. After overall follow-up of 5.0 ± 3.6 years (median: 3.7 years; interquartile range: 1.4 to 8.9 years), 38.1% were arrhythmia-free. All 3 patients with triggers limited to the LAA remained free of AF recurrence. One patient undergoing LAA isolation developed LAA thrombus during follow-up.

Conclusions: The incidence of true LAA triggers is very low (0.3%). Most patients with LAA triggers have additional nonpulmonary vein triggers, and despite elimination of LAA triggers, long-term arrhythmia recurrence rates remain high. Potential risks of empiric LAA isolation during AF ablation (especially first-time AF ablation) may outweigh benefits.
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http://dx.doi.org/10.1016/j.jacep.2019.08.012DOI Listing
January 2020

Association of Left Atrial High-Resolution Late Gadolinium Enhancement on Cardiac Magnetic Resonance With Electrogram Abnormalities Beyond Voltage in Patients With Atrial Fibrillation.

Circ Arrhythm Electrophysiol 2020 02 15;13(2):e007586. Epub 2020 Jan 15.

Cardiovascular Imaging Section, Department of Radiology (B.D), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Background: Conflicting data have been reported on the association of left atrial (LA) late gadolinium enhancement (LGE) with atrial voltage in patients with atrial fibrillation. The association of LGE with electrogram fractionation and delay remains to be examined. We sought to examine the association between LA LGE on cardiac magnetic resonance and electrogram abnormalities in patients with atrial fibrillation.

Methods: High-resolution LGE cardiac magnetic resonance was performed before electrogram mapping and ablation in atrial fibrillation patients. Cardiac magnetic resonance features were quantified using LA myocardial signal intensity score (SI-Z), a continuous normalized variable, as well as a dichotomous LGE variable based on previously validated methodology. Electrogram mapping was performed pre-ablation during sinus rhythm or LA pacing, and electrogram locations were coregistered with cardiac magnetic resonance images. Analyses were performed using multilevel patient-clustered mixed-effects regression models.

Results: In the 40 patients with atrial fibrillation (age, 63.2±9.2 years; 1312.3±767.3 electrogram points per patient), lower bipolar voltage was associated with higher SI-Z in patients who had undergone previous ablation (coefficient, -0.049; <0.001) but not in ablation-naive patients (coefficient, -0.004; =0.7). LA electrogram activation delay was associated with SI-Z in patients with previous ablation (SI-Z: coefficient, 0.004; <0.001 and LGE: coefficient, 0.04; <0.001) but not in ablation-naive patients. In contrast, increased LA electrogram fractionation was associated with SI-Z (coefficient, 0.012; =0.03) and LGE (coefficient, 0.035; <0.001) only in ablation-naive patients.

Conclusions: The association of LA LGE with voltage is modified by ablation. Importantly, in ablation-naive patients, atrial LGE is associated with electrogram fractionation even in the absence of voltage abnormalities.
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http://dx.doi.org/10.1161/CIRCEP.119.007586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031051PMC
February 2020

Application of noninvasive signal-averaged electrocardiogram analysis in predicting the requirement of epicardial ablation in patients with arrhythmogenic right ventricular cardiomyopathy.

Heart Rhythm 2020 04 19;17(4):584-591. Epub 2019 Nov 19.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.

Background: Signal-averaged electrocardiogram (SAECG) provides not only diagnostic information but also the prognostic implication of ablation in arrhythmogenic right ventricular cardiomyopathy (ARVC).

Objective: This study aimed to validate the role of SAECG in identifying arrhythmogenic substrates requiring an epicardial approach in ARVC.

Methods: Ninety-one patients with a definite diagnosis of ARVC who underwent successful ablation for drug-refractory ventricular arrhythmia were enrolled and classified into 2 groups: group 1 who underwent successful ablation at the endocardium only and group 2 who underwent successful ablation requiring an additional epicardial approach. The baseline characteristics of patients and SAECG parameters were obtained for analysis.

Results: Male predominance, worse right ventricular (RV) function, higher incidence of syncope, and depolarization abnormality were observed in group 2. Moreover, the number of abnormal SAECG criteria was higher in group 2 than in group 1. After a multivariate analysis, the independent predictors of the requirement of epicardial ablation included the number of abnormal SAECG criteria (odds ratio 2.8, 95% confidence interval 1.4-5.4; P = .003) and presence of syncope (odds ratio 11.7; 95% confidence interval 2.7-50.4; P = .001). In addition, ≥2 abnormal SAECG criteria were associated with larger RV endocardial unipolar low-voltage zone (P < .001), larger RV endocardial/epicardial bipolar low-voltage zone/scar (P < .05), and longer RV endocardial/epicardial total activation time (P < .001 and P = .004, respectively).

Conclusion: The number of abnormal SAECG criteria was correlated with the extent of diseased epicardial substrates and could be a potential surrogate marker for predicting the requirement of epicardial ablation in patients with ARVC.
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http://dx.doi.org/10.1016/j.hrthm.2019.11.018DOI Listing
April 2020

Performance of Prognostic Heart Failure Models in Patients With Nonischemic Cardiomyopathy Undergoing Ventricular Tachycardia Ablation.

JACC Clin Electrophysiol 2019 07 8;5(7):801-813. Epub 2019 May 8.

Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Objectives: This study sought to assess the performance of established risk models in predicting outcomes after catheter ablation (CA) in patients with nonischemic dilated cardiomyopathy (NIDCM) and ventricular tachycardia (VT).

Background: A correct pre-procedural risk stratification of patients with NIDCM and VT undergoing CA is crucial. The performance of different pre-procedural risk stratification approaches to predict outcomes of CA of VT in patients with NIDCM is unknown.

Methods: The study compared the performance of 8 prognostic scores (SHFM [Seattle Heart Failure Model], MAGGIC [Meta-analysis Global Group in Chronic Heart Failure], ADHERE [Acute Decompensated Heart Failure National Registry], EFFECT [Enhanced Feedback for Effective Cardiac Treatment-Heart Failure], OPTIMIZE-HF [Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure], CHARM [Candesartan in Heart Failure-Assessment of Reduction in Mortality], EuroSCORE [European System for Cardiac Operative Risk Evaluation], and PAINESD [Chronic Obstructive Pulmonary Disease, Age > 60 Years, Ischemic Cardiomyopathy, New York Heart Association Functional Class III or IV, Ejection Fraction <25%, Presentation With VT Storm, Diabetes Mellitus]) for the endpoints of death/cardiac transplantation and VT recurrence in 282 consecutive patients (age 59 ± 15 years, left ventricular ejection fraction: 36 ± 13%) with NIDCM undergoing CA of VT. Discrimination and calibration of each model were evaluated through area under the curve (AUC) of receiver-operating characteristic curve and goodness-of-fit test.

Results: After a median follow-up of 48 (interquartile range: 19-67) months, 43 patients (15%) died, 24 (9%) underwent heart transplantation, and 58 (21%) experienced VT recurrence. The prognostic accuracy of SHFM (AUC = 0.89; goodness-of-fit p = 0.68 for death/transplant and AUC = 0.77; goodness-of-fit p = 0.16 for VT recurrence) and PAINESD (AUC = 0.83; goodness-of-fit p = 0.24 for death/transplant and AUC = 0.68; goodness-of-fit p = 0.58 for VT recurrence) were significantly superior to that of other scores.

Conclusions: In patients with NIDCM and VT undergoing CA, the SHFM and PAINESD risk scores are powerful predictors of recurrent VT and death/transplant during follow-up, with similar performance and significantly superior to other scores. A pre-procedural calculation of the SHFM and PAINESD can be useful to predict outcomes.
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http://dx.doi.org/10.1016/j.jacep.2019.04.001DOI Listing
July 2019

Long-term efficacy and safety of adjunctive ethanol infusion into the vein of Marshall during catheter ablation for nonparoxysmal atrial fibrillation.

J Cardiovasc Electrophysiol 2019 08 30;30(8):1215-1228. Epub 2019 May 30.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Introduction: We aimed to clarify the effect of vein of Marshall (VOM) ethanol infusion for treating VOM triggers and/or mitral flutter after first-attempt endocardial ablation in patients with nonparoxysmal atrial fibrillation (AF).

Methods And Results: Of the 254 consecutive patients (age, 56 ± 10 years; 221 male) undergoing catheter ablation for drug-refractory nonparoxysmal AF, 32 (12.6%) received VOM ethanol infusion. The patients were stratified into group 1 (pulmonary vein isolation [PVI], substrate modification, VOM ethanol infusion), group 2 (PVI, substrate modification), and group 3 (PVI alone). Propensity-matched analysis (N = 128) of long-term outcomes (3.9 ± 0.5 years) revealed a higher AF recurrence risk in group 2 (hazard ratio [HR], 4.17; 95% confidence interval [95% CI], 1.63-10.69; P = .003) and group 3 (HR, 1.82; 95% CI, 1.09-3.04; P = .021) than in group 1, as well as a higher atrial arrhythmia recurrence risk in group 2 than in group 1 (HR, 2.42; 95% CI, 1.16-5.03; P = .018). A higher procedural termination rate was observed in group 1 than groups 2 and 3 (41.7% vs 17.2% vs 18.8%; P = .042). On multivariate analysis, VOM ethanol injection was an independent predictor of freedom from recurrence of AF (HR, 0.20; 95% CI, 0.08-0.52; P = .001) and atrial arrhythmia (HR, 0.35; 95% CI, 0.17-0.74; P = .005), whereas a left atrial diameter >45 mm and hypertension were independent risk factors for recurrence. Periprocedural complications rates were comparable among the groups.

Conclusion: Adjunctive VOM ethanol infusion is effective and safe for treating nonparoxysmal AF in patients with VOM triggers and/or refractory mitral flutter, providing good long-term freedom from AF and atrial arrhythmia.
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http://dx.doi.org/10.1111/jce.13969DOI Listing
August 2019

Electrophysiological and clinical characteristics of catheter ablation for isolated left side atrial tachycardia over a 10-year period.

J Cardiovasc Electrophysiol 2019 07 1;30(7):1013-1025. Epub 2019 May 1.

Department of Medicine, Heart Rhythm Center and Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.

Aims: Most left atrial tachycardia (LAT) is associated with atrial fibrillation (AF). The clinical and electrophysiological characteristics and outcomes of LAT without AF have not been investigated. This study sought to determine the long-term ablation outcomes and predictors of recurrence of isolated LAT.

Methods: This is a single-center study of consecutive patients with isolated LAT. Atrial arrhythmia recurrence was determined from follow-up records of patients who underwent LAT ablation from 2008 to 2017. Clinical and electrophysiologic characteristics associated with atrial arrhythmia recurrence were identified.

Results: A total of 50 patients (53 ± 19 years, 46% male) with 59 LAT (1.16 ± 0.47 per patient) were enrolled. Over a mean follow-up of 37 ± 33 months, atrial arrhythmia recurrence occurred in 22 (44%) patients, 11 with atrial tachycardia (AT) only, five with AF only, and six with concurrent AT and AF. The incidence of pulmonary vein (PV) origins increased significantly in the repeat procedure (P = 0.036). Multivariate analysis identified left ventricular ejection fraction (LVEF) as the only predictor of any atrial arrhythmia recurrence and LAT recurrence, while smoking and identified macroreentrant LAT in the index procedure predicted AF recurrence.

Conclusion: This study demonstrated a higher rate of atrial arrhythmia recurrence, including AF, among patients with initially isolated LAT. A lower LVEF predicted any atrial arrhythmia and LAT recurrence, whereas smoking and index macroreentrant AT mechanism predicted long-term AF. PV ATs were frequently observed in recurrent patients irrespective of index procedure origin.
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http://dx.doi.org/10.1111/jce.13945DOI Listing
July 2019

Comparison of the arrhythmogenic substrate between men and women with nonischemic cardiomyopathy.

Heart Rhythm 2019 09 28;16(9):1414-1420. Epub 2019 Mar 28.

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Outcomes of ventricular tachycardia (VT) ablation in structural heart disease have been reported to differ by sex. Whether this is due to differences in the underlying arrhythmogenic substrates among patients with nonischemic cardiomyopathy (NICM) remains unclear.

Objective: The purpose of this study was to compare the characteristics of arrhythmogenic substrates between women and men with NICM.

Methods: We analyzed 160 consecutive patients (26 women) with NICM who were undergoing VT ablation at the Hospital of the University of Pennsylvania. Of these 160 patients, 59 (13 women) underwent cardiac magnetic resonance (CMR) before the ablation procedure. The arrhythmogenic substrate was analyzed qualitatively and quantitatively by CMR and/or detailed electroanatomic mapping.

Results: There were no significant differences in left ventricular scar percentage as defined by CMR (9.5% ± 7.8% in women vs 11.2% ± 8.6% in men; P = .5), endocardial bipolar voltage (<1.5 mV; 11.3% ± 19.3% in women vs 11.5% ± 16.3% in men; P = .4), endocardial unipolar voltage (<8.3 mV; 38.0% ± 30.8% in women vs 45.6% ± 30.9% in men; P = .2), or epicardial bipolar voltage (<1.0 mV; 21.5% ± 38.9% in women vs 10.7% ± 13.9% in men; P = .6). There were no significant differences in scar transmurality as defined by CMR (5 categories: endocardial, midwall, epicardial, transmural, and right ventricular endocardial). Similarly, there were no significant differences in scar distribution as defined by CMR or electroanatomic mapping (anteroseptal vs inferolateral).

Conclusion: Scar percentage, transmurality, and distribution are similar between women and men with NICM.
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http://dx.doi.org/10.1016/j.hrthm.2019.03.024DOI Listing
September 2019

Characteristics of recurrent ventricular tachyarrhythmia after catheter ablation in patients with arrhythmogenic right ventricular cardiomyopathy.

J Cardiovasc Electrophysiol 2019 04 4;30(4):582-592. Epub 2019 Feb 4.

Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.

Background: The reason for recurrence of ventricular arrhythmia (VA) after catheter ablation in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is not clear.

Methods: In this study, 91 ARVC patients (age, 47 ± 13 years; 47 men) who underwent catheter ablation for drug-refractory ventricular arrhythmia (VA) were enrolled. The patients were categorized into single or multiple procedures (n = 28). The baseline characteristics and electrophysiological features of the patients were examined to elucidate the reason of the VA recurrences.

Results: A total of 186 VAs were induced during the index procedure and 176 (94.6%) were eliminated. Successful, partially successful, and failed ablations were achieved in 89.0%, 8.8%, and 2.2% of the patients, respectively. During a mean follow-up period of 32 ± 26 months, 35 patients had VA recurrences. Forty-two repeat procedures were performed for 81 induced VAs in 28 patients. Of the 42 repeat procedures, successful, partially successful, and failed ablations were achieved in 37, 4, and 1 of the procedures, respectively. Most of the recurrent VAs (70 [72.9%]) originated from the newly-developed circuits owing to the scar progression. The patients with repeat procedure had worsening right ventricular remodeling. The multivariate analysis revealed that history as endurance athlete significantly predicted the need of a repeat procedure in spite of the initially successful endocardial/epicardial ablation and negative inducibility (hazard ratio: 3.014, 95% confidence interval: 1.493-6.084, P = 0.002).

Conclusions: In spite of the initial complete VA elimination, history as an athlete was associated with scar progression, RV remodeling, and VA recurrences from the newly developed arrhythmogenic substrates/circuit in ARVC.
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http://dx.doi.org/10.1111/jce.13853DOI Listing
April 2019

Dynamic unipolar voltage criteria of right ventricular septum for identifying left ventricular septal scar.

J Interv Card Electrophysiol 2020 Apr 29;57(3):353-359. Epub 2019 Jan 29.

Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.

Purpose: The right ventricular (RV) septal unipolar voltage (UV) for predicting left ventricular (LV) septal scar wall thickness (WT) remains to be elucidated.

Methods: From 2013 to 2015, data obtained from RV and LV electroanatomic maps of 28 patients (mean age, 53 ± 16 years; 19 men [67.9%]) with/without identified LV septal scars were reviewed. Patients with an RV septal scar were excluded (n = 90). Direct measurement of septal WT was conducted (mean distance, 10.4 ± 3.3 mm). Patients in group 1 had a normal LV substrate, while those in group 2 had an LV septal scar. Fisher's linear discriminant formula was used to determine the dynamic UV criteria.

Results: A total of 552 points were collected: 323 in 12 patients from group 1 and 229 in 16 patients from group 2. The UV of the RV septum is capable of identifying the opposite LV endocardial bipolar scar and is proportional to the WT of the interventricular septum. In the absence of an RV endocardial scar, the formula of "RV septal cut-off value = 0.736 × WT - 0.117 mV" has better sensitivity and specificity for predicting the LV septal scar (0.96 vs. 0.68 and 0.91 vs. 0.80, respectively) than the predefined fixed criteria of 8.3 mV with a net reclassification improvement of 25.7% (P < 0.001).

Conclusions: The combined measurement of UV and WT is more sensitive than the predefined fixed UV criteria for defining deep scars.
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http://dx.doi.org/10.1007/s10840-019-00512-3DOI Listing
April 2020

Comparison of phase mapping and electrogram-based driver mapping for catheter ablation in atrial fibrillation.

Pacing Clin Electrophysiol 2019 02 27;42(2):216-223. Epub 2018 Dec 27.

Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei City, Taiwan.

Introduction: Adjunctive driver-guided ablation in addition to pulmonary vein isolation has been proposed as a strategy to improve procedural success and outcomes for various populations with atrial fibrillation (AF). First, this study aimed to evaluate the different mapping techniques for driver/rotor identification and second to evaluate the benefits of driver/rotor-guided ablation in patients with paroxysmal and persistent AF (PerAF).

Methods: We searched the electronic database in PubMed using the keywords "atrial fibrillation," "rotor," "rotational driver," "atrial fibrillation source," and "drivers" for both randomized controlled trials and observational controlled trials. Clinical studies reporting efficacy or safety outcomes of driver-guided ablation for paroxysmal AF or (PerAF) were identified. We performed subgroup analyses comparing different driver mapping methods in patients with PerAF. The odds ratios (ORs) with random effects were analyzed.

Results: Out of 175 published articles, seven met the inclusion criteria, of which two were randomized controlled trials, one was quasiexperimental study, and four observational studies (three case-controlled studies and one cross-sectional study). Overall, adjunctive driver-guided ablation was associated with higher rates of acute AF termination (OR: 4.62, 95% confidence interval [CI]: 2.12-10.08; P < 0.001), lower recurrence of any atrial arrhythmia (OR: 0.44, 95% CI: 0.30-0.065; P < 0.001), and comparable complication incidence.

Conclusions: Adjunctive driver-guided catheter ablation suggested an increased freedom from AF/AT relative to conventional strategies, irrespective of the mapping techniques. Furthermore, phase mapping appears to be superior to electrogram-based driver mapping in PerAF ablation.
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http://dx.doi.org/10.1111/pace.13573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542555PMC
February 2019

Usefulness of the CHADS-VASc Score to Predict the Risk of Sudden Cardiac Death and Ventricular Arrhythmias in Patients With Atrial Fibrillation.

Am J Cardiol 2018 12 13;122(12):2049-2054. Epub 2018 Sep 13.

Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.

Sudden cardiac death (SCD), the most devastating manifestation of ventricular arrhythmias (VAs), is the leading cause of mortality in patients with atrial fibrillation (AF). We hypothesized that the CHADS-VASc score, consisting of age and several clinical risk factors, could be used to estimate the individual risk of SCD/VAs for AF patients. From year 2000 to 2011, 288,181 newly-diagnosed AF patients without antecedent SCD/VAs were identified from "Taiwan National Health Insurance Research Database." During the follow-up of 1,065,751 person-years, 11,166 patients experienced SCD/VAs with an annual risk of 1.05% which increased from 0.34% for patients with a CHADS-VASc score of 0% to 2.63% for those with a score of 9. The CHADS-VASc score was a significant predictor of SCD/VAs with an adjusted hazard ratio of 1.21 (95% confidence interval 1.20 to 1.22) per 1 point increment of the score. As the CHADS-VASc score increased from 1 to 9, the hazard ratio of SCD/VAs continuously increased from 1.28 to 4.17 compared with patients with a CHADS-VASc score of 0. In conclusion, CHADS-VASc score was a convenient scoring system which could be used to predict the risk of SCD/VAs in AF patients in addition to its ability for stroke risk stratification.
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http://dx.doi.org/10.1016/j.amjcard.2018.08.056DOI Listing
December 2018